Puberty Health and Sex Education Content for Online Educational Resources for Gender-Independent, Intersex, Non-Binary, and Transgender (GIaNT) Youth

Abstract

Gender-independent, intersex, non-binary, and transgender (GIaNT) youth have puberty health and sex education needs that are different from cisgender youth. Unfortunately, this population has historically been excluded from curricula pertaining to these issues in schools throughout the U.S. and Canada. While sex education programs are limited for all youth, and navigating puberty can range from exciting to scary for all youth, GIaNT youth are particularly vulnerable to facing negative outcomes by being omitted from such curricula. Because they are not able to access adequate information in schools and in their family/friend networks, a majority of GIaNT youth turn to the internet to seek out resources for education on puberty health and sex education. To this end, our team is in the process of creating an online educational resource (OER) that is age-appropriate and affirming for GIaNT youth to be provided with resources that are personalized to users’ unique needs. This literature review discusses content suggestions for inclusion of comprehensive puberty health and sex education that caters to GIaNT youth and their unique needs.

1. Introduction

Gender-independent, intersex, non-binary, and transgender (GIaNT) youth have puberty health and sex education needs that differ from their cisgender peers [1,2,3]. Throughout the U.S. and Canada, sexual education curricula are designed and implemented often with cisgender youth in mind, leaving non-cisgender youth’s specialized puberty health and sex education needs unaddressed [2,3]. A couple of studies have previously been conducted on this population and topic to identify the gaps in existing curricula and to hear from GIaNT youth directly what they would like to see, content-wise, in a sexual education program [2,3]. These youth, through focus groups and interviews, have demonstrated an urgent necessity and desire for comprehensive and inclusive puberty health and sex education curricula to be made accessible for them, especially through online platforms. GIaNT youth perceived online settings to be “safe” [2,4,5] because they can navigate these spaces without external influences like caretakers, parents, peers, figures of authority, or homophobic and/or transphobic judgment [3,4]. Due to the exclusion of puberty health and sex education in existing curricula for GIaNT youth, a majority of this population access this information online [3,4]. For example, GIaNT youth in Perth, Australia communicated to facilitators/researchers during focus group sessions that their only exposure to sexual education curricula focused on issues of pregnancy and sexually transmitted infections, and only in the context of cisgender youth [6]. While this is useful information for all youth, such curricula are exclusionary towards the unique needs that GIaNT youth have indicated as important and relevant to them regarding navigating puberty and sex. To this end, disseminating comprehensive puberty health and sex education information online, in GIaNT youth’s preferred and more accessible avenue, is promising [5,7,8].

This literature review informs our research team’s online educational resource (OER) that combines gaming, online open-access resources, and puberty health/sex education information. The aim is to create an OER that is affirming, age-appropriate, and engaging for youth within this population. The findings from this paper will be used to develop the content for this resource. In addition to our team’s research, the findings from this paper can be used to advance the literature and research on the development and use of puberty health and sex education information for GIaNT youth, be used by sex educators, sex education curriculum-development, and those who look to create an online educational resource dealing with puberty health and sex education. During a preliminary search of the existing literature, key categories were developed to implement on our website: puberty health, sex education, social transition, medical transition, healthcare, mental health, and healthy relationships. This paper has been structured on (1) gaming/OER use and (2) suggestions for content inclusions for OERs and curricula for GIaNT youth, including puberty health and sex education needs. Our vision for this literature review and our accompanying OER is to inspire other researchers, web developers, and puberty health and sex educators to make use of this information in the development of their programs and resources.

Background

Gender-affirming care is when social and healthcare providers recognize, acknowledge, and center supportive care for marginalized communities [9,10,11,12]. Gender-affirming care for GIaNT youth and young adults has been found to improve their mental well-being and overall health and has been shown to reduce the risk of negative mental health outcomes for GIaNT youth [13]. Having access to information for gender-affirming care can be the first step to preventing negative mental health effects and suicidality caused by pervasive cisnormative ideals and a lack of access to care that extends to most of the Western world [14,15]. Many of the existing online resources available focus on one topic or aspect of puberty health or sex education needs for GIaNT youth. For example, many of the existing games and OERs for GIaNT youth focus on mental health and possible modes of mental health intervention [6,16]. While mental health is, of course, one aspect of an integrated view of health (especially when caring for GIaNT youth), it is not a holistic approach to healthcare, thereby limiting the wide range of health needs for GIaNT youth [17,18]. A national survey examining transgender discrimination in the United States found that 41% of transgender respondents reported attempting suicide, compared to 1.6% of the cisgender population [19]. To this end, it is important to approach this concept with careful consideration as to what content should be included in a PHSE curriculum that is holistic, positive, and affirming for GIaNT youth. The suggested content categories for such a resource are separated and taken up in the results section of the paper.

