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Recommendations for physician appointments of LGBTQIA+ adolescents with chronic conditions
Pedro Henrique P. Sampaioa,
Corresponding author
, Darusa C. Souzaa, Pedro Henrique M. Mendesa, Ligia B. Queiroza, Benito Lourençoa, Marcia T. Coutob, Clovis A. Silvaa
a Adolescent Unit, Instituto da Criança e Adolescente, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
b Department of Preventive Medicine, Faculdade de Medicina, Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="para0001" class="elsevierStylePara elsevierViewall">Enhanced management of infectious diseases&#44; improvement in health-related quality of life&#44; nutrition&#44; and hygiene&#44; along with increased life expectancy&#44; are driving an epidemiological transition among adolescents&#46; This transition is marked by the increase of pediatric chronic diseases as significant health issues among youths&#46;<a class="elsevierStyleCrossRef" href="#bib0001"><span class="elsevierStyleSup">1</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0002"><span class="elsevierStyleSup">2</span></a> Numerous physical&#44; emotional&#44; and behavioral changes occur during adolescence&#44; and an additional long-term illness can delay growth&#44; puberty&#44; sexuality and the maturation of other biological systems&#46;</p><p id="para0002" class="elsevierStylePara elsevierViewall">A notable increase in knowledge regarding many chronic conditions across various pediatric specialties has been reported in recent years&#46; These advancements in children and adolescents&#8217; chronic conditions have been particularly observed in Adolescent Medicine&#44; Allergy and Immunology&#44; Cardiology&#44; Endocrinology&#44; Gastroenterology&#44; Genetics&#44; Hematology&#44; Transplantation Care&#44; Hepatology&#44; Infectious Diseases&#44; Nephrology&#44; Neurology&#44; Nutrition&#44; Oncology&#44; Orthopedics&#44; Palliative and Pain Care&#44; Pediatric Surgery&#44; Pulmonology&#44; Premature Infant Care&#44; Psychiatry&#44; Rheumatology&#44; and other fields&#46;<a class="elsevierStyleCrossRef" href="#bib0001"><span class="elsevierStyleSup">1</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0002"><span class="elsevierStyleSup">2</span></a> However&#44; when a health-threatening condition&#44; such as a chronic illness&#44; overlaps with the challenges faced by an LGBTQIA&#43; &#40;Lesbian&#44; Gay&#44; Bisexual&#44; Transgender&#44; Queer&#44; Intersex&#44; Asexual&#44; and others&#41; adolescent at this stage of life&#44; it significantly amplifies the risk and vulnerability to psychological distress&#46; This overlap also raises important questions about both mental and physical health&#44; as well as health-related quality of life&#46; Therefore&#44; it is important to recognize that LGBTQIA&#43; adolescents dealing with chronic illnesses may experience higher levels of psychological distress due to stigma and discrimination&#46; Consequently&#44; they may face additional barriers in the context of healthcare and treatment&#46;</p><p id="para0003" class="elsevierStylePara elsevierViewall">Studies of LGBTQIA&#43; adolescents and youths have shown that they may experience a higher prevalence of HIV and other sexually transmitted infections&#44; bullying&#44; physical abuse&#44; anxiety&#44; and depression&#46;<a class="elsevierStyleCrossRef" href="#bib0003"><span class="elsevierStyleSup">3</span></a> A systematic review and meta-analysis study revealed that among adolescent sexual minority males who had engaged in sexual activity within the past 6-months or were sexually active&#44; 44 &#37; reported engaging in anal intercourse without condom use&#44; 50 &#37; did not use a condom during their last sexual encounter&#44; and 32 &#37; reported using alcohol or drugs at their last sexual experience&#46;<a class="elsevierStyleCrossRef" href="#bib0004"><span class="elsevierStyleSup">4</span></a> When addressing the risk of HIV infection among adolescents and young people&#44; especially LGBTQIA&#43; individuals&#44; combined prevention strategies&#44; particularly the availability of Pre-Exposure Prophylaxis &#40;PrEP&#41;&#44; have proven to be effective preventive measures&#46; However&#44; PrEP was more commonly accessed by adolescents and young men who have sex with men&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">5</span></a> Another study focusing on adolescent and young gay and bisexual men identified substantial barriers to accessing and adhering to PrEP&#44; particularly influenced by social factors such as race and socioeconomic status&#46; Using an intersectional approach&#44; the study highlighted the significance of considering the subjective and relational experiences of young people in the development of HIV prevention strategies&#46; It emphasized the necessity for a more inclusive approach informed by PrEP users themselves to enhance the effectiveness of HIV prevention programs and overall healthcare delivery&#46;<a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a></p><p id="para0004" class="elsevierStylePara elsevierViewall">Sexual and gender minorities also reported more frequent polysubstance use than non-minorities&#46;<a class="elsevierStyleCrossRef" href="#bib0007"><span class="elsevierStyleSup">7</span></a> Furthermore&#44; transgender and gender-diverse individuals should have prompt access to healthcare services&#46; Treatments for gender transition such as gonadotropin-releasing hormone agonists and gender-affirming hormones may impact growth&#44; as well as bone&#44; cardiovascular&#44; and reproductive health&#46;<a class="elsevierStyleCrossRef" href="#bib0008"><span class="elsevierStyleSup">8</span></a> These points are also crucial to discuss and individualize the approach to address these issues for each LGBTQIA&#43; adolescent with a chronic condition&#46;</p><p id="para0005" class="elsevierStylePara elsevierViewall">Another significant finding is that only a small number of physicians providing LGBTQIA&#43; care to adolescents felt sufficiently equipped to address the needs of their sexual-minority patients due to a lack of education and resources&#46;<a class="elsevierStyleCrossRef" href="#bib0009"><span class="elsevierStyleSup">9</span></a> Moreover&#44; some LGBTQIA&#43; adolescents with chronic conditions may refrain from attending multiprofessional and multidisciplinary appointments due to concerns about facing discrimination and anticipated stigma&#46; These findings may significantly impact adolescent adherence to medications and rehabilitation programs&#44; potentially resulting in disease flares&#44; damage&#44; and complications of pediatric chronic