Acceptability and perceived usefulness of the MyPEEPS mobile app for young transgender men

Abstract

Young transgender men (YTM) remain underserved by HIV prevention efforts. It is estimated that 3% of transgender men have an HIV diagnosis despite a rate of only 0.4% among the U.S. population, and young people account for more than half of new HIV diagnoses. We conducted in-depth interviews with a sample of participants who used MyPEEPS YTM to assess acceptability and perceived usefulness of the app. Qualitative analysis of the interviews was guided by the Unified Theory of Acceptance and Use of Technology and allowed us to identify app benefits including HIV prevention reinforcement and facilitation of conversations surrounding sexual health. Thematic findings highlight that MyPEEPS YTM functioned as a relational and affirming resource in settings where culturally competent care is often unavailable. For nursing, these insights provide actionable strategies to enhance clinical practice, enrich educational preparation, and advocate for policies that support equitable access to digital health interventions.

Introduction

Transgender (trans) men face a disproportionate burden of HIV and remain underserved by HIV prevention efforts (Hosek & Henry-Reid, 2020; McKetchnie et al., 2023). As of 2021, it is estimated that 3% of trans men had an HIV diagnosis despite a rate of only 0.4% among the general U.S. population (California Department of Public Health, 2021; McKetchnie et al., 2023). Additionally, young people aged 13 to 34 years account for more than half (56%) of the new HIV diagnoses; the youngest age category (13–24) accounts for 19% of the overall new HIV diagnoses (HIV.gov., 2025). Young trans men (YTM), which is defined in the present study as people assigned female sex at birth who identify as a trans man or along the transmasculine spectrum ages 15 to 25 years, face an increased risk of HIV seroconversion. Risk may be elevated due to biological factors, such as increased susceptibility from vaginal tissue changes while undergoing testosterone therapy, and social conditions such as stigma and discrimination (Poteat et al., 2017; Radix, Bond, et al., 2022). Trans patients have frequently reported providers denying them care due to gender identity, using incorrect names or pronouns (Seelman et al., 2017) and being misidentified as cisgender (cis) due to discomfort in coming out to providers, especially if demographic forms do not allow them the opportunity to do so (e.g., no inclusion of separate spaces for sex assigned at birth vs. gender identity) (Sevelius, 2009). A 2015 survey among 27,715 trans adults found that nearly one-fourth of respondents reported delaying care when sick due to fear of discrimination (James et al., 2016). Lower engagement with healthcare systems contributes to disproportionate uptake of HIV testing and prevention among trans populations (Melendez & Pinto, 2009; Poteat et al., 2017; Radix et al., 2020).

YTM are often overlooked and frequently excluded from routine reporting of new HIV diagnoses in the United States limiting the availability of detailed data about transmission categories (aidsmap, 2020). Yet, sexual contact accounts for the vast majority (89%) of all new HIV diagnoses (HIV.gov., 2025). Data amongst trans men underscores several key risk factors including cis male partners, substance use, and sex work (Golub et al., 2019). Importantly, the U.S. National Transgender Discrimination Survey reported that 82% of respondents who identified as trans men did not identify as heterosexual (Reisner et al., 2016) and a retrospective chart review of 577 patients found that HIV prevalence was highest among those who exclusively had sex with cis men (Radix, Larson, et al., 2022). A false assumption of primarily cis female sexual partners may lead trans men who are potentially at risk for HIV acquisition to be excluded from HIV prevention recommendations and efforts (Golub et al., 2019).

While pre-exposure prophylaxis (PrEP) is a highly effective biomedical intervention for HIV prevention, the U.S. Food and Drug Administration (FDA) approval of PrEP regimens for trans men has been delayed, with only one (tenofovir disoproxil fumarate [F/TDF]) of the two oral medications tested among people assigned female at birth (CDC, 2025). Most recently, an injectable PrEP regimen which is administered every 6 months, Lenacapavir, (Kelley et al., 2025) was approved by the FDA (Gilead, 2025). Importantly, clinical trials for Lenacapavir included trans men and gender nonbinary participants (Kelley et al., 2025) who are normally excluded from PrEP clinical trials (Lee, 2023). There is evidence that PrEP uptake is insufficient with a survey among 843 trans men who have sex with men that indicated that although 84.1% had heard of PrEP, only 28% reported use (Reisner et al., 2021) highlighting the need for more sexual health interventions for YTM. Trans men frequently question drug interactions between PrEP and testosterone or PrEP and birth control, information that is typically excluded from mainstream health curriculums targeted towards cis men (Kidd et al., 2023). Patients also commonly report a need for a stronger foundation of primary care, including cervical screening, birth control, and social support, opening opportunities for further engagement with care and HIV prevention (Rowniak et al., 2017).