2. Materials and Methods

This paper is a literature review that uses an inductive, exploratory thematic analysis. This paper was written following an accompanying scoping review in accordance with the Johanna Briggs Institute (JBI) guidelines [20]. After completing the scoping review and identifying gaps in the existing literature on this topic, our team built upon these findings by supplementing them with qualitative research to fill the gaps in the literature that the scoping review identified. The sources used in this article were found by conducting in-depth database searches in the following databases, which included both peer-reviewed and grey literature, in July 2023: CINAHL, Cochrane, Epistemonikos, ERIC, Gender Studies Database, GenderWatch, LGBTQ+ Source, ProQuest, ProQuest Dissertation and Theses Global, PsychInfo, and Scopus. Searches were conducted using the following Boolean search terms: [Line #1] Adolescen* or Child* or teen* or youth or “young adult” OR “young people” OR kids [AND Line #2] “sexual minorit*” OR “Sexual orientation” OR “gender minorit*” OR “gender identit*” OR “gender expression*” or “gender divers*” or “Questioning Persons” or “Gender Transition” or transgender or non-binary or nonbinary or “gender diverse” or “gender minorit*” or agender or “gender queer” or genderqueer or bigender or LGBT* OR intersex OR 2SLGBTQIA+ OR “gender independent” OR “trans and nonbinary” OR “trans and non-binary” OR transsexual* OR “gender nonconforming” OR “gender non-conforming” OR “gender-nonconforming” OR GNC OR “trans men” OR “trans women” OR “trans people” OR “FTM” OR “female to male” OR “MTF” OR “male to female” OR SGMY OR “sexual and gender minorit*” [AND Line #3] OER OR “open educational resource*” OR “interact* media” OR “digital interven*” OR “serious gam*” OR MMO OR “massive multiplayer online” OR “educational gam*” OR “digital gam*” OR “Video Gam*” or gam* OR “internet resource*” OR “online resource*” OR “digital resource*” OR “role play gam*” OR RPG OR avatar* OR “online gam*” OR “game-based learning” OR “game element” OR “game utilization” OR “game based learning” OR “computer gam*” OR “internet-based intervent*”.

The database searches were not limited to any region, country, or timeframe. A majority of the results were from the U.S./Canadian context, in English, and published within the past 10 years, which our team indicates is because of the recent emergence of literature relating to transgender topics that has begun in recent years. For this literature review, only English texts were chosen, and the geographical setting of this review focuses on the United States and Canada; however, supplemental studies were also included (namely in Australia), and all are within a Western context.

The first author of this article screened the populated articles and reviewed them for relevancy. Then, they selected a series of articles that shed light on a variety of topics related to GIaNT youth. Supplemental evidence was integrated using keyword searching in Western Online Libraries and Google for additional topics, notwithstanding these key categories (for example, social transition). Furthermore, some citations were included as part of Newman-Seymour’s background as a comprehensive sex educator and sexual assault prevention program facilitator with the University of Windsor and Western University.

Analysis

The categories used in this paper for content inclusion were established using an inductive, exploratory thematic analysis. The papers that were reviewed were analyzed for key content themes that became apparent to the researchers during the review process. These themes became the content categories: puberty health, gender dysphoria, gender exploration, social transition, medical transition, legal transition, and sex education. An additional category, terminology, was added by our research team to aid in the comprehension of concepts by youth. Relevant information was extracted from the included papers and synthesized in the findings section for each theme or category. In a review paper, Kirby et al. [21] analyzed 83 studies to measure the impact of comprehensive sex education curricula. The authors found that effective programs implemented the goals, objectives, and teaching strategies of the curricula themselves, and their implementation. Here, we strive to make connections between each category to be included and the goals, objectives, teaching strategies, and their implementation in an online format.

