Exploring sexual health and risk of sexually transmitted infections among gender diverse individuals

Abstract

Introduction: Transgender, non-binary, gender non-conforming, and other gender diverse individuals (TGN) may be at higher risk of sexually transmitted infections (STIs). Transgender women specifically bear a disproportionate burden of HIV and other STIs worldwide. This study describes STI knowledge, risks, and prevention practices among TGN to better characterize barriers to sexual health care and identify potential platforms for sexual health education focusing on STI prevention.

Materials and Methods: Qualitative interviews were conducted with N = 14 TGN individuals until thematic saturation was reached. Transcripts were coded and analyzed using thematic analysis.

Results: Four major themes emerged: (1) Sexual risk behaviors and STI prevention practices varied across participants; (2) individuals who demonstrated more knowledge about STIs either had a significant identifiable sexual educational experience or had a past personal experience with an STI; (3) individuals were interested in receiving information about STIs and sexual health from health care providers, school sexual education programs, and online resources based on a desire for accessible, private, factual, and inclusive content; and (4) public messaging around sexual health and STIs was seen both as potentially stigmatizing, but also important for increasing awareness of available services.

Discussion: We found that while important, considering gender alone may not adequately characterize risk of STI infection for TGN populations, and more research is needed to better characterize risk profiles. Individuals were interested in learning about sexual health and STI prevention from school curricula, health care settings, online resources, and public messaging advertisements, and had recommendations to ensure that these forms of information sharing were relevant, inclusive, and non-stigmatizing.

Introduction

Globally, transgender women bear a disproportionate burden of HIV and other sexually transmitted infections (STIs) such as syphilis, chlamydia, and gonorrhea (Baral et al., 2013; Reisner et al., 2016; Van Gerwen et al., 2020). While limited surveillance data exists for STI risk among transgender women in the US, a 2013 review of data in 15 low, middle, and high income countries, determined that the odds ratio of being infected with HIV for transgender women compared with all adults of reproductive age was 48.8 (95% CI 21·2–76·3) (Baral et al., 2013). In Australia, it was shown that transgender women and men were more likely to be infected with HIV when compared with cisgender heterosexual people (OR, 2.89; 95% CI, 1.69–4.92; p < 0.001 and OR, 4.85; 95% CI, 3.31– 7.11; p < 0.001 respectively) (Callander et al., 2019). When compared with cisgender gay and bisexual men, the researchers found that both transgender women and men were less likely to be infected with HIV (OR, 0.62; 95% CI, 0.42–0.95; p < 0.001 and OR, 0.36; 95% CI, 0.21–0.62; p < 0.001 respectively). For other STIs, the study found that when compared to cisgender heterosexual people, transgender women were more likely, and transgender men were as likely to receive a new diagnosis of a bacterial STI (chlamydia, gonorrhea, and infectious syphilis) (adjusted odds ratio [aOR], 1.56; 95% CI, 1.16–2.10; p = 0.003 and aOR, 0.72; 95% CI, 0.46–1.13; p = 0.16 respectively); compared to gay and bisexual men, transgender women were as likely, and transgender men were less likely (aOR, 0.98; 95% CI, 0.73–1.32; p = 0.92 and aOR, 0.46; 95% CI, 0.29–0.71; p = 0.001 respectively). Less data is available characterizing the risk of HIV and STI infections among transgender men and even less is available for other gender-diverse individuals with genders outside of the gender binary (including non-binary, gender non-conforming, and gender fluid individuals among others). The studies that have included these individuals are often limited in their sample size or ability to collect data and report heterogeneous results. However, some data suggests that risk may be associated with sexuality or sex assigned at birth rather than exclusively gender (Green et al., 2015; Maheux et al., 2021; Reisner et al., 2010; 2019; Reisner & Hughto, 2019; Reisner & Murchison, 2016; Scandurra et al., 2019; Stephens et al., 2011; Tordoff et al., 2022). For example, one of these studies performed a mixed methods analysis with transgender men who have sex with non-transgender men and concluded that they may be at high risk of becoming infected with an STI when it is often assumed that that transgender men are at lower risk (Reisner et al., 2010).

