Lesbian, Gay, Bisexual,

Transgender, and Questioning Youth


 Objectives

 Identify three risk factors faced by LGBTQ youth

 Discuss the ways that homophobia contributes to

LGBTQ health outcomes

 List three elements of LGBTQ-competent health care

delivery

 Describe resources for LGBTQ youth


 What Is Healthy Sexuality?

Sexual development and growth is a

natural part of human development

Healthy sexual expression is different

than sexual risk

Same-sex sexual behavior is included in

the realm of healthy sexuality

 Why Is Training for LGBTQ
Youth-Competent Care Important?

 Youth and LGBTQ community are marginalized,

have increased health risks

 Providers rarely receive LGBTQ-specific training

 Providing LGBTQ youth-competent care is a skill

 National, statewide, and city initiatives to improve access to health

care for LGBTQ youth
 ACA may increase number of previously uninsured,
disproportionately LGBTQ and/or adolescents


 Case: Joseph

 Joseph is a 13-year-old male

who comes to the clinic
with his mother. She is
concerned that:
 Most of his friends are
girls.
 He is drawn to traditionally
feminine activities.
 She caught him wearing his
sister’s clothes.


 How Does Joseph’s Mother’s
Disclosure Make You Feel?


 Confronting Personal Biases

Understand personal biases

Provider discomfort can be

damaging

It is an ethical obligation to refer

patient for appropriate care


 Creating a Safe Space

Train all staff

Zero tolerance Assure

for insensitivity Confidentiality

Display LGBTQ-
Provide support
affirming
resources
materials

 Office Culture

• Patient Centered
• Private and/or Confidential
• Cultural Appreciation and Diversity


 Office Procedures

 Forms contain gender-neutral language

 EMR prompts

 “Parent” versus “mother/father”


What Do the Mother’s Concerns Reveal?

 Very little

 Joseph may be questioning

his sexuality and/or gender
identity but dress and other
outward appearances do not
indicate sexual orientation
or identity


 Sexual Sexual
Attraction Orientation

Paradigm of
Sexuality Sexual
Biological
Sex Behavior

Gender
Identity/
Expression

 Spectrum of
Gender and Sex
Female Male
Natal Gender/Anatomy

Female Male
Gender Identity

Feminine Masculine
Gender Expression

Heterosexual Homosexual
Sexual Orientation


 Awareness of Gender Identity

Between ages 1 and 2

Conscious of physical differences between
sexes

At 3 years old
Can label themselves as girl or boy

By age 4
Gender identity is stable
Recognize that gender is constant

 Prevalence/Stability of Gender Identity
 Data depends on definition, populations, culture
 Gender variant 1:500
 Transitioned 1:20,000

 Development considerations
 Many children 5-12 years with gender dysphoria do not
continue to suffer as adolescents
 Some identify as homosexual or bisexual
• Natal males: 63% to 100%
• Natal females: 32% to 50%


 Prepubertal Children
 Gender play

 vs

 Consistent, persistent, insistent gender nonconformity or

gender dysphoria


 Gender and Sexual Identity


Approaching Gender Identity with
Adolescent Patients

Ask: When you think of yourself as a person, do you

think of yourself as male, female, somewhere in
between, or another gender?


 Terminology: What’s in a Name?

Transgender = umbrella term for individuals & communities.

A person whose identity does not conform unambiguously to conventional
notions of male or female gender roles, but blends or moves between
them.

Gender nonconforming = individuals who do not follow other people’s

ideas or stereotypes about how they should look or act based on the female
or male sex they were assigned at birth.

Cisgender = a person whose gender identity conforms unambiguously to

conventional notions of gender, and matches their natal/biologic gender


 Transgender Umbrella

 Bi-gendered  Cross-dresser

 Gender bender  Pre/post-operative

 Two-spirit  Intersex

 Stud  Femme queen

 Gender queer  Femme boi or Femme boy


 Identities and Transition

Identities include but are not limited to:

MTF = male to female, FTM = female to male,

transgender woman transgender man

Transition 
Process and time when person goes from living as one


gender to living as another gender

 Case: Joseph
 Joseph tells you that he is not sure if he thinks of himself
as a girl or a boy.

 He feels “okay” with this but it makes him sad that his
mother is so upset with him.

 What can you do?


