Pregnancy Risk Among Bisexual, Lesbian, and Gay Youth: What Does Research Tell Us?

Research Facts and Findings, April 2015

A publication of the Act for Youth Center of Excellence

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by Karen Schantz

In adolescence, when sexual exploration is new, many people have both male and female sexual partners. Regardless of their identity or orientation, youth can be vulnerable to pregnancy involvement. Sexual health programs are often slightly adapted
so that abstinence and STD education will be inclusive of lesbian, gay, bisexual, and transgender (LGBT) youth. However, the pregnancy prevention needs of sexual minority youth are not always a clear priority. This article summarizes recent investigations into the pregnancy risk of LGB teens, and concludes with recommendations from researchers.

The state of research

In 1999, Saewyc and colleagues published their finding that lesbian and bisexual girls who participated in the Minnesota Adolescent Health Survey had an elevated risk of pregnancy (cited in Institute of Medicine, 2011). Since that surprising finding, a number of other studies have either confirmed a higher rate or concluded that lesbian and bisexual young women (who have had sex with males) have similar rates of pregnancy compared to heterosexual females. Most of this research has been conducted outside the United States or used samples that are not nationally representative. Only one US study examining pregnancy among LGB youth has used a nationally representative sample (Tornello, Riskind, & Patterson, 2014).

What groups have been surveyed?

Research findings

Prevalence of bisexual behaviors

To better understand the extent of same-sex behaviors in adolescence, researchers analyzed a large, nationally representative sample of youth age 15-21 who were not married or living with a partner (McCabe, Brewster, & Tillman, 2011). While only 3% of males and 6% of females in the 2002 survey described themselves as "homosexual" or "bisexual," higher numbers -- 4% of males and 11% of females -- reported that they had engaged in same-sex activity. Clearly, describing oneself as either "gay/lesbian" or "heterosexual" does not necessarily rule out bisexual behavior, especially among young women. A counter-intuitive finding of this study was that females who identified themselves as lesbian or bisexual or who reported same-sex attraction were more likely to engage in sex with males than were females who identified themselves as heterosexual.

Analysis of the 2005 and 2007 New York City Youth Risk Behavior Surveys also found that sexually active girls were more likely than boys to engage in bisexual behaviors (9% vs. 4%, respectively) (Pathela & Schillinger, 2010). Two out of three youth who had same-sex partners also had opposite-sex partners. Perhaps unexpectedly, at least two school-based studies have found that most sexually active students who reported engaging exclusively in same-sex behavior identified themselves as heterosexual (Goodenow et al., 2002; Pathela & Schillinger, 2010).

Pregnancy risk

Whether they identify as lesbian/gay or bisexual, adolescent women who have sex with men have pregnancy rates that are as high or higher than their heterosexual counterparts (Charlton et al., 2013; Saewyc, 2011; Tornello et al., 2014). At least two studies in school settings have also shown that gay and bisexual boys are more likely to be involved in a pregnancy than are heterosexual boys (Parkes et al., 2010; Saewyc et al., 2008). In the UK, one large study found that youth with same and opposite sex partners had greatly increased odds of pregnancy involvement, compared to youth who engaged solely in heterosexual sex (Parkes et al., 2010).

Risk behaviors

How do we explain these rates in a population that might be expected to have lower levels of pregnancy involvement? Studies have repeatedly demonstrated that youth who have had both male and female partners face higher risk factors for pregnancy than do teens who engage in exclusively heterosexual behaviors.

Compared to their heterosexual counterparts:

Among young sexual minority youth, higher levels of risky sexual behavior (variously defined) are associated with:

Environmental factors

Teens' decisions about sex and fertility are influenced by a host of environmental factors and relationships that may be protective or hostile. A girl who has been rejected by her family may believe that a baby will give her the love and connection she misses. A boy who is tormented by others for being gay may want a baby to disguise his sexuality. Less directly, environmental risk factors such as living in communities or families where violence, hunger, and substance abuse are the norm compound to raise the odds for adolescent pregnancy (Kirby, 2007). Over 500 risk and protective factors that influence adolescent pregnancy and sexual health have been identified by researchers (Kirby, 2007). Youth who are members of sexual minority groups experience disproportionately high levels of some of these factors.