Since at least 2001, there has been a call for public health intervention to address the increased risk of STI infection among transgender, gender non-binary, gender non-conforming, and other non-cisgender (identified collectively as transgender non-binary or TGN) populations (Clements-Nolle et al., 2001). Since that time, total STI diagnoses across the US have increased. Between 2014 and 2019 reported cases of syphilis (primary, secondary, and early-late), gonorrhea, and chlamydia have increased by 104%, 76%, and 25% respectively in the United States (Division of STD Prevention, 2021). While the number of new HIV diagnoses continues to decrease in the US, the number of HIV diagnoses for transgender men and transgender women have increased by 4% and 44% respectively from 2015 to 2019 and collectively account for 2% of new diagnoses annually—notably this data is not stratified by sexuality or sexual partners’ identities (Division of HIV/AIDS Prevention, 2020). This data was reported before the COVID-19 pandemic began in 2020 and recent trends post-pandemic suggest that STI trends continue to increase (de la Court et al., 2022; Gabster et al., 2022; Ogunbodede et al., 2021). Considering the increase in HIV diagnoses for TGN people despite US national decreases, and the otherwise lack of US surveillance data relating to the health of TGN populations, further research and data are needed to better inform sexual health care and STI prevention strategies for TGN communities.

TGN communities face significant barriers to receiving quality health care including stigma and structural barriers (Casey et al., 2019; Gonzales & Henning-Smith, 2017; Hobster & McLuskey, 2020; James et al., 2016). Additionally, it has been reported that sexual health education available to TGN adolescents is often limited and when existent, is neither inclusive of TGN genders nor sufficient to prepare them to engage in safe sexual practices (Haley et al., 2019; Pampati et al., 2021; Warwick et al., 2022). These barriers to health education and health care for TGN individuals are complex, exist at multiple levels of society, and likely relate to the intersectional identities that TGN people hold including their socioeconomic status, race, employment, incarceration status, and housing status (MacDougall et al., 2023; Saadat et al., 2023; White Hughto et al., 2015). Further research inclusive of TGN populations could help identify and create potential interventions to provide the sexual health information needed to empower TGN individuals to decrease their risk of STI infection.

Considering the limited current data, this study uses qualitative methods to describe STI knowledge, risks, and prevention practices among TGN individuals currently receiving health care. Our goal is to provide needed background to address barriers to sexual health care and to identify potential gender affirming and inclusive platforms for sexual health education for TGN populations including STI prevention.

Materials and methods

Study design and study participants

Interviews were conducted between August 2020 and October 2022 with TGN individuals recruited from three clinics in Providence, RI that provide gender-affirming health care and serve predominantly LGBTQ + populations. Individuals were eligible to participate in the study if they spoke English, were over 18 years old, reported having sex within the past 12 months, and identified as transgender, non-binary, gender non-conforming, or as another non-cisgender gender. Informed consent was obtained from all individual participants included in the study. All research protocols were approved by the Lifespan Institutional Review Board in Providence, RI. Investigators and clinic staff discussed the best way to recruit based on the clinic setting. This resulted in recruitment by in-person research staff in one clinic and fliers in the waiting rooms of the other two.

Data collection

Individuals who were recruited completed an informed consent, demographics, and sexual behavior questionnaire online through Research Electronic Data Capture (REDCap), a HIPAA-compliant data management software system (Harris et al., 2019).

Individuals were interviewed over the phone at a time scheduled following their completion of the survey. Interviews were conducted following a semi-structured qualitative interview guide that included questions within one of five domains: (1) Introduction and Identity, (2) Interaction with the Health Care System and Medical Mistrust, (3) Overview of Participant Experience with STIs and STI Screening, (4) Sexual Practices, and (5) Disseminating Information about Sexual Health and STIs. Interviews continued until thematic saturation was reached. Individuals who completed an interview received a $15 gift card as compensation for their time and participation.

Data analysis

Interview transcripts were analyzed using methods of thematic analysis (Braun & Clarke, 2006). An initial coding scheme was created based on the semi-structured interview guide and literature review. A coding scheme was used to review the transcripts, and codes were revised iteratively throughout the review process. Coded transcripts were entered into NVivo 20 a qualitative software package that assisted with the analysis and identification of overarching themes. Themes and representative individual quotes are presented below.