 Gender Interview Skills

Ask Permission: Ask Joseph if it is okay for you to

speak with his mother

Validate: Joseph’s mother’s concerns

Explain that many teens explore

Reassure: gender roles and norms

Identify Offer yourself and other

community organizations as
Resources: resources

 Key Points
 Prepubertal gender nonconformity may eventually evolve
in a variety of gender and sexual expressions

 Peripubertal gender nonconformity is more predictable and

less to change

 Gender dysphoria for DSM-5 coding (not gender identity

disorder)

 Gender care may be better served using a developmental

perspective

 Case: Sophia
 Sophia is a 16-year-old female who comes to the clinic for
a physical

 She indicates she is having sex but not using contraception

on her intake form

 How do you discuss sensitive issues

with young patients?


 Comprehensive HEEADSSSS
• Is a tool to be used to stimulate dialogue rather than a checklist
• Ask sensitive questions later in the interview
• This may be the time to ask parents to leave the room
• “I ask all my patients the following questions”
• Consider starting at 13 y/o

H: Home
HEADS model allows
E: Education/Employment patient to be validated as a
E: Eating person rather than focusing
A: Activities just on their risks
D: Drugs
S: Sexuality
S: Suicide/depression
S: Safety
S: Spirituality/Strengths*
25
 Case: Sophia

 As you begin the sexual interview,

Sophia discloses that she self-
identifies as a lesbian.


 Definitions of Sexual Attraction

Females Bisexual/Pansexual Males


 Sexual Attraction Questions
 Are you attracted to:
 Different sex
 Same sex
 Both or all sexes
 Neither
 Not sure yet

 How comfortable do you feel with this/these attractions?

 Have you told your family or friends about this/these attractions?


 Sexual Orientation Defined

Heterosexual—straight

Homosexual—gay, lesbian
Refers to an
individual’s pattern of Bisexual
physical and emotional
arousal toward other Pansexual
people
Queer

Other


 Determinants of Sexual Orientation
 Sexual orientation is not a “choice”
 Most likely determined by combination of influences:
 Genetic, hormonal, environmental
 More important to focus on
 Sexuality, relationships, intimacy is an
expected part of development
 How does patient feel about their sexuality?
 How does family or community support this aspect of
selfhood?


 Awareness of Sexual Orientation
 First awareness of homosexual attraction occurred at:
 ~9 for males
 ~10 for females
 Studies indicate many LGB youth self-identify at age ~16
 For some, internal coming-out process does not occur until
later in life


Assessing Sexual Orientation and Same-Sex Behavior
Among Teens

 Lack of nationally representative surveys assessing sexual

orientation/same-sex behaviors

 Prevalence of LGBTQ youth difficult to ascertain

 Addressed in some youth risk behavior surveys

 Not in National YRBS
 12 states and the District of Columbia include such questions
• Inconsistency in question content by state
• Inconsistency in question(s) asked each year


 Trends in Assessing LGBT Students
Number of States* Asking About Sexual Orientation Over Time, by Question

10

7
Self Reported Sexual
6
Orientation
5 Gender of Sexual
4 Partners/Contacts
Harrassment Due to Perceived
3
Sexual Orientation
2

0
1995 1997 1999 2001 2003 2005 2007 2009

 *Note: District of Columbia was counted as a state in the above

gaydata.org 2010
 Growing Up Today Study (’97-’03)

Percent of Students Reporting Sexual Orientation By Sex

Heterosexual Mostly heterosexual Bisexual Gay/Lesbian Not sure

1.5 Males Females

0.3
0.7 2003
1 0.2 2.7
N= 7,750
6
12.6

1997
N=5,700
83.5
91.3


 MN HS 1990s: Another Student Sample

Increase in
35,000 12- to 18-
homosexual
year-olds surveyed in
attraction with
Minnesota
increased age

1.1%: bisexual 2.2% age 12;

88.2%:
or 5.9% age 16;
predominantly 10.7% “unsure”
predominantly 6.4% age 18.
heterosexual
homosexual


 Case: Sophia

 Sophia self-disclosed her sexual

orientation.

 If she had not, would you approach

this topic with your patient?


