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.

Using GPS-defined venue-based affiliation networks among Black sexual minoritized men and transgender women to identify locations for HIV prevention interventions.

PURPOSE: HIV biomedical intervention uptake is suboptimal among Black sexually minoritized men (SMM) and transgender women (TW). Venues where people meet and interact shape HIV-related risk and prevention behaviors. We aimed to construct GPS-defined venue-based affiliation networks and identify the unique set of venues that could maximize reach of HIV biomedical interventions among Black SMM and TW. METHODS: We used baseline survey and GPS data from 272 Black SMM and TW in the Neighborhoods and Networks (N2) Cohort Study in Chicago, Illinois (2018-2019). We mapped participants' GPS data to the nearest pre-identified SMM- and TW-friendly venue (n=222) to construct affiliation networks. Network analyses were performed to identify influential venues that can yield high reach to intervention candidates. RESULTS: Participants were affiliated with 75.5% of all pre-identified venues based on GPS data. Two influential venues were identified in the non-PrEP use network, which when combined, could reach 52.5% of participants not taking PrEP. Participants that could be reached through these two influential venues reported more non-main sex partners than participants not affiliated with either venue (p=0.049). CONCLUSION: We demonstrate a potential for GPS-defined venue-based affiliation networks to identify unique combinations of venues that could maximize the impact of HIV prevention interventions.

The implications of hormone treatment for cancer risk, screening and treatment in transgender individuals.

There is evidence that gender-affirming hormone treatment (GAHT) for transgender individuals modulates their risk for specific malignancies including breast and prostate cancer, and meningiomas. However, there is insufficient data to make precise risk estimates accounting for age and inherited cancer risk. As such, screening recommendations remain broad. Even less evidence exists for best practice in the management of active or historical cancers in the transgender population. Guidance is therefore mainly extrapolated from cisgender populations but with considerations of the significant benefits of GAHT in the face of any hormonal risk. Clinical experience, the multidisciplinary team and shared decision making with the patient are vital in providing person-centred care, while further research is acquired.

French Validation of the oMtFSFI Questionnaire for Assessing the Sexual Function of Transgender Women After Vulvo-vaginoplasty.

INTRODUCTION: The Operated Male-to-Female Sexual Function Index (oMtFSFI) questionnaire is the first scoring system developed to assess sexual function after gender-affirming vulvo-vaginoplasty, and was initially developed and validated in Italian. The aim of this study was to provide linguistic validation of the questionnaire in French through several steps including use of the questionnaires across a series of patients who had undergone gender-affirming vulvo-vaginoplasty between 2020 and 2022 at two French academic centers. METHOD: The French version of the oMtFSFI questionnaire was obtained through a double translation (Italian to French) and a back-translation (French to Italian), validated by a scientific committee, and cognitively assessed by a panel of expert patients. The questionnaire was then distributed to transgender male to female patients who had undergone genital gender affirming surgery at two French academic centers. RESULTS: The oMtFSFI score consists of 18 questions exploring 7 domains (genital self-image, desire, arousal, lubrication, orgasm, satisfaction, sexual pain). Among the sixty-four patients who responded to the questionnaire, 16 patients (25%) reported abstaining from sexual activity involving vaginal penetration at the time of the study were excluded. The mean total score was 37, corresponding to mild to moderate sexual dysfunction and 60.4% of the patients reported normal overall sexual function. The level of sexual satisfaction was normal for 68.8% of the patients and the genital self-image was normal for 52.1%. Most of the patients (79.2%) reported at least mild dyspareunia and 10.4% had critical sexual dysfunction. Surgery improved gender dysphoria in 96.7% of patients. There was a strong correlation between the overall oMtFSFI score and the happiness Visual Analog Scale (VAS) (p<0.001) as well as with the quality of life VAS (p<0.001). CONCLUSION: The French version of the oMtFSFI questionnaire is the only scoring system specifically developed to assess sexual function after vulvo-vaginoplasty in transgender women linguistically validated in French. Its validation in French language makes it an interesting tool for research and clinical practice.