3. Results

3.1. Population

Transgender is referred to as an “umbrella” term that includes any individual who is not cisgender. This can include, but is not limited to, folks who are transgender women, transgender men, non-binary, gender-fluid, genderqueer, and more [10,22]. Intersex people are sometimes included in this category, but the best practice is for intersex people to determine for themselves if they identify as transgender or not [10,22]. Non-binary refers to individuals who do not acknowledge their gender identity to fit within the unwavering binary construction of man/woman [10,22]. This may include people who are gender-fluid, genderqueer, or agender [10]. Some people who are non-binary identify as transgender, but some individuals do not. In this literature review, our team uses gender-diverse, gender-questioning, and/or gender-independent in reference to any person who may view themselves as not cisgender, or who may be questioning their gender but have not aligned themselves with a single gender identity.

Our team defines youth as individuals aged nine to twenty-six. This age range was decided on during the early stages of this project because we found that much of the existing literature about GIaNT youth had older age ranges than we expected. None of the studies reviewed explained the justification for a seemingly older age range than what most people would categorize as youth; however, we inferred this age range may be for three reasons: (1) the potential use of (or desire to use) puberty blockers, effectively lengthening the puberty timeframe [23,24]. (2) The possibility of a second puberty, in reference to GIaNT individuals who choose to utilize hormonal therapy in their gender-affirming care process. Hormonal therapy brings about a second puberty process (physically) for individuals who have already surpassed puberty [23,24]. (3) The scarcity of resources and difficulty in accessing care for GIaNT youth led many individuals to come to an understanding of their gender identity in non-cisnormative timelines [23,24,25]. For these reasons, our team expanded our age range to affirm and implement a trans-centered lens to GIaNT youths’ puberty health needs. To justify the lower age range (beginning at 9 years old), there are a few reasons: (1) Overwhelmingly, research shows that the earlier people have access to comprehensive puberty health and sex education, the more effective it is at reducing the risk for unwanted pregnancy, STBBI transmission, and engaging in non-consensual and/or risky sexual activities [26,27]. Current suggestions for beginning sex education for youth begin at age five, or pre-school-aged youth, to prevent childhood sexual assault and abuse and other health risks like STBBI transmission [28,29,30]. (2) Furthermore, puberty can begin as early as 9 years old [31]. Having access to information on what to expect regarding changes in the body at the onset of puberty can provide GIaNT youth with information that may be useful to them before these physiological changes begin. It can help them make better informed decisions on what may be useful medical interventions, like the use of puberty blockers to delay the onset of puberty [32].

3.2. Suggestions for Content Inclusions for OER’s and Curricula for GIaNT Youth Puberty Health and Sex Education Needs

3.2.1. Terminology

A key feature of an OER and/or a curriculum supporting puberty health and sex education for GIaNT youth is a clear understanding of terminology for both the developers/educators and the youth receiving the information. To keep the experience of navigating the OER engaging and age-appropriate for youth, we recommend a quiz or interactive game at the beginning of the user experience to gauge comfort in terminology. This was inspired by an existing OER: https://genderfulresearchworld.com/ (accessed on 7 December 2023) [33]. The website is designed as a map, allowing the user to navigate different “stops” or learning objectives/concepts. Our team believes this layout/design to be fun and engaging, while still remaining educational. In regards to the content, we suggest expanding on the following terms early on to set a foundational language needed as other concepts are developed: sex, gender, gender binary, gender identity, gender dysphoria, gender expression, transgender, trans-masculine (transmasc), trans-feminine (transfemme), non-binary, gender-independent/gender-diverse, gender-questioning, pronouns, and social transition [34,35].

3.2.2. Puberty Health

Puberty refers to the physical changes to a person’s body from childhood into adulthood. This can manifest as development into sexual maturity in genitals, changes in voice, changes in body-weight distribution, emotional changes, hormonal changes, and body hair development [36]. For most people, this happens around ages eight to fourteen, but for others, these changes can begin at a younger or older age [36]. As discussed above, this period can be longer for GIaNT youth in comparison to cisgender youth [37,38]. Puberty changes can be a time that imbues a wide range of emotions (including fear and excitement) for all youth, but can be particularly difficult for GIaNT youth who are not provided with adequate information regarding puberty in gender-marginalized contexts. Puberty can also be a time that is particularly dysphoric for GIaNT youth [39,40]. For this population, having access to vetted information that is relevant to their feelings towards their identities is necessary for this transitory period in their lives. As such, information regarding gender dysphoria, gender exploration, puberty blockers, social transition, medical transition, and legal transition should be provided to them [8,41]. In what is to follow, these concepts are discussed.

