Abstract
Lesbian, gay, bisexual, transgender, queer and questioning (LGBTQ) youth experience numerous disparities, including but not limited to access to health care, HIV risk, safety in school, educational opportunities, and family support. Historically, research on this community lumped together LGBQ experiences with experiences of transgender and nonbinary (trans/NB) individuals, despite sexual orientation and gender identity being unique identities. Using representative statewide data from the 2015 Healthy Kids Colorado Survey (HKCS) (N = 15,970), this study examines sexual behaviors through a more nuanced and intersectional lens. We find that young LGBQ and trans/NB people in Colorado have differential experiences of sexual behavior compared with their heterosexual and cisgender counterparts. Being LGBQ and especially being trans/NB, having current depression, suicidal ideation, and experiencing electronic bullying are all associated with an increase in the likelihood of ever having sex and total number of partners, and lower age of sexual debut. These findings and their implications highlight the importance of inclusive sexuality education and culturally responsive services for all young people.
Introduction
Transgender and nonbinary (trans/NB) adolescents are those whose gender expression and gender identity (i.e., their deeply held, internal sense of gendered self) are not aligned with the social expectations given the sex assigned to them at birth (American Psychological Association, 2015). Despite the amount of research inclusive of lesbian, gay, bisexual, queer and questioning (LGBQ) and trans/NB adults and youth, many conflate sexual orientation and gender identity, even though they are unique constructs with differential health experiences (Frohard-Dourlent, Dobson, Clark, Doull, & Saewyc, 2017). Although there may be situations where conceptually the two identities could be combined, it is also important to be able to assess them individually as well as their intersection. This study explores LGBQ and trans/NB adolescents’ sexual behavior experiences (specifically, whether they have ever been sexually active, age of sexual debut, and number of partners) and associations with mental health and bullying, using representative data from the Healthy Kids Colorado Survey (HKCS), and offers suggestions for improving services for young people in the United States.
Prevalence of LGBQ and Trans/NB Identities
Given that neither sexual orientation nor gender identity is collected as part of large nationally representative surveys such as the U.S. Census, estimates tend to vary on how many LGBQ adults live in the United States, with prevalence rates of LGBQ adults aged 18 years and above ranging from 2.2% to 6.8% (Copen, Chandra, & Febo-Vazquez, 2016; Gates, 2011). The numbers are even higher among youth in the United States, with studies reporting higher proportions: 2% identify as lesbian or gay, 6% identify as bisexual, and another 3.2% stating they are unsure about their sexual orientation, for an estimated total of about 11% of youth (Kann et al., 2014). It is important to note a substantial portion of research about sexual identities and orientations, including those regarding youth, do not offer response sets that encompass the large spectrum of identities that are used increasingly in youth communities, such as queer, omnisexual, asexual, pansexual, and demisexual (Human Rights Campaign, 2018; Jacobsen & Donatone, 2009).
An estimated 0.6% to 5% of adults in the United States are trans/NB (Herman, Flores, Brown, Wilson, & Conron, 2017; Transgender Law and Policy Institute, n.d.). Young people aged 13 to 24 years are more likely to identity as trans/NB than previously, with various studies reporting 0.7% to 3.2% of young people identifying as trans/NB (Eisenberg et al., 2017; HKCS, 2015; Herman et al., 2017; Wilson & Kastanis, 2015) and another 1.6% questioning their gender (HKCS, 2015). The trans/NB umbrella of identity is inclusive of all people whose gender is not in alignment with the social expectations associated with the sex assigned to them at birth. As a category, trans is inclusive of those who want to transition completely from male to female or from female to male, as well as those who have fluid genders or no gender at all. This includes individuals who are nonbinary, gender diverse, genderqueer, gender-fluid, and agender. As the terminology pertaining to gender identity changes frequently and depends on many individual variables, prevalence rates vary from source to source (Olson-Kennedy et al., 2016). Throughout this article we will use the term trans/NB to refer to any youth who does not identify as cisgender (non-transgender).
