“At your age, you’re going to have a lot of urges. You’re going to want to take off your clothes and touch each other. But if you do touch each other, you will get chlamydia… and die.”

This scene from the 2004 film “Mean Girls”, in which a teacher lectures a group of students on matters of the flesh, may be a comic exaggeration of the absurdity of sexual education in American high schools, but it isn’t far off the message I received as a teen growing up in Hong Kong.

The Hong Kong public education system is often criticised for its failure to provide comprehensive sex education to the city’s student population, and rightly so. Most of my friends, especially those who attended Christian or Catholic girls’ schools like I did, remember sexual education as a one-off session on how to use sanitary pads, as well as biology classes for those who took the subject.

The lack of practical information is, in part, due to the extensive influences of Christian churches, which tend to take a conservative approach to sex education. There also tends to be a ‘don’t ask, don’t tell’ mentality in Chinese society around anything deemed ‘perverse.’

Even so, attitudes surrounding sexual and reproductive health (SRH) have improved in recent years thanks to society’s efforts in promoting SRH education and related services. But many programmes are still designed for cisgender people (those whose gender identity is congruent with the sex they were assigned at birth).

Transgender people (who do not identify with the sex they were assigned at birth) and gender diverse people (who do not identify with conventional genders) often fall through the cracks of an outdated system.

Conflations abound

A closer look at sexual and reproductive health services in Hong Kong reveals some inclusive resources earmarked for the LGBT (Lesbian, Gay, Bisexual, and Transgender) community, however such services lean heavily towards cisgender gay individuals while overlooking trans people.

This is because many people still incorrectly assume that gay cis men are the most likely group to be exposed to HIV. Even advocacy groups have fallen behind: AIDS Concern, for instance, declined an interview request, stating that they offer very little in the way of testing services for transgender clients, as opposed to cisgender.

The casual grouping of LGBT to represent different sexual orientations and gender identities contributes to a common misunderstanding that gender identity and sexual orientation are interchangeable. But conflating these identities does a disservice to the diverse individuals huddled under this broad umbrella.

In the sexual and reproductive health space, the ‘G’ gets most of the attention while the rest of the letters are often left to fend for themselves. This leaves members of the transgender and gender-diverse community, especially those assigned female at birth, particularly vulnerable.

Aiden* is one such individual. Assigned female at birth, Aiden is a gay trans man who uses dating apps like Grindr for casual sexual encounters. During a recent visit to the Family Planning Association Hong Kong (FPAHK) to test for a sexually transmitted infection, Aiden was asked: “How would you describe your sexual orientation?”

The options were: heterosexual, gay, or bisexual. This might seem like a step in the right direction, but for trans and gender-diverse people, using sexual orientation as a proxy for gender identity creates problems on multiple levels. First, they may have to misgender themselves or their partners in order to receive adequate care.

“I’ve had sexual relations with both cis and trans men, so the correct answer would have been ‘gay,’” says Aiden. However, since one of his partners was a trans man, Aiden selected “bisexual.”

He understood what the question was getting at: What kinds of sexual behaviour had he engaged in? “I felt bad because I had to misgender one of my sexual partners.” For Aiden, having to misgender his sexual partner as a “woman” in order to inform his doctor of his sexual history felt disrespectful to his community.

In addition, conflating sexual orientation with gender does not actually tell the SRH provider precisely what types of sexual behaviour the client engaged in, thus allowing potential health risks to go undetected.

Let’s consider another example. If a trans man ticks “straight” on the Family Planning Association questionnaire, a doctor might assume he is exclusively dating cis women and proceed to check only for STIs.

However, if the trans man is also dating trans women, the doctor could inadvertently overlook other risks, such as pregnancy. In such cases, simply choosing “gay” or “straight” does not fully explain sexual history or associated health concerns.

A closer look at sexual and reproductive health services in Hong Kong reveals some inclusive resources earmarked for the LGBT (Lesbian, Gay, Bisexual, and Transgender) community, however such services lean heavily towards cisgender gay individuals while overlooking trans people.

This is because many people still incorrectly assume that gay cis men are the most likely group to be exposed to HIV. Even advocacy groups have fallen behind: AIDS Concern, for instance, declined an interview request, stating that they offer very little in the way of testing services for transgender clients, as opposed to cisgender.

DIY education

This flaw in the Family Planning Association survey is merely a symptom of the general lack of knowledge among frontline sexual and reproductive health providers about both gender-diverse identities and the medical procedures they may need.

“I didn’t expect the nurse to be able to answer my question,” Aiden says, sipping a coffee before telling me about his experience getting a contraceptive vaginal ring inserted at the FPA. This is a common sentiment expressed by many trans and gender-diverse people who have sought healthcare services.

Aiden says he told his nurse and doctor that he is transgender and would soon be undergoing hormone replacement therapy (HRT). “The doctor told me I could have the ring taken out once I start HRT,” he says. “That’s misinformation.”

