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Transgender Youths’ Sexual Health and Education: A Qualitative Analysis

Published:October 03, 2021DOI:https://doi.org/10.1016/j.jpag.2021.09.011

      Abstract

      Study Objective

      To characterize transgender adolescents’ sexual behaviors, identities, and their perceived experiences with sex education.

      Design

      Semi-structured interviews were conducted and addressed sexual experiences and perceptions of sex education received from family, school educators, and healthcare providers. Interviews were audio recorded, transcribed, and analyzed utilizing NVivo 12 software for thematic analysis.

      Setting

      Child and adolescent gender services clinic at a Midwestern university-based medical center in the United States.

      Participants

      30 transgender adolescents between the ages of 15 to 20.

      Interventions and Main Outcome Measures

      Themes generated during semi-structured interviews.

      Results

      Sexual orientations were inclusive of attractions to a spectrum of gender identities. Libido was perceived to be impacted by gender-affirming hormone therapy, which was unanticipated for some adolescents. Family and school-based sex education was perceived to be relevant only for heterosexual and cisgender adolescents. Inclusive education for transgender adolescents was desired. Counseling provided by gender-affirming providers on sexual health was trusted and other healthcare providers were perceived to lack training on gender-inclusive care.

      Conclusion

      This study demonstrated that families and school educators did not provide sex education perceived to be applicable to transgender adolescents. Similarly, healthcare providers of transgender adolescents were perceived to not provide inclusive or comprehensive medical care in comparison to physicians who routinely provide gender-affirming care. Gaps in education and healthcare could be improved with sex education outreach or training for families and school educators as well as the development and implementation of professional competencies for pediatricians on transgender adolescent healthcare.

      Keywords

      Introduction

      Only 29% of adolescents 12 to 15 years old communicate with their family about sex in comparison to 54% who discuss sex with dating partners.
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      Early adolescents disclose more to their friends than to their parents about many sex-related topics, but more frequent communication with parents is associated with a higher likelihood of discussing sexual issues with romantic partners.
      • Widman L
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      Sexual communication between early adolescents and their dating partners, parents, and best friends.
      Youth who engage in more frequent and comfortable sexual communication with dating partners are more likely to delay sexual debut and use condoms consistently with sexual activity.
      • Widman L
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      Sexual communication between early adolescents and their dating partners, parents, and best friends.
      Sex education can be received from many resources and is broadly defined as age-appropriate, culturally relevant, and scientifically accurate information on sex and relationships.
      • Leung H
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      Development of Contextually-relevant Sexuality Education: Lessons from a Comprehensive Review of Adolescent Sexuality Education Across Cultures.
      In the United States school sex education is state mandated with autonomy given to school districts and boards regarding specific curricula.
      • Leung H
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      Development of Contextually-relevant Sexuality Education: Lessons from a Comprehensive Review of Adolescent Sexuality Education Across Cultures.
      Only 17 states require sex education to be medically accurate: in the location of our study, HIV education, not comprehensive sex education, is mandated, but not required to be medically accurate.

      Guttmacher Institute: Sex and HIV Education. State Laws and Policies. https://www.guttmacher.org/state-policy/explore/sex-and-hiv-education. Updated 2021 May 1. Accessed 2021 May 10.

      In contrast, individual parental attitudes toward sexual activity and sex education may be influenced by cultural or religious beliefs.
      • Kar SK
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      Understanding normal development of adolescent sexuality: A bumpy ride.
      Sex health counseling from healthcare providers can complement sex education received from other resources. However, only 1 out of 3 adolescent patients receive sex education during health maintenance visits with their pediatrician or family physician, and this conversation lasts on average less than 40 seconds.
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      Sexual orientation or identity can be defined as an attraction to the same gender (lesbian, gay, or homosexual), an attraction to the opposite gender (straight or heterosexual), an attraction to multiple genders along the spectrum of gender identity (bisexual or pansexual), or the absence of sexual attraction (asexual).
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      Pansexuality is defined as an attraction to a range of genders, in contrast to bisexuality which can reflect an attraction to only men and women; however, literature demonstrates that people who identify as bisexual view it as an “umbrella term” that can encompass attractions to binary or nonbinary identities similar to pansexuality.
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      A population-based study of sexual orientation identity and gender differences in adult health.
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      Lesbian, Gay, Bisexual, and Transgender Health: Findings and Concerns.
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      Sexual orientation in the 2013 National Health Interview Survey: A quality assessment.
      Institute of Medicine
      The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding.
      Youth Risk Behavior Surveillance (YRBS) survey found nationwide 8.7% of youth in 9th through 12th grade identified as bisexual.

      Centers for Disease Control and Prevention. 2019 Youth Risk Behavior Survey Data. Available at: www.cdc.gov/yrbs. Accessed on September 20, 2021.