3.2.3. Gender Dysphoria

Some GIaNT youth may experience gender dysphoria [36]. Gender dysphoria is typically understood as the psychological distress a person experiences when there are incompatibilities between their assigned sex at birth and their gender identity [36]. Gender dysphoria can be experienced in a variety of ways, severity, and timelines for different people [36,41]. Historically, GIaNT people have been subjected to pathologization and hyper-medicalization in the Western context; hence, this aspect of puberty health education needs to be disseminated with care. Unfortunately, in the United States and in Canada, an individual needs to follow the states’ or provinces’ process to be diagnosed with “gender dysphoria” to undergo any form of medical intervention, if they choose to do so, in accordance with existing diagnostic criteria with the DSM-5 [36].

3.2.4. Gender Exploration

In Western societies, it is often enforced that a person’s gender is “naturally” associated with their assigned-sex-at-birth status, which is referred to as gender essentialism [42,43,44]. For GIaNT youth to be able to comfortably speak about their bodies and sense of self, they need to have a clear understanding of the distinction between gender and sex—that sex is linked to biological terms and is typically assigned at birth, whereas gender is how a person feels about themselves. Sex and gender are socially constructed in binary terms, which has been disproven by multiple empirical research fields [42,45,46,47]. Intersex people positively trouble our society’s narrow understanding of sex belonging on a binary, and people of varying gender identities do the same with the gender binary. Gender can be fluid, meaning how someone views their identity today could change from day-to-day or at later times in life [42,48]. There are no concrete rules on how to go about gender identity development. For some, they may have a clear understanding from a young age that their gender does not associate with their assigned sex at birth. For others, this understanding can develop into their elder years, and for some people, for example, gender-fluid and non-binary people, this can change day-to-day or even throughout the day, depending on the individual and modes of expression of the self (i.e., clothing). Some individuals, like agender people, do not feel as though they identify in accordance with any gender at all. More in-depth definitions of a range of gender options can be explained using Index 1. Furthermore, there needs to be a clear understanding that gender, in opposition to how it is commonly constructed and understood in our society, exists not as a binary, but along a spectrum or continuum [45,48,49]. This information can help them learn about different ways of being that stray from cisnormative ideals that are pervasive in Western society. Some youth will have a concrete formation of their identities, and others may not. Some youth may question their gender, explore other options, and decide that they are indeed cisgender. Offering GIaNT youth affirming support and encouragement in a manner that makes them feel supported and non-judged is of the utmost importance. Drawing from the existing literature, we suggest making age-appropriate gender exploration information available for youth in an online format.

3.2.5. Social Transition

Social transition can be understood as not explicitly medical forms of transition/ing. This can include name changes, pronoun changes, gender expression changes, chest binding, use of packers, makeup, vocal training, and growing or cutting one’s hair. For many, this is the first step in expressing or experimenting with their gender outwardly [50]. Social transition can act as a time before medical transition for those who choose to undergo medical interventions. For GIaNT people, social transition can be a period in which there are feelings of fear, heightened dysphoria, and emotional distress. As such, emotional support and understanding from their social circles are the most promising modes of mitigating the high possibility of negative mental health outcomes if met with judgment, shame, and abandonment—all of which have historically been common experiences for GIaNT people during the coming out/social transition process [51,52].

3.2.6. Medical Transition

Medical transition is the process of physically changing one’s body through medical intervention to assist an individual with expressing themself in accordance with their gender identity [11]. Some examples of medical transition are puberty blockers, gender-affirming hormone therapy, and surgeries like “top” or “bottom” surgery, fat transfers/removals, or facial feminization/masculinization surgery [11]. Some GIaNT people choose to utilize some forms of medical intervention, while others do not. Just as each person’s sense of self and gender is unique from each other, so are the ways in which they choose to use (or not use) medical interventions.

