Inclusive sexual health counseling and care

Sexual health screening and counseling is an important part of wellness care for all adolescents, and transgender and gender nonconforming (TGNC) youth are no exception. TGNC youth may avoid routine health visits and sexual health conversations because they fear discrimination in the health care setting and feel uncomfortable about physical exams.¹ Providers should be aware of the potential anxiety patients may feel during health care visits and work to establish an environment of respect and inclusiveness. Below are some tips to help provide care that is inclusive of the diverse gender and sexual identities of the patients we see.

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Obtaining a sexual history

1. Clearly explain the reasons for asking sexually explicit questions.

TGNC youth experiencing dysphoria may have heightened levels of anxiety when discussing sexuality. Before asking these questions, acknowledge the sensitivity of this topic and explain that this information is important for providers to know so that they can provide appropriate counseling and screening recommendations. This may alleviate some of their discomfort.

2. Ensure confidentiality.

When obtaining sexual health histories, it is crucial to ensure confidential patient encounters, as described by the American Academy of Pediatrics and Society for Adolescent Health and Medicine.^2,3 The Guttmacher Institute provides information about minors’ consent law in each state.⁴

3. Do not assume identity equals behavior.

Sexual and gender identity may not be predictive of sexual behaviors, and providers should not assume behaviors based on a patient’s identity.

Here are some sexual health questions you need to ask:

• Who are you attracted to? What is/are the gender(s) of your partner(s)?
• Have you ever had anal, genital, or oral sex? If yes:

Do you give, receive, or both?

When was the last time you had sex?

How many partners have you had in past 6 months?

Do you use barrier protection most of the time, some of the time, always, or never?

Do you have symptoms of an infection, such as burning when you pee, abnormal genital discharge, pain with sex, or irregular bleeding?

• Have you ever been forced/coerced into having sex?

Starting with open-ended questions about attraction can give patients an opportunity to describe their pattern of attraction. If needed, patients can be prompted with more specific questions about their partners’ genders. It is important to ask explicitly about genital, oral, and anal sex because patients sometimes do not realize that the term sex includes oral and anal sex. Patients also may not be aware that it is possible to spread infections through oral and anal sex.

4. Anatomy and behavior may change over time, and it is important to reassess sexually transmitted infection risk at each visit

Studies suggest that, as gender dysphoria decreases, sexual desires may increase; this is true for all adolescents but of particular interest with TGNC youth. This may affect behaviors.⁵ For youth on hormone therapy, testosterone can increase libido, whereas estrogen may decrease libido and affect sexual function.⁶

Physical exam

Dysphoria related to primary and secondary sex characteristics may make exams particularly distressing. Providers should clearly explain reasons for performing various parts of the physical exam. When performing the physical exam, providers should use a gender-affirming approach. This includes using the patient’s identified name and pronouns throughout the visit and asking patients preference for terminology when discussing body parts (some patients may prefer the use of the term “front hole” to vagina).^1,7,8 The exam and evaluation may need to be modified based on comfort. If a patient refuses a speculum exam after the need for the its use has been discussed, consider offering an external genital exam and bimanual exam instead. If a patient refuses to allow a provider to obtain a rectal or vaginal swab, consider allowing patients to self-swab. Providers also should consider whether genital exams can be deferred to subsequent visits. These techniques offer an opportunity to build trust and rapport with patients so that they remain engaged in care and may become comfortable with the necessary tests and procedures at future visits.

Dr. Gayathri Chelvakumar

Sexual health counseling

Sexual health counseling should address reducing risk and optimizing physical and emotional satisfaction in relationships and encounters.⁹ In addition to assessing risky behaviors and screening for sexually transmitted infections, providers also should provide counseling on safer-sex practices. This includes the use of lubrication to reduce trauma to genital tissues, which can potentiate the spread of infections, and the use of barrier protection, such as external condoms (often referred to as male condoms), internal condoms (often referred to as female condoms), dental dams during oral sex, and gloves for digital penetration. Patients at risk for pregnancy should receive comprehensive contraceptive counseling. TGNC patients may be at increased risk of sexual victimization, and honest discussions about safety in relationships is important. The goal of sexual health counseling should be to promote safe, satisfying experiences for all patients.