Ensuring Sexual Health Education Addresses Patient Needs
October 1, 2025 8 minutes read
By Melinda Young
New research suggests contraception use is lower and adolescent pregnancy rates are slightly higher for transgender boys than cisgender girls. This is a group that needs more attentive sexual and reproductive health education, counseling, and care from OB/GYNs and other clinicians.1
“Because trans and nonbinary people are such a small percentage of the population, there hasn’t been a lot of population-focused research about their actual sexual behaviors, and I would say there has been some kind of stereotypes about trans and nonbinary young people,” says Elizabeth Saewyc, PhD, RN, FSAHM, FAAN, a professor and distinguished university scholar and executive director of the Stigma and Resilience Among Vulnerable Youth Centre in the School of Nursing at the University of British Columbia in Vancouver, BC, Canada.
“One stereotype is that because they have so much gender dysphoria, nothing sexual is going to happen — they don’t have sex at all,” Saewyc explains. “The opposite stereotype has to do with what people know about transgender people, which is that many have been kicked out of their homes and are homeless and that they experience survival sex and sex work.” Neither stereotype addresses these populations’ actual experiences with sex, contraception, and pregnancy, and this is why researchers can help increase clinical knowledge.
For example, new research shows that rates of teenage vaginal sex are similar with nonbinary, cisgender, and trans youth, Saewyc says.1 The chief differences are that transgender boys report half the rate of condom use at last sexual encounter than cisgender girls. Also, nonbinary youth and transgender boys were younger than cisgender girls the first time they had sex.1 “For trans boys, they were almost a year younger on average,” Saewyc says. Survey data about age at first sex included penile-vaginal sex, penile-anal sex, oral sex, and sex with fingers.1
Nonbinary young people also are engaging in sex at younger ages than cisgender girls.1 “They’re starting younger, and that may not be consensual,” Saewyc says. “They’re not necessarily having more partners in their lifetime, but they’re half as likely to have condom use at last sex,” she adds. “They’re also getting pregnant and also need sexual health education and access to condoms and contraception.”
Researchers used data from a longitudinal survey that is designed to study adolescent health and violence. The original cohort was recruited in 2006, and an additional 4,659 youth were surveyed between June 2018 and March 2020.1 Because youth were recruited online, they have access to the internet and also have diverse ethnic backgrounds, Saewyc notes.
“The majority of them identify as having the average household income; 20% said their household income was lower than average; 53% said it was similar, and 17% said it was higher than the average household,” she adds. “They may have a more educated parent group with a majority completed some college and 15% completed graduate school. So, it’s a fairly educated group.”1
Based on respondents’ family income and education, one might think this was a group that had better access to sexual health services, whether they are transgender, cisgender, or nonbinary, she notes.
“It’s a national sample, and it is a reasonably middle class with slightly better educated parents of 14- to 16-year-olds — adolescents in their middle teenage years,” Saewyc explains.
The survey did not ask detailed questions about the respondents’ first sexual encounters, so there is no way to know why transgender boys and nonbinary adolescents reported younger ages at first sexual encounter. It also is important to note that among all youth, sexual activity was fairly low, she says.
“We’re talking about 62% of cisgender girls, 50% of trans boys, and 53% of nonbinary youth had not had any kind of sex — oral or other things,” Saewyc explains. “When talking about vaginal sex, between 14% and 18% have had it, so it’s important to be aware that the majority of these 14- to 16-year-olds had not had sex.”1
Researchers asked about sexual behaviors but tried to exclude people who were coerced into having sex or who were sexually abused. “We asked them to only include sex when they wanted to have sex,” Saewyc says.
The findings suggest that all youth need sexual health education that is gender inclusive and has information that targets their concerns and needs, she says. “There are wide variations in access to sex education across the United States, but even when young people have sex education, it’s unclear whether they have gender inclusion and information that is targeting them in their sex ed,” Saewyc explains. “If it’s not about them or they think it’s not relevant, young people may not pay attention, so they are missing some key information because either they are not getting it, or it’s not addressed to them and they don’t think it applies to them.”
Pregnancy risks, contraception, and information about sexually transmitted infections (STIs) need to be expressed in language that is gender inclusive and also addresses the typical sexual experiences of transgender boys and nonbinary youth, she adds.
Saewyc offers these suggestions for sexual and reproductive health counseling for sexual minority youth:
Ask, do not assume: Eliminate personal stereotypes and biases by asking all youth about their sexual behaviors, contraception use, and knowledge of the risk of pregnancy and STIs.
“Good practice in terms of U.S. adolescent guidelines suggests that all practitioners, family doctors, OB/GYNs, and pediatricians should be asking adolescents sexual health questions and ask about substance use and risk behaviors,” Saewyc says. “Those kinds of questions should be asked in safe, nonjudgemental ways as part of regular adolescent healthcare.”