Results

Participants included 14 TGN individuals. Based on the pre-interview survey, six individuals identified their gender as non-binary, seven as transgender men (most listed their gender as man, male, or boy), and one as a transgender woman. Twelve individuals were assigned female at birth (AFAB) and had vaginas and two were assigned male at birth (AMAB) and had penises. There were multiple sexual identities represented including individuals who identified as queer (n = 5), pansexual (n = 4), gay (n = 2), lesbian (n = 1), and heterosexual (n = 1). During the interviews individuals often felt that their gender and/or sexuality was better characterized by descriptive information rather than traditional “boxes” or categories of gender and sexuality.

Most participants were emerging or in early adulthood and ages ranged from 18 to 31 years old with a mean of 23.1 years old. Individuals were diverse with regard to race and ethnicity. They were able to select multiple racial identities and identified as Black (n = 3), Asian (n = 2), Native Hawaiian/Pacific Islander (n = 1), and White (n = 10). Of these, two individuals also identified as Hispanic/Latino. All individuals had health insurance and most made less than $20,000 a year. For additional demographic information see Table 1.

Table 1.

Participant demographics from survey data.

Age (range (mean))	18–31 (23.1)
Gender * (n)
Transgender Men	7
Transgender Women	1
Non-binary	6
Sex assigned at birth (n)
Female	12
Male	2
Sexuality (n)
Queer	5
Pansexual	4
Gay/Lesbian	3
Straight	1
Bisexual	1
Ethnicity (n)
Hispanic/Latino/a	3
Non-Hispanic/Latino/a	11
Race † (n)
Black	3
White	10
Asian	2
Native Hawaiian/Pacific Islander	1
Income (n)
Less than $10,000	5
$10,000 to $15,000	2
$15,001 to $25,000	3
$25,001 to $35,000	1
$35,001 to $50,000	1
$50,001 to $75,000	2
Housing (n)
Rent an apartment/house (alone or with others)	7
Staying with family	6
I would rather not answer	1
Total number of people in household (range (mean))	1-9 (2.9)

^*Participants self-identified their gender. Identities have been consolidated for this table. For instance, ‘Transgender Men’ include people that identified as ‘male,’ ‘trans-man,’ and ‘boy’ and as transgender.

^† Participants were able to select more than one race

Our findings included four themes; (1) Sexual risk behaviors and STI prevention practices varied across participants; (2) individuals who demonstrated more knowledge about STIs either had a significant identifiable sexual educational experience or had a past personal experience with an STI; (3) individuals were interested in receiving information about STIs and sexual health from health care providers, school sexual education programs, and online resources based on a desire for accessible, private, factual, and inclusive content; and (4) public messaging around sexual health and STIs was seen both as potentially stigmatizing, but also important for increasing awareness of available services. These themes and subthemes are described below with supporting participant quotes.

Theme 1: Sexual risk behaviors and STI prevention practices varied across participants

Transgender men and non-binary individuals who were AFAB and lower risk sex behaviors

Most individuals who were AFAB described engaging in activities that present low-moderate risk of STI infection including oral and digital sex and using sex toys with partners who were AFAB. Many of these individuals were in monogamous relationships or had a limited number of past sexual partners. A few individuals were having receptive vaginal or anal sex with non-monogamous partners with penises and using condoms regularly. Many individuals used additional measures to prevent STI transmission including regular STI testing, discussions with partners about STIs and STI screening before sex, internal condom use, dental dam use, gloves with hand-vagina sex, external condoms use over sex toys, not sharing sex toys, and sex toy hygiene.

Multiple individuals expressed that they were having less sex due to gender dysphoria related to their genitals. One said:

I think a lot of the reason why I’m not super sexually active is a lot because of like bottom dysphoria and stuff like that. It gives me a lot of anxiety to like, do that.

Another individual reported having less sex due to fear of being preyed on by abusive partners specifically as a result of their gender saying:

…trans youth in general and specifically like trans-fems, it can be really dangerous cause…they’re super fetishized … kids are put into like really dangerous situations with like men, you know, from online or whatever.