      Transgender and non-binary (TGNB) are terms used to describe people whose gender identity does not match their assigned biologic sex at birth and can include identities not defined within a binary classification of gender.
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      Psychological and medical care of gender nonconforming youth.
      Gender identities exist on a continuum and do not only consist of those who medically and legally transition to a different gender.
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      Factors Associated with Health Care Discrimination Experiences among a National Sample of Female-to-Male Transgender Individuals.
      Western cultural and social attitudes emphasize a dichotomous model of gender that may not be adequately inclusive of TGNB adolescents’ gender identities.
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      There is a growing body of literature documenting TGNB adolescents’ sexual activity, pregnancy, and sexually transmitted infection (STI) rates. A study of transgender youth 12 to 29 years old seen at an urban community health center in the United States found that 87.3% were sexually active and nearly half engaged in unprotected anal or vaginal sex.
      • Reisner SL
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      Laboratory-confirmed HIV and sexually transmitted infection seropositivity and risk behavior among sexually active transgender patients at an adolescent and young adult urban community health center.
      Canadian transgender youth 14 to 25 years old had a 5% pregnancy rate, which was comparable to population-based estimates for cisgender heterosexual teens.
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      Some studies report fewer sexual experiences for TGNB youth while others cite more frequent sexual experiences, less barrier protection, and more referrals for STI and HIV testing for TGNB youth in comparison to cisgender counterparts.
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      Gender and sexual orientation minorities are commonly analyzed in research as a single entity described as lesbian, gay, bisexual, transgender and queer (LGBTQ).
      • Magee JC
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      Families’ lack of understanding about LGBTQ youth sexuality is a main barrier to communication with their sexual and gender minority children about sex.
      • Newcomb ME
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      Similarly, clinician perception of their knowledge of TGNB health is that they lack of LGBTQ cultural competency and have insufficient training related to LGBTQ youth sexual health, which they attribute to lack of institutional support for providing these services.
      • Knight RE
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      Examining clinicians' experiences providing sexual health services for LGBTQ youth: considering social and structural determinants of health in clinical practice.
      One qualitative research study characterized the sex health education received by transgender adolescents and recommended content for more comprehensive, inclusive sex education curricula specifically for gender minorities.
      • Haley SG
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      • Kantor AZ
      • et al.
      Sex Education for Transgender and Non-Binary Youth: Previous Experiences and Recommended Content.
      The objectives of this study were to better understand 1) how TGNB youth define “sex;” 2) where they receive sex education and its relevance for their lived sexual experiences; 3) how TGNB youth perceive their own sexual identities; and 4) their perception of the impact of gender-affirming hormone therapy (GAHT) on sexual experiences. This study will add to existing qualitative research on TGNB youths’ sexual practices, their use of barrier protection and contraception, their understanding of STI testing, and their experienced barriers to healthcare.

      Materials and Methods

      Sample and recruitment

      This research was part of a larger qualitative study on sexual and romantic relationships and associated behaviors of transgender adolescents.
      • Araya A
      • Selkie E
      • Shumer D
      • et al.
      Romantic Relationships in Transgender Adolescents: a Qualitative Study.
      Participants were recruited by convenience sampling from a pediatric gender services clinic in a Midwestern university-based medical center. Inclusion criteria included fluency in English, age equal to or greater than 15 years, and gender nonconforming, transmasculine or transfeminine gender identity. Medical transitioning with GAHT was not a requirement of inclusion. Eligible participants and their families were contacted by telephone to assess potential interest in study participation. If interested, written parental consent and adolescent assent (or adolescent consent for participants age 18 and over) were obtained at the time of the next gender services clinic appointment. 30 participants were recruited with sampling of approximately 60:40 transmasculine and transfeminine individuals, which is reflective of the clinic's patient population. 30 participants were selected as point of data saturation that would allow for further subgroup analysis.
      • Conrad C
      Research Design in Qualitative/Quantitative/Mixed Methods. In: The SAGE Handbook for Research in Education: Pursuing Ideas as the Keystone of Exemplary Inquiry.
      This study was approved by the University of Michigan Health System Institutional Review Board.

      Interview process

      Prior to participation in semi-structured interviews, a short paper demographic survey was completed. Interviews were conducted confidentially with participants and by a trained physician interviewer (A.A.) who had experience in gender services care but was not directly involved in participants’ care. Interviews were audio recorded and transcribed by the interviewer after completion. Participants received $30 independent of interview completion.
      Interview questions were developed and reviewed with clinicians, nursing, and social work staff at the gender services clinic. Interview structure began with general questions about gender and sexual identities, social and medical transitioning, and then progressed to specific questions on sexual health, experiences, and education.

      Data coding and analysis

      NVivo qualitative analysis software was utilized to enable transcription and data analysis in an iterative and nonlinear fashion. Inductive coding led to conceptual reduction of data into descriptive themes and subcategories with the gradual development of a matrix of codes and themes through an iterative process. Quantitative analysis with specific measures or counts were not reported in order to describe phenomena and relate all themes.

      Results

      Participants

      18 transmasculine and 12 transfeminine participants 15 to 20 years old (average of 17 years and 6 months) were interviewed. 2 participants were not receiving GAHT at the time of interview. With regards to ethnicity and race, 21 participants were non-Hispanic White, 5 were Hispanic white, and 4 were American Indian or Asian American (Table 1). Socio-economic status was self-described on a Likert-type scale of “how well off” the participants’ families were (Table 1).
      • Currie C
      • Griebler R
      • Inchley J
      Health Behaviour in School-aged Children (HBSC) study protocol: background, methodology and mandatory items for the 2009/10 survey.
      • Currie C
      • Samdal O
      • Boyce W
      Health Behavior in School-Aged Children: a World Health Organization Cross-National Study: Research Protocol for the 2001/02 Survey.
      Reported sexual orientation varied and included heterosexual, homosexual, bisexual, pansexual, and asexual identities. 23 of the participants reported a history of sexual activity and of these the age of sexual debut ranged from 14 to 18 years old. Number of lifetime sexual partners ranged from 0 to 15. 12 participants were in a romantic and/or sexual relationship at the time of interview with the remainder being single.
      Table 1Demographics (N = 30)
      Age, year, average17.6
      Race n (%)
       White26 (86.7)
       American Indian1 (3.3)
       Asian American3 (10.0)
      Ethnicity, n (%)
       Hispanic or Latino5 (16.7)
       Not Hispanic23 (76.7)
       Mixed Heritage2 (6.7)
      Gender Identity, n (%)
       Masculine18 (60)
       Feminine12 (40)
      How well off, n (%)
       Not at all1 (3.3)
       Not really4 (13.3)
       A little bit9 (30.0)
       Pretty well off13 (43.3)
       Very well off3 (10.0)
      Analysis revealed seven main themes: 1) definitions of sex; 2) perceived impact of GAHT on sexual attraction, identity, and orientation; 3) perceived impact of GAHT on libido; 4) family discussions about sex; 5) sex education topics; 6) barrier protection and STI screening; and 7) clinician sex health counseling.