3.2.7. Legal Transition

Legal transition pertains to the bureaucratic process of changing someone’s name and/or gender marker on their official legal documents, such as a state-issued driver’s license, birth certificate, and passport. Different states, countries, and provinces have different types of legal documentation that should be made relevant to the user of the OER. Additionally, different governing bodies have different options for gender markers. For example, the recent changes in the United States of America highlight the forced gender binary, whereas countries like Canada and Mexico offer an “X” to indicate non-binary gender on travel documents [53,54]. Just as other forms of transition may not be taken up by all transgender people, this is the case for legal transition as well. Some people may fear being “outed” to governing bodies, police forces, and employers [42]. For others, this may be a safer option due to passing as another gender, or to reflect their current physical gender expression as perceived by cisnormative society. Resources and information on these various legal processes should be included in a way that is geographically relevant to the user.

3.2.8. Sex Education

As mentioned previously, school-based sex education curricula have historically excluded GIaNT people from discussions on sex education [2,3]. Omitting GIaNT youth from sex education curricula is one aspect of cisnormativity that is pervasive in many geographical locations. It has been recommended that such sex education curricula be implemented for all youth in schools that are inclusive of GIaNT youth—to promote the normalization of transgender people, reduce stigma, and foster an inclusive environment for youth at school and in romantic and non-romantic relationship formations [55]. That being said, there is a concern around safety and comfort for GIaNT youth, particularly those who are “out,” for this information to be provided amongst their cisgender peers. This is an area that requires further exploration. Furthermore, GIaNT people are also commonly de-sexualized, fetishized, and/or pathologized [55,56]. This can be attributed to cisnormativity and the subsequent devaluing of GIaNT people’s lives and autonomy. In this light, the topic of sex education must be approached respectfully, requiring educators and web developers to have a significant understanding of the complexities of GIaNT youth’s sex education.

To begin, the inclusion of the sexual anatomy of body types of all sexes is crucial. Knowing one’s body parts is the first step in understanding one’s sexual functions, exploring pleasure, and communicating needs to a sexual partner or healthcare practitioner [17]. This is especially important for GIaNT youth, as this can reduce their risk for sexual assault and contraction of STIs/STBBIs and improve their medical literacy when interacting with healthcare providers, particularly in the context of seeking gender-affirming care [57,58,59]. Riggs and Bartholomaeus [55] suggest re-gendering and/or de-gendering body parts and gametes, as specific mentions of these could be upsetting and/or dysphoric. Current suggestions are moving away from sexual anatomy and towards sexual function to affirm GIaNT youth when learning and talking about their bodies, as this can reduce experiences of dysphoria [55]. For example, referring to what is commonly known as the penis/clitoris as “erectile tissue,” referring to the scrotum/labia as a “pouch of skin”, and eggs/sperm as gametes [60]. Some GIaNT youth refer to their genitals in terms that affirm their gender identity by way of associating their genitals with what is commonly referred to by the associated sex [55]. For example, some transgender boys/men refer to their clitoris as their dick/penis [55]. These methods are referred to as de/re-gendering body parts, which is a promising practice in reducing the risk of experiencing gender dysphoria [55]. This could also be a helpful practice for cisgender youth, as it promotes a norm of gender neutrality, fosters a shared language when discussing sex and pleasure, and can be useful for cisgender people, too, who engage in romantic and/or sexual relationships with GIaNT people [55]. Particularly in the context of GIaNT youth, the practice of moving away from constructs of gender essentialism and towards gender-neutral language for anatomy can be affirming [55].

Beyond emotional distress, feelings of dysphoria around one’s body and/or genitals can cause GIaNT youth to withdraw from pursuing romantic relationships and/or sexual activity, and/or restrict the types of intimacy they will engage in [55]. Discomfort in talking about one’s body, sex, and desire increases the likelihood of sexual violence or avoidance of sex altogether, which is an unfair effect of sex education marginalization [55,61]. Mitigating feelings of dysphoria is of concern when dealing with GIaNT people in regards to sex education. Therefore, providing GIaNT youth with a shared language to discuss these matters can reduce dysphoria, and promote open conversations with partners around sex, contraceptive use, and pleasure—all of which permit a more pleasurable experience and reduce the risk of STI/STBBI transmission, unwanted pregnancy, and sexual violence [37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61].