Many identified their risk as lower than cisgender individuals or the same as anyone else with their sexual behaviors. When talking about risk one individual said:

I feel like it [STI risk] is for me probably lower just because I don’t often, like, penetrative sex is not something I’m personally interested in. So, I feel like my risks of getting an STD or STI are fairly low just because of that.

Individuals cited desires to be healthy, discussions about STIs with their partners, and worries about becoming infected with an STI as reasons to be screened for STIs and to protect themselves from STIs. Individuals with self-identified lower knowledge about STIs were generally more worried about the potential for infection. One individual said:

I feel like I just don’t know enough about the way that it’s [STIs] transmitted and how susceptible I am. I just. Yeah, I just feel honestly, like, scared.

Transgender men and non-binary individuals who were AFAB and higher risk sex behaviors

A few individuals who were AFAB engaged in higher risk sexual behaviors including receptive anal and vaginal sex with people with penises regularly without a condom. Individuals discussed not having a condom or partner preference as reasons not to use protection. One transgender man described reasons for having high risk sex including risk compensation considering lower risk of HIV infection while taking PrEP (or Pre-Exposure Prophylaxis, a daily antiviral medication to prevent HIV infection) and gender affirmation experienced by having frequent sex with cisgender men in the context of the perception that cisgender gay men have more frequent casual sex partners. He said:

I think probably my promiscuity is related to, you know, like it’s kind of a stereotype that gay guys sleep around a lot. And so…as a trans guy… I’m kind of overcompensating in that respect.

Transgender women and non-binary individuals who were AMAB and higher risk sex behaviors

The two individuals in the study who were AMAB engaged in some moderate to high-risk sex behaviors based upon having condomless anal sex with a partner who had not recently been tested for STIs or assumed higher risk sex behaviors based upon number of partners and the number of past reported STI infections (one individual felt uncomfortable sharing their specific sexual practices). They believed their risk was no different than a cisgender person engaging in sexual behaviors like theirs’. One individual said:

I feel like, anybody can get anything. Any sexually transmitted thing, it doesn’t matter who you are or what you are. It matters how your sexual practices are. If you’re practicing safe sex or not, you’re going to…see the pros and the cons of doing it.

Both individuals had been on PrEP though one had since become infected with HIV and had started antiretroviral therapy. Both cited current or past risk compensation while on PrEP as a reason to have higher risk sex. One said:

I’ve been playing a little bit fast and loose with it only because I know that A) I take PrEP and B) that I just got tested.

Theme 2: Individuals who demonstrated more knowledge about STIs either had a significant identifiable sexual educational experience or had a past personal experience with an STI

Individual knowledge based on past educational experience

Most individuals had not had an STI infection in the past. Of these individuals without a history of STIs, those who identified as knowing more about STIs and demonstrated this knowledge described specific educational experiences where they had learned about STIs. Experiences varied and included high school sexual education curricula, conferences, college-level academic research, and conversations with medical providers. Individuals demonstrated knowledge of STIs by discussing different STIs, their symptoms, how they are transmitted, and methods of STI prevention.

Some individuals felt they had had comprehensive school sexual health curricula as this person did:

I remember we had a pretty like informative course held by a [university] student at my high school. So, we got pretty good knowledge about that. And, we also talked about like…different identities and like how like different people identify like sexual orientation- and gender-wise.

Another individual described a conference they went to in college:

I got involved with our queer conference group and it was … a whole conference specifically about sexual education and sexual health for queer people.

Other individuals spoke about educational conversations with medical providers. This person spoke about interactions with their primary care physician:

She was a lot more open to teaching me different things that I should know and that I should have known, like, years ago…. I felt like I could talk to her a lot more about a lot of different things.

Individuals with knowledge based on past experiences with STIs

The three individuals that had tested positive for an STI (including one who had a false-positive test) had knowledge relating to those STIs. Some of these individuals discussed their infection as the first time they learned about that STI in depth. Here one individual talked about a recent infection with herpes:

I didn’t really know a lot about it. It wasn’t really on my radar. But then I did a lot of research in the days afterwards and realized it’s, you know, how manageable it is.

