Transgender and gender nonconforming youth have some of the highest sex education needs, but lack the resources and programs to meet them. For example, research shows that transgender females of color experience the highest rates of HIV infection of any other group.

The few studies of transgender youth’s sexual health risk factors and behaviors investigate outcomes among transgender homeless youth, finding that many of them participate in sex work, and have a low rate of condom use (PDF, 435KB).

There are some developing evidence-based programs that target this population, but overall, research, policies and programs are sorely behind.

Improving Sexual Health Outcomes for Transgender and Gender Nonconforming Youth

When it comes to making sex education inclusive for transgender youth, there are several things to consider, according to Dr. Nancy McLaren, Director of the Transgender Health Clinic at the University of Virginia.

“You can’t make any assumptions on sexual practices based on who they are with—gender is one thing, and sexual orientation another,” McLaren explains.

To improve sexual health among transgender and gender nonconforming youth it’s important to deliver sex education programs specific to their experiences and needs.

Brian Mustanski, director of the Northwestern University Institute for Sexual and Gender Minority Health and Wellbeing, created and tested Queer Sex Ed, an online sex education program for both sexual- and gender-minority youth. The program incorporates gender-neutral language throughout and consists of a selection of online videos on topics including condom use, coming out, and being part of a community. The modules also direct participants to resources to find a local HIV testing site and birth control.

It’s important to make transgender youth aware that they still need contraception to prevent pregnancy, not just sexually transmitted infections, McLaren says. For example, transgender males may think taking testosterone hormones prevents pregnancy, but while it decreases fertility it doesn’t eliminate it.

Moreover, it’s important to speak candidly with youth about the fact that they are at higher risk for violence and unwanted sex, and encourage forms of long-acting reversible contraception (LARCs) in the event that they are victimized, McLaren recommends.

Advocates for Youth has a fact sheet on LARCs for young women, such as intrauterine devices (IUDs) that last for five years and implants in the arm that last for three years, and these also apply to transgender males. However, McLaren emphasizes that transgender youth must acquire the hormonal IUD and implant that contain only progesterone, not estrogen, which may conflict with cross-hormones they may be taking during their transition.

When working to improve the sexual health of transgender youth, it’s also important to create a safe environment for these young people to learn and access services.

Kris Gowen, a researcher at Oregon Health & Science University, recommends that educators and service providers interested in becoming more inclusive take a look at the Teaching Transgender Toolkit, a curriculum for use with a range of audiences including college students, community groups, faith communities, and parent and family groups. The toolkit is designed to foster awareness and acceptance through gay-straight alliances and policies for safe zones.

Mustanski recommends that educators and parents access the Gender Identity & Expression Map, a comprehensive youth-friendly resource describing the difference between sex and gender, gender identity and expression, and how to use gender pronouns and terms appropriately.

Uneven Progress in Inclusive Sex Education Policy and Research

“We live in interesting times,” Mustanski says, “and so much depends on where you live.”

Alabama, South Carolina, Texas, and Utah have laws known as “no promo homo” laws that prohibit educators in public schools from discussing lesbian, gay, bisexual, transgender, and questioning (LGBTQ) people, issues or history, or only allow discussion in a negative light.

At the same time, McLaren notes, states like Virginia and Pennsylvania have robust transgender health services embedded in their state or local health departments. Additionally, nine states, including Oregon and California, have mandates that require inclusive discussion of sexual orientation and identity in sex education programs. The full list of states and their inclusivity can be found in the March 2016 Guttmacher Institute brief (PDF, 143KB). However, even in these states, the mandate is not perfect.

“That all sounds good on paper, but the bottom line is that it’s a law without a penalty if you don’t follow it . . . there’s no oversight committee and there are no evidence-based practices or curricula,” Gowen says.

While more can be done to provide effective sex education programs for LGBTQ youth, especially for transgender and gender-nonconforming youth, Gowen thinks the links between inclusive school environments and better well-being across the board are clear.

“Creating a safe environment for young people to thrive in, no matter who they are, is going to help with sexual health outcomes,” she says. “Acknowledging various sexual orientation and identities during lessons helps create environments in schools where LGBTQ young people thrive, feel better about themselves, and make better decisions.”

More data about the connection between safe spaces and sexual health is on the way. The annual Oregon Healthy Teen Survey, which measures sexual health outcomes and other indicators of well-being, is adding a question about gender identity. In addition, the Centers for Disease Control and Prevention’s Youth Risk Behavior Survey is following suit, which means researchers will eventually be able to analyze changes over time in the sexual health and well-being of gender-minority youth at the national level.