A quick online search confirms that transmasculine people undergoing hormone replacement therapy still need to use birth control. Even if they stop getting their periods as a result of testosterone hormone therapy, they can still get pregnant if they practise unsafe or unprotected sex. This seems to be a common misconception among transmasculine people, which makes it all the more important for healthcare providers to bust, rather than perpetuate, myths like these.

It was by chance that Aiden had done his research prior to his appointment. “I get most of the information from internet forums like Reddit,” he says. “There simply aren’t enough government resources [on sexual and reproductive health issues for trans men].”

Even though he is comfortable raising his concerns with medical professionals, Aiden understands why others might be hesitant to do so since healthcare providers are assumed to be the authority. Aiden especially worries about younger trans people and those who have newly accepted their trans identity. They may lack access to the relevant information due to language barriers (as most services are in English) or because they don’t have a community to source knowledge from.

Comprehensive sex education (CSE) continues to be a difficult subject in the trans and gender-diverse community. “Talking about bodies and bodily functions can trigger dysphoria [distress or unease arising from the conflict between a person’s gender identity and their sex assigned at birth] for trans people,” says Kaspar Wan, founder of grassroots trans-servicing organisation Gender Empowerment. “There is also a general lack of interest in CSE within the community.”

Aiden speculates that the absence of conversations about sexual and reproductive health among trans men is a ‘chicken or the egg’ problem: There is “not enough SRH information for and about trans men” and trans men are “not being very sexually active.”

‘At the wrong clinic?’

Genderqueer athlete Kai*, who uses the pronoun ‘they,’ was assigned female sex at birth. Kai is muscular and strong – most would assume they are a cisgender man based on their physique and voice. They haven’t had a lot of experience seeking sexual and reproductive health services but had an awkward encounter at an obstetrician-gynecologist clinic four years ago.

Kai started having irregular periods (something they had also experienced as a teenager) after taking testosterone. They didn’t want to see the obstetrician-gynecologist they had visited during adolescence, fearing their former doctor might make comments about “how big they’ve become” or how “they looked like a man.” Instead, Kai thought it would be easier to go to a new ob-gyn who was referred by a friend. But they encountered an equally alienating experience.

“The receptionist kept asking me on the phone if I’m making an appointment for my wife, or my girlfriend,” Kai says with a hint of wry amusement as they recall the exchange. “I had to keep insisting that it was for me.” Kai recalls being the only person who turned up alone to the clinic, much to the dismay and surprise of some of the pregnant women (accompanied by their partners) who were sitting in the waiting area.

“‘Sir, are you at the wrong place? This is an ob-gyn clinic,’ the nurse behind the reception desk said to me right off the bat. I told her I had made an appointment for myself and she asserted again that it’s an ob-gyn clinic,” says Kai. “I just said ‘I know. I’m a girl.’ She looked back and forth at me and my ID card before she finally registered me.” Kai entered the doctor’s office amidst the curious gazes of the couples in the waiting area.

“The doctor quickly figured out I was an athlete and asked if I used any supplements or hormones. I said I did, for sport,” says Kai, who had recently started bodybuilding around that time. “She then lectured me for half an hour and asked me, ‘What did you do this [to your body] for?’ I didn’t go back after that. I needed a doctor to follow up on my medical history, instead of judging me.”

What can be done?

Barriers to accessing trans-sensitive sexual and reproductive health information and services are not unique to Hong Kong, or even Asia. Several organisations, including Asia Pacific Transgender Network, have assessed transgender sexual and reproductive healthcare across the region and found the literature on HIV, STI, and sexual health lacking, particularly for trans men. For example, no Asia-wide data on HIV prevalence exists for trans men.

In 2011, the National Gay and Lesbian Task Force and the National Center for Transgender Equality released the National Transgender Discrimination Survey, in which 62 per cent of trans men in the United States said they had to “teach their medical care providers about transgender care” at some point in their lives.

SRH providers should have a basic understanding and respect for the needs of their trans clients. Knowledge about how certain SRH procedures and treatment might interact with the clients’ transition-related care, such as hormone replacement therapy and gender-affirmation surgery are the baseline. “The attitude of SRH providers is equally important,” says Aiden. “Getting a ring inserted is painful enough, it would really take a toll on me if I also got misgendered by the medical staff during the process.”

Instead of segregating SRH information and services into “men’s and women’s health,” SRH providers can adopt trans-inclusive language to make accessing SRH services less alienating for trans clients. The people we spoke to also suggested that clinics ask for the client’s pronouns and remove Mr, Mrs, Miss honorifics from documents.

Transmasculine people still face many hurdles, which can be further complicated by issues such as oocyte cryopreservation (‘egg freezing’), abortion, and sexual violence.

Overall, SRH for the trans community remains a largely under-researched area in Hong Kong that could benefit from in-depth studies funded by the government and academic institutions. There isn’t a ‘one-size-fits-all’ solution, but trans people deserve the right to make informed decisions and be afforded access to adequate SRH services, just like everyone else.

*Names changed at the request of subjects.