Transcript Lesbian, Gay, Bisexual, Transgender, and Questioning Youth

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
for insensitivity
Provide support
resources

Assure
Confidentiality
Display LGBTQaffirming
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
Attraction
Biological
Sex
Sexual
Orientation
Paradigm of
Sexuality
Gender
Identity/
Expression

Sexual
Behavior
Spectrum of
Gender and Sex
Female
Natal
Gender/Anatomy
Female
Male
Male
Gender Identity
Masculine
Feminine
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,
transgender woman
FTM = female to male,
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:
Validate:
Ask Joseph if it is okay for you
to speak with his mother
Joseph’s mother’s concerns
Reassure:
Explain that many teens explore
gender roles and norms
Identify
Resources:
Offer yourself and other
community organizations as
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 HEADS model allows
H: Home
E: Education/Employment
E: Eating
A: Activities
D: Drugs
S: Sexuality
S: Suicide/depression
S: Safety
S: Spirituality/Strengths*
patient to be validated as
a person rather than
focusing just on their
risks
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 physical and
emotional arousal
toward other people
Bisexual
Pansexual
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 SameSex 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
9
8
7
Self Reported Sexual
Orientation
6
5
Gender of Sexual
Partners/Contacts
4
Harrassment Due to Perceived
Sexual Orientation
3
2
1
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
Mostly heterosexual
Heterosexual
1.5
1
Gay/Lesbian
Bisexual
Males
0.2
2.7
6
0.7
Females
Not sure
0.3
2003
N= 7,750
12.6
1997
N=5,700
91.3

83.5
MN HS 1990s: Another Student
Sample
35,000 12- to 18year-olds surveyed
in Minnesota
88.2%:
predominantly
heterosexual

1.1%:
bisexual or
predominantl
y homosexual
10.7% “unsure”
Increase in
homosexual
attraction with
increased age
2.2% age 12;
5.9% age 16;
6.4% age 18.
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”
61%
56%
25%
5%

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)
Sexual
Identity
Percentage
Median
Number in
Pediatric
Practice*
Heterosexu
al
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,
(Age
Range)
Biological
Female
Biological
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)
Patients


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/
transphobia
Decreased
access to
competent
health
services
Internalizing effects
of homophobia/
transphobia
*
*
*
*
Poor health and
psychological
outcomes
*Where culturally
competent medical
and mental health
care can be a
mitigating factor

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
Youth may internalize
societal homophobia
leading to
Self-medication and substance
abuse
Shame
Risk-taking behavior
Suicidality

Substance Abuse
Tobacco
59.3% vs. 35.2%
LGBTQ youth are more
likely to have used
substances
before the age of 13:
Tobacco
47.9% vs. 23.4%
Alcohol
89.4% vs. 52.8%
Alcohol
59.1% vs. 30.4%
Cocaine
25.3% vs. 2.7%
Cocaine
17.3% vs. 1.2%
In the last 30 days,
LGBTQ youth are more
likely to have used:

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
homeless youths
identify as LGBT
Studies have reported
that Sexual Minority
Homeless Youth have
In one study, LGB youth were 4 to 13
times more likely to be homeless than
their heterosexual peers
Lifetime sexual partners
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,
LGBT Youth reported:
Increased risk of
bullying and
harassment due to
sexual orientation
82% report verbal
harassment
(threatened)
55% report electronic
harassment
“cyberbullying”
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/
transphobia
Impact of homophobia/
transphobia
• Trauma/violence
• Discrimination
• Rejection
• Lack of civil rights
Decreased
access to
competent
health services
* Where culturally
competent medical and
mental health care can
be a mitigating factor
*
*
• Stigma
• Shame
• Isolation
• Stress
• Depression
• Anxiety
• Low selfesteem
*
• (Resiliency)
• (Better
coping
strategies)
*
Poor health outcomes
• No screening
• Low compliance
• Present late in disease
• Unsafe sex
Poor psychological outcomes
• Suicide
• Unsafe sex
• Substance use
• Eating disorders
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 1520
 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 to
heterosexual
youth, lesbians
and bisexual
females:
19 times less likely to
perceive at themselves at
risk for STI

Are about as likely to have
had intercourse
Experience twice the rate
of pregnancy (12% vs. 6%)
Are more likely to have had
two or more pregnancies
(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
All
Neither
Males
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
**
Any Oral Sex
50.00%
40.00%
30.00%
20.00%
10.30%
10.00%
5.40%
11.90% 9.30%
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
Any Oral or Anal Sex
30%
Any Oral Sex
Any Anal Sex
25%
20%
15%
10%
5%
1.70% 1.30% 1.10%
3.90% 3.70%
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?
 Who makes the decisions
about when to have sex?
Are you
ready for
sex?
Is your partner
trustworthy
& caring?
 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

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

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

Please Complete Evaluations Now