Discuss Sexuality in Clinical Encounters
 Due to discrimination and fear, many LGBTQ youth have
difficulty accessing health care

 Most LGBTQ youth are “invisible” and often will not raise
issue until asked

 Asking normalizes notion that there is a range of sexual

orientations and gender identities


 Asking about Sexual Attraction

 How can you respectfully ask

about sexual orientation?
 If you had a crush on
someone, would it be a boy,
girl, neither
or both?
 Are you sexually attracted to
guys, girls, or both?
 When you think of yourself in
a relationship is it with a guy,
a girl, or both?


 Asking About Sexual Behaviors
 Need to be sensitive AND specific
 Younger kids
• Have you held hands or cuddled?
• Have you kissed or touched each other’s private parts?
• ……
 Older teens
• Have you ever had: oral sex, vaginal sex, anal sex?
• What parts went where?
• Did you put your penis in his/her vagina, butt, or mouth?
• Did you take his/her penis in your vagina, butt, or mouth?


 Avoid Assumptions
 Don’t assume:
 Patients are heterosexual
 Bisexuality is a phase
 Sexual orientation based on gender of partner
 Sexual orientation or gender identity based on appearance
 Sexual orientation or gender identity is the same as last visit
 LGBTQ patients are engaging in risky behavior
 LGBTQ patients have unsupportive families


 Barriers to Care: Medical Training
 Most medical schools neglect LGBT issues

 One study found that most medical schools devoted 5

hours or less to teaching anything more than asking, “What
is the gender of your sexual partner?”

 One-third of medical schools assigned no time at all to

LGBT topics


 Barriers to Care: Provider Attitude
 Lambda Legal survey through partner organizations, 4,916
LGB respondents, 2009
 Almost 8% of LGB and 27% of transgender and gender
nonconforming reported being denied care because of their
identity/orientation
 11% reported that providers refused to touch them or used
excessive precautions
 Transgender and gender-nonconforming respondents
reported facing discrimination and barriers to care 2-3 times
more frequently than LGB respondents

16. Lambda Legal (2010)

 Consequences of Barriers
 1 out of 2 LGBT adults withheld their sexual orientation
from a provider
 1 of 4 withheld information about sexual practices (5 times
more than heterosexual peers)

Harris Poll (2002 & 2003). Gran JM et al (2011). Krehely J (2009).

 Case: Sophia

 How do you respond to Sophia’s

disclosure?


 Patient “Coming Out”—What Next?

Assess comfort with feelings

Identify to whom (if anyone) the patient has disclosed the

information
Counsel regarding consequences of disclosure to family,
friends, etc.
Discuss ways to facilitate communication with parents


 Coming Out—LGB Youth
 Sexual minority youth are coming out at younger ages
 Human Rights Campaign
• 10,000 13- to 17-year-olds in 2012
 Awareness of same-sex attraction is age 9
 Disclosure is at age 16 years*
 Each youth has unique experience
 Time in development
 Exploration
 Risk taking
 Added support


 LGBT Teens Who Are “Out”
To close Friends

To classmates

At school 61%
To immediate family 56%
To teachers

To extended Family 25%

To doctor

To sport coaches

Within religious community

To Minister/Clergy 5%

0 10 20 30 40 50 60 70 80 90 100
 Possible Negative Outcomes
of “Coming Out”
 HEADSSS Screen for…
 Family discord and rejection
 Religious condemnation
 Runaway, homelessness
 School, peer, work problems
 Social stigma
 Isolation
 Victimization & physical violence
 Risk-taking
 Sex behaviors
 Drug use
 Depression, suicide

 LGB Prevalence (YRBS 2001–2009)

Number in
Sexual
Percentage Median Pediatric
Identity
Practice*

Heterosexual 90.3–93.6 93% 620-775

Gay/Lesbian 1.0–2.6 1.3% 9–11

Bisexual 2.9–5.2 3.7% 25–31
Unsure 1.3–4.7 2.5% 17–21
*Average pediatrician has a panel of 2,000 to 2,500 patients.
Typically, 30% are age 12 or older

 Coming Out—Transgender

Mean, Biological Biological

Patients
(Age Range) Female Male

Age of
Presentation 14.8 (4–20) 15.2 (6–20) 14.3 (4–20)

Tanner Stage 3.9 (1–5) 4.1 (1–5) 3.6 (1–5)

Total n, (%) 97 (100) 54 (55.7) 43 (44.3)



