Sexually transmitted infection testing among transgender and non-binary persons: results of a community-based cross-sectional survey.

BACKGROUND: Studies show higher rates of sexually transmitted infections (STIs) among transgender (trans) and non-binary (TNB) persons compared with the general population. Scant studies have examined non-HIV STI testing (henceforth referred to as STI testing); fewer inclusive of trans men and non-binary persons. We characterised the prevalence of STI testing and time since last STI test and gender-based differences in these outcomes among TNB persons. METHODS: Data were analysed from a 2018 community-based participatory cross-sectional survey (n =528). Prevalence of lifetime STI testing history and time since last STI test were reported overall and compared across genders (trans men, trans women, non-binary assigned female at-birth, non-binary assigned male at-birth) using Chi-squared, then bivariable and multivariable logistic regression analyses to compare lifetime STI testing history (ever vs never) across sociodemographic and health care characteristics. RESULTS: Most (n =425; 80.5%) participants reported having ever had an STI test; over half (59.8%) ever tested had tested within the past year. Bivariate analyses showed no significant gender differences in lifetime STI testing history (P =0.298) or time since last STI test (P =0.118). In a multivariable model, higher age, reporting multiple committed partners (vs single/divorced), known HIV status, and ever receiving information about pre-exposure prophylaxis (PrEP) were positively associated with ever having had an STI test, whereas Latinx race/ethnicity (vs white) was negatively associated. CONCLUSIONS: Findings showed high rates of lifetime STI testing and recent testing, with no gender-based differences. Never testing rates were concerning considering screening recommendations. Broad based (non-gender specific) TNB-focused interventions may be warranted to increase uptake.

A Scoping Review of Empirical Asexuality Research in Social Science Literature.

Research on asexuality as a part of the experience of human sexuality has increased over the last two decades. However, there has not yet been a systematic review of the extant literature on asexuality. This paper aims to provide a systematic scoping review of literature on asexuality with articles published in 2004 through August 2021. After a systematic search procedure, 48 studies were included. A codebook was developed to extract broad information about the literature on asexuality, including sampling techniques, research participant sociodemographics, and conceptualization of asexuality. Results of the review indicate that the research is currently split between qualitative and quantitative methods. The literature primarily relied on convenience sampling within asexual online communities. The primary online community was Asexual Visibility and Education Network (AVEN), which may have contributed to the majority of participants being White, presumptively cisgender, women between the ages of 20-30. Analysis of the overall literature scope demonstrates no support for asexuality as a medical condition (i.e., a disorder requiring treatment) and instead supports the need to recognize asexuality as a complex identity and sexual orientation. Implications for research are discussed, such as the need for additional research on the topic of human sexuality that includes asexuality as a sexual orientation as well as the need for more intersectional research within the literature.

Trans Men's Access to Knowledgeable Providers and Their Experiences in Health Care Settings: Differences by Demographics, Mental Health, and Degree of Being "Out" to Providers.

Transgender adults face a health care system rife with stigma, including a lack of culturally responsive providers and high likelihood of discrimination and mistreatment. However, there is a gap in knowledge about trans men-those assigned a female sex at birth who identify as men or as transmasculine-including subgroups, such as trans men of color. Using data from the U.S. Transgender Survey, the largest transgender survey conducted in the United States, this study analyzes whether trans men's access to knowledgeable providers and their experiences of mistreatment in health care were related to demographic and mental health characteristics and degree of being "out" to providers. Among 7,950 trans men, respondent race and ethnicity, education level, disability status, psychological distress, suicidality, and being less "out" were associated with assessing one's health care provider as not knowledgeable about trans-related care. Mistreatment in health care was more common among Alaska Native/American Indian trans men; those who lived in or near poverty; those who were queer, pansexual, bisexual, or an orientation not listed; those with a disability; those experiencing distress or suicidality; and those who were more "out." This article discusses how findings can inform culturally responsive health care interventions with trans men.

Predictors of healthcare mistreatment among transgender and gender diverse individuals: Are there different patterns by patient race and ethnicity?

