LGBT Kids in the Juvenile Justice System Need Physician Advocates

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When Allen ran away from home, he was hoping to get a change to affirm his gender identity. Allen was assigned female at birth, but he identified as male. His mother, however, was not supportive of his gender identity and threatened to send him to reparative therapy. Allen crossed state lines when he was apprehended by police, and despite not having committed a crime he was sent to the local juvenile detention center where he was placed in the girls’ facilities. He waited there until authorities could contact his mother.

Allen’s experience is typical for many LGBT youths in the juvenile justice system, where these young people are disproportionately represented compared to their heterosexual, cisgender peers. The reasons for this disparity are varied and complex; however, they are rooted in anti-gay and anti-trans stigma and discrimination. Despite the challenges LGBT youths face while in custody, physicians can play a role in promoting the health and well-being of this vulnerable population outside and within this system.

Current estimates of LGB youths within the United States range from 6 to 8 percent.1Kann L, Olsen E, McManus T, Harris W, Shanklin S, Flint K, Queen B, Lowry R, Chyen D, Whittle L, Thornton J, Lim C, Yamakawa Y, Brener N, Zaza S. Sexual Identity, Sex of Sexual Contacts, and Health-Related Behaviors Among Students in Grades 9–12 — United States and Selected Sites, 2015. MMWR Surveillance Summaries. 2016;65(9):1-202. However, about 12 percent of minors in state-run or state-contracted facilities self-report as LGB.2Bureau of Justice Statistics, U.S. Department of Justice. Sexual Victimization in Juvenile Facilities Reported by Youth, 2012. Washington, D.C.: Bureau of Justice Statistics; 2013. These disparities extend to gender and race. About 13 percent of girls and 5 percent of boys in the U.S. report an LGB identity. Within the juvenile justice system, however, 23 percent of girls and 8 percent of boys report an LGB identity. Additionally, although the majority of youths in juvenile justice facilities are black or African American,3Bureau of Justice Statistics, U.S. Department of Justice. Sexual Victimization in Juvenile Facilities Reported by Youth, 2012. Washington, D.C.: Bureau of Justice Statistics; 2013. gay and bisexual boys are more likely to be white.4Wilson B, Jordan S, Meyer I, Flores A, Stemple L, Herman J. Disproportionality and Disparities among Sexual Minority Youth in Custody. Journal of Youth and Adolescence. 2017;46(7):1547-1561. In contrast, lesbian and bisexual girls are more likely to be Latina.

Being homeless is one of the greatest risk factors for entering the juvenile justice system.

LGBT youths in a juvenile justice facility face additional trauma compared to other young people in detention. Among youths in juvenile correctional facilities, 2.5 percent report sexual victimization from peers.5Bureau of Justice Statistics, U.S. Department of Justice. Sexual Victimization in Juvenile Facilities Reported by Youth, 2012. Washington, D.C.: Bureau of Justice Statistics; 2013. However, gay and bisexual boys are 11 times more likely to experience sexual victimization from peers than are heterosexual boys.6Wilson B, Jordan S, Meyer I, Flores A, Stemple L, Herman J. Disproportionality and Disparities among Sexual Minority Youth in Custody. Journal of Youth and Adolescence. 2017;46(7):1547-1561. These estimates could be higher, since LGB minors may not report such incidents to authorities, afraid nothing will be done.

Statistics on transgender minors within the juvenile justice system are sparse. Many transgender youths are placed in facilities meant to hold young people of the sex these children were assigned at birth. When admitted to a juvenile justice facility, transgender youths often act or dress in a manner reflective of their sex assigned at birth to avoid harassment, violence, and mistreatment from peers and staff. Additionally, many studies on juvenile justice combine LGB and transgender kids into a single demographic. Such policies make it difficult to estimate how many transgender youths are within the system.