      Definitions of sex -

      Sex was defined by participants with regard to purpose, physical act(s), and/or consent. Purpose for sex ranged from desire to experience physical intimacy, sexual pleasure, orgasm, emotional intimacy, romantic or spiritual connection with a partner. Physical acts that were considered “sex” included penetrative sex (oral, vaginal, or anal) or any contact with or stimulation of genitalia (Table 2 Section A). Consent was also reported as a defining aspect of sex (Table 2 Section A). Two participants had difficulty defining sex in that they were “not that acquainted” and never “gotten that far with anybody.” Others who did not report a specific definition of sex considered it to be individualized and different for each person (Table 2 Section B).
      Table 2Themes on sex concepts and attraction
      ThemesQuotes
      Section A: Contact and consent as defining aspects of sexPleasurable physical intimacy. It doesn't have to be, I'm trying to think of the word for it, it doesn't have to be traditional, air quotes, sex-penis in vagina. It doesn't have to be that, it can be touches anywhere on the body, in erogenous zones. So long as it is pleasurable in some way. – transfeminine 19-year-old

      Yeah, I mean, contact with other people's genitals I guess, in any way shape or form that is intentional and like consensual. – transmasculine 17-year-old

      I guess it's like 2 people that consent to having a really good time and hopefully an orgasm at the end. – transmasculine 17-year-old
      Section B: Individualized definition of sexI think it's up to whoever is engaging in it to define how they feel about that in their own relationships and I don't think that sex is necessarily any, it doesn't have to be one way, typical penetration or anything like that. It's really up to whatever party is involved, how they define it for themselves. – transmasculine 17-year-old

      Whereas when you put different sexualities and gender identities into the mix then it's not so black and white and it's not as comfortable. Um, I consider sex to be any activity you engage with somebody else for… with the intent of orgasm or sexual pleasure. – transfeminine 19-year-old
      Section C: Opposite-gender attractionYeah, interest in women remained. I'm much more fluid and loose about sexuality since I really started to socially live my life as like a man and sort of present that way. My sexuality is probably 95% women and 5% men. – transmasculine 19-year-old

      I say men and women, but I don't know if I would actually have sex with a girl. I'd say I'm physically attracted to men and women, but I don't think I would have sex with a girl. – transfeminine 19-year-old
      Section D: Same-gender attractionI guess it kind of clicked towards the end, that I don't have any romantic attraction to her whatsoever, or any female in general. – transmasculine 18-year-old

      I'd say around when I knew I wanted to identify as male I knew I was gay. – transmasculine 16-year-old
      Section E: Other attraction or attraction regardless of genderI don't really care to be honest with you. I know there's labels for it but eh. If I like it, I'll date it. – transfeminine 19-year-old

      Probably bisexual. Like I am attracted to men and women, but there's no strict line basically. If I were to meet someone under the non-binary category I wouldn't be like, no I'm only attracted to men and women. – transmasculine 18-year-old
      Section F: Perceived impact of GAHT on attraction and identityI do notice that before starting testosterone, I was more attracted to girls and since, you know, I don't know if its correlation or causation or whatever, that has definitely shifted to guys. – transmasculine 17-year-old

      I don't know it kind of just happened. I feel like the estrogen may have had something to do with it. I feel like what attracted me to someone became more masculine features. I've always been attracted to more masculine features in the first place but it became heightened when I got to be treated the way that I felt by those same people. - transfeminine 20-year-old

      I heard some people they're like, after testosterone, I liked some gender, yeah that didn't happen with me, I feel like I've been pretty much the same. – transmasculine 19-year-old
      Section G: Increase in libido with GAHTDefinitely side effects I wasn't expecting was a super high sex drive now when I had virtually no sex drive before taking testosterone. – transmasculine 17-year-old

      Not really, nothing really came as a surprise, Like I have a couple close friends that are on testosterone, so I got to see what they were going through and I always did my own research at home about it to kind of see what to expect. There wasn't really anything I wasn't expecting. – transmasculine 18-year-old

      Before I started [gender clinic doctor] gave me a packet that detailed all the side effects. One that I definitely didn't expect, but then I asked other people, other transguys, they were like yeah, that's pretty common. Is like increased libido and everything that which was pretty unexpected, but whatever. – transmasculine 17-year-old
      Section H: Decrease in libido with GAHTI stopped having really large sexual urges… Kind of like when you start testosterone, your sex drive goes from here to here and it goes all over the place. Then after being on it for almost a year now, it's just slowed down and halted. – transmasculine 17-year-old

