"I wouldn't have felt so alone": The sexual health education experiences of transgender and gender diverse youth living in the southeastern United States.

BACKGROUND: Transgender and gender diverse youth experience multiple disproportionate adverse sexual health outcomes. Sexual health education teaches knowledge, attitudes, and skills for promoting sexual health, including reducing risk for sexually transmitted infection, HIV acquisition, and unintended pregnancy. Provision of sexual health education may be protective, but research remains scarce. METHODS: We conducted a multi-stage thematic analysis of 33 in-depth interviews among transgender and gender diverse youth (ages 15-24) living in the southeastern United States on their sexual health education experiences. RESULTS: Our study participants described school-based sexual health education as unhelpful due to a lack of relevant information, inadequately prepared teachers, and a perceived negative tone toward sexuality. They reported relying on online sources of sexual health information, finding relevant content and community despite some limitations. Participants desired content and pedagogy that expands beyond binary and white-centric presentations of sexuality and gender and sought resources that provide relevant, accurate, and judgment-free information while holding positive framing around sexuality and gender. CONCLUSION: There is much work needed to improve the breadth, quality, and relevance of school-based sexual health education. Sexual health education can improve by strengthening critical media literacy skills of youth; raising staff cultural competency on gender, race, and sexual identity through training and supports; using culturally relevant and inclusive curricula; and partnering with community-based organizations. Transgender and gender diverse youth would benefit from sexual health education from multiple sources which is queer-friendly, affirms their existence, and provides information on gender, race, and sexuality in positive and expansive ways.

The CDC's Division of Adolescent and School Health Approach to Sexual Health Education in Schools: 3 Decades in Review.

BACKGROUND: School health education, including sexual health education, plays a crucial role in shaping adolescents' protective health behaviors, experiences, and outcomes. Adolescents need functional knowledge and skills to practice, adopt, and maintain healthy behaviors for preventing sexually transmitted infections (STIs), including human immunodeficiency virus (HIV), and unintended pregnancy. METHODS: The US Centers for Disease Control and Prevention's Division of Adolescent and School Health (CDC/DASH) has advanced school-based approaches to STI/HIV and pregnancy prevention through surveillance, research and evaluation, and program partnership and collaboration for over 3 decades. RESULTS: CDC/DASH uses systematic and innovative strategies to identify the breadth of adolescent sexual health evidence; characterize key elements of effective educational curricula; and provide practical guidance to support school-based delivery. CDC/DASH's approach to effective health and sexual health education in schools has changed dramatically over the past 30 years and must continue to progress. CONCLUSION: This paper describes how and why that approach has evolved and outlines directions for the future.

Minority Stress, Coping, and Transgender Youth in Schools-Results from the Resilience and Transgender Youth Study.

BACKGROUND: Transgender youth report high rates of negative experiences in schools. Using a lens of minority stress, this study sought to examine in-school experiences of transgender youth to understand youth coping and to identify key opportunities for improving school environments for transgender youth. METHODS: Participants included 41 youth across 33 in-depth interviews (Mage  = 21.7) and two focus groups (N = 8; Mage  = 17.3). Thematic analysis was used to analyze data. Themes related to stress, coping, and facilitators/barriers to stress/coping were derived and coded. RESULTS: Distal stressors, such as structural discrimination and prejudice events, were found to contribute to the exclusion of transgender youth from school life, while proximal stressors, such as concealment and expectations of rejection, reinforced transgender youth's feelings of personal isolation. Participants expressed coping with both challenges by advocating for inclusion through direct action with teachers and administrators and seeking/finding connection with trusted staff and peers. CONCLUSIONS: Findings suggest that creating safe and supportive environments at school for transgender youth is an attainable goal, as all identified barriers to inclusivity and connection were modifiable. By considering the needs of transgender youth in policies and programming, schools may improve climate for and wellbeing of transgender students.

School district-provided supports to enhance sexual health education among middle and high school health education teachers.