Social and Family Context
 Barriers to LBBTQ-Sensitive
Adolescent Health Care

 LGBTQ patients experience discrimination

 Many providers not comfortable treating LGBTQ youth
 Almost 8% of LGB and 27% of transgender and gender
nonconforming reported being denied care because of their
identity/orientation
 Exacerbated by barriers to general adolescent care
 Unable to use insurance, lack of insurance and/or fear of
disclosure
 Lack of access to appropriate SRH information
 Adolescents think they are invincible


Homophobia as a Barrier to Health Care

Perceived lack of confidentiality

Fear of health care provider reaction upon disclosure

Provider’s assumption of heterosexuality

Internalized shame and/or guilt


 Relationship between Homophobia/Transphobia and
Health Outcomes

Impact of
homophobia/ * Internalizing effects
transphobia of homophobia/
transphobia

Decreased
*
access to
* * *Where culturally
competent medical
competent and mental health
Poor health and
health services care can be a
psychological mitigating factor
outcomes


5. O’Hanlan, et al (1997)
Impact of Homophobia/Transphobia: Social
and Family Context

6. Maslow (1970)
 Effects of Homophobia

Decreased sense of self-worth

Self-medication and substance

Youth may internalize abuse
societal homophobia
leading to
Shame

Risk-taking behavior

Suicidality


 Substance Abuse
LGBTQ youth are more
In the last 30 days, LGBTQ
likely to have used
youth are more likely to
substances
have used:
before the age of 13:

Tobacco Tobacco
59.3% vs. 35.2% 47.9% vs. 23.4%
Alcohol Alcohol
89.4% vs. 52.8% 59.1% vs. 30.4%
Cocaine Cocaine
25.3% vs. 2.7% 17.3% vs. 1.2%


 Mental Health

2-7 times more likely to attempt suicide

~2 times as likely to report depression

Young MSM are more likely to suffer body image

dissatisfaction and disordered eating behaviors


 Homelessness

30-40% of In one study, LGB youth were 4 to 13 times

homeless youths more likely to be homeless than their
identify as LGBT heterosexual peers

Studies have reported Lifetime sexual partners

that Sexual Minority
Homeless Youth have Rates of HIV/STIs

Younger Ages of Sexual Initiation


 Intimate Partner Violence (IPV)

 A nationally representative sample found that almost one-

quarter of adolescents in same-sex relationships reported
some type of partner violence

 Transgender people experience higher rates of IPV than both

heterosexual and other LGBQ communities

 Threat of “outing” a partner is a unique form of

psychological abuse


 Safety and Victimization at School

2011 Findings from a Nationwide School Survey

In the past year,

82% report verbal
LGBT Youth reported:
harassment
(threatened)
Increased risk of
55% report electronic
bullying and
harassment
harassment due to
“cyberbullying”
sexual orientation
38% report physical
harassment
(pushed/shoved)

 Negative Effects of a
Hostile School Environment

Poorer Psychological Well-Being

(Depression and low self-esteem)

Lowered Educational Aspirations and

Academic Achievement

Absenteeism
(Missing class/school days)

 Internalizing effects of homophobia/
Impact of homophobia/ transphobia
transphobia • Stigma • (Resiliency)
• Shame • (Better coping
• Isolation strategies)
*
• Trauma/violence
• Discrimination • Stress
• Rejection • Depression
• Lack of civil rights • Anxiety
• Low self-esteem

*
Decreased access
to competent
* *
health services Poor health outcomes
• No screening
• Low compliance
• Present late in disease
• Unsafe sex
* Where culturally Poor psychological outcomes
competent medical and • Suicide • Substance use
mental health care can be a • Unsafe sex • Eating disorders
mitigating factor
 Mitigating Factors
 Effects of discrimination are mediated by available social
support, development stage of youth, and other personal
characteristics
 Family/ friend support
• Youth who experience severe family rejection are 8 times
more likely to attempt suicide
 Support in schools
• Presence of Gay-Straight Alliances, curriculum inclusive of
LGBT issues, and supportive staff in schools linked to
healthier outcomes


 Resilience of LGBTQ Youth

 Many LGBTQ teens lead

healthy, productive lives
 Resilient adaptations to
social biases and
mistreatment
 Develop and possess
remarkable strength and
self-determination


 Hope Remains
 Three-quarters (77%) of LGBT youth say they know
things will get better

 Young people are resilient

 “This is me, this is how I was born, and I’m happy with it”