Disproportionate rates of HIV incidence and prevention in medical settings suggest there is a need for targeted sexual health interventions to promote HIV education among YTM. A potential solution is mobile health (mHealth) technology which circumnavigates the barriers of traditional medical settings and has been a growing strategy for HIV prevention and management within the past two decades alongside the proliferation of smartphones in the United States (Maloney et al., 2020; Muessig et al., 2013; Nelson et al., 2020). While there exists an abundance of mHealth apps for HIV prevention, most are tailored toward cis men who have sex with men (MSM); those tailored toward trans men are still lacking (Poteat et al., 2017). Based on a scoping review, as of 2017 most HIV prevention interventions for trans populations target trans women. Out of the 32 studies listed, only one intervention was exclusively for trans men; LifeSkills 4 Men which was developed in 2013 in Boston (Poteat et al., 2017). Of note, the Transpire app which facilitated access to HIV and STI prevention information, at-home self-test kits, condoms, lube, and mental health and substance use resources was tested among 60 trans men and found to be acceptable during a 3-month intervention period (Jones et al., 2024). Studies among this target population, however, are scarce and there is a need for more similar apps to improve sexual health outcomes (Jones et al., 2024).

Given disparities and a shortage of interventions to support sexual health among YTM, we adapted an existing mHealth intervention called “MyPEEPS Mobile App” (Schnall et al., 2022) to be used among a cohort of 80 YTM in a randomized clinical trial (RCT). In the current study, we aim to present the acceptability and perceived usefulness of the adapted app “MyPEEPS YTM” through a theoretically guided analysis of in-depth interviews that were conducted among a sample of participants from the pilot RCT.

Methods

MyPEEPS YTM Intervention

The original MyPEEPS Mobile App consisted of a sexual health curriculum delivered through avatars and a series of modules incorporating quizzes, scenarios, and videos aimed at increasing HIV and sexual health literacy. It was tested among a cohort of 763 same sex attracted adolescents cis males aged 13 to 18 years to prevent or reduce sexual risk for HIV acquisition and the intervention demonstrated a 44% overall reduction in condomless anal sex compared with the delayed intervention group at 3-month follow-up (Schnall et al., 2022).

MyPEEPS YTM adopts the same format as the original app (avatars, quizzes, scenarios, visits), but the curriculum is adapted to fit the needs of YTM (See Figure 1 for App Screenshots). App features and content were developed and evaluated by YTM during youth advisory boards and usability testing prior to the pilot RCT (Adedoja et al., 2024). MyPEEPS YTM addresses institutional barriers by walking participants through navigating clinical settings and providing information on health priorities specific to YTM. Within the adapted app for YTM were 25 activities (See Table 1) for participants to complete during the pilot study to improve sexual health outcomes. These activities include specifying preferred names for body parts and sexual practices, as well as different scenarios and education about topics such as substance use, privilege in society, HIV, condom use, hormone injection, safe web-based dating practices, communication, relationship dynamics, misinformation about transmasculine health, and coping mechanisms (Adedoja et al., 2024).

Figure 1.

App screenshots.

Table 1.

Features of MyPEEPS YTM

	Activity	Abbreviated Description
1	Intro	MyPEEPS YTM Profile Setup
2	Bulls-I	Define body parts
3	BottomLine	Sexual activity
4	Underwear Personality Quiz	Introduce app user to characters
5	Safety First	Video that introduces a sexual safety dilemma
6	HIV True/False	Education about HIV and prevention
7	P Learns About Safer Sex	Education about healthy ways to cope with difficult emotions
8	Tackling Testing	Education about HIV and STI testing and PrEP
9	Spread Out	Game to understand spread of HIV
10	Steps to Effective Condom Use	Learning how to use a condom effectively
11	Safer Injection	Activity to understand steps for safe injection
12	Jeopar-T	Understanding transmasculine health
13	Checking in on your BottomLine	Revisit of sexual activity
14	Sexy Settings	Education about sexual safety practices in certain settings
15	Going Downhill Fast	Activity to understand substance use during sex
16	Move Up, Move Back	Education about disadvantage and privilege in society
17	Disclosure	Information on how to safely disclose trans status
18	Healthy Relationships	Education about healthy and unhealthy relationships
19	Checking in on your BottomLine Again	Revisit of sexual activity
20	Red Flag, Green Flag	Education about setting and sticking to boundaries
21	Peep in Love	Education about intense feelings and sexual behavior
22	4 Ways to Manage Stigma	Education about coping approaches in stigmatizing settings
23	Get a Clue	Education about responses in unique sexual settings
24	Last Time Checking In On Your BottomLine	Final revisit of sexual activity
25	BottomLine Overview	Review BottomLine

Note. YTM, young transgender men.

Ethics

All study procedures were approved by the Institutional Review Board under approval number AAAT8624 prior to the recruitment and enrollment of any participants. All participants signed informed e-consent prior to enrollment into the study. Upon signing e-consent at the enrollment visit, participants also agreed to be asked to participate in an interview following the intervention period. The pilot RCT was registered on clinicaltrials.gov with the number NCT05424718.

Recruitment

From June to September 2023, 80 participants were enrolled in the MyPEEPS YTM study. Recruitment was carried out using online advertisements on Reddit, Facebook, SnapChat, and Instagram. To participate in the MyPEEPS YTM Study, participants were screened to meet the following criteria: (a) between 15 and 25 years of age; (b) female sex assigned at birth; (c) identify as a trans man or along the transmasculine spectrum (including transmasculine non-binary gender); (d) understand and read English; (e) live within the United States; (f) own a smartphone; (g) self-report condomless receptive anal or vaginal penile sex with either a cisgender male or transgender woman (e.g., individual assigned male at birth) in the past year; and (h) self-report HIV-negative or unknown status.

Following participation in the trial, YTM were asked to participate in an in-depth interview at their 6-month follow-up to assess acceptability and perceived usefulness of the app. YTM were recruited until saturation was reached which resulted in 20 interviews. We intentionally selected participants representing diverse experiences based on (a) app completion and (b) demographic characteristics.

Visit Procedures

During the 6-month pilot RCT, participants in the intervention and delayed intervention arms (N = 80) tested MyPEEPS YTM (Schnall et al., 2025). At each visit (Baseline, 3-month follow-up, 6-month follow-up) surveys were administered to participants via Qualtrics XM. Demographic information from the surveys is included in the results section to describe the study sample. RCT findings can be found elsewhere (Schnall et al., 2025).

Participants were encouraged to complete all 25 activities within the app (See Table 1). In summary, the 20 selected participants had varying levels of engagement with the app (time spent, number of activities completed, number of logins), most participants (95%) engaged with the app and one participant (5%) did not use the app at all during the intervention period. The number of times participants logged into the app ranged from 1 to 18 with an average of six logins per user (SD ± 4.4), meaning that participants finished most or all or the activities in as little as one and as many as 18 sittings. Seventeen participants (85%) completed all 25 activities; two (10%) completed 24 activities (one skipped Activity 11, one skipped Activity 12; See Table 1), and one (5%) did not complete any activities. On average, participants spent the most time (Median time spent: 10 min 36 s) on Activity 8 (Tackling Testing; See Table 1) and the least amount of time (Median time spent: 19 s) on Activity 24 (Last Time Checking In On Your BottomLine; See Table 1). Overall, the median time spent on the app was 59 min 41 s.

In-depth interviews were conducted using secure HIPAA-compliant Zoom web meetings, typically ranging between 45 to 60 min in length. Interviews were held one-on-one between a study team member and the participant and were audio-recorded for transcription. Compensation ($30) was sent in the form of an Amazon gift code to participants who successfully completed an in-depth interview. All de-identified interviews were transcribed verbatim prior to coding.

Two models, which are explained in detail below, were used to guide data collection and analysis.