      Definitely don't have as much of a sex drive, I guess… Whenever I do, it's usually exclusively in sexual situations. That's a thing. It's definitely being slowly declining throughout the few months. – transfeminine 17-year-old
      Section I: No change in libido with GAHTSurprisingly it hasn't. I've been on it for a [specific duration greater than a year], surprisingly not at all. – transfeminine 19-year-old
      Section J: Impact of change in libidoUm, getting an erection, no. Happens just as easily but less often as [sic] it did. That's actually another, another beneficial side effect that I didn't think of initially, is I don't feel as driven by sex anymore, or by sexual impulses. – transfeminine 17-year-old

      I guess there's a heightened sex drive when it comes to testosterone, but it's not something I'm really consumed over. It's nothing that I want to be with someone for this specific reason. I guess it's not something that I think about a whole lot. – transmasculine 18-year-old

      My libido has increased and I've been seeking out more sexual relationships, but not to the point where it's gotten me in trouble or anything. – transmasculine 16-year-old

      Perceived impact of GAHT on sexual attraction, identity, and orientation-

      A small number of participants identified as heterosexual or attracted to the opposite gender of their affirmed gender (Table 2 Section C). Of these, many identified along spectrums of same and opposite gender attraction. A majority identified as homosexual, bisexual, or pansexual while others did not label themselves specifically but described attraction to people of all genders or regardless of gender (Table 2 Section D and E). Sexual identities or attractions changed prior to and after social and/or medical gender-affirmation. Some participants who experienced change in sexual attraction after transitioning attributed this to GAHT (Table 2 Section F).

      Perceived impact of GAHT on libido -

      Most transmasculine participants reported increased libido with testosterone therapy, which was anticipated due to personal research prior to starting GAHT (Table 2 Section G). Few participants experienced diminished libido and one came to identify as asexual since they were “really not that sexual a person” (Table 2 Section H). Increase in libido did result in a few participants seeking more sexual encounters (Table 2 Section J).
      Decreased to absent libido in transfeminine participants receiving estrogen for GAHT was largely described (Table 2 Section H). Few transfeminine participants reported no change in libido with GAHT (Table 2 Section I). Additional changes to sexual function with estrogen therapy included decrease in frequency of erections and/or difficulty achieving orgasm, but these changes did not occur in the majority. Diminution of libido was not desired by some but was a positive side effect for other participants (Table 2 Section J).

      Family discussions about sex -

      Sex was not consistently discussed between participants and their families (Table 3). Members of participants' families who initiated these discussions were mothers, fathers, grandmothers, and grandfathers. A subset reported that their families offered to discuss concerns about sexual health with them, but ultimately did not engage in explicit sex education. When discussions about sex did occur, they were perceived to be superficial and not constructive (Table 4 Section K). Those participants who did not receive guidance or advice from within the household described many perceived limitations for this.
      Table 3Family Discussion of Sex
      Family did explicitly discuss sex, n (%)19 (63.3)
      Family did not explicitly discuss sex, n (%)10 (33.3)
      Family discussion about sex not reported, n (%)1 (3.33)
      Table 4Themes on sex education and conversations
      ThemesQuotes
      Section K: Ineffective family educationI've confronted my mother through texts. And she was like “oh yeah, you're fine, use protection or whatever.” – transfeminine 17-year-old

      I never heard my parents mention anything about [sex]. I think they just kind of, they have like expectations that we all just know. – transfeminine 18-year-old
      Section L: Education limited by poor family communicationYeah, my mom thinks it's hilarious. She'll just say really dumb stuff to embarrass us sometimes. She's 100%, she would sit down in front of everyone with a megaphone and do it. – transfeminine 17-year-old

      They never ended up [talking about sex]. That is neither here, nor there for me, because I didn't expect them to, I guess. They are very closed off, so to speak. They don't talk about things. They don't talk about emotions and things like that very often. We don't have very in-depth conversations about like anything other than the news or pop culture. – transmasculine 17-year-old
      Section M: Absence of family educationI think she never feared it'd be something I'd do until I'm a lot older and more confident. So maybe she believed that sex wasn't a concern for me, something she just let slide by. Maybe her herself feels weird on giving me information, her now daughter after being her son for 15 years – transfeminine 18-year-old

      I don't think so. I think it might be a matter of like, they just don't want to have that conversation – transfeminine 17-year-old
      Section N: Reliance on other resourcesProbably because we already had the education on [sex] and the tools to learn it ourselves considering we all have computers. – transfeminine 17-year-old

      [My family] expected our school to take care of that, at least, that's what it seemed like from my end. – transmasculine 17-year-old
      Section O: Heteronormative education[School] only [taught] us penis goes into vagina stuff. It's like, that might apply to some people, but I don't know if it will apply to everyone here… [School] kind of mentioned that oral and anal is a thing, but they don't go into depth and I've never heard them talk about toys. – transmasculine 17-year-old

      School does, they show you what the parts are and do, they don't really show you how to protect against things… how you contract it. Use birth control. Stuff like that, but that's very straight, a male and a female. They don't really teach you like if it's two girls or if it's two guys, the things you can do that are different. – transmasculine 15-year-old
      Section P: Cisgender educationI think [my family was] kind of like confused on how the whole sex thing would work, and you know that's just because they don't know. They're not trans, they wouldn't know. Not even that they weren't trans they wouldn't know, but they weren't educated. – transmasculine 17-year-old