conditions&#46;</p><p id="para0006" class="elsevierStylePara elsevierViewall">Pediatricians should have offices that are teen-friendly and welcoming to all adolescents&#44; regardless of sexual orientation and behavior&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">10</span></a> Adolescent Health and Medicine Society supports that all healthcare providers who care for adolescents should be trained to provide competent and nonjudgmental care for LGBTQIA&#43; youth&#46;<a class="elsevierStyleCrossRef" href="#bib0011"><span class="elsevierStyleSup">11</span></a> Indeed&#44; the Adolescent Unit of our university and tertiary hospital has been providing care for LGBTQIA&#43; adolescents and their families with both healthy and chronic conditions over the past several years&#44; focusing on a person-centered care approach&#46; However&#44; further qualitative and quantitative studies involving LGBTQIA&#43; teens with chronic conditions will be essential to fully understand and address their specific needs&#46;</p><p id="para0007" class="elsevierStylePara elsevierViewall">It is essential to standardize the systematization and dynamics of first and further medical appointments for LGBTQIA&#43; adolescents with chronic illnesses&#44; and the authors suggest three or two steps&#46; As outlined in <a class="elsevierStyleCrossRef" href="#tbl0001">Table 1</a>&#44; the first medical appointment for adolescents and family members with chronic illnesses should follow a structured approach consisting of three or two steps&#46; Within our group&#44; the authors recommend that the initial medical appointment be structured into three distinct steps&#46; During the first step&#44; healthcare providers should explain the dynamics of care&#44; emphasizing aspects of privacy&#44; confidentiality&#44; accessibility&#44; collaborative approach&#44; and non-discrimination language and policies&#44; and a care oriented to the adolescent&#180;s ability to make informed decisions as they grow older&#46; The second stage of the first appointment involves a session only with the adolescent&#39;s family members&#44; aiming to gather the family and youth&#39;s medical history&#46; This stage allows an opportunity for parents and caregivers to express their fears and concerns to the general or pediatric specialty physician&#44; while also creating a supportive environment for them to discuss their own experiences&#46; Finally&#44; the third step is dedicated solely to the adolescents&#44; providing them with a safe space to express themselves freely and discuss any further worries or questions they may have&#46; This includes topics such as sexual and emotional development&#44; as well as issues related to their chronic condition&#46; Further appointments for teens with an adolescent medicine specialist or another pediatric specialty physician will be divided into two steps &#40;<a class="elsevierStyleCrossRef" href="#tbl0001">Table 1</a>&#41;&#46; The physical examination and laboratory assessment of LGBTQIA&#43; adolescents with chronic illnesses are performed in the same manner as for any adolescent&#46; Importantly&#44; this also includes attention to signs and symptoms specific to each adolescent&#39;s chronic condition&#44; ensuring comprehensive and tailored healthcare delivery&#46;</p><elsevierMultimedia ident="tbl0001"></elsevierMultimedia><p id="para0008" class="elsevierStylePara elsevierViewall">Clinicians should remember that distinct racial&#47;ethnic&#44; religious&#44; and demographic groups may have stressors for LGBTQIA&#43; adolescents with chronic illnesses&#46; The experience of &#8220;coming out&#39; for LGBTQIA&#43; teens may also be discussed during the appointment&#46; It may be a constructive experience for some adolescents&#44; fostering acceptance and a sense of liberation&#46; However&#44; for others&#44; it can be harmful&#44; resulting in stigma&#44; humiliation&#44; peer rejection&#44; discrimination&#44; and ostracism&#44; which can consequently lead to significant emotional issues&#46;<a class="elsevierStyleCrossRef" href="#bib0011"><span class="elsevierStyleSup">11</span></a> Suicide and hospital admissions for suicide-related thoughts and behaviors are relevant issues for LGBTQIA&#43; adolescents&#44; particularly for those with chronic conditions&#46; Schools may also offer a unique opportunity to support suicide prevention with the promotion of positive social relationships and fostering a safe and inclusive community environment&#46;<a class="elsevierStyleCrossRef" href="#bib0012"><span class="elsevierStyleSup">12</span></a></p><p id="para0009" class="elsevierStylePara elsevierViewall">In conclusion&#44; it is vital to prioritize awareness and comprehension of the distinctive and specific requirements of LGBTQIA&#43; teens with chronic conditions&#46; Nonjudgmental multiprofessional and multidisciplinary clinics&#44; characterized by effective communication skills and devoid of biases&#44; along with emotional care&#44; support groups&#44; and community resources&#44; are mandatory for delivering high-quality care to this population&#46;</p></span>"
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top"><span class="elsevierStyleBold">Second step&#58;</span> Only adolescent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0023"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="top"><span class="elsevierStyleBold">Medical confidentiality&#44; privacy&#44; accessibility&#44; collaborative approach&#44; and non-discrimination policies</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0024"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">These points are explained in detail during the first step of the initial appointment and are reiterated whenever questioned to ensure clarity&#46; A nonjudgmental healthcare environment and effective communication skills are essential&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0025"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="top"><span class="elsevierStyleBold">Establishing a connection between physician and adolescent</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0026"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Establishing a safe and non-judgmental space is crucial&#46; The discussion should occur in a confidential environment where teens feel secure and respected&#46; Empathy&#44; respect for autonomy and open communication without judgment are encouraged in all appointments&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0027"></a><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="4" align="left" valign="top"><span class="elsevierStyleBold">Inquiring about family data and dynamics</span></td><a