PRECEDE-PROCEED

The interview guide used by study staff was informed by the predisposing, reinforcing, and enabling constructs in evaluation (PRECEDE) portion of the Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation-Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development (PRECEDE-PROCEED) model of health program planning and evaluation, a multilevel approach for development and implementation of interventions (Green et al., 1980). In addition to the evaluation of public health programs, this framework has been applied to the evaluation of health information technology and has been proposed by several authors as a strategy for assessing predisposing, enabling, and reinforcing factors for use and acceptance of health information technology tools (Kukafka et al., 2003; Odlum et al., 2012; Schnall et al., 2011). Structured interview questions are listed in Table 2. These theoretically-guided questions were used as a basic guide for study team members and were asked organically based on participant responses. Study team members were free to stray from the guide when necessary to better understand participants’ unique experiences.

Table 2.

Structured Interview Guide

Structured Interview Guide
What are your experiences with accessing HIV prevention information? Describe your experience finding information relevant to YTM. How does this information compare to the information in MyPEEPS YTM?
What was your experience using MyPEEPS YTM and how did it affect your decisions about your sexual behaviors?
What were some of the barriers to using the App? Incorporating the content into your daily life? (predisposing factors)
What are your ideas about strategies for overcoming these barriers? (enabling factors)
What are some of the ways that your overall health might benefit from MyPEEPS YTM? (reinforcing factors)

Note. YTM, young transgender men.

UTAUT

We developed a codebook using a technology acceptance framework, the Unified Theory of Acceptance and Use of Technology (UTAUT) model, to better understand adoption of the technology. UTAUT was created with aims of supporting the technology development process and has previously been utilized to study the usability and acceptability of mHealth technology (Brin et al., 2025; Schomakers et al., 2022; Soehnchen et al., 2023; Venkatesh et al., 2012; Zhang et al., 2024). UTAUT comprises four core determinants of intention and usage: (a) Performance Expectancy, the degree to which an individual believes that using the system will help him or her to attain gains in job performance; (b) Effort Expectancy, the degree of ease associated with use of the system; (c) Social Influence, the degree to which an individual perceives it is important others believe they should use the new system; and (d) Facilitating Conditions, the degree to which an individual believes that an organizational and technical infrastructure exists to support use of the system (Venkatesh et al., 2003). In Venkatesh’s model, Performance Expectancy, Effort Expectancy, and Social Influence determine Behavioral intention, a person’s subjective probability that he will perform some behavior (Fishbein & Ajzen, 1975) and all four constructs determine Use Behavior, the actual use of the system/technology (Venkatesh et al., 2012).

In this study, we leveraged the PRECEDE-PROCEED framework to guide interview question development and UTAUT to structure qualitative analysis. While PRECEDE-PROCEED helped identify predisposing, enabling, and reinforcing factors shaping YTM’s access to HIV prevention resources, UTAUT provided constructs to evaluate how participants perceived and engaged with the app as a technological tool. Importantly, the two frameworks are complementary. For example, interview questions about barriers to incorporating the app into daily life (PRECEDE “enabling factors”) often generated responses coded under Effort Expectancy in UTAUT, while questions about how the app might benefit participants’ overall health (PRECEDE “reinforcing factors”) aligned with Performance Expectancy and Behavioral Intention codes. Similarly, questions on strategies for overcoming barriers (PRECEDE “enabling factors”) informed coding under Facilitating Conditions. By pairing PRECEDE-informed prompts with UTAUT constructs during analysis, we ensured that contextual influences on health behaviors were directly connected to individual-level technology adoption. We have previously used this approach integrating Fogg’s functional role triad for computing technology model (Fogg, 2002) with the self-determination theory (Deci & Ryan, 2004) to illustrate how mHealth technology can be used as a persuasive strategy for improving the health of persons living with HIV (Schnall et al., 2015). In the case of this study, the integration of the frameworks between data collection and interpretation allowed us to capture both the structural and interpersonal dynamics shaping app acceptability and use among YTM. For example, PRECEDE-informed prompts about enabling or reinforcing factors elicited narratives that deepened UTAUT interpretation—barriers to daily integration illuminated Effort Expectancy beyond interface usability (e.g., structural exclusion), and reports of broader health benefits enriched Performance Expectancy by linking knowledge gains to concrete intentions to test for HIV and negotiate safer sex.