Individuals with no or limited knowledge about STIs and missed opportunities for sexual health education

Individuals with limited knowledge about STIs reported limited to no exposure to sexual health education in their school or otherwise. This included school curricula that only taught about abstinence or cisgender heterosexual sexual relationships. Many individuals discussed that this lack of sexual health education was inadequate as did this person:

Oh, jeez, I don’t know anything. I’m so behind. I feel like, you know, my schooling was religious, and we didn’t get any of that in school.

While some individuals included conversations with medical providers as opportunities to learn about sexual health, many individuals said that medical providers either asked them about sexual health in a way that they did not find applicable to their gender and sexuality or “glossed over” these topics entirely. When asked if their medical providers asked about gender and sexuality one individual said:

They still tend to go over that, but the way they go over that is still…in kind a heteronormative way. I remember when like going in for like birth control options and stuff. Like everything that they talked about was just kind of like in a heteronormative normative setting and not like how it affects, how it would affect like a queer relationship…

Individuals’ knowledge of PrEP

The exception to the variation in knowledge about STIs and sexual health was knowledge of PrEP. Almost all individuals were aware of PrEP and knew that it was a medication taken to prevent HIV infection. Many believed that PrEP was only for cisgender gay and bisexual men, like this individual:

I was under the impression it was only for cis-males who are gay.

Individuals reported that they had learned about PrEP from commercials, advertisements in magazines, medical providers, and friends.

Theme 3: Individuals were interested in receiving information about STIs and sexual health from health care providers, school sexual education programs, and online resources based on a desire for accessible, private, factual, and inclusive content

Preference to learn from medical providers

When discussing preferred settings for learning about STIs and sexual health, some individuals believed this information would be best shared in conversations with a medical provider. In some cases, this was because of the perceived expertise of medical professionals and their ability to give factual answers.

…because it’s [sexual health] not something you’d, you’d really like to talk about, like with your mom or your teacher or something like that. You want to … feel comfortable talking about it with some someone professional, someone that’s going to give you the right answer. So, I think the best resource is probably just your doctor.

Other individuals preferred to learn about STIs from medical providers because of the privacy and the ability to have “one-on-one, personal” conversations at their medical providers’ offices.

When discussing medical providers as resources for sexual health information individuals brought up a desire for medical providers to be open, gender-affirming, and non-judgmental [see next section, sub-theme 3b].

Past experiences with and recommendations for medical providers

While individuals cited medical providers as a preferred setting for learning about sexual health, most had a range of past negative and stigmatizing experiences with medical providers. Some generally liked their providers but felt more “vulnerable and insecure” asking about sexual health, like this individual who said:

I don’t get the impression he [the doctor] was like homophobic or transphobic, but just wasn’t in the practice of like it was not like a that I got the impression a doctor who served many, many queer people or trans people.

Others had experiences that were more significantly negative and/or stigmatizing. One individual spoke about meeting a new psychiatrist that asked multiple questions about gender-affirming care that were outside the scope of reasons for the visit. Here he describes his reaction to this set of questions and how it made him feel:

…he [the psychiatrist] asked me… “are you done transitioning?” … it took me a bit, but I was just like, “Oh, so that is you asking what genitals I have?” … the next time I saw him, he kind of like continued and asked like a little bit more about that. And it just made me feel like super uncomfortable…it’s just very triggering

Multiple individuals also reported avoiding health care due to significant frustration in interactions with insurance companies specifically when requesting coverage for gender-affirming care. One said:

I had to fight them [their insurance company] to get my surgery done…I called my insurance company, like, “I’ll commit suicide if you don’t cut my boobs off.” Like, this is not a joke. Do you want me to be dead or do you want me to be in a mental hospital for the rest of my life and pay for that?

Many individuals also had positive experiences with medical providers. These providers were predominately providers of gender-affirming care or providers known to be LGBTQ + friendly. One individual described how they felt when they received this type of care:

I just felt human. I just felt like a patient getting care and I felt like all of my needs were addressed….it didn’t feel over the top or like, self-congratulatory or, or like they were trying too hard or anything.