name="en0028"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Where is your place of residence&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0030"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Who shares the household space with you&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0032"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Is the environment characterized by peacefulness or conflicts&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0034"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">How do interpersonal relationships function in your home&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0035"></a><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="5" align="left" valign="top"><span class="elsevierStyleBold">Inquiring about school and social impact</span></td><a name="en0036"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Do you feel safe at school and in your neighborhood&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0038"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Have you experienced bullying&#44; physical aggression&#44; or verbal threats&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0040"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Do you have a group of friends&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0042"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Do you ever feel lonely or without friends&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0044"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Do you experience any difficulties with learning or academic performance&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0045"></a><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="5" align="left" valign="top"><span class="elsevierStyleBold">Inquiring about dietary habits and body image issues</span></td><a name="en0046"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Have you ever tried any type of dietary regimen&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0048"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Have you experimented with restrictive diets or prolonged fasting&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0050"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Do you experience episodes of binge eating&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0052"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Are you satisfied with your physical appearance&#47;body&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0054"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Do you feel comfortable with your current weight and height&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0055"></a><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="6" align="left" valign="top"><span class="elsevierStyleBold">Inquiring about drug and psychoactive substance use</span></td><a name="en0056"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">To assess the risk and vulnerability related to legal substances such as alcohol&#44; tobacco&#44; e-cigarettes&#44; hookah&#44; as well as illegal substances&#58;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0058"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Do you consume alcoholic beverages&#63; If yes&#44; how often&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0060"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">When was the last time you drank excessively&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0062"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Where do you usually consume alcohol&#63; &#40;e&#46;g&#46;&#44; at home&#44; in bars&#44; at parties&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0064"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Do your friends often engage in heavy drinking&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0066"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Does anyone in your home consume alcoholic beverages&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0067"></a><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="10" align="left" valign="top"><span class="elsevierStyleBold">Inquiring about sexual behaviors&#44; gender identity&#44; sexual orientation&#44; reproductive health&#44; incidence of unplanned pregnancies&#44; and Sexually Transmitted Infections &#40;STIs&#41;</span></td><a name="en0068"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Are you currently involved in a romantic relationship&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0070"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Do you feel in love with anyone now&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0072"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Are you engaging in physical intimacies with anyone&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0074"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Have you had sexual experiences with individuals of the opposite sex&#44; the same sex&#44; or do you have no specific preference&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0076"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Have you ever had any reproductive health concerns or issues&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0078"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Have you experienced any unplanned pregnancies&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0080"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Have you ever been tested for HIV and other Sexually Transmitted Infections &#40;STIs&#41;&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0082"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Have you ever been diagnosed with an STI&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0084"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Are you currently using any methods of contraception&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0086"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Would you typically use daily HIV Pre-Exposure Prophylaxis &#40;PrEP&#41; or post-exposure prophylaxis to prevent HIV when engaging in sexual activities without a condom&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0087"></a><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="7" align="left" valign="top"><span class="elsevierStyleBold">Inquiring about mental health</span></td><a name="en0088"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">How do you typically cope with feelings of sadness or distress&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0090"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Do you prefer to be alone in silence when you&#39;re feeling sad&#44; or do you seek comfort from