Qualitative Analysis

We used a deductive approach to code the interview transcripts using UTAUT (Fife & Gossner, 2024). The codebook consisted of five codes; definitions were adapted from the original framework (Venkatesh et al., 2003) with modifications according to the app and study population. Three coders reviewed transcripts in Dedoose software, applying the UTAUT codebook. All three researchers coded the first two transcripts with a preliminary codebook and then met twice to discuss any discrepancies and changes to the preliminary codebook. Once the codebook was finalized, each remaining transcript was assigned to two coders (Cofie et al., 2022). Coders used memos within Dedoose to report any emergent themes and codebook edits and met weekly to review them. In each weekly meeting, coders discussed passages in depth to address any discrepancies in the codes. This iterative coding process which has been used in other team-based qualitative analyses (MacQueen et al., 1998) continued until all transcripts had been fully coded.

Results

Through the analysis, we identified five thematic domains reflecting participants’ engagement with the app: (a) App-supported empowerment in safer sex decision-making (Behavioral Intention), (b) Balancing accessibility with navigation barriers (Effort Expectancy), (c) Filling gaps left by exclusion from trans-inclusive health systems (Facilitating Conditions), (d) Centralizing trans-specific knowledge to reduce uncertainty (Performance Expectancy), and (e) Extending knowledge-sharing within trusted networks (Social Influence). While these domains align with UTAUT constructs, participant narratives revealed insights that extend beyond the framework. Table 3 demonstrates the integration of UTAUT and PRECEDE constructs. Results are detailed below with exemplar quotes followed by the race, ethnicity, gender and age of the participant cited.

Table 3.

Crosswalk Table: Integration of PRECEDE → UTAUT → Themes

PRECEDE Construct	Sample Interview Question	Mapped UTAUT Code	Qualitative Theme
Predisposing Factors	“What are your experiences with accessing HIV prevention information?”	Performance Expectancy	Participants described difficulty finding trans-specific resources and reported the app made knowledge easier to access.
Enabling Factors	“What were some of the barriers to using the app or incorporating the content into daily life?”	Effort Expectancy/Facilitating Conditions	Participants cited navigation challenges but also valued app accessibility when clinical resources were lacking.
Reinforcing Factors	“What are some of the ways your overall health might benefit from MyPEEPS YTM?”	Behavioral Intention/Performance Expectancy	Participants reported adopting harm reduction practices, consistent condom use, and increased intention to test for HIV.
Enabling Factors	“What are your ideas about strategies for overcoming these barriers?”	Facilitating Conditions/Social Influence	Participants highlighted peer sharing and community trust as key supports for continued use of the app.

Note. YTM, young transgender men.

Study Sample

A total of 20 participants completed a follow-up interview at their final study visit. Participants self-identified as White (40%), Black (15%), Asian (15%), Native American (10%), Multiracial (10%), Pacific Islander (0.05%), and Other (0.05%). Age of participants ranged from 15 to 25 years old with a median age of 22.5 (SD ± 2.70). Participants were from New York (40%), Washington (10%), Florida (5%), Oregon (5%), Colorado (5%), Massachusetts (5%), Pennsylvania (5%), Texas (5%), Wisconsin (5%), Minnesota (5%), California (5%), and Missouri (5%).

App-Supported Empowerment in Safer Sex Decision-Making (Behavioral Intention)

Participants generally believed that the information that they learned from app would change their future behaviors. They noted that they integrated new harm reduction practices into their daily lives because of their interaction with the app. These include condom use, routine and consistent HIV/STI testing, and safe injection practices. One person said,

“I don’t use condoms, but it makes me want to use them…I think MyPEEPS promotes safety.” (Black, Not Hispanic, Trans Man, 23)

Another participant added,

“It was nice to have a refresher on how to apply a condom. I think a lot of folks think they know how to do that. But there’s a lot of different intricacies to that.” (White, Not Hispanic, Agender, 25)

Importantly, participants mentioned that future conversations with their partners would be different as a result of the use of the app and appreciated the skills they gained related to boundary setting in relationships, “I can see where it’s important to really have those conversations or you know still get tested…like, you know, like in the MyPEEPS, the first situation was like someone going through a relationship.” (Puerto Rican, Trans Man, 22).