Vocal Approach to Transgender Individuals: The Journey Taken in Chile and Argentina

In recent years, there have been international references to the vocal approach for the specific group of transgender individuals, although the Latin American literature is still very timid on this matter. The purpose of this article is to identify the current norms, statistics, and vocal approach towards transgender individuals in Chile and Argentina, considering the experience of two speech and language pathologists with more than twenty years of experience on voice therapy. Reflections were made on the transgender reality in these countries, the limitations in the implementation of the depathologization of the transgender group were outlined, some current and unreliable statistics were presented, some innovative actions in the public system were highlighted, and the lack of knowledge about the benefits of vocal work for transgender men and women was discussed. The identified aspects could benefit from multicenter research that strengthens speech therapy actions with this group, contributing to depathologization and positive approach.

Desde los últimos años es posible encontrar referencias internacionales sobre el abordaje vocal al grupo específico de las personas transgénero, aunque la literatura latinoamericana sigue muy tímida en este asunto. La propuesta de este artículo es identificar las normas vigentes, estadísticas y abordaje vocal hacia las personas transgénero en Chile y Argentina, considerando la experiencia de dos fonoaudiólogas con más de veinte años de experiencia en terapia vocal. Se hicieron reflexiones sobre la realidad transgénero en los países citados, se delinearon las limitaciones en la puesta en práctica de la despatologización del grupo transgénero, se expusieron algunas estadísticas -vigentes y poco confiables-, se plasmaron algunas acciones novedosas en el sistema público y el desconocimiento sobre los beneficios del trabajo vocal en hombres y mujeres transgénero. Los aspectos detectados podrían beneficiarse de investigaciones multicéntricas que fortalezcan acciones fonoaudiológicas con este grupo, contribuyendo a la despatologización y el abordaje positivo.

Hepatitis C virus infection is uncommon at baseline and during follow-up among individuals using PrEP in the Dutch national PrEP programme between 2019 and 2022.

OBJECTIVES: Studies showed that men who have sex with men (MSM), including those using pre-exposure prophylaxis (PrEP), are at increased risk of hepatitis C virus (HCV) infection. We evaluated HCV prevalence and incidence, along with their associated determinants, in a cohort of PrEP-using individuals in the Netherlands. METHODS: In 2019, the Netherlands launched a 5-year national programme that offers subsidised PrEP to eligible individuals. We used prospectively collected data from individuals registered in this programme between 2019 and 2022. Individuals underwent annual testing for HCV antibodies and additional HCV-RNA testing when antibodies were present. We calculated the prevalence of past/current HCV infection at first visit and overall incidence rate (IR) during follow-up. Univariable logistic and Poisson regression models were used to identify determinants associated with past/current prevalent or incident HCV infection, respectively. Behavioural factors referred to those occurring in the previous 6 months. RESULTS: A total of 10 563 (n=10 319, 97.7% MSM) were included. At first visit, 66 of 10 563 (0.6%) had a past/current HCV infection, which was associated with older age [odds ratio (OR) per 10 years=1.57, 95% confidence interval (CI)=1.31 to 1.88], the use of PrEP before first visit (OR=3.03, 95% CI=1.79 to 5.13), receptive condomless anal sex (CAS) (OR=2.73, 95% CI=1.25 to 5.98), chemsex (OR=2.44, 95% CI=1.49 to 3.99) and injecting drug use (IDU) (OR=6.61, 95% CI=2.35 to 18.61). Among 9851 individuals contributing to 17 150 person-years (PYs) of follow-up, 64 incident HCV infections (IR=0.37 per 100 PYs, 95% CI=0.29 to 0.48) were identified. Factors associated with incident HCV infection were receptive CAS [incidence rate ratio (IRR)=2.59, 95% CI=1.12 to 6.02], chemsex (IRR=1.78, 95% CI=1.06 to 2.98), sexually transmitted infection diagnosis (IRR=2.30, 95% CI=1.23 to 4.31) and IDU (IRR=6.15, 95% CI=2.20 to 17.18). CONCLUSIONS: Past/current prevalence and incidence of HCV were low among individuals in the Dutch PrEP programme. Infections were associated with behaviour known to be associated with HCV. Instead of annual HCV testing, as stated in most PrEP care guidelines, testing frequency for HCV could be based on behaviours associated with HCV acquisition.

Gender-affirming vaginoplasty online resources exceed patient health literacy: A readability analysis.