Using data from the 2015 United States Transgender Survey, this study investigates which patient sociodemographic characteristics and psychosocial risks are associated with likelihood of transgender mistreatment in healthcare and how patterns vary for patients of color. Numerous predictors, including alignment of identity documents, were associated with healthcare mistreatment. Among subgroups of transgender patients of color, psychosocial risks were more consistently significant than sociodemographic characteristics in predicting mistreatment. National and international health organizations are called to enact clear policies that affirm transgender patients and patients of color and establish a commitment to effectively serving these populations within their ethical codes.

Differential Access to Transgender Inclusive Insurance and Healthcare in the United States: Challenges to Health across the Life Course.

This commentary explores how different types of insurance (Medicare, Medicaid, state government, and private insurance) address issues of transgender-related care, and how access to transgender affirming insurance coverage and healthcare across life stages depends both on type of insurance and geographical location. We argue that the current state of transgender health insurance policy and practices are inadequate for achieving goals of continuity of care and positive health outcomes across the life course. Transgender individuals are uninsured at a higher rate than their cisgender (non-transgender) counterparts, face discrimination or refusal of care from their providers, and, if insured, experience denials of coverage from insurance companies. These ruptures in coverage can be addressed through extending insurance coverage for all treatments necessary to affirm a transgender person's gender identity, training to support transgender affirming healthcare, and research on the health needs of the transgender community across the life course.

Transgender-Related Insurance Denials as Barriers to Transgender Healthcare: Differences in Experience by Insurance Type.

BACKGROUND: Insurance-based denials are common barriers for transgender and non-binary individuals in accessing medically necessary gender-affirming care. Little is known about how experiences of transgender-related insurance denials may vary by insurance type. OBJECTIVE: This study investigates the association between transgender and non-binary individuals' experiences of different forms of transgender-related insurance denials and insurance type. DESIGN AND PARTICIPANTS: The 2015 United States Transgender Survey was conducted by the National Center for Transgender Equality to ascertain US transgender and non-binary experiences across multiple life experiences, including individual health status, health services access and utilization, and experiences with denials. MAIN MEASURES: Multivariate logistic regressions were conducted, and adjusted risk ratios were calculated, to analyze the likelihood of experiencing eight different forms of denials by insurance type, including private, Medicare, Medicaid, and military-related, and having multiple types of insurance coverage. KEY RESULTS: Models revealed significant relationships between transgender-related insurance denials and insurance type for 11,320 transgender and non-binary adults. Compared with those with private insurance, Medicaid coverage was associated with an increased likelihood of experiencing denials for hormone therapy (adjusted risk ratio (ARR) = 1.22; CI = 1.05-1.42; p = 0.02); having no in-network surgery providers was associated with Medicare (ARR = 1.84; CI = 1.29-2.62; p = 0.009) or Medicaid (ARR = 1.54; CI = 1.20-1.98; p = 0.003); and military-based insurance was associated with transition-related surgery denials (ARR = 1.53; CI = 1.36-1.72; p < 0.001). CONCLUSIONS: Researchers and practitioners must consider the link between type of insurance coverage and experiences with different forms of transgender-related insurance denial. These results provide continuing support for broad non-discrimination policy efforts, but also direct our attention to targeted insurance policy interventions by form of denial, which can promote equitable access for transgender and non-binary people across all healthcare needs.

Intimate Partner Violence in Transgender Populations: Systematic Review and Meta-analysis of Prevalence and Correlates.