The Conflation of Trans/NB and LGBQ Youth in Existing Research
Many existing studies of trans/NB and LGBQ adolescents conflate sexual orientation and gender identity, and more research is needed to examine the specific needs of each of these groups of adolescents independently (Fassinger & Arseneau, 2007; Galupo, Bauerband, et al., 2014; Galupo, Davis, Grynkiewicz, & Mitchell, 2014). LGBQ and trans/NB respondents are often combined together as a single analytic category, frequently to facilitate quantitative research with these adolescents. Few studies in the past have assessed for trans/NB and LGBQ adolescents and their multiple identities, and when they have been assessed it has often been conducted with limited items that have not allowed for the breadth of LGBQ and trans/NB identities to be represented (e.g., often “transgender” has been included as a sexual orientation response option). This combined analytic strategy has been an important step in developing knowledge about LGBQ and trans/NB youth as a whole compared to cisgender heterosexual youth (James et al., 2016). Nonetheless, cisgender LGBQ respondents have differential experiences compared with their trans/NB peers (Frohard-Dourlent et al., 2017). There is a need for more intentional and culturally responsive research which recognizes gender identity and sexual orientation as intersecting yet separate constructs that act as independent factors which impact behavioral health outcomes.
LGBQ and Trans/NB Adolescent Sexual Behavior
Some research documents the differential sexual experiences of adolescents by their sexual orientation and has shown increased risky sexual behaviors among LGB adolescents compared with their heterosexual and questioning peers. Among a representative sample of high school students in the United States, ever having had sexual intercourse was reported by 40.9% of heterosexual students, 50.8% of LGB students, and 31.6% of students who were questioning their sexual identity (Kann et al., 2014). In an online study of cisgender adolescents aged 13 to 18 years in the United States, rates of any sex (oral, vaginal, or anal) for heterosexual males and questioning males were significantly lower than rates for both gay and bisexual adolescent males (Ybarra & Mitchell, 2016). Similarly, the rates were significantly lower for heterosexual and questioning cisgender female adolescents than for lesbian and bisexual adolescent females (Ybarra & Mitchell, 2016). Early sexual debut—defined as sex before a certain age, often 13 years—is associated with increased sexual risk, substance use, and suicidality in youth (Lowry, Dunville, Robin, & Kann, 2017). For U.S. high school students in 2015, 3.4% of heterosexual students reported sex before the age of 13 years, compared with 7.3% of LGB students and 8.8% of questioning students (Kann et al., 2014).
Furthermore, studies of adolescent’s sexual behavior have shown higher numbers of sexual partners among LGBQ adolescents. In one study, while 11.2% of heterosexual students reported having had more than four partners in their lifetime, 14.7% of LGB students and 12.9% of questioning students reported the same (Kann et al., 2014). Earlier, Garofalo, Wolf, Kessel, Palfrey, and DuRant (1998) found that LGB adolescents were more likely to report having three or more previous sex partners relative to their heterosexual peers. In a review of studies of LGB youth health, Coker, Austin, and Schuster (2010) found that both LGB identity and behavior (defined in their review as same-sex and both-sex) were associated with increased numbers of sexual partners. Among sexually active youth nationally, recent sexual contact (last 3 months) was reported by 30.1% of heterosexual students, 35.1% of LGB students, and 22.9% of questioning students (Kann et al., 2014). These few studies’ estimates suggest that nonheterosexual adolescents engage in increased risky sexual behavior relative to their heterosexual peers.
More recently, research has started to explore the experiences of trans/NB people other than trans women (i.e., those assigned male at birth, with a current gender identity of woman or transgender woman), who have historically been the focus of most transgender sexuality research (Institute of Medicine, 2012). Although trans/NB individuals are sometimes included in research on the lesbian, gay, bisexual, transgender, and queer (LGBTQ) community as a whole (e.g., they are often a small portion of total participants and have been excluded from many studies), there are a few studies that specifically explore the sexual behaviors of trans/NB youth. Trans/NB young people are more likely than their cisgender (non-transgender) counterparts to already have had their first sexual experience (30.0% vs. 22.0%) and to have had more than two partners in the past year (15.5% vs. 8.5%), based on a recent study from Minnesota that looked at these behaviors among ninth- and 11th-grade students (Eisenberg et al., 2017). An additional study found that trans/NB youth of color are more sexually active than their cisgender counterparts, with 98% of transgender women of color aged 16 to 25 years reporting having been sexually active within the past year, and almost half reporting having had condomless anal intercourse in the same time frame (Garofalo, Deleon, Osmer, Doll, & Harper, 2006). Trans/NB young people assigned male at birth are more likely to have had sex (33.2% vs. 28.6%), have had more than two partners in the past year (18.1% vs. 14.4%), and have been intoxicated during last sexual activity (31.7% vs. 17.2%) than young trans/NB people assigned female at birth. To date, there are no peer-reviewed studies that focus on the sexual behavior of nonbinary or genderqueer youth, despite the call from both nonbinary youth and researchers to conduct more inclusive research (Frohard-Dourlent et al., 2017).