Recommendations from Researchers

How can pregnancy disparities for LGB adolescents be addressed? Researchers have put forward a range of recommendations and calls to action, from sex education designed for specific populations to universal approaches that address the social determinants of health.

Some investigators recommend tailored sex education and services, given the unique contexts for each sexual minority group (Herrick et al., 2013; Mustanski, 2015). For example, Mustanski points to coming out to one's parents as an issue with serious implications for health and well-being -- one that could be partly addressed by well-designed interventions. He also suggests that technology-based interventions be developed that can reach LGB youth when they are exploring their sexuality, seeking partners and information online or through apps. Sex education and services that are tailored to LGB youth should include pregnancy prevention, and be culturally appropriate (Herrick et al., 2013).

Though most do not become pregnant, bisexual girls as a population bear the burden of especially high pregnancy rates, suggesting that they may benefit from interventions that take their specific needs into account (Tornello et al., 2014; Mustanski, 2015). Researchers also note that while data on bisexual health disparities are mounting, our understanding of bisexuality is poor; further research and theory development are needed to help us better support bisexual youth (Saewyc, 2011).

However valuable, tailored programs will not benefit all LGB youth, since many young people do not identify with these labels (Goodenow et al., 2002; McCabe et al., 2011). Sex education that reaches the larger population should address the development of sexual orientation and LGB health, including pregnancy risk. As Saewyc and colleagues point out, "If sexual education programs ignore LGB youth sexual health issues, [LGB youth] may conclude that the information is irrelevant to their lives, and 'tune out' important information about contraception and safer sexual practices," leaving them unprepared (2008).

Beyond sex education, some researchers call for addressing sexual health through interventions that attend to social determinants and contextual factors, such as building stronger family support or addressing school climate and connectedness (Herrick et al., 2013; Saewyc et al., 2008). LGB support groups in schools, for example, can lessen victimization and improve the environment for sexual minority youth (Coker et al., 2010). Research into the factors that help LGB youth thrive -- as most do -- could lead to interventions that promote resiliency and reduce sexual risk behaviors (Herrick et al., 2013; Mustanski, 2015; Saewyc, 2011).

Health disparities among sexual minority youth are not limited to pregnancy and sexual health, of course. Studies have linked the harassment, stigma, family rejection, and sexual and physical abuse that many LGBT youth face to a range of poor health outcomes (for summaries, see Coker et al., 2010 and Saewyc, 2011). This too may argue for a more universal, ecological approach, such as positive youth development, that improves health across many dimensions by building assets and resiliency for all youth.

In an editorial entitled "Same-Sex Attraction and Health Disparities; Do Sexual Minority Youth Really Need Something Different for Healthy Development?" (2011), Halpern contends that despite the high levels of risk seen among these youth, sorting people into sexual orientation categories may fly in the face of human experience: In its lived complexity, sexuality defies categorization. Healthy sexual development, however, is relevant to all youth. According to Halpern, youth need the same assets no matter what their sexual orientation, and "...more nuanced assessment of factors, such as the quality, timing, and meaning of sexual experiences -- rather than the biological sex of one's partner -- are the keys to understand and promote healthy sexuality." She suggests that we build assets for all youth, rather than focusing on same-sex attraction as the most essential aspect of development for youth who are LGB.

Are tailored or universal approaches more effective? We don't yet know. Fortunately, research is underway that in time will offer new insights. Pregnancy prevention among LGBT youth has become a public health priority, as evidenced by US Department of Health and Human Services efforts to identify, evaluate, and fund interventions that are relevant to and effective with sexual minority youth. Until we have a clearer picture, we can support young people by acknowledging the complexity of sexuality, and partnering with youth to create the conditions for health and well-being.