I’m often asked by other providers about ways to have affirming conversations about sex and sexuality with transgender and nonbinary adolescents. Providers recognize that fear and embarrassment in having conversations about sex, in general, can override their desire to help patients feel empowered about their sexuality. Further discomfort in talking about sexuality with transgender and nonbinary adolescents undermines the environment of inclusivity and acceptance providers often are wishing to create.
However, further stigmatizing transgender and nonbinary patients by NOThaving these conversations fails to validate a critical part of human experience and reduces opportunities for honest and affirming conversations.
Sexuality is one potentially incredible part of being human. It encompasses behaviors, feelings, relationships and ways in which we can express our inner selves. Talking about sexuality is important, and in practice, it can be fun, awkward, incredible, and daunting. Most importantly, it should be done with care and consideration for all bodies, all orientations, and all ways to engage in sexuality.
In my research and clinical work, I operate from a sex-positive perspective. It stems from the work of Dr. K. Paige Harden, a behavioral geneticist at the University of Texas, Austin. At its essence, the sex-positive framework focuses on consent, positive outcomes of sexuality and lack of evidence of negative outcomes for most people.
In working with patients, sex positivity means validating the complex interplay of gender, sexual identity and sexuality they experience. It means holding developmentally-appropriate conversations about pleasure and desire, as well as providing accurate information about proper use of birth control, condoms and dental dams for all bodies to reduce the risk of pregnancy and STI. It also means encouraging conversations around actively seeking and giving consent.
Combining a sex-positive and a gender-affirming approach is possible. I’ll provide some starting points for consideration. Keep in mind that not all will be right for every client, and they can and should be adjusted so that they are developmentally relevant and appropriate:
1. EDUCATE YOURSELF.
There are a variety of resources you can access to better understand aspects of sexuality, sexual identity, and gender identity. Planned Parenthood, Scarleteen, both have comprehensive websites with information on sexuality and gender identity. Trans Bodies Trans Selves also serves as a textbook with helpful and informative chapters on many aspects of sexuality. It is written from a multitude of voices and perspectives and highlights a diversity of experiences.
2. Start with identities and build from there.
With any adolescent make sure to ask early and with genuine interest and authenticity about different facets of their identity. Create a space for them to tell you about how they understand their gender identity. As romantic and sexual attraction reflect the complexity of the experience of attraction, ask about sexual orientation/identity, and romantic orientation separately. Gender, sexual and romantic identities are distinct parts of the human experience, and there are myriad ways in which the three can converge in each of us. Consider yourself lucky to be trusted with a process of self-identity and discovery. Find ways to let your patients tell you about themselves and describe their experiences on a spectrum or continuum, rather than trying to fit their experience into rigid boxes.
3. Question your presumptions about sexuality.
Know that people from all experiences have their own relationship to sexuality. This means asking every patient about sexuality and not picking and choosing the individuals you have decided are more likely to want to have sex. Challenge your biases about gender, (dis)ability, body type, mental and physical health and their relationship to sexuality. Access resourceschallenging presumptions about sex and disability as well.
4. Be open in your discussion of pleasure and erogenous zones.
There are all sorts of ways to experience pleasure. Necks, arms, legs, ears and nipples, you name it, there is room for seeking out pleasurable experiences all over our bodies. In addition, conversations about pleasure open up conversations about the exploration of sexuality on one’s own. As with anyone discovering their sexuality, it can help to first figure out some basic aspects of pleasure on one’s own. It allows for individuals to take things at their own pace. This may be particularly important for adolescents who are beginning Hormone Replacement Therapy (HRT) that may be physically shifting their body.
5. Affirm asexuality.
Being sex positive does not imply that all sex is good, or that not having sex means that people will miss out on positive experiences. Rather, it means trusting your patients to know their identities and what experiences of sexuality will be most affirming, including desiring no sexual relationships at all. Affirming asexuality also means affirming it as an identity, and not just as a route to risk reduction.
6. Talk about dysphoria.
The way in which dysphoria manifests can affect how people experience aspects of sexuality. For example, parts of the body that individuals are comfortable touching or having touched can vary by levels of specific dysphoria about those parts. Remember, individuals experience dysphoria differently. It can be diffuse or specific, and may not be there at all. In your conversations, be gentle. Talking about dysphoria can aggravate dysphoria. You can also ask your patients to let you know how their dysphoria interferes with desire for sexuality. Much like depression, dysphoria may lessen sexual desire altogether.
7. Refer to body parts in a way that makes your client feel affirmed.
Ask your patients how they refer to the parts of their body. Using their terminology provides another opportunity to affirm your patient. Do this both when you are talking together, and in situations where the patient has first consented to your use of that language with other providers. Another option your patient may prefer is that you use parts-first language such as: “People with penises…” and “People with vaginas…” You can also fill in your client’s terminology here. Note that, when you are talking about sexual behavior there are also a variety of ways you can refer to behaviors by just referring to parts.