Based on these experiences, individuals had recommendations and preferences for their medical providers. A common preference was for a provider that was more open and non-judgmental. One individual said they preferred:

…a doctor that’s more open. Or, like, doesn’t seem so judgmental when it comes to questions about sex or getting STD tested or how to have safe sex.

Many individuals also desired providers that were more familiar with care for TGN people and affirming of their genders. This included things like the correct use of individuals’ pronouns and providing administrative paperwork that allowed for accurate documentation of individuals’ gender and sexuality. Speaking generally about medical provider preference one individual said:

I think it would be better if they did have just like that basic knowledge of it…. I understand that … trans people can go to a specific clinic for that, but it would be nice to have like just your primary [care provider] and them to kind of understand a little bit more than we do.

Individuals also expressed that seeing providers that reflected their own identities, including age, race, gender, and sexuality, was beneficial for their care. Most had not had this experience but desired it. One individual who had a transgender therapist said:

…that made such a difference. Being able to talk to somebody that, like, has a basic understanding of, like, my humanity and I don’t have to, like, explain, like, little details is…lifesaving honestly.

Additionally, many individuals felt that they were “less comfortable with old white [cisgender] men” as their providers. Ultimately, most expressed that they would be comfortable with any provider that treated them equally to other patients and did not stigmatize TGN patients as this individual noted:

…if I have a like a cis-white guy as my doctor, that’s perfectly fine, as long as I’m treated the same way, you know? I don’t mind.

Preference and recommendations for school sexual education programs

Many individuals said that middle and high school sexual education curricula were ideal places to learn about STIs because of their ability to reach most people. They noted that it was important for these curricula to be inclusive of people of different gender and sexual identities as discussed by this individual:

…high schools in particular … they give like sex ed classes with like one class in like four years and they … only teach about straight stuff. I feel like it should be more like open with because not everyone is straight.

Others discussed a need for school sexual education to be factual and comprehensive:

Like in school, you should definitely be learning about this [sexual health]…it does no service to anybody to sugar coat it and do it in a way that like makes kids feel like shame or just like, you know, like just like a lack of understanding.

Preference for online resources

Many individuals noted reputable online resources as preferred venues for learning about sexual health because of their accessibility and the privacy of accessing the information on your own. One said:

I definitely feel like it should be something that there’s more information about online, just where, where it’s more accessible.

Another noted online resources are preferable to a medical provider for these reasons:

But there’s definitely also reputable websites that people can learn from that are maybe more accessible or less embarrassing than talking to a doctor.

Individuals mentioned using search engines, inclusive sexual health websites, and general health websites to look up sexual health information in the past.

Individuals’ preference for inclusive sexual health education content

Individuals had different recommendations for content included in sexual health messaging and curricula. Most discussed that content should be inclusive of TGN and other LGBTQ + identities. This included how to stay safe in sexual relationships regardless of the genitalia a person and their partner have, as this person discussed:

It shouldn’t just be penis, you know, and vagina. It should be like if both people have vaginas like this is how you have protected sex. If or people have penises this is how you do it. If you’re like, you know, a penis and a vagina this is how you have protected sex.

Individuals brought up other topics they believe would be beneficial if included in sexual health education including physical and emotional safety in relationships, safe practice of kink, and sexual pleasure.

Theme 4: Public messaging around sexual health and STIs was seen both as potentially stigmatizing, but also important for increasing awareness of available services

Most individuals were open to seeing advertisements about STI prevention and sexual health, citing the need for accessible information. Speaking about PrEP advertisements one individual said:

…PrEP ads are all over, like, gay magazines, as it should be. I mean, that’s great. I love seeing PrEP ads in gay magazines because it feels like finally they’re targeting like the correct audience.

Many were open to advertising on phone-based dating applications “because that’s, that’s where people go to hook up.” Dating applications that were mentioned included Grindr, Tinder, and Taimi. Others included Her, Craigslist, and OkCupid.

Many individuals were also interested in advertisements conveying information about sexual health and STI prevention on social media platforms. Individuals predominately mentioned Instagram, TikTok, and Facebook.