 Case: Sophia Continued

 On a follow up visit for tiredness,

Sophia seems distracted

 When you ask her what is wrong, she

says she is worried that she might be
pregnant


Bisexual and Lesbian Women: Greater Risk
for Negative Health Outcomes
 Data source (2006-2010 NSFG): Self-identified bisexual,
lesbian, and heterosexual women aged 15-20

 Results for bisexual/lesbian women:

 Younger age at heterosexual debut
 More male and female sexual partners
 More likely to report forced sex by male partner

 Greatest use of EC and highest frequency of abortion

among bisexual young women


 WSW STI Risk

Nationwide, 6,935 self-identified lesbians

17.2% reported past history STI

Increased Risk
• Trichomonas
• HPV
• Bacterial vaginosis
• HIV

 CDC 2010 Guidelines for WSW
 Routine age appropriate screening guidelines
 Pap
 Chlamydia screening

 WSW may be at risk, benefit from screening

 Trichomonas
 Bacterial Vaginosis
 HSV
 HPV
 HIV


 Contraceptive Use
 Young women who identified themselves as “unsure” of
their sexual orientation are:
 Almost twice as likely to report no contraceptive use at last
sex


 Pregnancy Risk

When compared Are about as likely to have

to heterosexual had intercourse
youth, lesbians
and bisexual
females: Experience twice the rate of
pregnancy (12% vs. 6%)

19 times less likely to Are more likely to have had

perceive at themselves at risk two or more pregnancies
for STI (23.5% vs. 9.8%)

 Contraceptive Counseling
 Discuss all methods of contraception

 Introduce EC and offer an advanced prescription with

refills


 Sophia: Case Wrap Up

Ask all adolescent patients about sexual orientation

Assess patients’ feelings about disclosures

Understand that behavior does not match identity—

discuss contraception and condom use


 Case: Martin
 Michael is 16 years old at office for sports physical
 He reports exercising, not using drugs, religion as
important aspects of his role as a student and athlete
 His mom confirms he is an exemplary student and star
athlete
When you ask him about having a
girlfriend, he says he has never.

When you follow up with asking

him who he is attracted to and has
he ever had a crush or romantic
relationship, he reports: “I have
sex with guys but I am not gay.”


 Skill: Avoiding Assumptions

Many male youth do not identify as

gay but have same-sex partners

Orientation/attraction do not always =

behavior

81% of females with same-sex attraction also report having sexual

experiences with males


 Definitions of Sexual Behavior

Females Both Males

All
Neither


 Sexual Behavior Questions
 Framing the question
 Developmentally appropriate
 To counsel and advise not judge!
 There are many ways of being sexual or intimate with
another person: kissing, hugging, touching, having oral
sex, anal sex, or vaginal sex.
 Have you ever had any of these
experiences?
 Which ones?
 With males, females, or both?


 LGB Youth Sexual Behaviors


Female Sexual Activity, Same-Sex Partners
2006–2008 National Survey of Family Growth
100.00%

90.00%

80.00%

70.00%

60.00%
Any sexual experience
50.00%
**
40.00%

30.00%
Any Oral Sex
20.00%
10.30% 11.90% 9.30%
10.00% 5.40%
0.00%

15-17 years 18-19 years

**Includes oral sex and answering “yes” more generally to having had any sexual experience with
another female

Male Sexual Activity, Same-Sex Partners

2006-2008 National Survey of Family Growth

30% Any Oral or Anal Sex Any Oral Sex Any Anal Sex

25%

20%

15%

10%

5% 3.90% 3.70%
1.70% 1.30% 1.10% 1.50%
0%
15-17 years 18-19 years


 Case: Martin

 He reports having sex with a “friend”

 His friend is at a local college
 After discussing the tests that you
will run, you ask about condom use
 He reports that he uses condoms
most of the time


 Discuss Healthy Relationships
 What does a healthy relationship look like to YOU?
Is your partner
Are you ready
trustworthy
for sex? & caring?
 Who makes the decisions
about when to have sex?

 Do you use condoms or

contraceptives?

STI
prevention? Contraception?

 STI Prevention Counseling

 Cover it up!!

