Transgender and gender diverse persons' sexually transmitted infection testing: a mixed methods study to understand primary care providers' training gaps and desires to promote sexual health equity.

backgroundTransgender (trans) and gender diverse (TGD) people experience sexual health inequities, including high rates of HIV and other sexually transmitted infections (STIs), driven by anti-trans stigma. Yet, TGD people also face barriers to STI testing related to anti-trans stigma, including a lack of access to knowledgeable and affirming primary care providers (PCPs), including physicians, nurse practitioners, and physician assistants. We sought to understand the current practices, comfort, and knowledge gaps of PCPs in performing gender-affirming STI testing, particularly non-HIV STI testing, among TGD persons, in order to inform future educational interventions.

methodsWe utilized a convergent parallel mixed-methods study design drawing on cross-sectional quantitative surveys (n = 50) and semi-structured qualitative interviews (n = 8) with PCPs (2024-2025). The survey assessed sociodemographic and practice-related characteristics, past training, knowledge of STI testing guidelines, and TGD-related attitudes/biases. Interviews explored how PCPs apply STI testing guidelines and navigate sexual history taking/physical exam among TGD persons. Quantitative data were analyzed using bivariable and multivariable regression analyses to determine factors independently associated with self-reported clinical competency to assess a TGD person. Qualitative data were analyzed using open inductive coding via directed qualitative content analysis.

resultsAmong survey participants (mean age: 38.7, SD: 10.8), almost half (46%) had ≤ 5 h of training on any topic specific to TGD health. PCPs' most desired future training topics included gender-affirming sexual history taking (62%), basic trans healthcare (e.g., gender-affirming hormone therapy [60%]) and STI screening guidelines (56%). Less than half of PCPs were aware of national TGD-specific HIV/STI testing guidance (48%). In multivariable analyses, having ≥ 6 h of training in TGD health (b=0.96, p<.01) and serving more TGD patients (b=0.81, p<.01) were significantly associated with self-reported clinical competency to assess a TGD person. Qualitative findings expanded upon quantitative findings, highlighting how gendered assumptions may influence provider testing recommendations in the absence of TGD-inclusive STI screening guidelines, and how a lack of formalized educational opportunities impede perceived competency, particularly in performing anal cytology for HPV-related cancer screening.

conclusionsFindings underscore the importance of training to improve equitable access to gender-affirming STI screening for TGD populations and mitigate barriers to sexual health equity. CLINICAL TRIAL NUMBER: Not applicable.