8. Challenge heteronormative scripts around sexual identity, sexual behavior and gender roles in sexuality.
What truly constitutes sex is up to the person having it. Thus, sex is not only considered sex when it involves penetration. Broadening how you conceptualize sex will allow you the opportunity to talk with patients more authentically about their desires around pleasure, partnership, and sex roles.
9. Talk about consent.
Talk about enthusiastic consent. Talk about it being absolutely OK for your patients to start something intimate and change their mind. Talk about their right to say: “I used to like that, but I don’t anymore.” One way to practice saying yes and then no is to role play with your patients by practicing saying “yes” to talking about a neutral topic in your office, and then having them practice changing their minds and standing their ground. For example, you can practice with examples from the consent video here.
10. Practice communication.
Communication is essential with sexual partners, and it is critical in supporting affirming sexual relationships. Successful sexual communication allows people to talk about their desires, the areas of their body that provide pleasure, and do or do not provoke dysphoria. Practice asking and answering open-ended questions. To emphasize the importance of communication with sex partners, help your patients to practice how to start conversations about sex on their own. Talk about key points they want to make, and talk about how to ask partners about their desires as well. The goal is for the practiced communication to allow for your patient to flexibly express their experience of desire, consent to participate in sexual behaviors or decisions not to.
11. Be ready for things to change.
As adolescents grow and develop, their desires and motivation to engage in sexual behaviors may shift. Flexibility is especially important with pubertal and HRT-related changes. For example, dysphoria may intensify with puberty. If this happens, parts of the body that did not previously provoke dysphoria may now do so when they are talked about, or touched by self or others. In addition, when adolescents start hormones, changes that come with HRT may shift aspects of desire, pleasure, and dysphoria. Again, be gentle.
12. Make plans for disclosure and safety.
It is by no means a requirement for transgender and nonbinary adolescents to disclose anything about the gender they were assigned at birth or their body parts. Each individual likely has specific goals regarding sharing their gender identity. In addition, they may also face greater risk in intimate relationships and disclosures. This is incredibly important as this risk is well-documented, according to the Williams Institute, 30 to 50 percent of transgender people experience intimate partner violence as opposed to 28 to 33 percent of the general population. Therefore, talk openly about the risk posed to transgender and non-binary individuals without victim blaming. Talk about ways to mitigate risk, as well as is possible. There is excellent information in this post about disclosing. Some possibilities are to disclose online first, to disclose in public places or with a trusted friend around.
13. CREATE access to care.
Make your office a place where patients don’t have to ask you for information, but where they can get information without even asking. Keep a jar of non-expired internal and external condoms, lube and dental dams in a visible and accessible place. Make sure your patients know they do not need to ask you to take one, two, or as many as they need. Create partnerships with gender and sexuality-affirming medical providers that are easier to access. Build relationship between your patients and these providers. One way is to make phone calls with your patients to help them schedule and connect to services. In addition, have resources at the ready like Vibrant, a company that makes sex toys for parts (not people). They have a section of their blog dedicated to gender-affirming toys. Scarleteen also provides information about sex toys.
14. Help caregivers affirm their child’s sexuality. When caregivers are involved, work with them to facilitate an understanding of the variety of ways their child’s gender identity, romantic or sexual orientation/identity and desire for sexuality intersect. When caregivers are only beginning to understand their child’s identities or are invalidating about aspects of their child’s identity, it can be very dysphoria provoking for adolescents to answer questions about their gender and sexuality. Be prepared to provide education about the intersection of identities and the diversity of ways that identities present. Talk with the adolescent about having conversations with their caregivers without the adolescent having to be present. Have them let you know what they are comfortable with you answering on their behalf. Work with caregivers to understand that their participation in conversations about sexuality is a critical way to engage and affirm their adolescent and an opportunity to help reduce risk and encourage positive outcomes.
15. Mistakes happen. When you make a mistake, fail to be affirming, or your presumptions make themselves known, just apologize. You can also state that you will work to not make the same error in the future. Then move on. Be sure not to place the burden on the adolescent of working through your error with you. Later, work on addressing your error on your own. One way is to practice your affirming language no matter where you are, or what you are doing.
With gained confidence that a provider is truly acting from a place of affirmation and self-education, transgender and non-binary adolescents may feel free to be more open about their identities and behaviors. Greater openness in conversations can lead to greater accessing of sexuality-related medical care, and a reduction in other risks as well.
In addition, you too may be able to learn, grow and be even more affirming in your practice- and perhaps in your own life as well.