      My mom, yeah, but mainly when I was 11 or 12, and once I came out as gay suddenly, I was out of her depth, and then I was trans I was even more. Now she asks me questions, rather than me asking her questions. – transmasculine 17-year-old

      I never learned anything about how my body works, obviously being a transgender girl, my body doesn't work the same way cis boys or girls bodies work and sex doesn't work the same way. – transfeminine 19-year-old

      Probably all of the, well everything that [school] taught us in sex ed, some of it kind of helps but most of it is pretty much useless to me or I just don't know how to would apply to me. I think they can talk about trans health more. – transmasculine 17-year-old
      Communication skills and dysfunctional family dynamics were common barriers (Table 4 Section L). Some participants thought their families would joke or tease them about sex. Other families were perceived to be emotionally disengaged and had participants who did not feel comfortable talking with them. Few actively avoided dialogues about sex to avoid disclosure of sexual activity and due to safety concerns about their families’ traditional values, conservative backgrounds, and transphobia.
      Most participants did not expect to receive information about sex from their families for varied reasons (Table 4 Section M). Commonly, families were perceived to be too busy. In some instances, it was assumed families thought participants were not sexually active or would not be sexually active until a later age. Other participants assumed their families did not desire, deem necessary, or prioritize sex education. Few assumed that they were passively aware of their families' expectations that “[they] all just know.” It was perceived that families thought sex education was received from other resources such as school, internet, or social media (Table 4 Section N).

      Sex education topics -

      Family sex education topics included puberty, menstruation, definition of sex, use of condoms, contraception, and STIs. Age at the time of family-based sex education ranged from 5 to 13 years old. Families gave sex education for opposite-gender relationships. Few transmasculine participants, only in brief and upon request, discussed sexual activity with same-gender partners with their families.
      School-based sex education curricula focused on condom use, avoidance of pregnancy, penile-vaginal intercourse, consent, and abuse. Initial participation in school-based sex education ranged from 4[th] to 12[th] grade. Anal and oral intercourse were briefly mentioned within the context of opposite-gender relationships for a small subset of participants. Same-gender relationships were mentioned in a cursory fashion for only a few participants. In these instances, educators were described as “mentioning LGBTQ or basically just gay matters” and that sexual activity can occur between people of the same gender (Table 4 Section O).
      Participants reported that their families did not give sex education applicable to TGNB adolescents. Participants believed that since their families were not transgender, they were not able to teach about intimacy, sex, or safe sex as a TGNB person. Instead, participants became a source of education for their families about their health (Table 4 Section P). Similarly, no school-based sex education curricula were inclusive of TGNB adolescents. School sex education was described as “pretty much useless” and “slightly LGBTQ positive” (Table 4 Section P). Education regarding sexual activities, health, and relationships for TGNB adolescents was sought elsewhere by participants from the internet, peers, and other LGBTQ affirmative community resources.

      Barrier protection and STI screening -

      Both transmasculine and transfeminine participants inconsistently used barrier protection. None reported use of dental dams or latex barriers for oral sex (oral-vaginal, oral-penile, or oral-anal). Barrier protection, when utilized, was for penile-vaginal or penile-anal intercourse and STI prevention (Table 5 Section Q). Few participants reported use of barrier protection and/or birth control for contraception or pregnancy prevention (Table 5 Section R).
      Table 5Themes on sexual practices, behaviors, and counseling
      ThemesQuotes
      Section Q: Limited or no use of barrier protectionNo, but we know well enough to where if we notice anything wrong then we'll get it checked out. – transfeminine 19-year-old

      With the other people that I've had sexual encounters with they've all had female assigned parts when they were born so I didn't really have to worry about [protection] at first, and then I realized there were some things that I still had to worry about. – transmasculine 17-year-old
      Section R: ContraceptionMy partner is on birth control, but we still use condoms just to make sure. – transfeminine 17-year-old

      Um, always use protection with the one person that was cis. I always used protection with him – transmasculine 17-year-old
      Section S: Frequency of STI screeningMe and [romantic partner] get checked once a month to make sure we don't have it and we do not use protection. – transfeminine 17-year-old

      I don't really know what the appropriate time frame would be so I've always just sort of if there's every any question of it. – transmasculine 19-year-old

      I think every couple of months is a decent idea if you have multiple partners. – transfeminine 19-year-old
      Section T: Barriers to STI screeningI don't know where to go. How to go about it. I never learned about any sort of that stuff. – transmasculine 18-year-old

      Not having to talk to my parents about it the very first step, you don't want “can we go get tested for STIs,” No. I'll wait till I'm over 18. – transmasculine 17-year-old
      Section U: Absent or limited clinician sex health counselingI get during check ups, I get asked the question are you sexually active. That's about it. They ask you if you are. It's just whether or not you know what being sexually active is. – transmasculine 18-year-old

      I never really had like the sex talk with my family physician. Not that I can remember anyway. – transfeminine 20-year-old
      Section V: Inadequate clinician sex health counselingNot really beyond the whole, now that you're this age, we can do screening without getting your parents involved and that was basically it. – transmasculine 17-year-old

      I feel like when I go to a general doctors for a checkup and what not, I have to teach them about stuff instead… It was fine, I like explained to the that like I'm trans and I have sex with men, which makes me gay. I'm not a straight woman. – transmasculine 18-year-old
      Section W: Reliance on gender services clinicianThe doctor [in the gender clinic] is probably the doctor I've shared the most information with because [they're] helping figure out all this transition stuff… I've been able to ask [them] any questions where I have any and I think the answers that I got were sufficient enough for what I wanted… I guess [they'd] know the most than random person you can't verify on the internet, so if [they don't] know I'm all out of options on where to look. – transfeminine 18-year-old