Bullying, Mental Health, and Sexual Risk Behaviors
Research has only recently begun exploring the link between bullying and sexual risk taking. In 2013, Holt and colleagues found that both perpetrators of bullying and victims of bullying were more likely to report casual sex and sex under the influence of drugs or alcohol, perhaps as a maladaptive coping response to their bullying experience. Studies have also assessed a connection between mental health symptoms and diagnoses with sexual risk behaviors, perhaps as a symptom of a larger mental health issue (e.g., mania) or as maladaptive coping. For example, adolescents who meet criteria for mania were more likely to report multiple recent sexual partners and test positive for a sexually transmitted infection, and adolescents who met diagnostic criteria for externalizing disorders, internalizing disorders, or mania were more likely to report ever having penetrative sex (Brown et al., 2010). Among a nonclinical group of high school students, both males and females (the only genders assessed) who reported 10 or more depressed/stressed days in the prior month were more likely to report having sex without a form of contraception (Brooks, Harris, Thrall, & Woods, 2002).
Research Hypothesis/Question
Given the limited research on sexual behavior among LGBQ and trans/NB adolescents, we hypothesized that among a representative sample of young people, there would be increased rates of sexual experiences (i.e., ever having had sex, number of lifetime sexual partners, and age of sexual debut) among LGBQ and trans/NB youth compared with their heterosexual and cisgender peers. In addition, given previous research linking both bullying and mental health to sexual risk taking among adolescents generally, we asked as follows: How are experiences such as bullying and mental health issues related to these sexual behaviors?
Method
Study Sample
Data for this study come from the 2015 HKCS, a biennial statewide voluntary survey administered in public middle and high schools by the Colorado Department of Public Health and Environment (CDPHE; 2017), the Colorado Department of Human Services, and the Colorado Department of Education. School districts are randomly selected to participate in the HKCS. Within districts, schools are randomly selected, and within schools, classrooms are randomly selected. At each level except the classroom level, superintendents or principals may opt out of participation and superintendents may also choose to exclude certain survey items in their districts. For districts and schools that choose to participate, parents and students are notified that the survey will take place and that it is a voluntary activity. Both parents and students can refuse to participate.
Data for this study are weighted to reflect enrollment at Colorado public high school institutions. Weights included in the current study account for differences in ethnicity, grade, and sex between the sample and student populations, sampling design, and schools and student nonparticipation and nonresponse (CDPHE, 2017).
Analytic Sample
This study includes the Colorado representative sample of high school students for a total of 15,970 surveyed students. Seven schools opted out of the questions examined in the current study, resulting in 1,160 (7.2%) students being dropped. Respondents were dropped if they did not answer questions pertaining to sexual behaviors examined in this study (n = 1,346, 8.5%). Respondents were also dropped if they answered that they did not understand the question about gender identity (n = 302, 1.9%) or if they indicated they were below the age of 14 years (n = 66, 0.4%) as this is outside the typical high school age for students in the United States. This brought the final analytic sample to 12,890 students. In examining the age of sexual debut dependent variable, respondents who answered they had never had sexual intercourse were dropped from the model (n = 4,729, 36.7%).
Variables were tested for missingness. All variables but three were determined to be missing at random (age, sex, gender identity, depressive symptoms, in-school bullying victimization, and online bullying victimization), with missing data ranging from a low of 0.2% to a high of 1.9%. These variables were imputed using either mean or mode replacement by school. For the variables determined to be missing not at random (race/ethnicity, sexual orientation, and suicide attempts in the previous year), multiple imputation with chained equations was used (van Buuren, Boshuizen, & Knook, 1999).