others&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0092"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Do you find yourself crying often when you&#39;re feeling down&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0094"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Have you ever experienced thoughts of wanting to disappear or hurt yourself&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0096"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Have you ever attempted to hurt yourself before&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0098"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">In the past two weeks&#44; have you felt little interest or pleasure in doing activities that you usually enjoy&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0100"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Have you felt consistently down&#44; depressed&#44; or hopeless recently&#63; If so&#44; how often&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0101"></a><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="6" align="left" valign="top"><span class="elsevierStyleBold">Inquiring about drugs&#44; vaccination&#44; and other treatment adherence</span></td><a name="en0102"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Where and how do you usually take your prescribed drugs and treatments&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0104"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Do you have assistance from anyone in managing your drugs and treatments&#63; If so&#44; who helps you&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0106"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Is there any supervision or oversight involved in your medication regimen&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0108"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">How does the responsibility for managing your medications and treatments feel for you&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0110"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">How do you perceive yourself in the role of being ill versus not ill&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0112"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Has your vaccination card been updated&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0113"></a><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="5" align="left" valign="top"><span class="elsevierStyleBold">Inquiring about psychology or psychiatric support</span></td><a name="en0114"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Are you currently receiving psychological or psychiatric support&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0116"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">If yes&#44; how long have you been receiving therapy&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0118"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Was your therapy individual or group-based&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0120"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Do you know which approach your therapy aligns with&#63; &#40;e&#46;g&#46;&#44; cognitive-behavioral therapy&#44; psychoanalysis&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0122"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Do you feel you have a good rapport with your psychologist or psychiatrist&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0123"></a><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="4" align="left" valign="top"><span class="elsevierStyleBold">Inquiring about spirituality and religion</span></td><a name="en0124"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Do you practice any religion or attend religious services&#63; If yes&#44; how often&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0126"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">What are your beliefs regarding spirituality or religion&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0128"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Do you engage in practices such as prayer or meditation&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0130"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Have you ever experienced existential conflicts or concerns about death&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0131"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="top"><span class="elsevierStyleBold">Violence</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0132"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Physical and sexual violence are issues common among adolescents and pose a significant risk to their safety and well-being&#46; When it comes to gender and sexual orientation-related violence&#44; interventions for violence prevention need to be increased to actively address factors linked to violence during adolescence&#46; Approaching this problem with sensitivity is important&#44; as a suffering teenager may find it difficult to initiate a conversation about such a sensitive issue&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spara001" class="elsevierStyleSimplePara elsevierViewall">Recommendations for physician appointment of LGBTQIA&#43; &#40;Lesbian&#44; Gay&#44; Bisexual&#44; Transgender&#44; Queer&#44; Intersex&#44; Asexual&#44; and Others&#41; adolescent with chronic conditions&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "cebibsec1"
          "bibliografiaReferencia" => array:12 [
            0 => array:3 [
              "identificador" => "bib0001"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Complexity of pediatric chronic disease&#58; cross-sectional study with 16&#44;237 patients followed by multiple medical specialties"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "CGB Passone"
                            1 => "SJ Grisi"
                            2 => "SC Farhat"
                            3 => "TD Manna"
                            4 => "AC Pastorino"
                            5 => "RA Alveno"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:3 [
                        "tituloSerie" => "Rev Paul Pediatr"
                        "fecha" => "2019"
                        "volumen" => "38"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0002"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pediatric chronic patients at outpatient clinics&#58; a study in a latin american university hospital"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "RA Alveno"
                            1 => "CV Miranda"
                            2 => "CG Passone"
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Original language: English
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos