Comparing self- and provider-collected swabbing for HPV DNA testing in female-to-male transgender adult patients: a mixed-methods biobehavioral study protocol

Peer-Delivered HIV Self-Testing, Sexually Transmitted Infection Self-Sampling, and Pre-exposure Prophylaxis for Transgender Women in Uganda: A Randomized Trial

BACKGROUND

Peer-delivered HIV self-testing (HIVST) and sexually transmitted infection self-sampling (STISS) may promote adherence to oral pre-exposure prophylaxis (PrEP), but no studies have analyzed this approach among transgender women (TGW) in sub-Saharan Africa.

SETTING

The Peer study was a cluster randomized trial in Uganda (October 2020-July 2022; NCT04328025).

METHODS

Ten TGW peer groups, each with 1 TGW peer and 8 TGW, were randomized 1:1 to receive quarterly in-clinic HIV testing with PrEP refills as standard-of-care (SOC) or SOC plus monthly peer delivery of oral-fluid HIVST, STISS, and PrEP refills (intervention). Participants were followed for 12 months. The primary outcome was PrEP adherence.

RESULTS

We screened 85 TGW and enrolled 82 (41 per arm). The median age was 22 years (interquartile range [IQR] 20-24). Twelve-month retention was 88% (72/82). At the 3, 6, 9, and 12-month clinic visits, 10%, 5%, 5%, and 0% of TGW in the intervention arm had TFV-DP levels ≥700 fmol/punch, versus 7%, 15%, 7%, and 2% in the SOC arm, respectively (P = 0.18). At all visits, any detectable TFV-DP levels were significantly higher in SOC than the peer delivery group (P < 0.04). PrEP adherence was associated with sex work (incidence rate ratio 6.93; 95% CI: 2.33 to 20.60) and >10 years of schooling (incidence rate ratio 2.35; 95% CI: 1.14 to 4.84). There was a strong correlation between tenofovir detection in dried blood spots and urine (P < 0.001). No HIV seroconversions occurred.

CONCLUSIONS

Peer-delivered HIVST and STISS did not increase low levels of oral PrEP adherence among TGW in Uganda. Long-acting PrEP formulations should be considered for this population.

Strategies to Optimize Cervical Cancer Screening Rates Among Transgender and Gender-Diverse People Assigned Female at Birth

Self-sampling for primary HPV detection for cervical cancer screening is now FDA-approved. Many persons interested in cervical cancer screening are eager to opt out of the invasive speculum exam and opt into the self-sampling. There is no limitation on which persons can choose self-sampling. Transgender, nonbinary, and gender-diverse assigned female at birth (TGD AFAB) people experience barriers such as gender dysphoria and discomfort with sensitive exams. They may find more comfort with this equivalent method of screening. However, no clinical guidelines describe the best practices to increase screening among this underserved population. Much community work needs to occur to make the language of screening gender-affirming for all participants. Solutions to currently invasive follow-up exams after abnormal screens need to be communicated in language directed by the TGD AFAB community.

Breast and cervical cancer in transgender men: literature review and a case report

Transgender individuals exhibit a higher prevalence of cancer-related risk factors, such as substance abuse and sexually transmitted infections. These factors, coupled with suboptimal adherence to cancer screening recommendations, may lead to a higher incidence of cancers, such as breast and cervical cancer, and contribute to delayed diagnoses in transgender patients. Herein, we report a unique case of a transgender man with a history of alcohol and drug abuse, undergoing gender-affirming exogenous testosterone therapy, who developed synchronous locally advanced breast cancer and human papilloma virus (HPV)-related cervical cancer. He underwent concurrent chemoradiation for cervical cancer and surgery followed by endocrine therapy for breast cancer. The treatments were suboptimals due to patient's comorbidities, among them liver cirrhosis leading to an early death. Additionally, we have conducted a review of existing literature, including case reports, clinical studies, and review articles investigating the role of potential risk factors specifically related to breast and cervical tumors in transgender men. Gender-affirming testosterone therapy is common among transgender men to induce gender affirmation, but its link to breast cancer risk remains ambiguous, with studies being limited and sometimes contradictory. Conversely, HPV is a well-established cause of up to 99% of cervical cancers. Despite persistent risk for cervical cancer in transgender men who retain their cervix, several studies indicate notable disparities in screening adherence, due to personal and structural barriers. Moreover, alcohol and drug use disorders, commonly encountered in transgender population, may negatively influence the adherence to screening programs. Current cancer screening guidelines for this population are somewhat unclear, and specific programs based on more robust data are urgently required along with further tailored studies.

[Transmasculine people: Gender affirming hormonal therapy, sexual and reproductive health prevention and care, a medical review and follow-up suggestions]

Transmasculine individuals have a poor access to health care, mostly regarding the sexual and reproductive health. Despite a lack of official guidelines, they need a gynecological follow-up, the aim of this review was to describe it. The present study involved an exhaustive search of MEDLINE, 68 articles were included to analyze the impact of hormonal therapy, prevention, and care regarding sexual and reproductive health of transmasculine individuals. Despite a lack of solid data, the global literature agrees that transmasculine individuals require sexual and reproductive health care. Care must be adapted to each pathway and may be impacted by gender-affirming care. The cancer risk does not seem to be increased in this population, particularly in relation to hormonal therapy. Prevention programs do not differ from those offered to cis women in the absence of gender-affirming surgeries. Transmasculine individuals require follow-up and care adapted to their needs and their pathways. Healthcare professionals must be trained to provide such care.

Prevalence and Determinants of Cervicovaginal, Oral, and Anal Human Papillomavirus Infection in a Population of Transgender and Gender Diverse People Assigned Female at Birth

Purpose: The human papillomavirus (HPV) causes cervicovaginal, oral, and anogenital cancer, and cervical cancer screening options include HPV testing of a clinician-collected sample. Transgender and gender diverse (TGD) people assigned female at birth (AFAB) face many barriers to preventive care, including cancer screening. Self-sampling options may increase access and participation in HPV testing and cancer screening. This study estimated the prevalence of HPV in self-collected cervicovaginal, oral, and anal samples from Midwestern TGD individuals AFAB. Methods: We recruited TGD individuals AFAB for an observational study, mailing them materials to self-collect cervicovaginal, oral, and anal samples at home. We tested samples for high-risk (HR; 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59) and other HPV genotypes (6, 11, 66, 68, 73, 90) using a polymerase chain reaction mass array test. Prevalence ratios for HPV infection at each site as a function of participant characteristics were estimated in log-binomial models. Results: Out of 137 consenting participants, 102 completed sample collection. Among those with valid tests, 8.8% (HR = 6.6%; HPV 16/18 = 3.3%) were positive for oral HPV, 30.5% (HR = 26.8%; HPV 16/18 = 9.7%) for cervicovaginal HPV, and 39.6% (HR = 33.3%; HPV 16/18 = 8.3%) for anal HPV. A larger fraction of oral (71.4%) than anal infections (50.0%) were concordant with a cervicovaginal infection of the same type. Conclusions: We detected HR cervicovaginal, oral, and anal HPV in TGD people AFAB. It is essential that we reduce barriers to cancer screening for TGD populations, such as through the development of a clinically approved self-screening HPV test.

Rationale and design of the Self-TI Study protocol: a cross-sectional human papillomavirus self-testing pilot study among transgender adults in England

INTRODUCTION

Persistent infection with high-risk human papillomavirus (HPV) is the causal agent of several cancers including cervical, anal and oropharyngeal cancer. Transgender men and transmasculine non-binary (TMNB) people with a cervix are much less likely to undergo cervical cancer screening than cisgender women. Transgender women and transfeminine non-binary (TWNB) people assigned male at birth may be at increased risk of HPV. Both TMNB and TWNB people face many barriers to HPV testing including medical mistrust due to stigma and discrimination.

METHODS AND ANALYSIS

The Self-TI Study (Self-TI) is a pilot study designed to measure acceptability and feasibility of HPV self-testing among transgender and non-binary people in England. TMNB people aged 25-65 years, with at least 1 year of testosterone, and TWNB people, aged 18 years and over, are eligible to participate. Participants self-collect up to four samples: an oral rinse, a first void urine sample, a vaginal swab (if applicable) and an anal swab. TMNB participants are asked to have an additional clinician-collected cervical swab taken following their routine Cervical Screening Programme sample. TWNB people are asked to take a self-collection kit to perform additional self-collection at home and mail the samples back to the clinic. Acceptability is assessed by a self-administered online survey and feasibility is measured as the proportion of samples returned in the clinic and from home.

ETHICS AND DISSEMINATION

Self-TI received ethical approval from the Research Ethics Committee of Wales 4 and ethical review panel within the Division of Cancer Epidemiology and Genetics at the US National Cancer Institute. Self-TI was coproduced by members of the transgender and non-binary community, who served as authors, collaborators and members of the patient and public involvement (PPI) group. Results of this study will be shared with the community prior to being published in peer-reviewed journals and the PPI group will help to design the results dissemination strategy. The evidence generated from this pilot study could be used to inform a larger, international study of HPV self-testing in the transgender and non-binary community.

TRIAL REGISTRATION NUMBER

NCT05883111.

Does discrimination prevent transgender and gender diverse people from seeking healthcare?: A nationwide cohort study in South Korea

Introduction

Using Asia's first nationwide cohort dataset, this study aimed to assess the prevalence of anti-transgender discrimination and healthcare avoidance and delay (HAD) and examine their associations among transgender and gender diverse (TGD) adults in South Korea.

Methods

We analyzed a two-wave (2020-2021) longitudinal dataset of 190 Korean TGD adults. Anti-transgender discrimination were classified accordingly: experienced at (1) neither wave, (2) baseline (2020) only, (3) follow-up (2021) only, and (4) both waves. We also asked about HAD in the past 12 months at follow-up for both transition-related and non-transition-related healthcare services. Multivariate modified Poisson regression was used to examine the associations between anti-transgender discrimination and HAD.

Results

Of 190 participants, 102 (53.7%) experienced anti-transgender discrimination at both waves, and 130 (68.4%) reported HAD at follow-up. Compared to those without any experiences of anti-transgender discrimination, those who experienced it in both waves had a 1.78-times (95% CI: 1.21-2.63) higher prevalence of non-transition-related HAD, but not among those who experienced it in either wave. In contrast, anti-transgender discrimination was not associated with transition-related HAD.

Conclusion

In order to enhance healthcare access for transgender and gender diverse (TGD) individuals, it is necessary to implement interventions, such as anti-discrimination laws, that protect them from discrimination.

Factors Associated with Unsatisfactory Pap Tests Among Sexually Active Trans Masculine Adults

Purpose: Unsatisfactory collection of cells during Papanicolaou (Pap) tests prevents the detection of cervical cancer and dysplasia. Prior research found that trans masculine (TM) individuals are significantly more likely than cisgender women to have an unsatisfactory Pap test. The purpose of this study was to identify factors that place some TM individuals at greater risk for an unsatisfactory Pap test than others. Methods: Between 2015 and 2016, 150 TM adults were enrolled in a cross-sectional survey assessing demographics, health characteristics, health care experiences, trauma history, and unsatisfactory Pap test history. Bivariate and multivariable logistic regression analyses conducted in 2020 examined associations between age, length of time on testosterone, smoking history, having to educate a provider about transgender people to receive appropriate care, anticipated health care stigma, post-traumatic stress disorder (PTSD) symptoms, and lifetime history of unsatisfactory Pap tests. Results: Of all participants, 20.2% had an unsatisfactory test in their lifetime, age ranged from 21 to 50 years, 55.1% used testosterone for 1 year or more, and 41.3% had PTSD symptoms. In the multivariable model, older age (adjusted odds ratio [AOR] = 1.15; 95% confidence interval (CI) = 1.04-1.27; p < 0.01), 1 year or more lifetime testosterone use (AOR = 3.51; 95% CI = 1.02-12.08; p = 0.046), and PTSD symptoms (AOR = 3.48; 95% CI = 1.10-11.00, p = 0.03) were significantly associated with increased odds of having an unsatisfactory Pap test. Conclusions: Older age, testosterone use, and PTSD symptoms are associated with lifetime unsatisfactory Pap tests among TM adults. Clinicians should assess TM patients' trauma and testosterone use history before Pap tests and utilize trauma-informed practices that facilitate the collection of adequate Pap samples.

Digital-Assisted Self-interview of HIV or Sexually Transmitted Infection Risk Behaviors in Transmasculine Adults: Development and Field Testing of the Transmasculine Sexual Health Assessment

BACKGROUND

The sexual health of transmasculine (TM) people-those who identify as male, men, or nonbinary and were assigned a female sex at birth-is understudied. One barrier to conducting HIV- and sexually transmitted infection (STI)-related research with this population is how to best capture sexual risk data in an acceptable, gender-affirming, and accurate manner.

OBJECTIVE

This study aimed to report on the community-based process of developing, piloting, and refining a digitally deployed measure to assess self-reported sexual behaviors associated with HIV and STI transmission for research with TM adults.

METHODS

A multicomponent process was used to develop a digital-assisted self-interview to assess HIV and STI risk in TM people: gathering input from a Community Task Force; working with an interdisciplinary team of content experts in transgender medicine, epidemiology, and infectious diseases; conducting web-based focus groups; and iteratively refining the measure. We field-tested the measure with 141 TM people in the greater Boston, Massachusetts area to assess HIV and STI risk. Descriptive statistics characterized the distribution of sexual behaviors and HIV and STI transmission risk by the gender identity of sexual partners.

RESULTS

The Transmasculine Sexual Health Assessment (TM-SHA) measures the broad range of potential sexual behaviors TM people may engage in, including those which may confer risk for STIs and not just for HIV infection (ie, oral-genital contact); incorporates gender-affirming language (ie, genital or frontal vs vaginal); and asks sexual partnership characteristics (ie, partner gender). Among 141 individual participants (mean age 27, SD 5 years; range 21-29 years; n=21, 14.9% multiracial), 259 sexual partnerships and 15 sexual risk behaviors were reported. Participants engaged in a wide range of sexual behaviors, including fingering or fisting (receiving: n=170, 65.6%; performing: n=173, 66.8%), oral-genital sex (receiving: n=182, 70.3%; performing: n=216, 83.4%), anal-genital sex (receptive: n=31, 11.9%; insertive: n=9, 3.5%), frontal-genital sex (receptive: n=105, 40.5%; insertive: n=46, 17.8%), and sharing toys or prosthetics during insertive sex (n=62, 23.9%). Overall barrier use for each sexual behavior ranged from 10.9% (20/182) to 81% (25/31). Frontal receptive sex with genitals and no protective barrier was the highest (21/42, 50%) with cisgender male partners. In total, 14.9% (21/141) of participants reported a lifetime diagnosis of STI. The sexual history tool was highly acceptable to TM participants.

CONCLUSIONS

The TM-SHA is one of the first digital sexual health risk measures developed specifically with and exclusively for TM people. TM-SHA successfully integrates gender-affirming language and branching logic to capture a wide array of sexual behaviors. The measure elicits sexual behavior information needed to assess HIV and STI transmission risk behaviors. A strength of the tool is that detailed partner-by-partner data can be used to model partnership-level characteristics, not just individual-level participant data, to inform HIV and STI interventions.

Factors associated with transmasculine adults recently engaging in sexual behavior with partners of unknown STI and HIV status

The sexual partnerships of transmasculine (TM) adults-those assigned female at birth who identify as transgender men or a masculine spectrum gender identity-and characteristics associated with STI/HIV risk behavior remains understudied. Participants in the current study were TM adults (n = 141) receiving care at a community health center in Boston, Massachusetts between March 2015 and September 2016. Using generalized estimating equations, we examined individual- and partnership-level factors associated with TM adults' odds of engaging in sexual behavior with a sexual partner of unknown STI/HIV status in the past 12 months. TM adults with casual sexual partnerships (vs. monogamous partnerships) and those in partnerships with cisgender men, other TM individuals, or transfeminine partners (vs. cisgender women) had statistically significantly higher odds of engaging in sexual behavior with a partner of unknown STI/HIV status in the past 12 months. Findings may inform future efforts to improve sexual health communication and STI/HIV disclosure between TM adults and their sexual partners.

Acceptability of self-sampling for etiological diagnosis of mucosal sexually transmitted infections (STIs) among transgender women in a longitudinal cohort study in São Paulo, Brazil

This study conducted among transgender women in São Paulo, Brazil assessed the acceptability and suitability of screening sexually transmitted infections (STIs), such as Chlamydia trachomatis and Neisseria gonorrhoeae, by sampling multiple anatomical sites (i.e. urethral, anorectal, oropharyngeal, and neovaginal), and utilizing self- or provider-collection methods. First, a convenience sample of 23 cohort participants were recruited during a scheduled study visit between October and November 2018. Data collection was through a short investigator-led quantitative survey in Portuguese, and included presentation of investigator-designed, gender-neutral instructional diagrams to guide self-sampling. Three supplemental focus group discussions (FGDs) with a total of 30 participants guided by semi-structured script were conducted in Portuguese between September and October 2019. All participants reported being assigned male sex at birth and self-identified with a feminine gender identity at time of study. All survey respondents (100%; n = 23) indicated willingness to provide samples for STI screening during a future study visit. Preference was for self-collection of urine samples (83%; n = 19), urethral swabs (82%; n = 18), and anorectal swabs (77%; n = 17). A lower preference for self-collection of oropharyngeal swabs (48%; n = 11) was observed. Most respondents (78%; n = 18) indicated that they would not prefer specimens to be collected by a health professional, mainly due to ‘more privacy’ (72%; n = 13). All respondents indicated that they would feel comfortable to provide a self-collected sample based on instructional diagrams shown. In FGDs, although the collection by a health professional was described as a technically safer option for some participants, there was a preference for self-collection to avoid discomfort and embarrassment in exposing the body. Overall, this sub-study suggested acceptability among transgender women of introducing self-sampling for etiological diagnosis of STIs from potential infection sites. Uptake and usability will be explored further in a cross-sectional STI prevalence study of transgender women in Brazil.

Human Papillomavirus Infection: Knowledge, Risk Perceptions and Behaviors among SMW and AFAB

Human papillomavirus (HPV) infection is the most common sexually transmitted infection (STI) in the United States, and persistent HPV infection has been established as playing a major role in the development of cervical cancer. Providing HPV vaccination and regular screening tests have reduced the risk of developing cervical cancer or helped to detect the cancer at an early stage. Despite the above measures, cervical cancer still remains a major public health problem worldwide. Infection with HPV, and consequently cervical cancer, affects all people with an intact cervix, so not only heterosexual women, but also women from sexual minorities (SMW) together with people assigned female at birth (AFAB). These populations may be even more likely to develop cervical cancer, mainly because they are less likely to be aware of HPV transmission and prevention of cervical cancer. In our review, we summarized the current state of HPV knowledge, collected data assessing the orientation of this issue among SMW and AFAB, and indicated the causes of possible negligence in the prevention of cervical cancer.

Rectal specimen self-collection for chlamydia and gonorrhea screening: a cross-sectional feasibility study at a community health center

Background

Men who have sex with men (MSM) are at increased risk for extra-genital sexually transmitted infections (STIs). Without extra-genital screening, many chlamydia and gonorrhea infections would be missed among MSM. Yet, many barriers exist to extra-genital testing, and, in particular, to rectal collection. Self-collection increases screening and detection of asymptomatic chlamydia and gonorrhea among at-risk MSM and transgender women. This feasibility study assessed use of rectal self-collection and its acceptance among patients and primary care providers (PCPs) at a large, general practice community health center. The primary objective of this project was to assess the feasibility of including rectal self-collection as part of an implementation study looking to embed an STI care program in a safety-net primary care setting that would shift routine screening tasks to non-provider clinical team members such as medical assistants and nurses.

Methods

Three PCPs identified and offered rectal self-collection to their MSM and transgender female patients who were due for routine or risk-based STI screening. For those patients who elected to participate in the study, the PCP’s medical assistant (MA) reviewed the self-collection instructions with them as part of their routine preventive care duties, and patients collected their own sample. Patients and PCPs completed brief cross-sectional surveys assessing the self-collection process.

Results

Of 1191 patients with sexual orientation and gender identity (SOGI) data on file who were seen for a medical visit by one of the three PCPs, 87 (7.3%) identified as MSM or transgender female. Seventy-five were due for rectal screening, of whom 33 (44%) were offered and completed rectal self-collection. Survey results indicated that self-collection was acceptable to and preferred over clinician-collection by both PCPs and patients.

Conclusions

This study demonstrated that rectal self-collection is feasible as part of STI screening in a high-volume primary care setting, and can be administered as part of the clinical tasks that MAs routinely conduct. The overall acceptance by both PCPs and patients will allow the inclusion of rectal self-collection in an implementation study looking to increase STI screening at a large community health center by facilitating MA-led collection during medical provider visits and by establishing standalone nurse-led STI visits.

Bridging Barriers to Cervical Cancer Screening in Transgender Men: A Scoping Review

Estimates of high-risk human papillomavirus (HPV) infection and susceptibility to HPV-related cancer in transgender men (TM) are comparable to prevalence rates found in cisgender women. Regular and thorough screening for cervical cancer is equally as crucial for TM as for cisgender women; however, despite continued risk for cervical cancer in TM and associated recommendations for screening, studies indicate disparities in rates of cervical cancer screening (CCS) in TM compared to cisgender women. The current scoping review explores TM’s knowledge and experiences of CCS and barriers to screening uptake in this population. A range of barriers were identified including the need for health-care services to provide care for TM within the context of a nonbinary approach to gender identity and health. Findings synthesized from relevant research studies (n = 15; published 2008–2019) are presented, and recommendations are drawn from these findings to inform primary health-care providers’ clinical practice and care of TM.

Longitudinal Cohort Study of Gender Affirmation and HIV-Related Health in Transgender and Gender Diverse Adults: The LEGACY Project Protocol

Background

Transgender and gender diverse (TGD) adults in the United States experience health disparities, especially in HIV infection. Medical gender affirmation (eg, hormone therapy and gender-affirming surgeries) is known to be medically necessary and to improve some health conditions. To our knowledge, however, no studies have assessed the effects of gender-affirming medical care on HIV-related outcomes.

Objective

This study aims to evaluate the effects of medical gender affirmation on HIV-related outcomes among TGD primary care patients. Secondary objectives include characterizing mental health, quality of life, and unmet medical gender affirmation needs.

Methods

LEGACY is a longitudinal, multisite, clinic-based cohort of adult TGD primary care patients from two federally qualified community health centers in the United States: Fenway Health in Boston, and Callen-Lorde Community Health Center in New York. Eligible adult TGD patients contribute electronic health record data to the LEGACY research data warehouse (RDW). Patients are also offered the option to participate in patient-reported surveys for 1 year of follow-up (baseline, 6-month, and 12-month assessments) with optional HIV and sexually transmitted infection (STI) testing. Biobehavioral data from the RDW, surveys, and biospecimen collection are linked. HIV-related clinical outcomes include pre-exposure prophylaxis uptake (patients without HIV), viral suppression (patients with HIV), and anogenital STI diagnoses (all patients). Medical gender affirmation includes hormones, surgeries, and nonhormonal and nonsurgical interventions (eg, voice therapy).

Results

The contract began in April 2018. The cohort design was informed by focus groups with TGD patients (n=28) conducted between August-October 2018 and in collaboration with a community advisory board, scientific advisory board, and site-specific research support coalitions. Prospective cohort enrollment began in February 2019, with enrollment expected to continue through August 2020. As of April 2020, 7821 patients are enrolled in the LEGACY RDW and 1756 have completed a baseline survey. Participants have a median age of 29 years (IQR 11; range 18-82). More than one-third (39.7%) are racial or ethnic minorities (1070/7821, 13.68% Black; 475/7821, 6.07% multiracial; 439/7821, 5.61% Asian or Pacific Islander; 1120/7821, 14.32% other or missing) and 14.73% (1152/7821) are Hispanic or Latinx. By gender identity, participants identify as 33.79% (2643/7821) male, 37.07% (2900/7821) female, 21.74% (1700/7821) nonbinary, and 7.39% (578/7821) are unsure or have missing data. Approximately half (52.0%) of the cohort was assigned female sex at birth, and 5.4% (421/7821) are living with HIV infection.

Conclusions

LEGACY is an unprecedented opportunity to evaluate the impact of medical gender affirmation on HIV-related health. The study uses a comprehensive research methodology linking TGD patient biobehavioral longitudinal data from multiple sources. Patient-centeredness and scientific rigor are assured through the ongoing engagement of TGD communities, clinicians, scientists, and site clinical staff undergirded by epidemiological methodology. Findings will inform evidence-based clinical care for TGD patients, including optimal interventions to improve HIV-related outcomes.

International Registered Report Identifier (IRRID)

DERR1-10.2196/24198

Examining Cervical Cancer Preventive Behaviors for Latinx Transmasculine Individuals among Medical Students

Latinx transmasculine men (LTM) can be at a particularly high risk for cervical cancer as they lie at the intersection of two health disparity populations (gender and ethnic minorities). Previous research using self-report measures has documented how negative interactions with providers are a key barrier for cervical cancer screening among LTM. However, no research to date has examined, via direct observation, cervical cancer preventive behaviors in clinical interactions with LTM. Thus, the objective of this study was to examine cervical cancer preventive behaviors in clinical interactions between medical students and an LTM. The team implemented standardized patient simulations (simulations of clinical interactions with actors portraying the role of a patient), self-report measures, and observational techniques. A total of 37 medical students participated in the study. The results were mixed with some key behaviors neglected (i.e., asking if the patient preferred to collect the HPV test sample by himself), while others were enacted (i.e., checking family history of cervical cancer). Further research is needed to better understand behaviors in clinical interactions with LTM as well as how to improve them.

A novel speculum-free imaging strategy for visualization of the internal female lower reproductive system

Fear of the speculum and feelings of vulnerability during the gynecologic exams are two of the biggest barriers to cervical cancer screening for women. To address these barriers, we have developed a novel, low-cost tool called the Callascope to reimagine the gynecological exam, enabling clinician and self-imaging of the cervix without the need for a speculum. The Callascope contains a 2 megapixel camera and contrast agent spray mechanism housed within a form factor designed to eliminate the need for a speculum during contrast agent administration and image capture. Preliminary bench testing for comparison of the Callascope camera to a $20,000 high-end colposcope demonstrated that the Callascope camera meets visual requirements for cervical imaging. Bench testing of the spray mechanism demonstrates that the contrast agent delivery enables satisfactory administration and cervix coverage. Clinical studies performed at Duke University Medical Center, Durham, USA and in Greater Accra Regional Hospital, Accra, Ghana assessed (1) the Callascope's ability to visualize the cervix compared to the standard-of-care speculum exam, (2) the feasibility and willingness of women to use the Callascope for self-exams, and (3) the feasibility and willingness of clinicians and their patients to use the Callascope for clinician-based examinations. Cervix visualization was comparable between the Callascope and speculum (83% or 44/53 women vs. 100%) when performed by a clinician. Visualization was achieved in 95% (21/22) of women who used the Callascope for self-imaging. Post-exam surveys indicated that participants preferred the Callascope to a speculum-based exam. Our results indicate the Callascope is a viable option for clinician-based and self-exam speculum-free cervical imaging.Clinical study registration ClinicalTrials.gov https://clinicaltrials.gov/ct2/show/record/ NCT00900575, Pan African Clinical Trial Registry (PACTR) https://www.pactr.org/ PACTR201905806116817.

Cervical cancer prevention in transgender men: a review

There is increased awareness of transgender physical and mental health widely and in academic research. A significant proportion of transgender men will retain their cervix with an increased risk of cervical cancer. In this review of cervical cancer screening among transgender men, we try to estimate how many transgender men still have a cervix, understand to identify challenges and barriers to cervical screening and propose possible solutions. Organised cervical screening programmes need to consider the needs of this population, in particular the provision of HPV self-sampling. TWEETABLE ABSTRACT: Transgender men need access to cervical screening.

Initial Psychometric Evaluation of a Brief Sexual Functioning Screening Tool for Transmasculine Adults: Transmasculine Sexual Functioning Index

INTRODUCTION

Evaluation of sexual functioning in transmasculine (TM) adults-those who identify as men, male, transmen, or non-binary yet were assigned a female sex at birth-is limited by lack of availability of brief screening measures.

AIM

Study aims were to (i) conduct initial psychometric evaluation of a brief screening tool to assess sexual functioning in TM adults for easy use in outpatient visits, epidemiologic studies, and assessment of treatment and surgical outcomes and (ii) assess the correlates of sexual functioning.

METHODS

The 6-item version of the Female Sexual Function Index was adapted and piloted for use with TM adults. The resulting scale, the Transmasculine Sexual Functioning Index (TM-SFI), was administered to 150 TM adults via computer-assisted self-interview. A multivariable model was fit to assess demographic, psychosocial, and gender affirmation correlates of sexual functioning.

MAIN OUTCOME MEASURE

The main outcomes of this study were the calculated reliability and validity of the TM-SFI and fit cumulative logit models to estimate associations of medical gender affirmation (chest surgery) and body image self-consciousness with level of sexual functioning.

RESULTS

Internal consistency reliability was good (Cronbach's alpha = 0.80). Item correlations ranged from 0.21 to 0.80 (P < .05). All scale items loaded onto a single factor (eigenvalue = 11.13; factor loadings > 0.50), evidence of good construct validity. After controlling for potential confounders, participants who had chest surgery exhibited significantly higher odds of being in the highest sexual functioning tertile relative to those without chest surgery (adjusted odds ratio = 2.46; 95% confidence interval = 1.08-5.64; P = .033). Moderate-to-high body image self-consciousness was associated with lower odds of sexual functioning (adjusted odds ratio = 0.42; 95% confidence interval = 0.18-0.94; P = .035).

CONCLUSION

Initial evaluation of the TM-SFI warrants formal psychometric validation against clinical diagnoses of sexual functioning concerns in TM patients. The brief screener can be used to assess sexual functioning in TM adults and may identify TM who could benefit from clinical interventions to improve sexual functioning. Reisner SL, Pletta DR, Potter J, et-al. Initial Psychometric Evaluation of a Brief Sexual Functioning Screening Tool for Transmasculine Adults: Transmasculine Sexual Functioning Index. J Sex Med 2020;8:350-360.

Barriers and facilitators to cervical cancer screening among transgender men and non-binary people with a cervix: A systematic narrative review

Cervical cancer mortality in the United Kingdom (UK) has decreased over the last decade, largely due to uptake of cervical cancer screening. However, only those with a female gender marker on their health records are invited, creating a significant barrier to gender minorities accessing screening. We undertook a systematic review to synthesise published literature on cervical cancer screening among eligible gender minorities, aiming to identify barriers and facilitators that might inform changes in UK policy and clinical practice. We conducted a broad search across Medline, Embase, PsycInfo and Global Health databases to 3rd January 2020 and included any original, peer-reviewed research, published in the English language that reported on cervical cancer screening among gender minorities assigned female at birth (AFAB). Twenty-seven studies were critically appraised and included in the final synthesis, which identified significant disparities in cervical cancer screening uptake between gender minorities AFAB and cis women. It revealed a lack of knowledge surrounding the relationship between gender minority status and cervical cancer risk among both service users and providers and highlighted significant barriers to access for gender minorities AFAB. Cervical cancer screening was not universally associated with dysphoria among gender minorities AFAB and we recommend that providers explore patients' preferences around screening, while avoiding assumptions. Providers should be proficient in examination techniques that maximise patient autonomy and minimise gender dysphoria or pain. Self-swabs for high-risk HPV may provide a more acceptable, evidence-based, alternative to Pap smears but there remains a need for further UK-specific research, to inform changes in policy.

Individual- and Partnership-Level Correlates of Protective Barrier Use in a Sample of Transmasculine Adults with Diverse Sexual Partnerships

The sexual partnerships of transmasculine adults-who were assigned female at birth and identify on the masculine gender continuum-remain understudied. This includes characteristics of transmasculine adults' sexual partnerships associated with engaging in HIV/sexually transmitted infection (STI) sexual risk behavior. This study examined individual- and partnership-level factors of transmasculine adults' sexual partnerships associated with using a protective barrier during sexual activity. Data came from cross-sectional surveys administered to 141 transmasculine adults. Participants provided demographic and sexual health information for up to three sexual partners from the past 12 months (n = 259 partnerships). Generalized estimating equations (GEEs) were used to investigate individual- and partnership-level factors associated with any use of a protective barrier during five sexual behaviors. Transmasculine participants engaged in an array of sexual behaviors with diverse sexual partners. Individual- and partnership-level factors of transmasculine adults' sexual partnerships were associated with their protective barrier use; however, these associations varied in statistical significance across the five sexual behaviors. At the individual level, younger participants had lower odds of protective barrier use during fingering or fisting. At the partnership level, protective barrier use was associated with a sexual partnership's configuration and the gender identity of a sexual partner. Relative to participants with cisgender female partners, those with cisgender male partners generally had lower odds of using a protective barrier. Study findings highlight the importance of studying factors associated with HIV/STI risk behavior located beyond the individual. These findings may have implications for improving measurements of HIV/STI-related risk for transmasculine adults.

Recent Penile Sexual Contact Is Associated With an Increased Odds of High-Risk Cervical Human Papillomavirus Infection in Transgender Men

BACKGROUND

Transgender men (TM) have a male, masculine, or nonfemale gender identity, yet were assigned female sex at birth on the basis of their external genitalia. The majority of TM are at risk of infection with one of several high-risk strains of the human papillomavirus (hr-HPV), acquired primarily through sexual contact, that cause 99.7% of cervical cancers. This study aimed to explore the association between sexual behaviors and current cervical hr-HPV infection in TM with a cervix.