Clinicians may have overly busy schedules and may not ask about patients’ knowledge of sexual behavior, STIs, and contraception because they assume youth are getting information from school-based sex ed. But the survey results suggest that this is not always the case, and adolescents need more information that is applicable to their own personal sexual health experiences, she adds.
Use inclusive language: “Talk about the sexual health needs of all young people,” Saewyc says. “One of the things we really did see is that it is important to ask about and normalize all kinds of sex, so all genders and sexual minorities feel seen and are willing to share what they’re doing.”
Young people who hear providers use language that includes them and ask questions that suggest an interest in their experience may be more likely to share what they are doing. They also may be more willing to hear the provider’s messages about risk reduction, she explains.
A simple way to be gender inclusive is to refer to a person’s body parts and not to their gender. For instance, a provider could say, “If you have these body parts, there are these risks for pregnancy,” Saewyc says.
“If you only ask if they had sex or had sexual intercourse, then it means the teenager has to know what sexual intercourse means and what counts as sex,” she adds. “Their understanding of what you are asking may not be aligned with your understanding as the clinician.”
Ask about a variety of sexual behaviors, describing what is meant: “Because it’s important to understand the potential around STI transmission, as well as potential for pregnancy, it’s not a bad idea to ask about a variety of sexual behaviors,” Saewyc says. “Preface that by saying, ‘I’m going to ask you about a variety of different kinds of things young people may do sexually because young people may have different potential health needs.”
Those questions could be the following:
- Have you had oral sex, and by that I mean a mouth on genitals, and did you receive or give that or both?
- Have you had sex with a sex toy? Or sex with fingers?
- Have you had sex where a penis goes into the vagina? Or a penis in the butt?
“Use terms that are familiar to them, and do not be vague about it,” Saewyc advises. “Asking these questions in a matter-of-fact way is helpful. It helps young people understand the possibility of STI transmission with sex toys and the ability to reduce risk by putting condoms on.”
Clinicians can talk about ways adolescents can prevent STIs and discuss, separately, ways to prevent pregnancy. “Ensure that gender-diverse youth are aware that if they’re on hormones, testosterone will not necessarily prevent pregnancy, even if it stops their period,” Saewyc says.
Keep contraceptive counseling relevant to gender minority patients’ experiences: Some gender minority youth may be unaware that some contraceptive methods can reduce or stop their menstrual cycle or help with skin conditions and cramping. When a provider describes those changes, they may be more interested in particular birth control methods, Saewyc notes.
“There are other benefits to some forms of contraception that are not strictly about preventing pregnancy or preventing STIs,” she adds. “That kind of information is often provided to cisgender girls, but it is not always related to the needs of non-cisgender, gender-diverse young people.”
Adolescents need options and information about the pros and cons of each method. Clinicians should not assume they have learned everything from the internet, Saewyc says. “They may be more exposed to some of it on the internet, but that access may be to inaccurate information that never brings contraception or condom use into conversations,” she explains. “Young people may not have accurate views of healthier, safer sex.”
Suggest a private conversation: “Recommendations for adolescent healthcare say there should be for all young people an opportunity for a private conversation with the clinician without the parent present,” Saewyc says. “This is for talking about a variety of health behaviors that kids may not want to disclose to their parents: substance use, mental health, and sexual behaviors. And it’s also important to assess sexual abuse and violence.”
For example, a young person who has been sexually assaulted while in a dating relationship may not have told their parents about this. Their parents may not even know they are dating, so asking about it while the parents are present will not elicit disclosure, she says.
“Even sexual assault because, sadly, if young people get sexually assaulted by someone they’re not dating, it may be in the context of their being out later than they’re supposed to be,” Saewyc says. “The incredible shame and distress they experience could make it hard for them to share with anyone — including their parents — what happened.” This is possible regardless of how good their relationships are with their parents.
“Young people are not necessarily going to disclose to their clinician, especially if they’re not actually taking puberty blockers or hormones, if they don’t feel it’s safe,” Saewyc explains. “So, it’s important to ensure your clinical setting makes it clear that people of diverse genders are welcome there; the way you talk to young people about sex and sexual behaviors and sharing your pronouns can be nice cues to help people trust you.”
Melinda Young has been a healthcare and medical writer for 30 years. She currently writes about contraceptive technology.
Reference
1. Ybarra ML, DuBois Z, Saewyc E. Sexual health of US transgender boys, nonbinary youth, and cisgender girls. JAMA Pediatr. 2025;179(7):773-780.
Clinicians can help make sure patients have the information they need about sexual health and contraception.
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