Schools support teachers in their professional learning, just as teachers support students in their learning. To accomplish this, schools can provide support systems that enhance teachers' knowledge, comfort, and instructional skills. This study examined the impact of two district-provided supports (curriculum and professional development) on sexual health instruction among middle and high school health education teachers. Data were abstracted and analyzed using inductive coding from 24 teacher interviews (2015-2016). Findings illustrate outcomes from both curriculum and PD on teachers' self-reported knowledge, comfort, and skills. The district-provided supports appeared to contribute to improved teachers' self-efficacy in delivering sexual health education.

Protective Factors Among Transgender and Gender Variant Youth: A Systematic Review by Socioecological Level.

Transgender and gender variant (GV) youth experience elevated risk for poor health and academic outcomes due mainly to social experiences of stigma and discrimination. To supplement the growing evidence on health risks encountered by transgender/GV youth, we identified factors theorized to be protective for these youth across all four levels of Bronfenbrenner's socioecological model (individual, relationship, community, societal). We conducted a systematic search of peer-reviewed research. The articles included in this review were published in peer-reviewed journals in English or Spanish between 1999 and 2014, analyzed data from a sample or subsample of transgender or GV participants with a mean age between 10 and 24 years, and examined the relationship of at least one theorized protective factor to a health or behavioral outcome. Twenty-one articles met inclusion criteria. Transgender/GV youth in included articles ranged from 11 to 26 years of age, were racially/ethnically diverse, and represented varied gender identities. Within these articles, 27 unique protective factors across four levels of the ecological model were identified as related to positive health and well-being. Self-esteem at the individual level, healthy relationships with parents and peers at the relationship-level, and gay-straight alliances at the community level emerged as protective factors across multiple studies. Our findings underscore the relative lack of research on transgender/GV youth and protective factors. Novel recruitment strategies for transgender/GV youth and better measurement of transgender identities are needed to confirm these protective relationships and identify others. Growth in these areas will contribute to building a body of evidence to inform interventions.

Systematic Mapping of Relationship-Level Protective Factors and Sexual Health Outcomes Among Sexual Minority Youth: The Role of Peers, Parents, Partners, and Providers.

Sexual minority youth (SMY) experience elevated rates of adverse sexual health outcomes. Although risk factors driving these outcomes are well studied, less attention has been paid to protective factors that potentially promote health and/or reduce negative effects of risk. Many factors within interpersonal relationships have been identified as protective for the sexual health of adolescents generally. We sought to systematically map the current evidence base of relationship-level protective factors specifically for the sexual health of SMY through a systematic mapping of peer-reviewed observational research. Articles examining at least one association between a relationship-level protective factor and a sexual health outcome in a sample or subsample of SMY were eligible for inclusion. A total of 36 articles reporting findings from 27 data sources met inclusion criteria. Included articles examined characteristics of relationships with peers, parents, romantic/sexual partners, and medical providers. Peer norms about safer sex and behaviorally specific communication with regular romantic/sexual partners were repeatedly protective in cross-sectional analyses, suggesting that these factors may be promising intervention targets. Generally, we found some limits to this literature: few types of relationship-level factors were tested, most articles focused on young sexual minority men, and the bulk of the data was cross-sectional. Future work should expand the types of relationship-level factors investigated, strengthen the measurement of relationship-level factors, include young sexual minority women in samples, and use longitudinal designs. Doing so will move the field toward development of empirically sound interventions for SMY that promote protective factors and improve sexual health.

Association between parent-adolescent communication about sex-related topics and HIV testing, United States. 2006-2013.

Adolescents need information about sex-related topics in order to reduce risk behavior and engage in healthy sexual decision-making. Parents have the potential to be an important source of this information. Using the 2006-2010 and 2011-2013 National Survey of Family Growth, we examined associations between parent-adolescent communication before age 18 about sex-related topics and HIV testing among respondents aged 18-24 that ever had sexual intercourse (women = 3893; men = 3359). Analyses showed that for both men and women, discussing how to prevent HIV/AIDS and how to use a condom with a parent before age 18 were positively associated with HIV testing. Among women only, discussions about methods of birth control, where to get birth control, and STDs were positively associated with HIV testing. Developing strategies and interventions to facilitate parent-adolescent communication about sex-related topics, particularly HIV prevention and condom use, may be important to increase HIV testing among young women and men.