METHODS

The primary aim of this analysis was to test for an association between participant self-report of sexual contact with a penis in the past 1 year and current infection with cervical hr-HPV as measured by provider-collected cervical HPV DNA assay. This is a secondary analysis of a bio-behavioral sexual health study conducted at a health center in Boston, MA from 2015 to 2016. Analysis was conducted using logistic regression with significance level set at P less than 0.05; the primary analysis was adjusted for self-reported age, current tobacco use, years of testosterone use, and HPV vaccination status.

RESULTS

Overall prevalence of hr-HPV was 15.9%. In adjusted analyses, participants reporting receptive penile vaginal sex with any of their most recent 3 sexual partners in the past 12 months had more than 5 times greater odds of current hr-HPV infection than those reporting no penile sex of any kind during this timeframe (odds ratio, 5.23; 95% confidence interval, 1.61-17.02).

CONCLUSIONS

Vaginal-receptive penile sex in the last 12 months was associated with a 5-fold increased odds of cervical high-risk HPV infection among TM. Findings can inform future population level study of associations between sexual behaviors and hr-HPV risk, which could lead to more individualized approaches to screening.

A Blueprint for Planning and Implementing a Transgender Health Program

Transgender and gender-diverse people face multiple barriers to accessing appropriate health care, including denial of service, harassment, and lack of clinician knowledge. This article presents a blueprint for planning and implementing a transgender health program within a primary care practice in order to enhance the capacity of the health care system to meet the medical and mental health needs of this underserved population. The steps described, with emphasis on elements specific to transgender care, include conducting a community needs assessment, gaining commitment from leadership and staff, choosing a service model and treatment protocols, defining staff roles, and creating a welcoming environment.

The contraceptive and reproductive history and planning goals of trans-masculine adults: a mixed-methods study

OBJECTIVES

This study aims to identify factors associated with the reproductive planning of trans-masculine adults.

STUDY DESIGN

Between 2015 and 2016, providers enrolled 150 trans-masculine adults in a sexual health study assessing sociodemographics, social support, gender affirmation, sexual partnering, and reproductive history and planning. A brief clinical interview assessed contraceptive use and concerns. Bivariate and multivariable logistic regression analyses examined associations between participant characteristics and three outcomes: current contraceptive use, lifetime pregnancy history and reproductive planning.

RESULTS

Overall, 37.3% are currently using contraceptives; 5.3% have been pregnant; and 20.0% plan to have biological children (9.3% plan to become pregnant; 12.0% plan to use their oocytes with a surrogate). Participants are less likely to use contraceptives if they are students vs. not, have socially affirmed their gender vs. not and have a partner vs. are single. Greater number of sexual partners is associated with the increased odds of contraceptive use. Further, as social support increases, the odds of having been pregnant decreases. Participants with a nonbinary gender identity are more likely to want to become pregnant than those with a binary gender identity, whereas those who have socially affirmed their gender are less likely to want to become pregnant than those who had not. Finally, participants of color more commonly planned to use their oocytes with a surrogate than white participants.

CONCLUSION

Sociodemographic, gender affirmation, social support and sexual partner factors are associated with contraceptive use and reproductive history among trans-masculine patients.

IMPLICATIONS

Healthcare providers must be aware of the diverse reproductive histories and pregnancy goals of trans-masculine individuals in order to provide comprehensive reproductive healthcare counseling and provision. More research is needed to better understand contraception and reproduction desires in trans-masculine individuals.

Sexually transmitted infections among HIV-infected and HIV-uninfected women in the Tapajós region, Amazon, Brazil: Self-collected vs. clinician-collected samples

The anogenital prevalence of sexually transmitted infections (STIs) and the use of cervico-vaginal self-collected vs. clinician-collected samples were evaluated for the diagnosis of human immunodeficiency virus (HIV)-infected and HIV-uninfected women in the Tapajós region, Amazon, Brazil. We recruited 153 women for a cross-sectional study (112 HIV-uninfected and 41 HIV-infected) who sought health services. Anal and cervical scrapings and cervico-vaginal self-collection samples were collected. Real-time polymerase chain reaction methods were used for Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis and Mycoplasma genitalium. A syphilis test was also performed. Risk factors for STIs were identified by multivariate analysis. The overall prevalence of STIs was 30.4% (34/112) in HIV-uninfected women and 24.4% (10/41) in HIV-infected women. Anogenital Chlamydia trachomatis infection was the most prevalent in both groups of women (20.5% vs 19.5%). There was significant agreement for each STI between self-collected and clinician-collected samples: 91.7%, kappa 0.67, 95% confidence interval (CI) 0.49-0.85 for Chlamydia trachomatis; 99.2%, kappa 0.85, 95% CI 0.57-1.00 for Neisseria gonorrhoeae; 97.7%, kappa 0.39, 95% CI -0.16-0.94 for Trichomonas vaginalis; and 94.7%, kappa 0.51, 95% CI 0.20-0.82 for Mycoplasma genitalium. Women with human papillomavirus had coinfection or multiple infections with other STIs. Risk factors for STIs were being ≤ 25 years old, being employed or a student, reporting a history of STI and having a positive HPV test. A high prevalence of STIs in women in the Tapajós region was found. Cervico-vaginal self-collection is a useful tool for STI screening and can be used in prevention control programs in low-resource settings, such as in northern Brazil.

Risk and protective factors for mental health morbidity in a community sample of female-to-male trans-masculine adults

BACKGROUND

Trans-masculine (TM) individuals, who are assigned female sex at birth and identify along the masculine gender spectrum, face mental health disparities relative to cisgender people. Limited research has sought to explore the multi-level risk and protective factors associated with mental health morbidity for TM populations.