Purpose: Ensuring that educational materials geared toward transgender and gender-diverse patients are comprehensible can mitigate barriers to accessing gender-affirming care and understanding postoperative care. This study evaluates the readability of online patient resources related to gender-affirming vaginoplasty. Methods: Online searches for vaginoplasty were conducted in January 2023 using two search engines. The readability scores of the top ten websites and their associated hyperlinked webpages were derived using ten validated readability tests. Results: A total of 40 pages were assessed from the vaginoplasty searches. The average reading grade level for all the webpages with relevant educational materials was 13.3 (i.e., college level), exceeding the American Medical Association's recommended 6th grade reading level. Conclusion: Complex patient resources may impede patients' understanding of gender-affirming vaginoplasty. Online patient education resources should be created that are more accessible to patients with diverse reading comprehension capabilities.

A guide to caring for patients who identify as transgender and gender diverse in the emergency department.

Through a review of current research, standards of care, and best practices, this paper serves as a resource for emergency physicians (EPs) caring for persons who identify as transgender and gender diverse (T/GD) in the emergency department (ED). Both patient- and physician-based research have identified existent potential knowledge gaps for EPs caring for T/GD in the ED. T/GD have negative experiences related to their gender identity when seeking emergency medical care and may even delay emergency care for fear of discrimination. Through the lens of cultural humility, this paper aims to address potential knowledge gaps for EPs, identify and reduce barriers to care, highlight gender-affirming hospital policies and protocols, and improve the care and experience of T/GD in the ED.

Translation and Evaluation of Psychometric Properties of the Persian 8-Item Internalized Transphobia (IT) Scale in Iranian Transgenders.

Objective: Internalized transphobia (IT) is influenced by societal norms and expectations, and it can have significant negative effects on the well-being and mental health of transgender individuals. The aim of this study was to translate and evaluate the psychometric properties of the Persian 8-item IT scale among Iranian transgender individuals in order to enhance the quality and quantity of research in this field. Materials and methods: This cross-sectional and methodological study utilized convenience sampling to recruit 119 transgender individuals in Mashhad, the second most populous city in Iran, in 2021. The Persian translation of the IT scale was developed using the backward-forward translation method. Subsequently, various types of validity and reliability were assessed, including content validity using the content validity index (CVI) and content validity ratio (CVR), face validity based on the impact score, construct validity through confirmatory factor analysis (CFA), internal consistency measured by Cronbach's alpha, and test-retest stability analyzed using the intraclass correlation coefficient (ICC). Results: The CVR ranged from 0.600 to 1, the CVI ranged from 0.800 to 1, and the impact score exceeded 1.5, indicating the appropriate content and face validity of the 8-item IT scale. The construct validity analysis revealed that the questionnaire is one-dimensional. The internal consistency, as measured by Cronbach's alpha, was 0.917, and the ICC for test-retest stability was 0.871. Conclusion: The Persian version of the IT scale demonstrated high and acceptable psychometric properties. The brevity of this scale facilitates its dissemination and utilization in clinical settings.

Metabolic and cardiovascular risks of hormone treatment for transgender individuals.

Identifying metabolic and cardiovascular risks of gender-affirming hormone therapy (GAHT) is challenging due to other confounding variables that affect patient outcomes and the diversity of treatment regimes. Masculinising hormone therapy produces atherogenic lipid profiles, while effects on other metabolic parameters are not consistent. There is insufficient evidence to conclude if cardiovascular disease risk among transmen is increased. The effects of feminising hormone therapy on metabolic parameters do not demonstrate a consistent pattern in the available literature. However, the risk of venous thromboembolism is greater in transwomen than in cis-gender men and women with a possible increase in cardiovascular disease risk. It is recommended to discuss the potential effects of GAHT on cardiovascular health and encourage patients seeking GAHT to adopt a healthy lifestyle. Performing baseline and periodic assessments of cardiovascular risk factors would enable early identification and interventions. In high-risk individuals, the cardiovascular effects of hormonal regimes might impact the treatment decision.

Reducing intersectional stigma among transgender women in Brazil to promote uptake of HIV testing and PrEP: study protocol for a randomised controlled trial of Manas por Manas.