Veale et al. [62] noted that their participants, through the process of de-/re-gendering, were not aware that they could become pregnant or make others become pregnant. Therefore, Riggs and Bartholomaeus [55] highlight for educators to refer to gametes, for example, in broader terms to acknowledge their role in reproduction and STIs/STBBIs. This can be achieved by talking about the combining of two different gametes as making pregnancy possible. Having conversations with GIaNT youth regarding the added factor of sexuality, and how sexualities are complicated by understandings of anatomy and gender, requires educators and web developers to have an in-depth understanding of the relationships among sex, gender, and sexuality.

In a study conducted in 2022, 30 transgender and non-binary youth aged fifteen to twenty were interviewed in a semi-structured format, accompanied by surveys to inform a better understanding of how transgender and non-binary youth (1) define “sex,” (2) access information on sex education and determine its relevance to them, (3) understand their own sexual identities, and (4) perceive gender-affirming hormone therapy’s impact on their sexual experiences [63]. The participants defined sex in regard to purpose, physical act(s), and/or consent. The participants explained the purpose of sex in a variety of ways: desire, physical/emotional intimacy, sexual pleasure, orgasm, and romantic or spiritual connection with a partner [63]. Physical acts that participants identified as sex included penetrative sex (oral, vaginal, or anal) or any contact with or stimulation of genitalia [63]. Consent was also reported as a defining aspect of sex, although the meaning or practice of consent was not defined. The participants also expressed that gender and sexual orientation minorities are commonly lumped together as a single entity in research studies, as they pertain to LGBTQ+ people as a singular group. Because most of the information available to them online lumps gender minorities with sexual minorities, it makes accessing relevant information more difficult for GIaNT youth. The participants reported that their parents/caretakers’ lack of knowledge about LGBTQ+ complexities regarding sex, gender, and sexuality is a main barrier to communication with their children about sex [63]. Moreover, the participants generally perceived clinicians’ understanding of GIaNT youth’s needs to be lacking cultural competency, resulting from healthcare professionals’ inadequate training related to LGBTQ+ youth’s sexual health, which the participants explained as a lack of institutional support for GIaNT youth’s needs [63]. In this study, 87.3% of the participants were sexually active, and nearly 50% engaged in unprotected anal or vaginal sex [63]. It can be reasoned that this vast engagement in unprotected sex can be attributed to the lack of sex education information that the youth have access to in the context of their gender-marginalized needs. To this end, we recommend more comprehensive, inclusive sex education curricula specifically for gender minorities.

Warwick et al. [63] also identified a key theme of the perception of gender-affirming hormone therapy on sexual experiences. On one hand, a majority of trans-masculine participants communicated to researchers an increased libido with testosterone therapy. They had anticipated this because of personal research prior to starting gender-affirming hormone therapy. This increase in libido led some to pursue more sexual encounters, establishing an urgent need for timely and adequate sex education for this population. On the other hand, for trans-feminine participants, most communicated a decreased-to-absent libido while using estrogen for gender-affirming hormone therapy. A few reported a reduction in the frequency of erections and/or difficulty achieving orgasm. Some participants perceived their decrease in libido as a positive side effect, although no further information was provided in that regard. This could be useful information to provide to GIaNT youth to provide them a clearer understanding of what to expect when receiving gender-affirming hormone therapy for trans-feminine participants.

Many participants in Warwick et al. [63]’s study discussed not wanting to approach their parents out of fear of rejection/not wanting to disclose their sexual and/or gender identities, feeling like their parents would not be able to provide information pertaining to their sexual/gender identities in a sexual context, out of fear of being teased, or perceiving sex education as unimportant or taboo for their parents. Similar to other studies, for participants who did have discussions with their parents surrounding sex, the talks were limited to cis/heterosexual relationships, puberty, menstruation, the definition of sex, use of contraceptives and condoms, and STIs, effectively disseminating similar topics and limitations as existing sex education programs offered to youth in public schools [23]. Participants in Warwick et al.’s study believed that since their families are not transgender, they are not reliable sources for teaching about intimacy, sex, or safe sex within the context of non-cis/heterosexual sex and relationships.