Measures
Age was measured by asking “How old are you?” with responses ranging from 12 years old or younger to 18 years old or older (students below 14 years old were dropped due to inconsistency with the age of students typically enrolled in high school). Race/ethnicity was created by combining two questions: “Are you Hispanic or Latino? (yes/no)” and “What is your race?” Available responses were American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Other Pacific Islander, and White. As students were able to select multiple options, a Bi/Multiracial category was also created. Sex was measured with the options of male or female. For sexual orientation respondents were asked “Which of the following best describes you?” with a response set of heterosexual (straight), gay or lesbian, bisexual, and not sure. Gender identity was measured with the following prompt: “A transgender person is someone whose biological sex at birth does not match the way they think or feel about themselves. Are you transgender?” Response options were as follows: “No, I am not transgender”; “Yes, I am transgender and I think of myself as really a boy or man”; “Yes, I am transgender and I think of myself as really a girl or woman”; “Yes, I am transgender and I think of myself in some other way”; “I do not know if I am transgender”; and “I do not know what this question is asking.” Participant responses for the sexual orientation and gender identity measure were combined to produce a variable representing the intersection of gender identity and sexual orientation, creating nine unique categories of gender X sexual orientation (see Walls et al., 2019).
Depressive symptoms were measured with this question: “During the past 12 months, did you ever feel so sad or hopeless almost every day for two weeks or more in a row that you stopped doing some usual activities? (yes/no).” Attempted suicide was assessed with the question: “During the past 12 months, how many times did you actually attempt suicide?” Answers were recoded to denote no suicide attempts, one suicide attempt, or two or more suicide attempts.
To capture bullying experiences, two items were used: “During the past 12 months, have you ever been bullied on school property?” and “During the past 12 months, have you ever been electronically bullied? (Count being bullied through e-mail, chat rooms, instant messaging, websites or texting),” both with yes/no responses.
To examine the sexual behaviors of respondents, three items were used: “Have you ever had sexual intercourse? (yes/no)”; “During your life, with how many people have you had sexual intercourse? (I have never had sexual intercourse, 1 person, 2 people, 3 people, 4 people, 5 people, 6 or more people)”; and “How old were you when you had sexual intercourse for the first time? (I have never had sexual intercourse, 11 years old or younger, 12 years old, 13 years old, 14 years old, 15 years old, 16 years old, 17 years old or older).”
Data Analysis
Data were analyzed using Stata 15.0 (StataCorp, 2017). To accommodate the use of weights, survey commands were used. First descriptive statistics were run, followed by a regression model for each dependent variable (sex ever, number of sexual partners, and age of sexual debut) examining demographics, mental health, and bullying variables. For “sex ever,” a logistic regression was utilized as the dependent variable was binary. For “number of sexual partners,” a negative binomial regression was used as the dependent variable is a count. We initially used a Poisson regression, but examination of the model indicated overdispersion, prompting migration to the negative binomial model (Long, 1997). For “age of sexual debut” variable, an ordinary least squares (OLS) regression was used. All descriptive and inferential statistics were run using the multiply imputed data.
Results
Descriptive Statistics
Descriptive statistics are reported for two samples: all respondents for the sex ever and number of sexual partners models (n = 12,890) and then just those who reported ever engaging in sexual intercourse for the age of sexual debut model (n = 4,729; see Table 1).
Descriptive Statistics for All Study Variables.
Note. LGB = lesbian, gay, and bisexual; DK = don’t know.
Inferential Statistics
Sex ever
Multivariate findings for sex ever can be found in Table 2. Every 1-year increase in age was associated with a 92% increase in the odds of having sexual intercourse (adjusted odds ratio [AOR] = 1.92, 95% confidence interval [CI] [1.85, 1.99]). Participants who indicated male sex were more likely to have engaged in sexual intercourse (AOR = 1.46, 95% CI [1.351, 1.599]) compared with those who indicated a female sex. When compared with White respondents, Asian (AOR = 0.33, 95% CI [0.22, 0.48]) adolescents were less likely to report having engaged in sexual intercourse, while Latino (AOR = 1.29, 95% CI [1.18, 1.42]) and Bi/Multiracial (AOR = 1.37, 95% CI [1.21, 1.56]) adolescents were more likely to have engaged in sexual intercourse. No other racial differences emerged as significant. Compared with cisgender heterosexual adolescents, cisgender LGB adolescents (AOR = 1.41, 95% CI [1.20, 1.64]) were more likely to have had sexual intercourse, while cisgender questioning adolescents (AOR = 0.63, 95% CI [0.49, 0.81]) were less likely to do so. LGB youth who didn’t know if they were transgender (AOR = 4.71, 95% CI [2.11, 10.53]) were more likely to have engaged in sexual intercourse than their cisgender heterosexual peers. Reporting depressive symptoms (AOR = 1.58, 95% CI [1.43, 1.73]) and past suicide attempts (AOR = 1.73, 95% CI [1.55, 1.92]) were both associated with increased odds of reporting having had sexual intercourse. Reporting being bullied online (AOR = 1.80, 95% CI [1.58, 2.04]) was associated with 80% greater odds of having had sexual intercourse, while being bullied at school was not significant.