Many individuals discussed that advertising was important but should be ubiquitous saying that sexual health was relevant to everyone. Some elaborated on this saying more universal advertising was needed because targeted advertisement to TGN people and the LGBTQ + community was overly stigmatizing due to the perceived association between the LGBTQ + community, STIs, and sexual promiscuity. This individual discussed this preference as a way of spreading information without stigma:

Yeah, I so I would love it if these ads didn’t just come on after like watching like queer shows. Because, like, that’s like the only time I ever notice it. And that’s, like, really discouraging. Yeah. I think that it should be everywhere. I mean, like, on bus stops, like on like all the channels, like commercials…this is relevant information to all people.

Discussion

This was among the first studies to explore sexual health practices and sexual education opportunities for TGN populations, especially with the inclusion of non-binary individuals. Individuals’ sexual and STI prevention behaviors were heterogenous. Our results highlight unique experiences that influence these behaviors and affect STI infection risk for TGN individuals. For example, this includes multiple individuals who discussed limiting certain kinds of sex due to experiences of gender dysphoria relating to their genitals as well as others citing sex as a way of feeling affirmed in their gender (whether they acted on these feelings or not). A review of the sexual health of transgender men by Stephenson et al. documented a similar variety in sexual behaviors and motivations (Stephenson et al., 2017). Penis-anus sex with men as a form of gender affirmation for transgender men who identify as gay has also been reported separately (S. L. Reisner et al., 2016; J. M. Sevelius, 2013).

These experiences leading to a heterogeneous set of sexual behaviors and motivations among TGN individuals speak to the importance of including TGN-inclusive demographic gender categories in addition to factors beyond gender in future surveillance data and research stratifying risk. These additional factors could include specific sex behaviors, genital anatomy including anatomy post-gender-affirming surgery, sexual orientation, or engagement in sex work. These factors may serve as important risk modifiers as suggested by a 2019 US national survey study finding that transgender men who have sex with men are a particularly high risk population (Reisner et al., 2019).

Our study explored sexual health knowledge and learning opportunities as a potential way to reduce STI infection risk among TGN individuals. Most individuals in our study shared a lack of knowledge about STIs and sexual health topics due to either a lack of past opportunities to learn about sexual health and STI prevention, or opportunities that presented information in ways that were not inclusive of, not relevant to, or stigmatizing of individuals based on their gender. A 2021 review and other research has similarly found that most TGN individuals have not had significant, positive, or sufficient past experiences with sexual health education (Haley et al., 2019; O’Farrell et al., 2021; Pampati et al., 2021; J. Sevelius, 2009; Warwick et al., 2022). The individuals in our study who had past positive experiences with sexual health education demonstrated significant knowledge about sexual health and STI prevention. This represents a potential for effective sexual health education for TGN individuals as has been demonstrated in the literature (Bockting et al., 2005; O’Farrell et al., 2021).

In exploring potential sexual health education interventions for TGN individuals, individuals in our study identified accessibility, comprehensiveness, factuality, and inclusiveness as the most important components. Based on these factors, individuals identified school-based curricula, online resources, and conversations with medical providers as ideal settings to learn this information. Notably, this was despite many individuals having had negative experiences with school curricula and medical providers in the past.

These results support the need for improvement in the comprehensiveness and inclusivity of school based sexual health curricula for TGN individuals. Requirements for sexual health education in schools in the United States are limited. As of July 2022, only 29 states and the District of Columbia require sexual health in schools, and only nine of those states require discussion of sexual health for LGBTQ + youth. Six other states require sexual health instruction that explicitly discriminates against LGBTQ + youth (SEICUS Sex Ed for Social Change, 2022). Additional legislative action and advocacy efforts are needed to ensure comprehensive and inclusive sexual health education. Limited research has identified specific content areas needed for sexual health care that is comprehensive and inclusive of TGN populations, however more research is needed in this area (Haley et al., 2019).

Our results also affirm the documented need for support in medical provider interactions with TGN individuals when providing sexual health care (Casey et al., 2019; Gonzales & Henning-Smith, 2017; Hobster & McLuskey, 2020; James et al., 2016). This includes improved insurance coverage for gender affirming care. Individuals desired providers and staff that are respectful, open, and gender-affirming, including specifics like correct usage of patient pronouns and inclusivity of diverse genders on clinic paperwork. They also identified a need for providers that reflect the identities of their patients, specifically the need for additional TGN providers. Additional recommendations for inclusive medical spaces have been outlined by Waryold et al. (Waryold & Kornahrens, 2020).

