Introduction

Puberty is the process of physical changes initiated by hormonal signals from the brain to the gonads between the ages of 8 to 14 years old. Sexual health and puberty education is mandated across all provincial and territorial curricula in Canada. However, this information tends to be inadequate or outdated, failing to meet either international standards or the 2019 Canadian Guidelines for Sexuality Education [1]. Few resources provide adequate support for gender-independent, intersex, non-binary, or transgender (GIaNT) children and youth whose gender identity does not directly align with conventional visible markers of physiological sex and its medicalization. Gender identity and gender-affirmation are integral to one’s sense of well-being at all stages of development [2].

When considering puberty health education for GIaNT youth, it is crucial to understand that such youth’s puberty health needs are not the same as their cisgender counterparts [3–5]. Overwhelmingly, puberty and sexual education programs are not inclusive to gender-diverse youth [4, 5]. GIaNT youth have expressed not only a need for comprehensive and inclusive puberty health education programs but also the desire to explore such pathways in an online setting [4, 5]. Online spaces are generally preferred amongst GIaNT and other 2SLGBTQIA+ (Two Spirit, lesbian, gay, bisexual, transgender, queer, intersex, asexual, and “+” stands for orientations and identities not named in the initialism) youth because these are regarded as “safe,” meaning, they can undergo transformative, affirming, and individualized education as they see fit [5–7] without external limitations like unsupportive caretakers/parents, or homophobic and/or transphobic judgement or bias [5, 7]. Since most youth gain access to puberty health information online [5, 7], digital platforms appear to be a promising method for disseminating such educational programs [7–9].

One popular form of digital platforms is called role-play games. Role-play games (RPG’s) are a popular genre of video game that allow the player to control a character’s actions within the game. This usually means the player makes autonomous, personalized choices on where to go in the world, decide how to navigate through story options, as well as interact with the game world in other ways, such as with items, places, and other characters. RPG’s are typically user-friendly, do not require intricate hand-eye coordination, and are story/character-based games. RPG’s are widely sought-out by GIaNT youth because they permit exploration of one’s gender identity and expression through fictional characters, which is a crucial component for emotional intimacy, relatability, safeness, and relevance among them [7, 10].

An initial search of the literature shows that the majority of games and online resources for GIaNT youth and children focus on mental health [11, 12], which includes accompanying concerns of smoking cessation and/or addiction [8, 13, 14]. The possibility of using online gaming as a mental health intervention is a common concern we have found in our preliminary search on the topic [8, 12]. While mental health is, of course, encompassed in a holistic view of health (especially in the context of gender-diverse youth), it makes up only one form of health, and does not include a broader scope of puberty health needs for GIaNT youth. For example, some of the GIaNT youth participants in research studies have expressed that their only exposure to sexual education curriculums center issues like pregnancy and sexually transmitted infections, and only in the context of cisgender youth [13, 15]. Such curriculums are not applicable to the needs and desires that GIaNT youth express towards information on puberty health.

A preliminary search of MEDLINE, the Cochrane Database of Systematic Reviews and JBI Evidence Synthesis was conducted, and we found two current systematic reviews that are similar to our review topic but not focused on identified objective. These systematic reviews are: 1.) Effectiveness, acceptability, and feasibility of digital health interventions for LGBTIQ+ Young People: Systematic Review by Gilbey et al. [9], and 2.) Sex education in the spotlight: What is working? systematic review by Lameiras-Fernández et al. [16] While similar in subject matter, neither of these systematic reviews specifically focused on GIaNT youth. Particularly the former article focused on mental health interventions, and not necessarily a holistic view of puberty health needs. Lameiras-Fernández et al. explored the limitations and possibilities of casting out sexual education curricula in digital settings to youth but did not focus on GIaNT youth. Therefore, the aim of this scoping review is to address this gap in literature.

For these reasons, the purpose of this scoping review protocol will be to search for what has been reported on the development and the use of gender-affirming online resources and games for GIaNT children and youth. JBI scoping review methodology will be utilized to identify the existing literature for online resources and games for GIaNT youth, as well as investigate existing literature on specialized needs for GIaNT youth puberty health education. This method of inquiry is ideal for mapping and exploring the literature on a topic, as it draws from a broad range of study designs and evidence types to inform the findings.

Methods

The proposed scoping review will be conducted in accordance with JBI methodology for scoping review as evident in the JBI Manual for Evidence Synthesis [23].

Search strategy

The search strategy will aim to locate both published and unpublished studies. An initial limited search of Web of Science and PubMed (MedLine) was undertaken to identify seed articles on the topic (Table 1).

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 1. Search strategy.

https://doi.org/10.1371/journal.pone.0294869.t001

The text words contained in the titles and abstracts of relevant articles, and the index terms used to describe the articles will be used to develop a full search strategy for CINAHL, Cochrane, Epistemonikos, ERIC, Gender Studies Database, GenderWatch, LGBTQ+ Source, ProQuest, ProQuest Dissertation and Theses Global, PyscInfo, and Scopus. The search strategy, including all identified keywords and index terms, will be adapted for each included information source. To include relevant grey literature, no limits on the type of the sources is applied. The reference lists of all studies selected for critical appraisal will be screened for additional studies. There will be no language restriction since preliminary search results were mostly in English. Study type or publication date will not be restricted. Due to the limited number of sources in the literature, sources published on any date will be included.

Data extraction

A draft extraction tool is provided (Table 2). The draft data extraction tool will be modified and revised as necessary during the process of extracting data from each included paper. Modifications will be detailed in the full scoping review. Data will be extracted from studies included in the review by two independent reviewers using the standardized JBI data extraction tool. The data extracted will include specific details about the populations, study methods, interventions, and outcomes of significance to the review questions. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. Authors of papers will be contacted to request missing or additional data, where required.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 2. Data extraction instrument.

https://doi.org/10.1371/journal.pone.0294869.t002

Supporting information

Acknowledgments

We would like to acknowledge the contributions of the team of researchers and game developers at Centennial College, and the administrative support for the Social Innovation Research Centre at Centennial College. Dr. Purnima Tyagi for leadership, and the team of game developers who participated in discussions informing this literature review: Miriam Verburg, Ronan Daniel, Nathaniel Hachey, Theodore Telega, Vladislav Volodin, and Marko Kuper. We would also like to acknowledge the feedback from Negar Namaei (an undergraduate student), Jennifer Easter (Centennial’s health sciences librarian), and the audience at the International LGBTQ+ Psychology and Related Social Sciences Conference, Preaching to the Choir, in Toronto, June 21 and 22, 2023.