      I have a doctor that if I had questions, I would go to [them] and ask [them]… The doctor [at the gender clinic]. - transfeminine 17-year-old
      Participants in sexual relationships reported “adequate” screening frequency to be anywhere from every month, 3 to 6 months, or 5 to 6 months. Increased frequency of STI screening occurred if participants had multiple partners or if there was concern about a partner's fidelity. After first having sexual contact with someone, time elapsed prior to receiving STI screening was anywhere from two weeks, two months, or few months. Some participants only received screening if they were initiating sexual activity with a new partner, someone of unknown STI status, or if a prior or current partner had a potential STI exposure (Table 5 Section S).
      Various reasons for not receiving STI screening included being too busy, not knowing where to go for free testing, and not wanting families to discover participants’ sexual activity (Table 5 Section T). Screening was deferred by some since they were without symptoms of STI or had been without sexual activity over the past few months. Other participants cited consistent use of protection, involvement in a monogamous relationship, few personal sexual contacts, or negative partner testing as justification for not receiving screening.

      Clinician sex health counseling -

      Healthcare providers did not engage in or had limited discussions with participants about their sexual activity and health (Table 5 Section U). When in-person counseling did not occur, it was common for information to be collected passively on screening questionnaires. Participants had a variety of interpretations of the screening question “are you sexually active?” It was thought by some to ask about the presence of sexual activity within the past week, month, or couple months. Others interpreted this question to ask about engagement only in certain sexual activities such as only oral or penetrative sex or “doing anything with your genitals.”
      Participants were comfortable with discussing sexual activity with gender services providers. Interactions with other types of providers varied. Comfort was attributed to the providers’ history of working with TGNB patients in comparison to other physicians who one participant described as those “don't work with transpeople.” Gender services providers were considered educated, trustworthy, and reliable. Most participants reported the need for primary care physicians to be educated about healthcare for TGNB individuals (Table 5 Section V and W).

      Discussion

      Thematic analysis revealed new concepts with respect to the lived experiences of TGNB youth and their perception of sex, knowledge of sexual health, and conversations with sex educators. Sex was considered an individualized concept based on physical contact, the engaging participants’ genitalia, and consent. Most defined sexual identity or orientation as an attraction regardless of gender or along a spectrum of gender. Education from families and schools on sex health was only perceived as relevant for cisgender adolescents engaging in penile-vaginal intercourse. Sex health history taking and medical counseling was seen as inadequate to participants, except from gender services providers. These perspectives on sex, sexual practices, and related knowledge can guide how to improve sex health education and medical counseling for TGNB youth and adolescents.
      Most TGNB youth did not receive sex education from their families, which they perceived to be due to parental lack of desire, time, or concern. In comparison, 70% cisgender males and 78% of cisgender females age 15 to 19 years old received specific sex education from their families in 2011-2013.
      • Lindberg LD
      • Maddow-Zimet I
      • Boonstra H
      Changes in Adolescents' Receipt of Sex Education, 2006-2013.
      When advice was provided it was seen to be communicated poorly and not relevant for the participant's sexual experiences. Conversations about sex were impacted by many factors including emotional disengagement and irreverence, suggesting that families find it difficult to adapt their approach to their child's affirmed gender and sexuality. Conversations about sex are known to be related to parenting style.
      • Grossman JM
      • Jenkins LJ
      Richer AM: Parents' Perspectives on Family Sexuality Communication from Middle School to High School.
      • Gowen LK
      • Winges-Yanez N
      Lesbian, gay, bisexual, transgender, queer, and questioning youths' perspectives of inclusive school-based sexuality education.
      Without parental guidance, TGNB youth seek other sex health resources including the internet and peers, which places them at risk for misinformation.
      • Haley SG
      • Tordoff DM
      • Kantor AZ
      • et al.
      Sex Education for Transgender and Non-Binary Youth: Previous Experiences and Recommended Content.
      • Evans YN
      • Gridley SJ
      • Crouch J
      • et al.
      Understanding Online Resource Use by Transgender Youth and Caregivers: A Qualitative Study.
      When parent-adolescent communication about sex is skilled, comfortable, and developmentally appropriate it results in more partners discussing sex and condom use.
      • Grossman JM
      • Jenkins LJ
      Richer AM: Parents' Perspectives on Family Sexuality Communication from Middle School to High School.
      • Whitaker DJ
      • Miller KS
      • May DC
      • et al.
      Teenage partners' communication about sexual risk and condom use: the importance of parent-teenager discussions.
      It is evident that families of TGNB youth need sex education outreach and training to teach them how to effectively discuss sex in a gender-affirming way.
      • Grossman JM
      • Jenkins LJ
      Richer AM: Parents' Perspectives on Family Sexuality Communication from Middle School to High School.
      This is critical as family conversations about sex are associated with a higher likelihood of talking with partners about sex, delaying sexual debut, and using condoms.
      • Widman L
      • Choukas-Bradley S
      • Helms SW
      • et al.
      Sexual communication between early adolescents and their dating partners, parents, and best friends.
      Sex was identified by participants as any consensual contact with a recipient partner's genitalia, which differs from many health educators’ teaching of sex as penile-vaginal intercourse between cisgender, heterosexual partners. The Centers for Disease Control and Prevention lists sexual orientation and gender identity as topics critical to adolescents’ sex health education.