Background: Transgender individuals experience unique vulnerabilities to intimate partner violence (IPV) and may experience a disproportionate IPV burden compared with cisgender (nontransgender) individuals.Objectives: To systematically review the quantitative literature on prevalence and correlates of IPV in transgender populations.Search Methods: Authors searched research databases (PubMed, CINAHL), gray literature (Google), journal tables of contents, and conference abstracts, and consulted experts in the field. Authors were contacted with data requests in cases in which transgender participants were enrolled in a study, but no disaggregated statistics were provided for this population.Selection Criteria: We included all quantitative literature published before July 2019 on prevalence and correlates of IPV victimization, perpetration, or service utilization in transgender populations. There were no restrictions by sample size, year, or location.Data Collection and Analysis: Two independent reviewers conducted screening. One reviewer conducted extraction by using a structured database, and a second reviewer checked for mistakes or omissions. We used random-effects meta-analyses to calculate relative risks (RRs) comparing the prevalence of IPV in transgender individuals and cisgender individuals in studies in which both transgender and cisgender individuals were enrolled. We also used meta-analysis to compare IPV prevalence in assigned-female-sex-at-birth and assigned-male-sex-at-birth transgender individuals and to compare physical IPV prevalence between nonbinary and binary transgender individuals in studies that enrolled both groups.Main Results: We identified 85 articles from 74 unique data sets (ntotal = 49 966 transgender participants). Across studies reporting it, the median lifetime prevalence of physical IPV was 37.5%, lifetime sexual IPV was 25.0%, past-year physical IPV was 16.7%, and past-year sexual IPV was 10.8% among transgender individuals. Compared with cisgender individuals, transgender individuals were 1.7 times more likely to experience any IPV (RR = 1.66; 95% confidence interval [CI] = 1.36, 2.03), 2.2 times more likely to experience physical IPV (RR = 2.19; 95% CI = 1.66, 2.88), and 2.5 times more likely to experience sexual IPV (RR = 2.46; 95% CI = 1.64, 3.69). Disparities persisted when comparing to cisgender women specifically. There was no significant difference in any IPV, physical IPV, or sexual IPV prevalence between assigned-female-sex-at-birth and assigned-male-sex-at-birth individuals, nor in physical IPV prevalence between binary- and nonbinary-identified transgender individuals. IPV victimization was associated with sexual risk, substance use, and mental health burden in transgender populations.Authors' Conclusions: Transgender individuals experience a dramatically higher prevalence of IPV victimization compared with cisgender individuals, regardless of sex assigned at birth. IPV prevalence estimates are comparably high for assigned-male-sex-at-birth and assigned-female-sex-at-birth transgender individuals, and for binary and nonbinary transgender individuals, though more research is needed.Public Health Implications: Evidence-based interventions are urgently needed to prevent and address IPV in this high-risk population with unique needs. Lack of legal protections against discrimination in employment, housing, and social services likely foster vulnerability to IPV. Transgender individuals should be explicitly included in US Preventive Services Task Force recommendations promoting IPV screening in primary care settings. Interventions at the policy level as well as the interpersonal and individual level are urgently needed to address epidemic levels of IPV in this marginalized, high-risk population.

Ableist Microaggressions and the Mental Health of Disabled Adults.

Microaggressions perpetuate inequalities and stereotypes against people from marginalized communities. Research demonstrates that ongoing experiences of identity-related microaggressions can negatively impact mental health outcomes, increase somatic symptoms, and increase negative affect. This study explores the relationship between experiences of ableist microaggressions and mental health outcomes among disabled adults by using a quantitative cross-sectional survey of 311 U.S. adults who identify as disabled/having a disability, to examine the correlation between ableist microaggressions (using the AMS-65) and mental health (assessed by the MHI-18). Findings indicate that increased experiences ableist microaggressions are negatively correlated with positive mental health outcomes, and that the visibility of disabilities/impairments are correlated with experiencing ableist microaggressions. These findings can inform the work of counselors, therapists, social workers, and other human service professionals when supporting disabled individuals, recognizing that their mental health may be related to these common and often unintentional oppressive interactions.

One size does not fit all: differential transgender health experiences.

Transgender and nonbinary (TNB) adults face a multitude of challenges when attempting to access general health care. Issues include fear of discrimination and encounters with providers who are not familiar with treating the needs of this population. These challenges may result in the delay or denial of medically necessary care. This study explores nuanced experiences of gender identity and sexual orientation around accessing health care. Using a statewide sample of TNB individuals (N = 417), analyses include descriptive statistics and logistic regressions predicting delayed care due to fear of discrimination and having any medical intervention to understand the importance of transgender-inclusive care and other experiences across identities. Findings indicate differential experiences across gender identity, sexual orientation, and age. Access to a trans-inclusive primary care provider was one of the strongest indicators both for not delaying care due to fear of discrimination and having had a medical intervention. Providers should be provided with more nuanced training about being culturally responsive and aware of differences across sexual orientation within the TNB community. This will move toward ensuring not only increased access to needed care and medical interventions, but toward potentially lowering the rate of those who delay access to care due to fear of discrimination.