Regardless of statistical prevalence, many transgender youths experience trauma and indignity in these facilities. In addition to being forced to live with residents of a different gender, these children are often forced to dress, groom, and act in a way that is inconsistent with their gender identity. Some will be put in isolation for the sake of their “protection,” which can lead to additional psychological trauma, hampering transgender youths’ ability to develop into healthy adults.7American Psychiatric Association. Incarcerated Juveniles Belong in Juvenile Facilities [Internet]. 2009. Available from: http://www.njjn.org/uploads/digital-library/resource_1050.pdf

Behind the scenes: why LGBT youths end up in the justice system

Why are LGBT children disproportionately represented in the juvenile justice system? The causes are rooted in people and environments unfriendly to LGBT kids, including family, school, and law enforcement.

Family rejection is frequent among LGBT minors, placing them at risk to interface with law enforcement. There are two ways that family rejection may result in LGBT youths entering the juvenile justice system. First, about one-fifth to one-quarter of LGBT youths report homelessness stemming from family rejection,8Injustice at Every Turn: A Report of the National Transgender Discrimination Survey – National LGBTQ Task Force [Internet]. National LGBTQ Task Force. 2011 [cited 2018 Dec 15]. Available from: http://www.thetaskforce.org/injustice-every-turn-report-national-transgender-discrimination-survey/,9The Unfair Criminalization of Gay and Transgender Youth: An Overview of the Experiences of LGBT Youth in the Juvenile Justice System [Internet]. Center for American Progress. 2012 [cited 2018 Dec 15]. Available from: https://www.americanprogress.org/issues/lgbt/reports/2012/06/29/11730/the-unfair-criminalization-of-gay-and-transgender-youth/ and 40 percent of homeless adolescents identify as LGBT.10On the Streets: The Federal Response to Gay and Transgender Homeless Youth [Internet]. Center for American Progress. 2010 [cited 2018 Dec 15]. Available from: https://www.americanprogress.org/issues/lgbt/reports/2010/06/21/7983/on-the-streets/ Being homeless is one of the greatest risk factors for entering the juvenile justice system. Secondly, even though their families may not kick them out of their home, there may be increased conflict in the home due to parental rejection of the child’s sexual orientation or gender identity. During these conflicts, many parents may request police involvement and press charges against their children for being “incorrigible,” landing them in the juvenile justice system.11The Unfair Criminalization of Gay and Transgender Youth: An Overview of the Experiences of LGBT Youth in the Juvenile Justice System [Internet]. Center for American Progress. 2012 [cited 2018 Dec 15]. Available from: https://www.americanprogress.org/issues/lgbt/reports/2012/06/29/11730/the-unfair-criminalization-of-gay-and-transgender-youth/

Many LGBT youths remain in juvenile justice facilities even though they have not committed a crime.

Another pathway for LGBT youths to enter the juvenile justice system is through school. According to GLSEN’s School Climate Survey, almost 80 percent of LGBT minors report being verbally harassed, 40 percent reported being physically harassed, and 19 percent reported being physically assaulted while at school.12Kosciw J, Greytalk E, Diaz E, Bartkiewicz M. The 2009 National School Climate Survey: The Experiences of Lesbian, Gay, Bisexual and Transgender Youth in Our Nation’s Schools [Internet]. ERIC; 2010. Available from: http://files.eric.ed.gov/fulltext/ED512338.pdf Additionally, one-third of LGBT youths report that when they told school officials of their victimization, school officials did nothing to address these reports.13Dunn M, Krehely J. Supporting Gay and Transgender Youth Most in Need [Internet]. Center for American Progress. 2012 [cited 2018 Dec 15]. Available from: https://www.americanprogress.org/issues/lgbt/reports/2012/03/09/11226/supporting-gay-and-transgender-youth-most-in-need/ Not only do school officials ignore these incidents, they also dole out harsh punishments to LGBT youths for minor offenses, often involving law enforcement.14Majd K, Marksamer J, Reyes C. Hidden Injustice- Lesbian, Gay, Bisexual and Transgender Youth in Juvenile Courts — Models for Change: Systems Reform in Juvenile Justice [Internet]. National Center for Lesbian Rights. 2009 [cited 2018 Dec 15]. Available from: http://www.modelsforchange.net/publications/237,15Himmelstein K, Bruckner H. Criminal-Justice and School Sanctions Against Nonheterosexual Youth: A National Longitudinal Study. Pediatrics. 2010;127(1):49-57. This is especially true in cases in which LGBT kids defend themselves against their aggressors. As a result, many LGBT children are expelled or drop out of school, increasing the risk of them entering the juvenile justice system.