Regression Models of How Age, Race, and Sexual Orientation Relate to Sex Ever, Sex Partners, and Sexual Debut.
Note. For logistic regression, odds ratios are adjusted for the other predictors in the model. For negative binomial regression, the incident rate ratios are reported. LGB = lesbian, gay, and bisexual; DK = don’t know.
p ≤ .05. **p ≤ .01. ***p ≤ .001.
Sexual partners
In the model examining sexual partners (Table 2, Model 2), we found that for every increase in year of age (incidence rate ratio [IRR] = 1.67, 95% CI [1.62, 1.71]), the rate for number of sexual partners increased by a factor of 1.67, holding all other variables constant. Participants who indicated a male sex (IRR = 1.56, 95% CI [1.46, 1.66]) had a rate that was 1.56 times greater than those who indicated a female sex. In comparison with White adolescents, identifying as Black (IRR = 1.33, 95% CI [1.09, 1.62]), American Indian or Alaska Native (IRR = 1.35, 95% CI [1.07, 1.72]), Latino (IRR = 1.21, 95% CI [1.12, 1.30]), or Bi/Multiracial (IRR = 1.38, 95% CI [1.26, 1.52]) was associated with higher counts of sexual partners, while identifying as Asian (IRR = 0.49, 95% CI [0.37, 0.65]) was associated with lower counts of sexual partners. Cisgender LGB (IRR = 1.43, 95% CI [1.27, 1.61]), transgender LGB (IRR = 1.48, 95% CI [1.09, 2.02]), and transgender questioning (IRR = 2.56, 95% CI [1.61, 4.07]) adolescents had rates that were greater than their cisgender heterosexual peers, while cisgender questioning (IRR = 0.82, 95% CI [0.67, 0.99]) adolescents emerged as having a rate that was lower than cisgender heterosexual adolescents.
Young people who experienced depressive symptoms (IRR = 1.34, 95% CI [1.24, 1.44]) and those who had attempted suicide in the past year (IRR = 1.41, 95% CI [1.31, 1.52]) had higher rates than those without depressive symptoms and with no suicide attempts, respectively. Finally, those who had experienced electronic bullying (IRR = 1.50, 95% CI [1.36, 1.66]) had a greater rate than those who had not, while experiencing bullying at schools was not a significant predictor of number of sexual partners.
Sexual debut
A multiple linear regression model was conducted to predict the influence of demographic variables and mental health (Table 2, Model 3) on age of sexual debut. The model, F(19, 4682.7) = 24.35, p < .001, R2 = .09, significantly predicted age at sexual debut. Participants who indicated male sex (β = −0.51, p < .001) were associated with almost half a year lower age of sexual debut compared with those assigned female at birth. In comparison with White adolescents, identifying as Black (β = −0.49, p < .001), American Indian or Alaska Native (β = −0.52, p < .001), Latino (β = −0.28, p < .001), or Bi/Multiracial (β = −0.48, p < .001) was associated with lower age of sexual debut ranging from approximately 3 to 6 months younger. In comparison with adolescents who identified as cisgender heterosexual, identifying as cisgender LGB (β = −0.43, p < .001), transgender heterosexual (β = −0.77, p < .001), transgender LGB (β = −0.72, p < .001), transgender questioning (β = −1.47, p < .001), and don’t know if transgender questioning (β = −0.81, p < .01) was associated with a range of approximately 6 to 21 months younger age of sexual debut.
For each shift in suicide attempts (none to 1 time, and 1 time to 2 or more times) young people, on average, had approximately a 4-month earlier sexual debut (β = −0.32, p < .001). Finally, experiencing in-school bullying (β = −0.15, p < .05) or electronic bullying (β = −0.16, p < .05) was associated with a lower age of sexual debut of approximately 2 months compared with those who reported no bullying experiences.