Sexual Victimization and Subsequent Police Reporting by Gender Identity Among Lesbian, Gay, Bisexual, Transgender, and Queer Adults.

Prevalence of sexual victimization among lesbian, gay, bisexual, transgender, and queer (LGBTQ) persons is frequently found to be higher than the prevalence reported by their heterosexual peers. Transgender individuals are often included solely as part of larger LGBTQ research samples, potentially obfuscating differences between sexual orientation and gender identity. In this study, the authors examined sexual assault/rape in a large convenience sample of LGBTQ adults (N = 1,124) by respondents' gender identity (cisgender, transgender) to determine whether differences exist in lifetime prevalence of sexual assault/rape and subsequent police reporting. Findings indicate transgender individuals report having experienced sexual assault/rape more than twice as frequently as cisgender LGBQ individuals. Authors found no statistically significant difference in reporting sexual violence to police. Implications for research and practice are discussed.

Exploring the relationship between transgender-inclusive providers and mental health outcomes among transgender/gender variant people.

Using a statewide survey of transgender and gender variant individuals (N = 417), this study examines the association between having a transgender-inclusive provider and three mental health concerns: current experience of depression, lifetime experience of anxiety disorder, and suicidality within the last year. Findings suggest that having a transgender-inclusive provider is associated with decreased rates of depression and suicidality, but not with lifetime experience of having anxiety. Implications for future research and education of providers are discussed.

MSW student perceptions of sexual health as relevant to the profession: Do social work educational experiences matter?

Many social work clients are at an increased risk for negative outcomes related to sexual behavior, including unwanted pregnancies and sexually transmitted infections (STIs). However, there is a dearth of literature on social work student experiences with these topics in social work classrooms and their perceptions about the topic's relevance to their practice. The purpose of this study is to explore relationships between experiences with STIs and contraception as topics in social work education and practica experiences on student perceptions toward sexual health as a relevant topic for social work. Among a national sample of MSW students (N = 443), experiences with STIs and contraception as topics in practica was significantly related to perceptions toward sexual health's relevance to social work. Findings and implications are discussed.

Differences Between Transgender and Gender Diverse Adults in Michigan Currently Using Gender-Affirming Hormone Therapy and Nonusers Reporting Interest in Future Use.

Purpose: This study explores the sociodemographic, insurance coverage, and substance use differences among transgender and gender diverse (TGD) individuals currently using hormone therapy (HT) and those who have an interest in future HT use. Methods: We surveyed TGD individuals in Michigan in 2018 to examine sociodemographic, health insurance, and substance use differences between those who had used HT and those who were interested but had never accessed HT using logistic regression models. Results: Respondents (N = 536) were 80.1% White and 18.0% nonbinary. About two-thirds of the participants had ever used HT (65.7%). In multivariate analyses, nonbinary participants were much more likely to be interested in future HT use than transmasculine individuals (odds ratio [OR] = 6.91), yet no significant difference between transmasculine and transfeminine individuals was found. Black participants also had higher odds of interest in future HT use (OR = 8.79). Those who did not know if they had trans-specific insurance coverage (OR = 42.39) and those who had no trans-specific insurance coverage (OR = 4.50) were more likely to be in the future interest group compared with those who reported full trans care coverage. Those with a bachelor's degree were less likely to be in the future interest group than those with some college education or an associate's degree, as were heavy marijuana users. Conclusion: Nonbinary individuals may be interested in HT but lack access, and known health care disparities around race and socioeconomic status may also impact HT access. Standard and transparent insurance coverage for gender-affirming care is sorely needed.