METHODS

Between August 2015-September 2016, 150 TM adults were enrolled in a one-time biobehavioral health study. A survey assessed socio-demographics, past 12-month everyday discrimination, lifetime intimate partner violence (IPV), resilience (using the Brief Resilience Scale), and other factors. Bivariate and multivariable logistic regression analyses examined associations between participant characteristics and four mental health statuses: post-traumatic stress disorder (PTSD), depression, anxiety, and non-suicidal self-injury (NSSI).

RESULTS

In this sample (76.7% had a binary gender identity, i.e., man or transgender man; 74.7% were white, 70.0% were under age 30 years), 42.2% had PTSD based on past 30-day symptoms; 25.7% had depression based on past 7-day symptoms; 31.1% had anxiety based on past 7-day symptoms; and 31.3% had engaged in NSSI within the past 12-months. Results from multivariable models: 1) PTSD: unemployment, lifetime IPV and past 12-month discrimination were each associated with increased odds of PTSD, while having a partner was associated with the reduced odds of PTSD. 2) Depression: lower educational attainment and past 12-month discrimination were each associated with the increased odds of depression, while greater resilience was associated with the reduced odds of depression. 3) Anxiety: low annual household income and past 12-month discrimination were each associated with the increased odds of anxiety, while resilience was associated with the reduced odds of anxiety. 4) NSSI: past 12-month discrimination was associated with the increased odds of past 12-month NSSI, while higher age and greater resilience was associated with the reduced odds of NSSI (all p-values < 0.05).

CONCLUSIONS

Unemployment, low income, limited education, everyday discrimination, and violence were risk factors for poor mental health, while being in a relationship, higher age, and personal resilience were protective against mental health morbidity. Findings highlight the need for interventions to address the individual, interpersonal, and societal factors that may be driving poor mental health in this population.

Healthcare Mistreatment and Avoidance in Trans Masculine Adults: The Mediating Role of Rejection Sensitivity

Objectives

Given that prior mistreatment can lead to heightened vigilance to and perceptions of future rejection, the present study examined whether this heightened vigilance, known as rejection sensitivity, mediates the association between healthcare mistreatment and healthcare avoidance in trans masculine (TM) adults.

Method

Between 2015 and 2016, 150 TM adults completed a comprehensive survey assessing socio-demographics, sexual health, and healthcare experiences. A 5-item scale assessing participants' sensitivity to rejection in healthcare scenarios was administered and psychometrically evaluated. Structural equation modeling was used to test whether rejection sensitivity in healthcare mediated the relationship between lifetime mistreatment in healthcare and past 12-month healthcare avoidance among TM adults.

Results

Overall, 68% of participants had experienced some form of mistreatment in healthcare in their lifetime and 43% had avoided healthcare in the past 12 months. For 5% of the sample, healthcare avoidance in the past 12 months resulted in a medical emergency. Path analyses revealed that healthcare mistreatment was positively correlated with rejection sensitivity and sensitivity was positively correlated with past 12-month healthcare avoidance. Rejection sensitivity mediated the relationship between mistreatment and healthcare avoidance (all p-values < 0.05).

Conclusion

Rejection sensitivity may contribute to healthcare avoidance among stigmatized TM patients; however, longitudinal research is needed to establish the temporal ordering of these processes. Multilevel interventions to reduce healthcare discrimination and help TM adults cope with the psychological and behavioral consequences of stigma are recommended.

Test performance and acceptability of self- versus provider-collected swabs for high-risk HPV DNA testing in female-to-male trans masculine patients

Background

High-risk human papillomavirus (hrHPV) causes virtually all cervical cancers. Trans masculine (TM) people (those assigned female at birth who identify with a gender other than female) have low uptake of conventional cervical cancer screening. Self-collected hrHPV DNA testing has high levels of acceptability among cisgender (non-transgender) females and may support increased cervical cancer screening uptake in TM individuals.

Objective

To assess the test performance and acceptability of self-collected vaginal specimens in comparison to provider-collected cervical swabs for hrHPV DNA detection in TM individuals ages 21–64 years.

Methods

Between March 2015-September 2016, 150 TM participants with a cervix (mean age = 27.5 years; SD = 5.7) completed a one-time study visit comprised of a self-report survey, self-collected vaginal HPV DNA swab, clinician-administered cervical HPV swab, and brief interview on acceptability of clinical procedures. Participants were randomized to complete either self- or provider-collection first to minimize ordering effects. Self- and provider-collected samples were tested for 13 hrHPV DNA types using a DNA Hybridization Assay. The primary outcome variable was the concordance (kappa statistic) and performance (sensitivity, specificity) of self-collected vaginal HPV DNA specimens versus provider-collected cervical HPV swabs as the gold standard.

Results

Of the 131 participants completing both the self- and provider-collected HPV tests, 21 cases of hrHPV were detected by the provider cervical swab (gold standard; 16.0% hrHPV prevalence); 15 of these cases were accurately detected by the self-collected vaginal swab (71.4% concordance) (Kappa = 0.75, 95% Confidence Interval [CI]: 0.59, 0.92; p<0.001). Compared to the provider-collected cervical hrHPV DNA sample (gold standard), the self-collected vaginal hrHPV DNA test demonstrated a sensitivity of 71.4% (95% CI: 0.52, 0.91; p = 0.0495) and specificity of 98.2% (95% CI: 0.96, 1.00; p<0.0001). Over 90% of participants endorsed a preference for the self-collected vaginal swab over provider-collected cervical swab.

Conclusion

Self-collected vaginal swabs are highly acceptable to TM as a means to test for hrHPV DNA. Test performance of this self-collection method for hrHPV detection in TM is consistent with previous studies in cisgender females. Self-collected vaginal swab testing for hrHPV DNA represents a reasonable and patient-centered strategy for primary cervical cancer screening in TM patients unwilling to undergo provider collection of specimens via speculum exam.