"It's a Big Ordeal": A Mixed Methods Study of the Experiences of Non-HIV STI Testing Among Trans and Gender Diverse People

Background and Purpose: Transgender (trans) and gender diverse (TGD) persons are disproportionately affected by a wide array of health disparities, including HIV and other non-HIV sexually transmitted infection (STI) inequities. Research focused on HIV disparities among transfeminine persons has predominated, whereas non-HIV STIs (e.g., chlamydia) and access to non-HIV STI testing among TGD people including transmasculine and nonbinary persons has been overlooked. Given that non-HIV STI testing is a critical component of primary care and can mitigate negative long-term impacts of non-HIV STIs (e.g., cancer), we examined gender-based differences in non-HIV STI testing uptake, as well as barriers and facilitators to uptake of non-HIV STI testing, to inform clinical interventions to increase uptake of testing among TGD persons.

Methods: This community-based explanatory sequential mixed-methods study drew on secondary quantitative data collected from TGD people 2018-2019 from the Michigan Trans Health Survey (MTHS; n=528) and primary qualitative focus group data collected from TGD people (n=36) 2022. Quantitative data were analyzed utilizing bivariable and multivariable logistic regression analyses to test associations between sociodemographic (e.g., age), clinical (e.g., gender-affirming hormone use), social (e.g., violence), and structural (e.g., health insurance) factors and ever vs. never non-HIV STI testing. Qualitative data analyses were conducted using a reflexive thematic analysis approach to coding followed by table top theming.

Results: Most participants (80.5%, n=425, mean age: 28.7, standard deviation: 9.7) had ever had a non-HIV STI test, with no statistically significant differences by gender. In multivariable analyses adjusting for sociodemographic characteristics (age, race), ever experiencing sexual violence (aOR: 2.77, 95% CI: 1.5, 5.14, p<0.01) and reporting a very/somewhat inclusive primary care provider or neutral/not inclusive primary care provider vs. no primary care provider (aOR: 4.82, 95% CI: 2.75, 8.45, p<0.001; aOR: 1.85, 95% CI: 1.03, 3.32, p<0.05, respectively) were significantly associated with non-HIV STI testing. Five key themes from qualitative data analyses showed the complexity of the non-HIV STI testing experience for participants: 1) The “why” of testing; 2) “I’ve been vocal”: The impact of individual agency on testing practices; 3) “It’s a big ordeal”: Running the gauntlet of testing; 4) “Doesn’t give me a hassle”: Gratitude for bare minimum care; and 5) “Open, honest, and transparent”: The importance of provider care, communication, and education for positive experiences.

Conclusions and Implications: Drawing on a gender-diverse sample of trans and nonbinary persons, we document high rates of non-HIV STI testing. Qualitative findings contextualize quantitative data by highlighting the significant strengths of participants as they navigate indifferent to hostile healthcare settings just to get access to the sexual healthcare they need and deserve. This study informs future interventions which increase non-HIV STI testing among trans and nonbinary populations, filling critical gaps in research and practice.