INTRODUCTION: Globally, transgender ('trans') women experience extreme social and economic marginalisation due to intersectional stigma, defined as the confluence of stigma that results from the intersection of social identities and positions among those who are oppressed multiple times. Among trans women, gender-based stigma intersects with social positions such as engagement in sex work and substance use, as well as race-based stigma to generate a social context of vulnerability and increased risk of HIV acquisition. In Brazil, trans women are the 'most at-risk' group for HIV, with 55 times higher estimated odds of HIV infection than the general population; further, uptake of HIV testing and pre-exposure prophylaxis (PrEP) among trans women is significantly lower than other at-risk groups. Through extensive formative work, we developed Manas por Manas, a multilevel intervention using HIV prevention strategies with demonstrated feasibility and acceptability by trans women in Brazil, to address intersectional stigma and increase engagement in the HIV prevention continuum. METHODS AND ANALYSIS: We are conducting a two-arm randomised wait-list controlled trial of the intervention's efficacy in São Paulo, Brazil, to improve uptake of HIV testing and PrEP among transgender women (N=400). The primary outcomes are changes in HIV testing (self-testing and clinic based), changes in PrEP uptake and changes in PrEP persistence at baseline and follow-up assessment for 12 months at 3-month intervals. ETHICS AND DISSEMINATION: This study was approved by University of California, San Francisco Institutional Review Board (15-17910) and Comissão Nacional de Ética em Pesquisa (Research Ethics National Commission, CAAE: 25215219.8.0000.5479) in Brazil. Participants provided informed consent before enrolment. We are committed to collaboration with National Institutes of Health officials, other researchers, and health and social services communities for rapid dissemination of data and sharing of materials. The results will be published in peer-reviewed academic journals and scientific presentations. TRIAL REGISTRATION NUMBER: NCT03081559.

Impact of sex used for assignment of reference intervals in a population of patients taking gender-affirming hormones.

Background: Gender-affirming hormone therapy with either estradiol or testosterone for transgender persons can significantly impact chemistry and hematology laboratory tests. The sex used for assignment of reference intervals (RIs) in the electronic health record (EHR) will influence normal/abnormal flagging of test results. Objective: To analyze common non-hormonal laboratory tests with sex-specific RIs ordered in patients with sexual orientation/gender identify (SOGI) field differences (one or more differences between legal sex, sex assigned at birth, and gender identity) in the EHR at an academic medical center in midwestern United States. Methods: We utilized a previously characterized data set of patients at our institution that included chart review information on gender identity and gender-affirming therapy. We focused on the subset of these patients that had orders for 18 common laboratory tests in calendar year 2021. Results: A total of 1336 patients with SOGI field differences (1218 or 91.2% identifying as gender-expansive; 892 or 66.8% receiving estradiol or testosterone as gender-affirming therapy) had a total of 9374 orders for 18 laboratory tests with sex-specific RIs. Hemoglobin, creatinine, alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase, and high-density lipoprotein were the most frequently ordered tests. For patients taking estradiol, 128 of 970 (13.2%) creatinine and 39 of 193 (20.2%) hemoglobin measurements were within the RI for one sex but not the other. For those taking testosterone, 119 of 531 (22.4%) creatinine and 49 of 120 (40.8%) hemoglobin measurements were within the RI for one sex but not the other. Values above the cisgender female RI but within the cisgender male RI were common for hemoglobin, alkaline phosphatase, alanine aminotransferase, and aspartate aminotransferase in patients taking testosterone. Conclusions: Clinicians should be aware of the potential impact of gender-affirming therapy on laboratory tests and what sex/gender is being used in the EHR to assign RIs.

Physiological impact of Tabata exercise on cardiometabolic and cardiorespiratory parameters in transgender people of Multan.

Objective: To investigate factors directly related to cardiometabolic and cardiorespiratory fitness in transgender people. METHODS: The cross-sectional, experimental study was conducted at the Government Girls Comprehensive Higher Secondary School, Multan, Pakistan, from January to February 2023, after approval from the ethics review committee of the Muhammad Institute of Medical and Allied Sciences, Multan, and comprised transgender people aged 17-28 years. Data was collected using the physical activity readiness questionnaire. All the participants were subjected to Tabata sessions for 4 weeks. Standard cardiometabolic and cardiorespiratory fitness values were noted at baseline and post-intervention. Data was analysed using SPSS 23. RESULTS: Of the 44 participants, 26(59%) were trans-men, 18(40.9%) were trans-women, 16(36.3%) were aged 17-19 years, and 10(22.7%) had other transgender individuals in their families. Cardiorespiratory and cardiometabolic parameters showed significant improvement post-intervention compared to baseline values (p<0.05). Conclusion: Tabata exercises were found to be useful in maintaining cardiorespiratory and cardiometabolic parameters as well in increasing the participants' motor performance.