Transgender and non-binary individuals report clinician puberty/sexual health counselling to be just as limiting [23,63]. Information is often collected flippantly using questionnaires. Many youths struggled to answer the questions regarding questions. For example, when they were asked about being sexually active, they had an unclear understanding of what “counts as sex,” which reflects the poor nature of existing sex education curricula that cater to cis/heterosexual youth. In other words, these programs may not effectively and affirmatively be educating cisgender or GIaNT youth. This inadequate understanding of sex and sexual activities situates youth at increased risk for vulnerable sexual activities [61]. With that, we strongly underscore that youth are provided with age-appropriate and gender-affirming information regarding what counts as “sex” and communicate clear definitions of what sexual assault means, complemented with nuanced conversations around consent.

Furthermore, in the context of sexual violence, GIaNT youth should be provided with information about contraceptive use. Agreeing to have sex under the conditions of contraceptive use, with the unknowing withdrawal of using the agreed-upon form of contraception, is called “stealthing” and is another form of sexual violence [61]. Clear agreements around boundaries with contraceptive use should be established among partner(s) prior to engaging in sexual activity. Condoms and dental dams should be shown to youth with accompanying information about how to use these items and their purpose for protection measures. There is an apparent myth pervasive around transgender individuals who choose to receive gender-affirming hormone therapy that doing so makes them unable to conceive [55]. This myth needs to be debunked, and other types of contraceptives, like an IUD device, that can be offered as a form of contraception for those who are able to become pregnant should be discussed. Another misunderstanding through the process of re-gendering one’s genitals is that some trans-masculine young individuals have reported that, since they refer to their erectile tissue as a dick/penis (by way of gender-affirmation and dysphoria mitigation), they were not aware of their risk of pregnancy [55]. Therefore, setting a strong foundation of the shared language of body parts and sexual functionality is pertinent to addressing pregnancy risk for GIaNT youth. Additional resources should be provided for youth on how to access contraceptives, as well as contact information for GIaNT-informed health practitioners in their communities that can help them navigate contraceptive use and pregnancy-risk reduction applicable to their needs.

Discussions around contraceptive use should then segue into conversations around STI/STBBI information. Credible discussions around this topic have been reported as a key desire for inclusion in sex education curricula that is relevant for GIaNT people [3,37]. Particularly in the context of GIaNT people, who are at increased risk for contraction, information around preventative measures should be taken seriously. GIaNT youth should be able to define STIs/STBBIs and understand how they are contracted in ways that re-/de-genders body parts while still making clear that certain sex acts carry larger risk factors than others (particularly penetrative use of mixed types of erectile tissue). As such, educators and web developers must inform youth of the role that gametes play in both reproduction and STIs/STBBIs [55]. There are many resources available online for people on STIs/STBBIs, but they are mostly in cis/binary terms. Due to the scope of this project, we will not dedicate much time to information on and suggestions for STIs in broader terms, but more information can be disseminated by accessing the University of California, San Francisco’s Transgender Care page: https://transcare.ucsf.edu/guidelines/ (accessed on 10 December 2024) [64]. In general, it is advised that GIaNT youth have a broader understanding of risk through both intercourse and outercourse, using and discussing preventative measures, such as contraceptive use, with their partner(s), regular testing, and taking PrEP if they are eligible [65,66,67]. GIaNT youth should be provided with resources regarding testing centers, where and how to access PrEP, and healthcare practices that are gender-affirming in their relevant communities. Some cities offer at-home testing, which could be a promising mode of support in the context of reducing dysphoria, distrust towards healthcare practitioners, and shame around sex/status [68]. Information about these locations should be included as additional resources if they are available in the youths’ communities.

