The importance of comprehensive, medically accurate, evidence-based, and inclusive sexual education and healthcare is well-established and reiterated by the American Academy of Pediatrics1, the ໿American College of Obstetricians and Gynecologists2, and the U.S. Department of Health and Human Services3. Such education and healthcare should not marginalize individuals based on their sexual orientation, gender identity, or differences in sex development2. Despite this, inconsistencies and substantial gaps occur between professional guidelines and practice in the sexual education and healthcare of youth4,5, with even less access for black, indigenous, people of color (BIPOC)6 and sexual minority (i.e., bisexual, pansexual, and queer) youth7. Transgender/gender diverse (TGD) youth are individuals whose gender identity does not align with their sex assigned at birth (SAB)8. Despite increasing rates of youth referred to pediatric gender-affirming health clinics nationally and internationally over the past decade9, there is a lack of research on the sexual health needs of TGD youth. Obstetricians and gynecologists are uniquely suited to address the sexual health needs of the general population, especially cisgender women. However, despite interest in further education and training, OB/GYNs lack basic training in caring for transgender patients10.

The current literature examining TGD youth sexual behavior has focused on risk behaviors11, transgender girls12, and HIV prevention13,14, with few studies assessing normative sexual behavior of TGD youth. Much of the evidence base relies on school-based health surveys with only one or two questions that assess sexual behavior (see Table 1, i.e., “Have you ever had sexual intercourse?”). Adolescents will vary in their definition of what sex means, and measures of sexual behavior for minority and at-risk populations such as TGD youth should include nuanced response options. Given that sexual behavior is a part of typical adolescent development15 and can contribute to significant risk behavior and adverse health outcomes, it is crucial to have an accurate, gender-inclusive understanding of the unique sexual experiences and behavior of TGD youth to support their sexual health and development.

Adolescent sexual behavior is well studied, with a particular focus on risky behaviors (e.g., unintended pregnancies, sexually transmitted infections, HIV). Recent nationwide prevalence based on the 2017 Youth Risk Behavior Survey (YRBS) data indicated that 39.5% of high school students engaged in sexual intercourse16. Similarly, 52.2% of high school students engaged in sexual contact; 9.8% reported having four or more sexual partners to date, 45.3% reported having sexual contact only with the opposite sex, 1.6% with the same sex, and 5.3% with both sexes16. Further, 68.3% of high school students reported dating someone in the last 12 months, and 6.9% endorsed being forced into sexual behavior against their will16.

Several school-based or online health surveys have suggested that TGD youth are more likely to engage in sexual behaviors, high-risk sexual behaviors (e.g., more sexual partners, sex at a younger age, less likely to use protection), and to be at a higher risk of experiencing dating conflict and sexual victimization than their cisgender peers17, 18, 19, 20, 21. The average number of sexual partners varies from 1-4, as described in these studies. However, these school-based and online surveys provide limited understanding of TGD youth sexual health as they provide only vague information and are not gender-inclusive (i.e., do not reflect the potential variations in TGD youth's definitions of sex nor descriptive information about the gender identity of their sexual partners) and measures created for cisgender youth may obscure our understanding of the sexual health needs of TGD youth.

A series of clinic-based studies conducted in the Netherlands are the only studies we identified that provide more nuanced information on the sexual behavior of TGD youth. Findings indicated that before gender-affirming treatment, TGD adolescents 10-18 years old were less sexually experienced than the Dutch general population (i.e., 36% reported kissing, 26% reported sexual touching, and 5% reported sexual intercourse)22. After gender-affirming surgery, ໿Bungener23 found that all types of sexual activity (i.e., masturbation, petting while undressed, and sexual intercourse) increased for TGD young adults compared to pre-surgery.

No studies to our knowledge have reported the sexual behavior and preferences of TGD youth utilizing a questionnaire that does not assume participants’ definitions of sex or the gender of sexual partners. To address these gaps in the literature, the current study aimed to (1) describe a clinic sample of TGD youth's self-reported sexual behavior and partners, (2) provide a comparison of rates to a nationwide prevalence study of adolescent sexual behavior16, and (3) share a clinically useful questionnaire with nuanced wording to illustrate how to assess and discuss sexual behavior with TGD youth.