      Sexuality Information and Education Council of the United States (SIECUS): State Profiles Fiscal Year 2018: Michigan. https://siecus.org/wp-content/uploads/2019/03/Michigan-FY18-Final.pdf. Updated 2018. Accessed 2021 May 10.

      However, sex education continues to lack instruction relevant for sexual and gender minorities.
      • Gowen LK
      • Winges-Yanez N
      Lesbian, gay, bisexual, transgender, queer, and questioning youths' perspectives of inclusive school-based sexuality education.
      Heterosexual cisgender females report receiving sexual education before becoming sexually active more often than those identified as lesbian or bisexual, the latter of which had poorer health outcomes.
      • Bodnar K
      • Tornello SL
      Does Sex Education Help Everyone?: Sex Education Exposure and Timing as Predictors of Sexual Health Among Lesbian, Bisexual, and Heterosexual Young Women.
      Only twelve and seven states are inclusive of diverse sexual orientations and gender identities respectively.
      • Hall WJ
      • Jones BLH
      • Witkemper KD
      • et al.
      State Policy on School-based Sex Education: A Content Analysis Focused on Sexual Behaviors, Relationships, and Identities.
      TGNB youth in our study wanted education on non-heteronormative, oral and anal sex, the use of sex assistive devices, and how to apply pregnancy and STI prevention to their sexual practices. Similar studies reflect that TGNB youth at large desire education with “gender-neutral language” that covers consent and relationships, sex and desire, STI prevention, fertility, contraception, and healthcare access in an affirming way.
      • Haley SG
      • Tordoff DM
      • Kantor AZ
      • et al.
      Sex Education for Transgender and Non-Binary Youth: Previous Experiences and Recommended Content.
      • Fontenot HB
      • Cahill SR
      • Wang T
      • et al.
      Transgender Youth Experiences and Perspectives Related to HIV Preventive Services.
      In a survey study on 360 undergraduate students from the United Statues, comprehensive sex-health education was more strongly related to higher health satisfaction for heterosexual students than LBG identifying students.
      • Evans R
      • Widman L
      • Goldey K
      The Role of Adolescent Sex Education in Sexual Satisfaction among LGB+ and Heterosexual Young Adults.
      When school education is inclusive of sexual and gender minorities it improves satisfaction and knowledge scores on STI prevention, pregnancy prevention, and HIV transmission.
      • Boyce KS
      • Travers M
      • Rothbart B
      • et al.
      Adapting Evidence-Based Teen Pregnancy Programs to Be LGBT-Inclusive: Lessons Learned.
      Clinicians who provided primary care for TGNB youth in this study obtained limited histories on sexual activity and gave no or limited sex health counseling. Stand-alone health questionnaires were common and what “sexually active” meant was interpreted differently by TGNB youth. No additional or qualifying information about sexual activity was elicited from these clinicians. Occasionally STI screening was offered, but education on pregnancy prevention, barrier protection, or STI transmission was not discussed. These findings are especially relevant to TGNB youth, who practice inconsistent barrier use and one third of them have a history of one or more STIs, with a four times higher odds in transfeminine youth.
      • Reisner SL
      • Jadwin-Cakmak L
      • Sava L
      • et al.
      Situated Vulnerabilities, Sexual Risk, and Sexually Transmitted Infections' Diagnoses in a Sample of Transgender Youth in the United States.
      In this study, some TGNB youth used contraception and barrier protection when sex could result in pregnancy, but they otherwise had limited or no use of barrier protection. Comprehension about STI screening varied, with some youth not knowing how or when to get tested in comparison to others who received testing every month. In the United States only about 15% of TGNB youth report testing for HIV and 22.6% report testing for other STIs.
      • Sharma A
      • Kahle E
      • Todd K
      • et al.
      Variations in Testing for HIV and Other Sexually Transmitted Infections Across Gender Identity Among Transgender Youth.
      Precise terminology and inclusive sex health history taking by clinicians is essential. This will produce an accurate risk assessment and guide subsequent medical counseling and patient education on pregnancy prevention, barrier protection, and STI screening.
      • Fontenot HB
      • Cahill SR
      • Wang T
      • et al.
      Transgender Youth Experiences and Perspectives Related to HIV Preventive Services.
      • Tolman DL
      • McClelland SI
      Normative Sexuality Development in Adolescence: A Decade in Review, 2000–2009.
      Despite limited conversations about sex with primary care providers, TGNB youth described positive and comfortable healthcare experiences with providers from the gender services clinic. In this study reliance on gender services providers was largely described for sex health education. In the United States only 25% of transgender youth feel their primary care provider is helpful for sexual health issues.
      • Fisher CB
      • Fried AL
      • Desmond M
      • et al.
      Perceived Barriers to HIV Prevention Services for Transgender Youth.
      Perception of inadequate physician education or knowledge and gender-minority competence is an barrier for TGNB youth seeking healthcare.
      • Fontenot HB
      • Cahill SR
      • Wang T
      • et al.
      Transgender Youth Experiences and Perspectives Related to HIV Preventive Services.
      • Fisher CB
      • Fried AL
      • Desmond M
      • et al.
      Perceived Barriers to HIV Prevention Services for Transgender Youth.
      • Clark BA
      • Veale JF
      • Greyson D
      • et al.
      Primary care access and foregone care: a survey of transgender adolescents and young adults.
      On the other hand, healthcare provider competence on gender minority health results in TGNB youth being three times more likely to have HIV or other STI testing.
      • Evans R
      • Widman L
      • Goldey K
      The Role of Adolescent Sex Education in Sexual Satisfaction among LGB+ and Heterosexual Young Adults.
