Table 6.

Recommendations for Practitioners

For all adolescent girls

Start with a clear privacy and confidentiality policy. Tell parent/guardian it is important to speak with adolescents individually. Tell the adolescent what kinds of information will be kept confidential (e.g., sexual orientation, sexual activity), and what kinds of information will need to be disclosed (i.e., consider state and local laws).

Use a positive, open, and welcoming approach for discussing sexual behavior. Use language that normalizes both having sex and not having sex. “Many adolescent girls choose to have sex and many choose not to. Both of these choices can be positive, if a person feels good and is getting good healthcare. Can I tell you more about the sexual health resources available here?”

Make contraception available to girls who want it, without shaming or judgment.

Discuss HIV. Normalize HIV/STI testing by telling girls that it is recommended for anyone who is sexually active, regardless of partner gender.

Ask questions regarding sexual attraction, behavior, and identity. For example:

“What have you noticed about your sexual attraction, if anything? Do you experience sexual attraction to men, women, or both?”

“When I ask about sexual activity that includes any gender partner. Have you been sexually involved with men, women, or both?”

“How do you identify your sexual orientation right now, if at all?” (Some may be in a process of questioning, or they may choose no label.)

Do not assume that attraction, behavior, and identity will be consistent with each other. Allow for these answers to change over time.

Provide counseling in risk management. The highest HIV/STI risks are in penile–vaginal and penile–anal sex. Acknowledge HSV and HPV risks in any genital contact, and offer to discuss risk management strategies relevant to sex between women.

For bisexual adolescent girls

Offer support for communicating with parents/guardians: “Have you talked to your parent/guardian about your sexual orientation?”

If so: “How did they respond?”

If not: “Do you want to? Do you have any concerns?”

For everyone: “Would you like resources or support for talking to your parent/guardian about your sexual orientation?”

Discuss condom use on penises and sex toys. Explain options for risk management during sex between women: “While many choose not to use gloves or dental dams, others find these to be useful methods for reducing concern about HPV and HSV.”

Ask where else they are getting their sexual health information (e.g., school, Internet) and whether it is LGBT inclusive.

Note the potential for bisexual invisibility and bisexual stigma to influence girls' personal relationships, mental health, and choices around whether and when to be open about their sexual orientation.