Individual-level protective factors for sexual health outcomes among sexual minority youth: a systematic review of the literature.

Although factors associated with negative sexual health outcomes among sexual minority youth (SMY) have been well documented, protective factors have been less studied. This review summarises the current state of science on individual-level protective factors for SMY and identifies gaps to inform future research. A systematic search of non-intervention, empirical peer-reviewed research was conducted. Articles that examined an a priori-identified individual-level protective factor and at least one sexual health outcome in a sample or subsample of SMY aged 10-24 years in Western, industrialised countries were eligible for inclusion. A total of 21 articles that reported data from 13 unique studies met inclusion criteria. Only two studies described findings for young sexual minority women and thus the literature synthesis was limited to studies reporting on young men who have sex with men (YMSM) in the USA. A total of 11 individual-level protective factors were examined. Subjective peer norms and attitudes about condom use were repeatedly protective in cross-sectional analyses. Findings related to self-efficacy, self-esteem and clear and positive identity were more mixed. The findings of this review suggest that attitudes and subjective peer norms related to condom use are promising intervention targets for YMSM. There is a need, however, for longitudinal research to confirm these protective effects and to consider them among other SMY. Moreover, protective factors related to skills and competencies have been insufficiently studied among SMY. Addressing these gaps will help develop a robust body of evidence to inform interventions.

Young Sexual Minority Males in the United States: Sociodemographic Characteristics And Sexual Attraction, Identity and Behavior.

CONTEXT: HIV incidence is increasing among 13-24-year-old U.S. men who have sex with men, yet limited research is available to guide HIV prevention efforts for this population. METHODS: National Survey of Family Growth data collected in 2002, in 2006-2010 and in 2011-2013 from 8,068 males aged 15-24 were analyzed to describe the population of U.S. young sexual minority males (i.e., males reporting same-sex attraction, identity or behavior). Correlates of sexual minority classification were assessed in logistic regression models. RESULTS: An estimated 10% of young males, representing a population of 2.1 million, were sexual minorities. Males had an elevated likelihood of being sexual minorities if they were aged 18-19 or 20-24, rather than 15-17 (prevalence ratio, 1.7 for each); belonged to nonblack, non-Hispanic racial or ethnic minority groups (1.6); had no religious affiliation, rather than considering religion very important (1.9); or lived below the federal poverty level (1.3). They had a reduced likelihood of being sexual minorities if they lived in metropolitan areas outside of central cities (0.7). Among young sexual minority males, 44% were 15-19 years old, 29% were poor and 59% resided outside central cities. Forty-seven percent had engaged in same-sex behavior. Of those with data on all measured dimensions of sexuality, 24% reported same-sex attraction, identity and behavior; 22% considered themselves heterosexual, yet had had a male sex partner. CONCLUSION: Future investigations can further explore subpopulations of young sexual minority males and assess sexual trajectories, resilience and HIV risk.

Advancing adolescent sexual and reproductive health by promoting healthy relationships.

The field of public health faces a challenge in preventing adverse sexual and reproductive health outcomes such as sexually transmitted diseases, unintended pregnancy, and dating and sexual violence among adolescents. Innovative approaches are needed to better address these issues. Focusing on healthy relationships is an emerging approach that may be used to promote adolescent sexual and reproductive health. In this report, we discuss the need for innovative and efficient strategies for adolescent sexual and reproductive health, the benefits of a healthy relationships approach, describe the need for a science-based conceptual framework on healthy relationships, and provide some considerations for developing a conceptual framework of healthy relationships in order to move the field of public health forward.