 Condom use
 With insertive or receptive sex
 Rectum, vagina, mouth
 Sex toys
 Do not share insertive sex toys without a condom
 Wash sex toys after each use
 Dental dam use with oral sex


 YMSM Condom Use

 27%-48% engaged in unprotected anal sex <6 months

before


 Counseling About Condom Use
 Explore why or why not
 Withhold judgment

 Respect concerns
 Listen to concerns of discomfort or sizing issues
 Offer a wide range of condoms including larger sizes and
different colors


 CDC 2010 Guidelines for MSM
 Routine laboratory screening for common STDs is
indicated for all sexually active MSM. The following
screening tests should be performed at least annually for
sexually active MSM:
 HIV
 Syphilis
 Test at anatomic sites of exposure:
 Urethral test with N. gonorrhoeae and C. trachomatis
 Rectal infection with N. gonorrhoeae and C. trachomatis
 Pharyngeal infection with N. gonorrhoeae


 Rectal/Pharyngeal
Chlamydia and Gonorrhea
• Nucleic acid based testing (NAAT) is most sensitive at
detecting both Chlamydia and Gonorrhea
• CDC recommends as first-line for testing urine,
cervical, and urethral specimens
• Not FDA approved for rectal or oropharyngeal swabs
but still recommended by CDC as first-line
• individual labs have established performance
specifications, allowing results to be used for clinical
management

GC culture on chocolate agar plate is an

acceptable alternative to NAAT; NAAT is more
 sensitive but culture allows for antibiotic
susceptibility testing
 Additional Considerations for MSM
 Consider screen or test for
 HSV type-specific serologies
 Hep A, B, C surface antibodies
 Anal trichomonas
 Don’t forget preventive vaccinations!
 Hepatitis A & B
 HPV Emerging questions?

• HPV oral
• Anal pap cancer


 Cases: Wrap-Up

Ask all adolescent patients about gender identity, sexual

orientation, specific sexual behaviors

Assess patients’ feelings, safety, support when counseling

about disclosures

Understand that biology, identity, and expression

may be diverse

Offer LGBTQ teens the same private/confidential care

for STI & pregnancy prevention, healthy relationship


support
 Review of Objectives
 Can you:

 Identify three risk factors faced by LGBTQ youth

 Discuss the ways that homophobia contributes to LGBTQ
health outcomes
 List three elements of LGBTQ competent health care
delivery
 Describe resources for LGBTQ youth


 Specialized Health Services
 Hasbro Children’s Hospital (Providence)—
www.hasbrochildrenshospital.org
 Children’s Hospital Los Angeles—http://www.chla.org
 BC Childrens Hospital (Vancouver)—www.bchildrens.ca
 Howard Brown Health Center (Chicago)—
www.howardbrown.org/hb_services.asp?id=37
 Mazzoni Center (Philadelphia)—mazzonicenter.org
 Whitman Walker Clinic (Washington, DC)—www.wwc.org
 Fenway Institute (Boston)—www.fenwayhealth.org
 Callen-Lorde Community Health Center (New York)—
www.callen-lorde.org


 Family Support Resources
 www.pflag.org—Parents and Friends of Lesbians and Gays

 familyproject.sfsu.edu—Family Acceptance Project


Provider Resources and Organizational Partners

 www.advocatesforyouth.org—Advocates for Youth

 www.aap.org—American Academy of Pediatricians

 www.aclu.org/reproductive-freedom American Civil Liberties Union

Reproductive Freedom Project

 www.acog.org—American College of Obstetricians and Gynecologists

 www.arhp.org—Association of Reproductive Health Professionals

 www.cahl.org—Center for Adolescent Health and the Law

 www.glma.org Gay and Lesbian Medical Association

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Provider Resources and Organizational Partners

 www.guttmacher.org—Guttmacher Institute

 janefondacenter.emory.edu Jane Fonda Center at Emory University

 www.msm.edu Morehouse School of Medicine

 www.prochoiceny.org/projects-campaigns/torch.shtml NARAL Pro-

Choice New York Teen Outreach Reproductive Challenge (TORCH)

 www.naspag.org North American Society of Pediatric and Adolescent

Gynecology

 www.prh.org—Physicians for Reproductive Health

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Provider Resources and Organizational Partners

 www.siecus.org—Sexuality Information and Education Council of the

United States

 www.adolescenthealth.org—Society for Adolescent Health and

Medicine

 www.plannedparenthood.org Planned Parenthood Federation of

America

 www.reproductiveaccess.org Reproductive Health Access Project

 www.spence-chapin.org Spence-Chapin Adoption Services

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Please Complete Evaluations Now