Balancing Accessibility With Navigation Barriers (Effort Expectancy)

Participants discussed aspects of the app that made it easy (facilitator) or difficult (barrier) to use. One example of a facilitator was the inclusion of captions in the app. Captions provided accessibility for users when navigating through the app modules, as one participant noted,

“The captions were great, amazing. Very good for accessibility and stuff.” (Black, Puerto Rican, Non-Binary, 19) Another said, “The way it was formatted was very engaging for my ADHD… told in a way that was easy to understand regardless of education level.” (Black, Puerto Rican, Non-Binary, 19)

Participants found that the app was well-designed for progressing to the following modules and said that this format promoted information retention and overall user experience. One participant noted accessibility by stating,

“All the resources [are] like in one place and knowing that they were specifically like for my experience as a trans person rather than like just random bits of information.” (Asian, Not Hispanic, Trans Man, 23)

Participants, however, also noted some barriers to consistent app usage. One said that there is a need for a table of contents and glossary of the information so users can easily refer back to the app content at any point. They added,

“[I wonder] if there’s a way where you could access [ further resources and links to topics that were covered] that’s in a folder or an icon.” (White, Not Hispanic, Agender, 25)

Another similarly said, “It would have been more beneficial if it was a literal scroll thing, just because it was just too slow for me. And I feel like even for some people, maybe it would be too fast.” (White, Not Hispanic, Trans Masculine, 23)

Filling Gaps Left by Exclusion From Trans-Inclusive Health Systems (Facilitating Conditions)

Overwhelmingly, participants noted that the app was beneficial in the absence of trans-inclusive organizations and infrastructures. More specifically, participants noted that the app was superior to traditional methods of learning about health. One participant said,

“[In sex ed] discussions about relationships [are] for cis people, but there is also no topics under transgender people, and specifically transgender gay men, or trans men and relationships… So, hearing this is like a breath of fresh air.” (Asian, Not Hispanic, Trans Man, 23)

Another similarly said, “It’s never been that easy to specifically like find out… how does like the side effects of testosterone, which can include like physical things like vaginal atrophy—like can that impact, like can that like raise your risk for HIV transmission?” (Asian, Not Hispanic, Genderqueer, 23).

Users noted that the app was tailored for the trans-experience and addressed health concerns that are unique to this community. One person said, “I definitely think [MyPEEPS avatars’] situations are relatable, like one of them was sleeping with an older dude and one was working in the sexual health resource center.” (Asian, Not Hispanic, Trans Man & Non-binary, 25)

One also appreciated the way gender diversity was normalized, “It didn’t like make a spectacle that, you know, this is a trans character; it was just like okay, well, this is him; this is how he identifies; this is his boyfriend.” (Native Hawaiian or Other Pacific Islander, Not Hispanic, Non-Binary, 25)

Another person mentioned that the app may be useful for someone who does not go to lesbian, gay, bisexual, transgender, queer, intersex and asexual (LGBTQIA)-specific healthcare centers, “I thought it was done really well, and it aligned with like my own experiences of like getting tested for STIs and stuff. So, talking about PrEP and stuff was good, because I’ve been to like LGBTIQ health-focused clinics.” (Multiracial, Chilean, Trans Man & Genderqueer, 18)

Importantly, participants noted that the use of language was inclusive across the app and incorporated culturally sensitive, and up-to-date language.

Centralizing Trans-Specific Knowledge to Reduce Uncertainty (Performance Expectancy)

Participants noted that the app allowed them to access desired health information. One said, “I’m polyamorous. And so that’s definitely an important thing, to make sure I’m safe. I learned a bit about that from my friend. But beyond that, it was also hard to know what to look into because everything’s so confusing.” (Black, Puerto Rican, Non-Binary, 19)

Another person noted that the app made it a lot easier for them to learn about PrEP use for transmasculine people, as opposed to trying to find information on the internet on their own, “It’s a lot of digging to find transmasc-specific sources, and a lot of the time, they’re like niche, and you can’t find the same breadth of information, which is partly just because it doesn’t exist.” (Multiracial, Hispanic or Latino, Genderqueer, 18)

Many individuals felt that they would have greatly benefitted from MyPEEPS YTM if it had been integrated into their health education at a younger age, noting the difficulty of finding information that specifically addresses trans-concerns in their everyday lives. One person said,

“It made me think a lot about how I navigated sex as a younger trans person, and how I got into a lot of situations where I had felt like I couldn’t say anything or I wasn’t sure how to navigate, or I didn’t have the information.” (Multiracial, Hispanic or Latino, Non-Binary, 25)

Similarly, another person said,

“An important part of sexual health and wellness [is] the connection with other people, and [the app included] information I especially wished I would have gotten when I was younger and in school about emotional well-being and red flags in relationships.” (White, Not Hispanic, Agender, 25)

Several participants described their experiences with learning about health in their primary education through a cis-gendered lens, with minimal mention of trans-related health needs.