Regarding HIV risk, transgender women are 34 times more likely to be HIV-positive compared to cisgender adult populations [69]. Meta-analysis shows that prevalence and risk behaviors are low in trans-masculine people [69]. Transgender individuals are typically faced with socio-economic, institutional, and interpersonal discrimination because of their transgender identities, which are associated with an increased risk of acquiring HIV [69]. These factors include, but are not limited to, stigma, harassment, limited access to adequate and inclusive health care, lack of access to stable housing, and mental health issues [69]. These problems exacerbate other consequential problems like sexually transmitted infections, substance use, mental health issues, sexual and physical violence, engaging in sex work due to limited job opportunities because of their transgender identities, and low levels of familial support [69]. Overwhelmingly, the best way to reduce the risk of these issues to by having strong support networks from loved ones [51,52]. For these reasons, risk, prevention, and treatment of HIV should be discussed with GIaNT youth in gender-affirming and age-appropriate sex education programs, as this population is at increased risk for contracting STBBIs. Additionally, GIaNT youth have expressed the need and desire for healthy sexual activity tailored to their needs to be included in comprehensive sex education programs [3,37].

4. Discussion

In this review of the literature, we discussed suggestions for inclusion for puberty health and sex education, like gender identity options for exploration, terminology, de-/re-gendering language around sexual functionality, contraceptive use, and STIs/STBBIs. Much more needs to be explored on this topic, however, like mental health, healthy and unhealthy relationships, fertility preservation, and de-transitioners, which could not be adequately taken up here due to the scope of this paper. Some researchers suggest inclusions for gender minorities be taught to all youth, in case they may be questioning their gender identity now or in the future, to normalize GIaNT people and to provide support for GIaNT peers and/or sexual/romantic partners. However, this avenue has not been studied. Therefore, we suggest further research into this concept. While it could be beneficial for all youth to learn about these topics, for themselves and for the potential of having GIaNT sexual partners, there is some concern about the potential for bullying of GIaNT youth peers in such a setting. Much more research needs to be done on this topic to mitigate negative health outcomes for GIaNT youth. OERs provided for GIaNT youth must be age-appropriate and gender-affirming; therefore, user-testing and focus groups would be advised for further investigations on this topic. Due to the scope of this paper, we offered a general overview of the content to be included. However, the content address here is, of course, not exhaustive. We suggest more in-depth content suggestions and topics to be made in future research, particularly expanding upon each of the topics addressed in this paper with more depth and breadth. Each of our sections—terminology, puberty health, gender dysphoria, gender exploration, social transition, medical transition, legal transition, and sex education—makes up an aspect of holistic and comprehensive PHSE curricula for GIaNT youth. However, what was taken up here was generalized, foundational knowledge that can and should be explored in greater depth in future research. And, due to the scope of this paper, we were not able to take up non-Western contexts. Given different cultural understandings of gender and gender diversity, it would be a disservice to both Western and non-Western GIaNT youth and readers to try to adequately take up these important topics in such a way. In particular, there are many countries with anti-LGBTQIA+ laws. That being said, the relevant search responses were all within Western contexts, without search limitations. This offers an additional avenue for more research to be conducted on this topic in non-Western contexts.

Future plans for this project include (1) website development to disseminate gender-affirming and comprehensive puberty health and sex education information and (2) pilot-testing this website with GIaNT youth through surveys and focus groups to make further modifications as needed. For these reasons, the purpose of this literature review is twofold: (1) to synthesize what researchers and community members have identified as gaps in existing puberty health and sex education curricula and (2) to use this existing literature to influence preliminary content guidelines for the development of gender-affirming online educational resources and games for gender-independent, nonbinary, and transgender youth.

5. Conclusions

Puberty health and sex education curricula are currently comprehensively lacking for all youth. The need for comprehensive PHSE for GIaNT youth is urgent, as they are currently not receiving such important information in traditional PHSE pathways, such as schools. GIaNT youth are at an increased risk for the negative outcomes of a lack of adequate conversations around puberty health and sex education, including mental health, marginalization from peers, dysphoria, risk of STIs/STBBIs, and sexual violence. For these reasons, it is important that such youth are provided with access to information that is relevant to their unique PHSE needs. Additionally, more in-depth conversations around puberty health and sex education, such as puberty blockers, hormone therapy use, surgeries, and how to access care from trusted providers, would be beneficial to this population. This paper serves as a preliminary foundation for further research in the context of disseminating a comprehensive puberty health and sex education curriculum for GIaNT youth online. Accessibility of online resources is found to be the preferred format for such information, as GIaNT youth have found that their family, friends, and school networks are currently not providing them with relevant information. To this end, a comprehensive puberty health and sex education curriculum, to be made available in an online setting, seems like an appropriate and promising mode of disseminating such information.