Prescription Pain Reliever Misuse Among Transgender and Gender Diverse Adults.

Purpose: Little is known about the prevalence and risks associated with transgender and gender diverse (TGD) persons' misuse of prescription pain relievers (PPRs). This study explores the relationship between PPR misuse and various sociodemographic identities and experiences of discrimination in health care among TGD adults. Methods: TGD participants (n=595) were recruited in 2018 to participate in a cross-sectional statewide trans health survey through convenience sampling. Chi-square tests of independence and logistic regressions were conducted to explore associations between sociodemographics and experiences of discrimination among persons who had ever misused PPRs, or who had misused PPRs in the past year. Results: Sociodemographics such as gender identity (odds ratio [OR]=0.44, p=0.01), race/ethnicity (OR=0.14, p<0.001), and sexual orientation influence TGD individuals likeliness of misusing PPRs (OR=0.40, p<0.001). Notably, those who were ever diagnosed with anxiety had a higher likeliness of having lifetime PPR misuse compared with those who were never diagnosed (OR=2.05, p=0.05), and those reporting past-year discrimination within the mental health care setting because of their gender identity were more than twice as likely to report past-year misuse than those who reported not experiencing it (OR=2.43, p=0.004). Conclusion: Certain subpopulations of TGD individuals may be at elevated risk of PPR misuse. It is imperative to acknowledge the impact of multimarginalized identities as well as differences across various identities and experiences within the TGD community while working to address non-PPR misuse.

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.

Cervicovaginal and Anal Self-Sampling for Human Papillomavirus Testing in a Transgender and Gender Diverse Population Assigned Female at Birth: Comfort, Difficulty, and Willingness to Use.

Purpose: Transgender and gender diverse (TGD) people assigned female at birth (AFAB) face numerous barriers to preventive care, including for cervical cancer screening. At-home human papillomavirus (HPV) testing may expand access to cervical cancer screening for TGD people AFAB. This study assessed the perceptions of TGD individuals AFAB who self-collected cervicovaginal and anal samples. Methods: We recruited TGD individuals AFAB to collect cervicovaginal and anal specimens at home using self-sampling for HPV testing, and individuals reported their perceptions of self-sampling. Associations between demographic and health characteristics and each of comfort of use, ease of use, and willingness to use self-sampling were estimated using robust Poisson regression. Results: Of 137 consenting participants, 101 completed the sample collection and the surveys. The majority of participants reported that the cervicovaginal self-swab was not uncomfortable (68.3%) and not difficult to use (86.1%), and nearly all (96.0%) were willing to use the swab in the future. Fewer participants found the anal swab to not be uncomfortable (47.5%), but most participants still found the anal swab to not be difficult to use (70.2%) and were willing to use the swab in the future (89.1%). Participants were more willing to use either swab if they had not seen a medical professional in the past year. Conclusions: TGD individuals AFAB were willing to use and preferred self-sampling methods for cervicovaginal and anal HPV testing. Developing clinically approved self-sampling options for HPV testing could expand access to cancer screening for TGD populations.

"Doing it on my own terms": Transgender and nonbinary adults' experiences with HPV self-swabbing home testing kits.

The human papillomavirus (HPV) carries a significant health risk for people with a cervix. Among transgender and nonbinary people, however, testing and treatment for HPV can pose difficulties, and even be traumatic at times. This current study is part of a larger mixed methods study conducted in Michigan in 2020, and it explores the experiences of transmasculine and nonbinary people with at-home self-swabbing HPV test kits and knowledge of HPV transmission/screenings. Phenomenological methods were used by conducting virtual qualitative interviews with ten transmasculine and nonbinary individuals with cervixes, ages 23-59. Interviews were independently coded by members of the research team and a tabletop theming method was used. Four themes were generated from the data: 1) Multilevel barriers; 2) "Get it done, so I know that I am safe"; 3) Contrasting preferences for care; and 4) Community calls for change. The discussion focuses on the implications of these findings for improving sexual health care for the transgender and nonbinary community, along with directions for further research.