Extending Knowledge-Sharing Within Trusted Networks (Social Influence)

Overall, feedback demonstrated that use of the app was not only influential on the individual level, but also on a social level. Participants discussed how the information and scenarios within the app would be beneficial for themselves as well as for others. Many people said that they generally gather information about trans health from their friends and communities rather than medical providers. Thus, the app was a suitable way to ensure that the correct information was spread throughout social circles.

For example, one person discussed the app’s inclusion of topics such as using birth control while on testosterone. They mentioned this is helpful information that is often misunderstood by the public, including among doctors. They shared a friend’s experience,

“A couple of other people at my community [were] told this misinformation, and they got pregnant… They were told that it was practically low chance to impossible that they would have a baby if they were on testosterone. And so those were a lot of things that I was noticing right away in the app, which made me really happy.” (Multiracial, Panamanian, Non-Binary, 25)

One participant, however, mentioned that the app could be improved to benefit all people within social circles by representing more diverse populations within the app. They said,

“Adding characters who have maybe some disabilities or some chronic illnesses that might affect their sex life and the way they communicate with people. ‘Cause I do have some chronic illnesses and disabilities.” (Native Hawaiian or Other Pacific Islander, Not Hispanic, Trans Man & Non-Binary, 25)

Another improvement that could be made to the app, as suggested by one participant, was to emphasize the importance of directness when having a conversation with friends about HIV and sexually transmitted infections (STIs).

“Having that directness be a facet of the characters interpersonal communication, can model for an audience.” (White, Cuban, Non-Binary, 22)

Discussion

This study demonstrates that MyPEEPS YTM was acceptable and perceived as useful by young transgender men (YTM). Using PRECEDE-PROCEED to guide interview development and UTAUT to structure analysis, we identified domains of app engagement that included empowerment in safer sex decision-making, balancing accessibility with navigation barriers, filling gaps left by exclusion from trans-inclusive health systems, centralizing trans-specific knowledge, and extending knowledge-sharing within trusted networks. Collectively, these findings highlight how an mHealth intervention can support YTM in managing HIV prevention and sexual health needs in the absence of affirming clinical environments.

While UTAUT constructs provided analytic scaffolding, participant narratives revealed interpretive insights that extended beyond the framework. For instance, under Behavioral Intention, participants not only described intentions to adopt condom use and regular testing but also emphasized relational empowerment—reporting increased confidence to negotiate with partners and set boundaries. Similarly, Facilitating Conditions highlighted how the app functioned as a proxy for supportive provider interactions many lacked. A cross-cutting theme emerged around the relational nature of learning: participants consistently described sharing information with peers and partners, underscoring that sexual health decisions are embedded in community and social networks. These insights move findings beyond codes, offering a deeper understanding of how YTM integrate digital tools into daily life. These additions clarify how PRECEDE-informed interview content (predisposing, enabling, reinforcing) generated richer UTAUT-based insights (e.g., Effort Expectancy informed by navigation barriers and systemic exclusion; Performance Expectancy informed by relational empowerment and boundary-setting), demonstrating complementary strengths of the two frameworks.

As previous studies have found that rates of condom use and HIV education are lower among transgender than cisgender youth (Phillips et al., 2023; Warwick et al., 2022) positive experiences with HIV prevention education within the app suggest MyPEEPS YTM presents an acceptable and accessible solution to promoting sexual health among YTM. Additionally, feedback on education and activities surrounding healthy relationships highlighted the value of this app component which is crucial given the correlation between healthy romantic relationships and sexual health, and the impact of gender affirming transition on the quality and satisfaction of romantic relationships (Marshall et al., 2020).