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.

Cross-Cultural Adaptation and Face Validation of the Chilean Version of the Operated Male to Female Sexual Function Index.

INTRODUCTION AND HYPOTHESIS: Transgender and gender-diverse people often experience discrimination or even outright exclusion when undergoing medical attention. It has been shown that gender-affirming treatments improve quality of life in transgender patients, and genital-affirming surgery (GAS) is increasingly spreading worldwide. Sexual function after male-to-female GAS has long been evaluated by using tools designed for assigned female at birth (AFAB), resulting in suboptimal assessments. Currently, the operated Male to Female Sexual Function Index (oMtFSFI) is the only validated questionnaire to assess the sexual function of operated transgender women. The current study was aimed at performing cross-cultural adaptation and to test the face validity of the Chilean version of the oMtFSFI. METHODS: We carried out an observational descriptive study. The questionnaire was translated into Spanish, adapted, and face validated in five phases with eight participants. The study was approved by the Universidad del Desarrollo Scientific Ethics Committee. RESULTS: According to participants, the questionnaire was shown to both pertinently and exhaustively evaluate the sexual function of post-feminizing genitoplasty transgender women. The questionnaire was well understood by the participants, except for a difficulty in understanding certain terms. Some participants criticized the perspective of the instrument in terms of the assumption of having a partner or having penetrative intercourse via the neovagina. The amendments to the Italian version of the questionnaire were discussed until an agreement on adaptation considering the patient´s perspective was reached. The present preliminary data support the face validity of the Chilean version of the oMtFSFI in the assessment of sexual function in operated transgender women. CONCLUSIONS: This adapted questionnaire could be a valuable tool for clinicians and researchers.

Gender affirming hormone therapy and transgender women fertility: Histologic predictors of germ cell presence.

Objective: Evaluate histological changes in testicular parameters after hormone treatment in transgender women. Methods: Cross-section study with patients who underwent gonadectomy at Hospital de Clínicas de Porto Alegre from 2011 to 2019. Hormone treatment type, route of administration, age at initiation and duration were recorded. Atrophy parameters were observed: testicular volume, tubular diameter, basal membrane length, presence of spermatogonia and spermatids (diploid and haploid spermatozoid precursors). Results: Eighty-six patients were included. Duration of hormone treatment is associated with testicular atrophy and spermatogenesis arrest. Other characteristics of hormone treatment such as age of initiation, route of administration and type of treatment were not associated with testicular histological changes. Testicular volume may predict spermatogenesis arrest. Basal membrane length and tubular diameter ratio is an interesting predictor of germ cell presence. Conclusion: Cross-sex hormone treatment affects testicular germ cell presence. Basal membrane length and tubular diameter ratio reduces inter variability of measurements and better exemplify how atrophic seminiferous tubules are. Fertility preservation should be addressed by healthcare providers in order to recognize gender affirming treatment impact on transgender health.

Health Care Utilization During the First 5½ Years of Authorized Service by Transgender U.S. Service Members (2016-2021).

Purpose: This study examined the utilization of gender-affirming health care by active-duty service members during the initial 5½ years that transgender and gender-diverse (TGD) individuals were authorized to serve in the U.S. military. The aim of this study was to inform policy discussions regarding inclusion of TGD individuals in the military. Methods: We conducted a retrospective cohort study using administrative health care data from the Military Data Repository (MDR). We assessed the association of demographic factors with the utilization of gender-affirming medical and surgical care. We calculated the incidence rate of initial TGD-related encounters and new prescriptions for gender-affirming hormones among Defense Department Service members between July 2016 and December 2021. Results: We identified 2481 service members with an initial health care encounter with an associated TGD-related diagnosis. More than half (53%) of these service members started gender-affirming hormones, and 14% underwent gender-affirming surgery. Mastectomies and hysterectomies accounted for more than 70% of surgeries. Service members made 3.22 initial encounters with a TGD-related diagnosis per 10,000 service members per year, with an overrepresentation of service members who were designated female in the MDR (8.62), junior enlisted (4.98), and young (4.64). Individuals designated female in the MDR comprised 17% of all service members but accounted for 46% of initial encounters, 51% of new prescriptions, and 73% of surgeries. Conclusion: The study revealed a higher-than-expected number of service members seeking gender-affirming care, particularly among service members designated female in the MDR. Military Health System clinicians provided most of this care, which may mitigate the cost of delivering this essential medical care.