Medical schools could promote these qualities in future providers by recruiting TGN students and teaching best practices when providing health care for TGN patients. Hana et al. provides a review of the current state of the inclusion of TGN identities in medical education including recommendations for inclusive curricula (Hana et al., 2021). For providers already in practice, continuing medical education opportunities could be an important way to improve provider interactions. For example, simulation within hospital systems was identified as improving provider competency in providing care for TGN patient (McCave et al., 2019). Continuing medical education also presents opportunities for quality improvement efforts exemplified by a community need assessment regarding gender-affirming care and the initiation of a TGN-inclusive health questionnaire at one clinic (Mann-Jackson et al., 2021; Tordoff et al., 2022).

Individuals were interested in receiving information about sexual health and STI prevention inclusive of TGN identities in the form of public health advertisements. They were particularly interested in receiving information on social media (most notably Instagram, TikTok, and Facebook) and dating apps (most notably Grindr, Tinder, and Taimi). These platforms or similar ones could serve as sites for future public health messaging. Universal knowledge of PrEP among those in the study is evidence that this kind of messaging can be effective. This knowledge is consistent with research demonstrating that public messaging about PrEP can be an effective way to spread awareness and increase PrEP uptake, however this messaging comes with a potential for furthering stigma (Jones & Salazar, 2016; Phillips et al., 2020). Most individuals in our study felt that the inclusion of TGN identities in advertisements for sexual health promotion was important but they had concerns about advertisements targeting them specifically. It is important to present sexual health messaging in inclusive and gender-affirming ways while avoiding further stigmatization. To do so, individuals in our study recommended that advertisements be inclusive of TGN and other LGBTQ + identities as part of larger populations as opposed to solely including LGBTQ + individuals. Similar recommendations have been reported in other studies including LGBTQ + populations (Harkness et al., 2021; Keene et al., 2021; Rogers et al., 2019).

Limitations

By nature, this qualitative study has limited generalizability but is meant to further pave the way for larger-scale quantitative and mixed-methods research. Specific limitations include a small sample size including mostly TGN who were AFAB. It is important to include transgender women in this work as they have been most consistently identified as at high risk for STI infection. It is also important to include a greater number of non-binary individuals who were AMAB. Additionally, individuals were recruited exclusively from settings known to be gender-affirming and LGBTQ + friendly. While this was done to include individuals able to speak to experiences with sexual health education and messaging in a variety of medical settings including those that were likely to be more positive, this likely leaves out many TGN individuals who do not have access to regular medical care. When working with populations known to face significant stigma from the health system such as TGN individuals, study recruitment can be difficult, particularly if seeking individuals not already engaged in health care settings.

Conclusion

Overall, findings suggest that TGN individuals’ sexual behaviors and STI prevention practices are heterogeneous. Individuals identified low and high-risk sexual behaviors and multiple facilitators and motivators for STI prevention. Some of the factors related specifically to being TGN such as gender-affirmation as a reason to have sex, and gender dysphoria as a reason not to. These nuances and variations in behavior suggest that gender alone may not be an adequate risk factor in future studies. While some effective options for sexual health education for TGN populations exist, there is a lack of sufficiently comprehensive and TGN-inclusive options providing the information needed to reduce STI risk and STI incidence within this population. School sexual education curricula, medical providers, and online resources were all identified as potential ideal venues for spreading information about sexual health and STIs. However, significant work is needed to assure that these resources are not stigmatizing and provide comprehensive information relevant to and inclusive of TGN people. Finally, messaging about sexual health and STIs in the form of advertisements, especially on social media and dating apps, may be effective and would be welcomed by TGN individuals, but can promote stigma if solely targeted at TGN and other LGBTQ + communities.

Correction Statement

This article has been corrected with minor changes. These changes do not impact the academic content of the article.

Funding Statement

This work was supported by the Brown Emerging Infectious Disease Scholars (EIDS) Program under Grant [5R25AI140490].

Disclosure statement

No potential conflict of interest was reported by the authors.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.