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Supportive adults key to reducing HIV among trans youth, study finds

Transgender teens and young adults widely lack “affirmative and culturally competent” sexual health resources, according to the report.
Image: A transgender flag during a rally to mark the 50th anniversary of the Stonewall Riots in New York
A person holds a transgender pride flag during a rally to mark the 50th anniversary of the Stonewall Riots in New York on June 28, 2019.Angela Weiss / AFP - Getty Images file

Support from parents and other adults plays a key role in reducing rates of HIV among transgender youth, according to a study published this month in the journal Pediatrics.

The study’s authors found that transgender and nonbinary youth often lack access to critical support systems to educate them about safer sex practices. The research team conducted three-day focus groups with 30 young people ages 13 to 24 and found that respondents widely lacked “affirmative and culturally competent” resources to understand their sexual health needs.

These resources ranged from a lack of LGBTQ-inclusive sexual education courses to parents who did not affirm the respondent’s gender identity when discussing topics related to sexual and romantic intimacy.

“Youth really need adults to be there for them, to meet their needs, and to be open and respectful of them,” the lead author, Holly Fontenot, a professor at the Boston College School of Nursing, told NBC News. “If youth had adult caregivers, teachers or health care providers that could provide that affirmation, they feel supported and then they might have better overall health outcomes.”

Written by researchers from the Fenway Institute, the University of Chicago, the Centers for Disease Control and Prevention and Boston College, the study notes that trans and nonbinary youth are less likely than their peers to engage in safe sex practices. According to researchers, this group is more “likely than cisgender youth to report first sexual intercourse before age 13 years, intercourse with four or more partners, drinking alcohol or using drugs before intercourse, and not using a condom at last intercourse.”

Those disparities continue into adulthood: A 2018 report published by the Johns Hopkins School of Public Health found that around one in four transgender women in the U.S. is living with HIV, and according to the CDC, more than two-thirds of trans people of all genders say they have never had an HIV test.

Fontenot said the research found that one of the roots of these disparities is a widespread feeling among trans and nonbinary youth that they are “isolated and left out of the conversation” about sexual health in classrooms and at home. One participant in the study admitted that they “really don’t know what counts as sex,” because the definition they had been given from parents and educators “is very heteronormative” and “doesn’t apply to LGBT people.”

“When they do ask for help, youth might feel stigmatized, diminished or have negative experiences with the adults in their lives instead of ones that affirm who they are and tell them that they’re loved and supported,” Fontenot said.

Others said they had no one to turn to — even in their own peer group — for advice that’s inclusive of their gender identities. “I don’t really get any support, but I would like support in knowing that it’s OK to question who you want to have sex with, and it’s OK to explore your body,” one member of the focus group is quoted as saying.

The lack of a support network left many of the trans and nonbinary young people surveyed without the basic skills to discuss intimacy and consent with their sexual and romantic partners. The majority of respondents described open communication with potential partners as “challenging,” and many said they struggled “with self-advocacy, particularly when negotiating sexual preferences with cisgender partners.”

“Participants noted that sex requires more communication when experiencing gender dysphoria, and inability to negotiate safe behaviors might lead to feeling ‘abused or taken advantage of,’” the study noted.

Fontenot said these responses show that it’s “really important” for adults to model healthy relationships for trans and nonbinary youth.

“If you’re already feeling different and afraid, then you’re really not going be able to advocate for yourself in terms of safer sex behaviors,” she said. “It goes to that affirmation and support for youth. If they feel they have inherent self-worth and that they’re a member of society that's loved and respected just like any other person, then they'll carry that into whatever romantic relationship they may form in the future.”

Sean Cahill, a co-author of the study and the director of health policy research at the Fenway Institute, an LGBTQ-focused research center, said these lessons apply not only to parents and teachers but also health care providers who work with trans and nonbinary young people.

“For example, school nurses can support youth in school but also work with community partners to develop educational resource lists for youth and their parents and guardians,” he said in a statement.

Fontenot said the study suggests several ways in which all adults can be better advocates for trans and nonbinary youth, whether in a professional or personal capacity. For instance, young people who participated in the focus groups expressed a desire for more “coaching and guidance around healthy communication,” and Fontenot encouraged parents to turn to LGBTQ advocacy organizations or resources geared toward LGBTQ youth if they aren’t sure how to have those conversations.

However, Fontenot acknowledged that the availability of “competent sexual health resources that are really medically informed and accurate” remains scarce online, which can be a major barrier to access in rural areas. Only 27 states and Washington, D.C., mandate both sex education and HIV education, according to the Guttmacher Institute, a sexual health research and policy nonprofit.

Five states — Texas, Oklahoma, Mississippi, Louisiana and Alabama — still have “no promo homo” laws on the books, which prohibit sex education and health teachers from discussing LGBTQ people in a positive light, if at all. (South Carolina, Arizona and Utah only recently had such laws repealed or struck down.)

“That's an area that needs great improvement because I don't think our country’s in a place where schools across the nation are going to be delivering inclusive sex education,” Fontenot said of LGBTQ-inclusive online sex ed resources. “We have to think about alternative venues to deliver comprehensive sex education that’s inclusive of multiple identities.”

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