Discussion
Our findings clearly demonstrate the importance of attending to the intersection of sexual orientation and gender identity when providing either education on healthy sexuality or sexual health–related services to young people. Across all three dependent variables examined—having ever had sex, the number of sex partners, and age of sexual debut—we found differences at this intersection, suggesting that a nuanced understanding of different needs of young people based on these identities (as well as age, sex, and race/ethnicity) is critical. These findings are a cautionary tale for researchers against either siloing sexual orientation and gender identity from one another into completely separate categories (as if no LGBQ individuals are also trans/NB) or combining them into the same category (one large LGBTQ group). There have, to date, been no studies examining sexual behavior that look at the intersection of gender identity and sexual orientation in this way. The conflation of these multiple categories of identity will likely fail to accurately capture the lived experiences of these young people, thereby limiting the ability of preventionists to address these groups of youth shown to have substantial sexual health needs (to be “at risk”) relative to their cisgender heterosexual peers. While some of the findings mirror existing studies, such as the fact that sexual orientation and gender identity may play a role in certain sexual behaviors, these findings indicate that it is necessary to parse out the intersections of gender and sexual orientation, rather than painting either one with a wide brush. Cisgender and transgender LGB young people, as well as cisgender and transgender young people who were not sure of their sexual orientation were, for the most part, more likely to have had sex, more sexual partners, and younger sexual debuts than their cisgender heterosexual counterparts. These differences were especially striking for transgender young people who were questioning their sexual orientation. This pattern of increased likelihood is in line with extant research demonstrating that LGB cisgender individuals and transgender young people of all sexual orientations have earlier sexual debuts than their heterosexual peers (Blake et al., 2001; Tornello, Riskind, & Patterson, 2014; van Griensven et al., 2004). One association that has been documented with earlier sexual debut and sexually risky behavior is having had adverse childhood experiences, including relationship strain between the young person and one or both parents (Hillis, Anda, Felitta, & Marchbanks, 2001). LGBTQ youth (as one grouping) have been shown to have higher rates of adverse childhood experiences (Andersen & Blosnich, 2013; Zietsch et al., 2012) which may partially explain our findings. Hillis and colleagues (2001) suggest that the need to obtain close interpersonal connections may be the driving force undergirding this pattern. However, these studies either looked at sexual orientation and gender identity as completely separate experiences or placed them together, while our findings note different experiences across the intersections.
Young people who were not sure if they were transgender—whether heterosexual, LGB, or questioning their sexual orientation—were not significantly different than cisgender heterosexual young people in any of these behaviors (except for those who were also LGB regarding age of sexual debut). But given the smaller cell sizes for these groups, these findings should be interpreted with caution. Additional research with a larger sample of young people who are not sure of their gender identity is warranted to clarify these results.
A similar pattern emerged when we examined the relationship between these dependent variables and mental health and bullying experiences. Young people who experienced depressive symptoms or who had attempted suicide were more likely to have had sex and more sexual partners than those who did not, and young people who had attempted suicide had younger sexual debuts than young people who did not report a suicide attempt. Except for having had an earlier sexual debut of approximately 2 months, young people who reported being bullied at school were not significantly different in these sexual behaviors than those who were not bullied at school. However, having experienced electronic bullying followed the same pattern of being associated with increased likelihood of having had sex, a higher number of sexual partners, and a younger sexual debut. Although causal direction cannot be determined with our data, the strong correlations nonetheless underscore the importance of social workers and other helping professionals being prepared to respond to the complex needs of young people in a manner that is culturally responsive and recognizes the accrual of risks across various life domains.
Currently, only four states (California, Colorado, Iowa, and Washington) and Washington, DC, require sex education to include content relevant to LGBTQ-identified youth. Some states, including Arizona, Texas, Utah, Louisiana, South Carolina, Mississippi, and Oklahoma, specifically prohibit LGBTQ-relevant information to be shared. At least one state (Alabama) has a policy that not only prohibits sharing information on LGBTQ identities but also requires teachers to actively speak against them (Sexuality Information and Education Council of the United States [SIECUS], 2015). Some other states, (e.g., North Carolina and Florida) require teachers to focus on monogamous different-sex marriage as the only option discussed in health or life skills courses (SIECUS, 2015). Despite 93.5% of parents supporting the provision of sex education to their high school children, a number of states, cities, and local school districts do not offer sex education in schools (Kantor & Levitz, 2017). For the most part, research has not examined the experiences of LGBQ and trans/NB individuals’ experiences of sexual education with the exception of one study that found that transgender young people did not believe that sexual health education was relevant to them as they believed they were at low risk for HIV and/or STI infection-transmission or unintended pregnancy (Magee, Bigelow, DeHaan, & Mustanski, 2012).