Neighborhood-level characteristics as effect modifiers on the efficacy of the MyPEEPS mobile intervention in same-sex attracted adolescent men.

To estimate the effect of neighborhood-level modification on the efficacy of the MyPEEPS Mobile intervention on the reduction of condomless anal sex acts among same-sex attracted adolescent men. A series of generalized linear mixed model was used to examine if the effect of the MyPEEPS Mobile intervention on condomless anal sex acts was moderated by neighborhood-level factors using data from the 2019 American Community Survey US Census Bureau. "The magnitudes of intervention were significantly smaller at both 6- and 9-month follow-up among adolescents living in neighborhood with high proportions of Hispanic or Latino residents (IRR6M = 1.02, 95 % CI: 1.01, 1.02; IRR9M = 1.03, 95 % CI: 1.01, 1.05) and high proportions of families with income below the poverty level (IRR6M = 1.07, 95 % CI: 1.01, 1.12; IRR9M = 1.05, 95 % CI: 1.01, 1.10), which indicated that living in communities with a higher concentration of residents living under poverty or of Hispanic/and Latino ethnicity significantly modified the effective of program intervention on condomless sex among adolescent MSM. Understanding how neighborhood characteristics modify the effect of HIV prevention interventions may be useful in better targeting delivery and tailoring content of interventions based on neighborhood level characteristics such as the ones identified in this study.

A comparison of gender diversity in transgender young people with and without autistic traits from the Trans 20 cohort study.

Background: There is an elevated co-occurrence of autism in trans individuals, with recent meta-analyses suggesting that 11% of trans individuals are autistic. The presence of autism in trans young people can create clinical challenges by adding complexity to the presentation, assessment and management of those presenting to gender clinics. Although many trans young people display traits of autism, how these traits relate to the nature of their gender diversity is unclear. Methods: This study compared gender identity, gender expression and gender dysphoria (GD) in trans young people with and without autistic traits. Baseline data from a cohort study of trans children and adolescents who first attended the Royal Children's Hospital Gender Service (Victoria, Australia) between February 2017 and January 2020 were analysed cross-sectionally. Autistic traits were assessed via the Social Responsiveness Scale-2. Gender was assessed using tools that measure gender identity, social transition, GD, body dissatisfaction, voice dysphoria, and chest dysphoria. Findings: 522 participants were included, of whom 239 (45.8%) exhibited autistic traits (SRS total T-score ≥60). Those with and without autistic traits were similar in their age (mean (SD) age 14.0 (2.9) and 13.1 (3.6) years respectively) and gender identity: the majority (73.7% (n = 174) and 70.5% (n = 198) respectively) identified in a binary way. Higher rates of social transition (specifically, changing pronouns) were noted in those with autistic traits (Difference in proportion 11.7, 95% confidence interval [CI] 2.4-21.1, p = 0.014). GD was high in both groups with ∼95% displaying clinically relevant levels of GD. Chest dysphoria was similar between groups, while voice dysphoria was higher in those with autistic traits (standardised mean difference [SMD] = 0.3, 95% confidence interval [CI]: 0.1-0.5 p = 0.00087). Dissatisfaction with secondary gendered characteristics (SMD = 0.3, CI: 0.1-0.5 p = 0.0011) and hormonally unresponsive body characteristics (SMD = 0.2, CI: 0.1-0.4 p = 0.016) was higher in trans young people with autistic traits. Interpretation: The similarly high severity of GD in those with and without autistic traits reinforces the importance of trans young people with and without autistic traits being availed the same opportunities to access gender-affirming care. Subtle differences identified between the groups in other areas of gender diversity suggest trans young people with autistic traits may have distinct needs and that gender-affirming care may need to be tailored accordingly. Funding: The Royal Children's Hospital Foundation, Hugh D.T. Williamson Foundation; Australian National Health and Medical Research Council-Clinical Trials and Cohort Studies scheme (GNT 2006529).