Prevalence and determinants of cervicovaginal, oral, and anal HPV infection in a population of transgender and gender diverse people assigned female at birth.

Introduction: HPV causes oral, cervicovaginal, and anogenital cancer, and cervical cancer screening options include HPV testing of a physician-collected sample. Transgender and gender diverse (TGD) people assigned female at birth (AFAB) face discrimination and stigma in many healthcare settings; are believed to be a lower risk for cervical cancer by many physicians; are less likely to be up to date on preventive health care services such as pelvic health exams; and are more likely to have inadequate results from screening tests. Self-sampling options may increase access and participation in HPV testing and cancer screening. Methods: We recruited 137 TGD individuals AFAB for an observational study, mailing them a kit to self-collect cervicovaginal, oral, and anal samples at home. We tested samples for HPV genotypes 6, 11, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, 68, 73 and 90 using a PCR mass array test. Results: 102 participants completed the study. Among those with valid tests, 8.8% were positive for oral HPV, 30.5% were positive for cervicovaginal HPV, and 39.6% were positive for anal HPV. A large fraction of anal (50.0%) and oral (71.4%) infections were concordant with a cervicovaginal infection of the same type. Conclusions: HPV infection in TGD people AFAB may be just as high, if not higher, than in cisgender women. 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.

Cervicovaginal and anal self-sampling for HPV testing in a transgender and gender diverse population assigned female at birth: comfort, difficulty, and willingness to use.

Background: Transgender and gender diverse (TGD) people assigned female at birth (AFAB) face numerous barriers to preventive care, including for HPV and cervical cancer screening. Self-sampling options may expand access to HPV testing for TGD people AFAB. Methods: We recruited TGD individuals AFAB to collect cervicovaginal and anal specimens at-home using self-sampling for HPV testing, and individuals reported their perceptions of self-sampling. Associations between demographic and health characteristics and each of comfort of use, ease of use, and willingness to use self-sampling were estimated using robust Poisson regression. Results: The majority of the 101 participants who completed the study reported that the cervicovaginal self-swab was not uncomfortable (68.3%) and not difficult to use (86.1%), and nearly all (96.0%) were willing to use the swab in the future. Fewer participants found the anal swab to not be uncomfortable (47.5%), but most participants still found the anal swab to not be difficult to use (70.2%) and were willing to use the swab in the future (89.1%). Participants were more willing to use either swab if they had not seen a medical professional in the past year. About 70% of participants who reported negative experiences with either self-swab were still willing to use that swab in the future. Conclusions: TGD AFAB individuals were willing to use and preferred self-sampling methods for cervicovaginal and anal HPV testing. Developing clinically approved self-sampling options for cancer screening could expand access to HPV screening for TGD AFAB populations.

Enhancing pre-employment transition services: A type 1 hybrid randomized controlled trial protocol for evaluating WorkChat: A Virtual Workday among autistic transition-age youth.

Autistic transition-age youth experience high rates of unemployment and underemployment, in part due to the social challenges they may face when having conversations in the workplace. In an effort to help enhance conversational abilities in the workplace, our collaborative team partnered to develop WorkChat: A Virtual Workday. Specifically, our team of scientists, community partners, and diversity and inclusion experts participated in a community-engaged process to develop WorkChat using iterative feedback from autistic transition-age youth and their teachers. With initial development complete, this study reports on the protocol that our collaborative team developed, reviewed, and approved to conduct a randomized controlled trial (RCT) to evaluate the real-world effectiveness and initial implementation process outcomes of WorkChat when integrated into post-secondary pre-employment transition services (Pre-ETS). Our aims are to: 1) evaluate whether services-as-usual in combination with WorkChat, compared to services-as-usual with an attention control, enhances social cognition and work-based social ability (between pre- and post-test); reduces anxiety about work-based social encounters (between pre- and post-test), and increases sustained employment by 9-month follow-up; 2) evaluate whether social cognitive ability and work-based social ability mediate the effect of WorkChat on sustained employment; and 3) conduct a multilevel, mixed-method process evaluation of WorkChat implementation.