Despite significant controversy regarding the provision of comprehensive sex education in the United States, studies have demonstrated that the implementation of sex education inclusive of all identities and backgrounds results in multiple positive sexual health behaviors, including delayed onset of sexual debut, reduced number of sexual partners, less condomless sex, and increased contraceptive use (Advocates for Youth, 2008; Kohler, Manhart, & Lafferty, 2008; SIECUS, 2015). The extant scholarship has, however, failed to address whether LGBQ and trans/NB young people have similar positive outcomes when provided with inclusive sex education.
Our results underscore the need for more inclusive sexual health services and education that addresses the needs of LGBQ and trans/NB youth. Given the findings related to age of sexual debut, these services and educational programs need to begin earlier than high school. We agree with the call for LGBTQ-inclusive sex education that has been issued by SIECUS and its professional partners: Advocates for Youth, the Human Rights Campaign, Planned Parenthood, Answer at Rutgers, and GLSEN (SIECUS, 2015). We further suggest that inclusive sex education specifically address the needs of trans/NB youth, as including LBGQ-responsive education is not enough. As more research is conducted to explore the sexual experiences of youth with diverse gender identities (including using more diverse definitions of sexual activity), this information should be used to help develop more nuanced and responsive sex education, including continuing education trainings for professionals, materials (e.g., posters, textbooks, videos, and podcasts) and curricula for educators, and evidence-based interventions for service providers. Currently, there is not enough information available for teachers, counselors, and other youth professionals to ensure that they are effectively including LBGQ and trans/NB identities in their classes and outreach (SIECUS, 2015).
Limitations
It is important to note some of the limitations that may be associated with our findings. As with all cross-sectional surveys, these data are a snapshot of one point in time, meaning that causations cannot be made, and findings may be different when examined with a longitudinal methodology. In addition, the language used around sexual orientation and gender identity is incredibly fluid and constantly evolving and shifting. Many identities common among young people such as queer, asexual, omnisexual, pansexual, nonbinary, gender-fluid, and gender queer were not included as response options on this survey, making it difficult to know how individuals with these identities responded, or whether they chose to skip some questions due to not feeling able to select an existing option. In addition, the small response rates from certain racial and ethnic groups (notably Asian, American Indian, Black/African American, and Native Hawaiian/Alaska Native) may have resulted in too little power to accurately detect significance around race. Moreover, the items that asked about sexual activity made assumptions about these activities following heterosexual norms; there were no questions about dams or gloves being used, or frequency of nonpenetrative sexual activities. Given the goal of this article to focus on LGBQ and trans/NB individuals, it is highly likely that these groups were further marginalized by the phrasing of questions about sexual activity.
One final limitation to note is that due to the nature of some questions on the survey (e.g., on sex, drugs, and alcohol), there were many levels at which groups and individuals opted out of specific questions or the survey itself. Some school districts and individual school principals chose to block out sections of the survey regarding sex and sexuality items, meaning that we do not know whether the participants from those districts or schools would have had similar responses to those students in areas fully participating, or if perhaps these students in less sexuality-affirming areas would have had different rates of sexual behaviors. Even given these limitations, this large, population-based statewide survey was one of the first to include both sexual orientation and gender identity, allowing researchers to better understand the nuances between and within these two constructs.
Conclusion
Despite the research that over many decades has lumped LGBTQ individuals together into one population, and despite the limited research around sexual behavior and the need for comprehensive sexuality education, these findings indicate that there is a complex interplay between sexual orientation and gender identity, and that separating them into two groups (LGB/questioning and transgender/nonbinary) does not offer an acceptably nuanced examination of sexual behaviors among these youth to address their sexual health needs. These findings underscore the importance of comprehensive and inclusive sexuality education and culturally responsive services for all young people. They also point to a need for the collection of more robust identity information and analysis for LGBTQ individuals.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
