Risk and Protective Factors in Romantic and Sexual Relationships: Findings From a National Survey of Transgender and Non-Binary Youth

Abstract

Background: Transgender and gender non-binary adolescents and young adults (TGNB AYA) are more likely to experience poor health outcomes compared to their cisgender peers, and are at especially elevated risk of HIV. Research on cisgender AYA has shown that intimate relationships play a critical role in health behaviors during adolescence and health outcomes throughout the life course. However, the role of romantic and sexual relationships as sexual health risk and protective factors for TGNB AYA is poorly understood. Research Question: How do TGNB AYA navigate HIV-related risk and protective factors in the context of their romantic and sexual relationships? Methods: We analyzed data from the Body Image, Sexual Health, and Relationships Project (B*SHARP), a mixed methods study that included a cross-sectional online survey of 715 TGNB AYA (ages 18-30 years) in the U.S. Participants were recruited via online community groups, social media advertising, and snowball sampling. Participants provided short narratives in response to two open-ended questions about how their romantic or sexual relationships and sexual health are impacted by their (i) social identities (number of unique responses = 443) and (ii) body image (number of unique responses = 259). A codebook was created through an iterative process based on the scientific literature and preliminary reviews of the data. Narratives were coded by two independent coders using Dedoose software. Thematic analysis was led by the lead author; themes were iteratively revised through periodic meetings of the analysis team. Results: Demographics: Participants’ gender identities included transwoman (31.7%), transman (17.5%), nonbinary (20.9%), genderqueer (7.1%), agender (5%) and other (17.8%). Race identities included White (43.7%), Multiracial (24.0%), Black/African American (13.7%), Latinx/Hispanic (9.8%), Asian (6.8%), and Native American (1.0%). Preliminary findings demonstrate that intimate relationships can act as both risk and protective health factors. Two patterns emerged discussed here as 1) health-challenging effects and 2) health-enhancing effects. Health-challenging effects included identity invalidation events, both individual and structural, and sexual coercive experiences. Health-enhancing effects included improved sexual self-efficacy, increased explicit sexual agreements, greater self-esteem, and furthered sense safety and security in gender identity. Conclusion: Providers should explore patient experiences with identity affirmation, discrimination, and sexual consent within the context of TGNB AYA’s intimate relationships. Providers should also recognize and build upon existing protective factors and strengths to better support the sexual health of this underserved population.