Easy access to sexual health information proved to be a crucial component of the app given that many YTM noted that they more frequently get health information from their trusted communities than their healthcare providers. Past research has shown that transgender and nonbinary individuals are often deterred from discussing health information with their providers due to stigmatization and feel that they have to choose between risking stigma and risking ineffective clinical problem-solving (Alpert et al., 2023). A 2023 study which consisted of qualitative interviews with 14 transgender, non-binary and gender non-conforming participants found that most participants preferred to get health information from medical providers, but they had a range of past negative and stigmatizing experiences and felt vulnerable and insecure when talking to their provider about sex; participants also noted that reputable online resources are more accessible and less embarrassing than talking to a doctor (Mickel et al., 2024). These findings support the implementation of an mHealth app with comprehensive sexual health information tailored toward YTM.

Our findings have several implications for nursing practice, education, and policy. Nurses often serve as the first and most trusted providers for sexual health counseling. MyPEEPS YTM can serve as an adjunct to clinical encounters by providing standardized, culturally responsive content on condom use, PrEP/testosterone interactions, and safe injection practices. By recommending or integrating such tools, nurses can build trust with patients reluctant to disclose sensitive information in clinical settings. Moreover, integrating MyPEEPS YTM as an adjunct to patient education in primary care, sexual health, and adolescent clinics; include point-of-care prompts for condom-use education, PrEP navigation, and linkage to affirming services.

Nursing curricula should be expanded to include transmasculine sexual and reproductive health needs, addressing gaps in PrEP knowledge, testosterone interactions, and relationship dynamics. Incorporate transmasculine sexual and reproductive health content into prelicensure and graduate courses, including PrEP/testosterone interactions, cervical screening considerations for transmasculine patients, and communication skills for boundary-setting conversations. The app’s content and participant feedback provide concrete resources for training nursing students in culturally responsive and affirming care. Furthermore, the app can provide continuing education resources through provision of modules that train nurses to use digital tools like MyPEEPS YTM during sexual health counseling, emphasizing culturally responsive and affirming care in settings with limited specialized resources.

Findings underscore the importance of policy and institutional support for digital interventions that extend HIV prevention beyond the clinic. Nursing leaders can advocate for Medicaid and insurance reimbursement of digital tools, ensuring equitable access for YTM in states with restricted access to gender-affirming services. Findings from this study highlight how nursing can lead in advancing equitable sexual health interventions for marginalized populations.

Several limitations warrant consideration. Our purposive sample was small (N = 20) and may reflect perspectives of participants more engaged with the trial. While purposeful sampling allows for selection of participants with unique experiences, it introduces potential bias and limits generalizability thus our sample was not necessarily representative of the total participant population (Palinkas et al., 2015). Self-selection bias is also possible; participants who agreed to participate in qualitative interviews may have been more engaged with, or favorable toward, the intervention, potentially inflating positive perceptions of acceptability and usefulness.

Additionally, social desirability bias could have inflated positive responses, and our heavy representation (40%) from New York—a state with strong protections for gender-affirming care—may limit transferability to regions with restrictive policies. Further, policies such as Medicaid coverage of gender-affirming care vary by state (Movement Advancement Project, 2025), so future studies should purposively recruit more participants from areas where access to care for YTM is limited or restricted to understand the usefulness of this app for delivery of health information. Additionally, the sample was mostly White (40%; approximately the same percentage as in the overall RCT sample (Schnall et al., 2025)) and the trial was short term (6 months) so further research is needed to understand how a larger, more diverse sample of YTM may perceive the app in the long-term. While saturation was reached, the thematic breadth may be narrower than in a larger or more diverse sample. These limitations suggest findings should be interpreted as exploratory, reflecting experiences of highly engaged YTM, rather than representative of all transmasculine youth.

Conclusions

By integrating PRECEDE-PROCEED and UTAUT, we demonstrated how contextual barriers and enabling factors informed individual adoption of mHealth interventions among YTM. Thematic findings highlight that beyond delivering HIV prevention information, MyPEEPS YTM functioned as a relational and affirming resource in settings where culturally competent care is often unavailable. For nursing, these insights provide actionable strategies to enhance clinical practice, enrich educational preparation, and advocate for policies that support equitable access to digital health interventions.