      Comprehensive, gender inclusive medical care requires further development and implementation of professional and medical education competencies.
      • Keuroghlian AS
      • Ard KL
      • Makadon HJ
      Advancing health equity for lesbian, gay, bisexual and transgender (LGBT) people through sexual health education and LGBT-affirming health care environments.
      • McCann E
      • Brown M
      The inclusion of LGBT+ health issues within undergraduate healthcare education and professional training programmes: A systematic review.
      When considering informed consent for GAHT in youth, the effect on fertility is discussed in numerous guidelines, but the impact on libido is only noted in the World Professional Association for Transgender Health Standards of Care.
      • Coleman E
      • Bockting W
      • Botzer M
      • et al.
      World Professional Association for Transgender Health: Standards of Care for the Health of Transsexual, Transgender, and Gender-Conforming People, Version 7.
      In this study, changes in libido with GAHT were anticipated as a side effect by most TGNB youth due to personal research or the medical consent process, but were unanticipated by some. This is a pertinent health issue for TGNB adolescents because it impacts satisfaction with sexual health and, based on study responses, may lead to contact with more sexual partners. Standard anticipatory guidance regarding possible changes in sexual health, function, and libido with GAHT would be beneficial. Similarly, TGNB youth perceived changes of sexual identity in response to GAHT and consistently utilized terminology about attraction along a spectrum of gender rather than a binary. Sexual identity development in the transgender community is an area of ongoing research.
      • Katz-Wise SL
      • Reisner SL
      • Hughto JW
      • et al.
      Differences in Sexual Orientation Diversity and Sexual Fluidity in Attractions Among Gender Minority Adults in Massachusetts.
      • Dickey LM
      • Burnes TR
      • Singh AA
      Sexual identity development of female-to-male transgender individuals: A grounded theory inquiry.
      • Bockting W
      • Benner A
      • Coleman E
      Gay and bisexual identity development among female-to-male transsexuals in North America: emergence of a transgender sexuality.
      • Auer MK
      • Fuss J
      • Höhne N
      • et al.
      Transgender transitioning and change of self-reported sexual orientation.
      • Davis SA
      • Meier SC
      Effects of testosterone treatment and chest reconstruction surgery on mental health and sexuality in female-to-male transgender people.
      Review of current literature demonstrates that the effect of gender-affirming hormones on the expression of sexual identity is not well defined.
      • Berenbaum SA
      • Beltz AM
      Sexual differentiation of human behavior: effects of prenatal and pubertal organizational hormones.
      Further research and analysis of TGNB adolescents' sexual identity as affected by GAHT would benefit from vocabulary that reflects a spectrum of sexual identity inclusive of diverse gender identities.
      One limitation of our study was that TGNB participants were seen in a specialty clinical setting. This may have excluded youth of lower socioeconomic status or youth with barriers to accessing care such as lack of transportation, family, or social support. Given the role family support can have on adolescent sexual health and activity, such youth would likely have unique experiences not demonstrated in this qualitative study. The majority of participants in this survey identified as white, and the perspectives of other adolescents who face racial discrimination, inequality, and barriers to healthcare likely would differ. Our participants were between the ages of 16 and 20, and adolescents outside this age range may have different experiences with sex education. More research should be conducted on nonclinical populations to elucidate additional perspectives, particularly from TGNB adolescents who do not pursue GAHT. In addition, one-on-one interview methods may have omitted participants who would otherwise have been willing to share their perspectives in a more impersonal format. However, the length of interviews, which ranged from 32 to 80 minutes, suggested that participants were comfortable sharing their experiences with the interviewer.
      While the results of this study are not representative of the experiences of all TGNB youth, it provides vital preliminary work for future research. Overall, future research should seek to examine gender identity separately from sexual orientation in order to reduce transgender and gender minority stigma
      • Worthen MGF
      An Argument for Separate Analyses of Attitudes Toward Lesbian, Gay, Bisexual Men, Bisexual Women, MtF and FtM Transgender Individuals.
      . Further analysis on the experienced barriers of the families of TGNB youth in discussing sex and sexual health would aid in the development of health education and outreach programs. Implementation of evidence-based sex health education programs could be assisted by clinician advocacy and removal of state-level legal and policy barriers to sexual and gender minority-inclusive sex education in schools. Finally, providers can utilize the findings of this study to improve their awareness of how TGNB youth conceptualize sex, their existing knowledge on STI and barrier protection, and the possible effects of GAHT on their sexual health and safety. It can also serve to motivate clinicians to seek out medical education, adapt their practices to be more gender-inclusive, and provide appropriate, preventative healthcare and counseling to TGNB youth.

      Acknowledgements

      We acknowledge and thank the Department of Pediatrics under the Diversity, Equity, and Inclusion Initiative at Michigan Medicine as a source of funding for this study. We acknowledge and appreciate the contributions of Sara Wiener, LMSW.

      Disclosure

      All authors have indicated they have no financial relationships or conflicts of interests relevant to this article to disclose.

      Financial disclosure

      All authors have indicated they have no financial relationships relevant to this article to disclose.

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