Both family rejection and harsh and unfair school systems and policies lead many LGBT youths to become homeless. As a result, some of them become involved in the underground economy to survive, such as the sex or drug trade. Additionally, many are arrested due to violations of laws related to homelessness, such as violating youth curfew laws or sleeping in public places.16Dunn M, Krehely J. Supporting Gay and Transgender Youth Most in Need [Internet]. Center for American Progress. 2012 [cited 2018 Dec 15]. Available from: https://www.americanprogress.org/issues/lgbt/reports/2012/03/09/11226/supporting-gay-and-transgender-youth-most-in-need/

Many LGBT youths are automatically assumed to be sex offenders regardless of whether they actually committed a sex crime. LGBT kids are more likely than their heterosexual peers to be prosecuted as a sex offender for age-appropriate, consensual sexual activity,17Majd K, Marksamer J, Reyes C. Hidden Injustice- Lesbian, Gay, Bisexual and Transgender Youth in Juvenile Courts — Models for Change: Systems Reform in Juvenile Justice [Internet]. National Center for Lesbian Rights. 2009 [cited 2018 Dec 15]. Available from: http://www.modelsforchange.net/publications/237 and when indicted, they need to register as a sex offender in a majority of states, creating additional barriers to school and employment.

Finally, many LGBT youths are detained by default: because release from detention requires discharge to a parent or guardian, from whom many of these children are fleeing, they can remain in these facilities even though no crime has been committed.

Physicians’ duty to LGBT youths

Although many physicians do not routinely interface with the juvenile justice system, they do have the ability to help promote the health and well-being of its LGBT youths. Physicians should encourage more research into LGBT kids in the juvenile justice system. Many databases on this topic do not ask questions on sexual orientation or gender identity, making it difficult to estimate the scope of the problem and correspondingly create recommendations on how facilities should address the needs of this population.

Physicians should additionally prevent LGBT minors from entering the juvenile justice system in the first place. They can make their clinic a safe space that allows LGBT patients to feel comfortable disclosing their sexual orientation or gender identity so the physician can address issues such as family acceptance and rejection. Physicians should help families accept and support their child. Resources such as the Family Acceptance Project and the film Leading with Love can be helpful in increasing family support for LGBT young people. Physicians should also work with schools to implement school policies that address sexual orientation and gender identity, especially policies related to bullying and harsh and unfair punishments.18The Unfair Criminalization of Gay and Transgender Youth: An Overview of the Experiences of LGBT Youth in the Juvenile Justice System [Internet]. Center for American Progress. 2012 [cited 2018 Dec 15]. Available from: https://www.americanprogress.org/issues/lgbt/reports/2012/06/29/11730/the-unfair-criminalization-of-gay-and-transgender-youth/

Although many physicians do not routinely interface with the juvenile justice system, they do have the ability to help promote the health and well-being of its LGBT youths.

Finally, if a physician works as a provider within the juvenile justice system, they should advocate for policies that address the needs of LGBT youths in that system. Although the needs are great, there are many organizations that are making recommendations on how to deliver equitable care to these children. The Annie E. Case Foundation has published standards for the treatment of LGBT youth within the juvenile justice system, and the Sexual Health Youth Coalition has also written a consensus statement outlining the need for these young people to access sexual healthcare programs and services, especially those that address issues related to sexual orientation and gender identity. Physicians can help provide training for staff on these policies, making these facilities a safer place for our LGBT kids.

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Gerald T. Montano, D.O., M.S.

Dr. Montano's training in pediatrics and adolescent medicine has provided him the expertise and skills in long-acting reversible contraception, mental health, eating disorders, and medical care for LGBT youths. The theme of his research is fostering the health and well-being of LGBT youths by improving parent-child relationships. He is a member of the Pennsylvania Commission on LGBTQ Affairs, the first such commission in the nation. Dr. Montano is a paid columnist for Pediatric News.

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