Purpose: Research and lived experience demonstrate that sexual orientation and gender identity (SOGI) can change over the life course; however, little empirical work exists to understand the prevalence of such changes. To address this gap, we used data from a large nationally representative panel of adults and adolescents to assess changes in self-reported SOGI over time and identify trends by sex assigned at birth, age, race and ethnicity, and survey mode.Methods: We reviewed SOGI data collected between 2014 and 2022 for a sample of 19,469 adults and 970 adolescents. Up to eight SOGI measurements per panelist were available over the nine-year period, collected through a combination of panel recruitment and demographic refresh surveys and topic-specific surveys.Results: Among adults older than 18 years, 4.1% reported a change in sexual orientation and 3.6% reported a change in gender identity. Among teens, who are developmentally more apt to change identity, 13.5% reported a change in sexual orientation and 9.3% reported a change in gender identity.Conclusions: Findings demonstrate that SOGI can change over time, particularly for adolescents, so it is important to re-ask SOGI questions to ensure current information. We recommend re-asking SOGI questions at least every three years of adults and every two years of adolescents. Potential undercounting of sexual and gender minority (SGM) respondents decreases visibility and our ability to understand health and economic disparities affecting these populations. Improvements in SOGI measurement can help advance data quality and, ultimately, evidence-based interventions in support of SGM communities that these data help to inform.

Sexual and gender minority (SGM) youth are at disproportionate risk of acquiring HIV, and as such, SGM youth should be meaningfully engaged in research aimed at developing effective, tailored HIV interventions. Youth Community Advisory Boards (YCABs) are an important element of community-engaged research and support the development of community-informed interventions. This article describes recruitment, facilitation, and retention of a YCAB composed of SGM youth in Greater Boston, to inform a national HIV prevention research project. These lessons can serve as a guide to future researchers who want to form YCABs as part of community-engaged research.

Transgender and gender diverse (TGD) youth experience significant risk for negative health outcomes, yet few studies exist that address TGD youth’s experiences of health care. This paper explores the equitable access and utilization of health care in a sample of TGD youth of diverse gender and racial/ethnic identities. Data for this analysis are from the TGD subsample (n = 1415) of the 2018 Survey of Today’s Adolescent Relationships and Transitions (START) Project. We assessed five health care experiences: being insured, having a current health care provider, being out to one’s provider, believing your provider was knowledgeable about transgender issues, and barriers to accessing care due to gender identity/expression. We examined the proportion of TGD youth who reported each of these outcomes and within-group differences by gender identity and race/ethnicity using descriptive statistics, logistic regression, and predicted probabilities. When differences were examined by gender identity, barriers to equitable care were consistently more present among transgender females than youth of other gender identities. There were few significant differences by race/ethnicity; however, dual referent models demonstrated barriers to equitable care were particularly evident among Black and Hispanic transgender women. We discuss these findings through the lens of intersectionality and highlight the importance of research and intervention work focused on reducing barriers to equitable care for TGD youth.

Purpose: The purpose of this research is to explore the relationship between substance use and sexual risk behaviors among transgender youth. Methods: Data from the transgender subsample of the Survey of Today's Adolescent Relationships and Transitions (n=1567) were analyzed to assess associations between substance misuse (binge drinking, prescription drug misuse, illicit drugs) and sexual risk behaviors (condom use during sex). Multivariate logistic regression models calculated adjusted odds ratios (AORs) for substance use by sexual risk behavior controlling for race/ethnicity, gender identity (transgender male, transgender female, genderqueer/gender nonconforming), age, sexual identity, and region. Results: Among participants, lifetime marijuana use (AOR=0.45), cocaine use (AOR=0.46), prescription drug misuse (AOR=0.52), and injecting substances with a needle (AOR=0.45) were all associated with lower odds of reporting condom use during the last act of receptive anal sex. Similarly, marijuana use in the last 30 days (AOR=0.46), lifetime marijuana use (AOR=0.25), heroin use (AOR=0.29), methamphetamine use (AOR=0.32), misuse of prescription drugs (AOR=0.40), and injecting substances with a needle (AOR=0.17) were all associated with lower odds of reporting condom use during the last act of insertive anal sex. No associations between substance use and condom use during last act of receptive frontal (vaginal) sex were found. Conclusion: We found that transgender youth who reported any lifetime substance use were more likely to report condomless sex during receptive and insertive anal sex than those who did not report substance use. Significant differences exist among demographic groups, type of substance use, and sexual risk behaviors for respondents based on gender identity.

Sexual and gender minority (SGM) youth experience more negative mental health conditions, like depression and suicidal ideation, than cisgender and heterosexual youth. However, relatively little data exist on the COVID-19 pandemic's effects on mental health and suicide-related disparities. Factors associated with poor mental health (e.g., physical isolation, increased time at home with parents/caregivers) changed during the pandemic and may differentially impact SGM youth. This presentation describes findings from a recent web-based, longitudinal survey of U.S. adolescents, comparing SGM to non-SGM youth across key mental health and suicide outcomes over two waves of data collected during the pandemic. CDC's Division of Adolescent and School Health contracted with NORC at the University of Chicago to conduct the longitudinal COVID Experiences Surveys, an assessment of the pandemic's impact on the health and well-being of children and adolescents. Adolescent respondents age 13-19 were recruited using AmeriSpeak®, NORC's probability-based survey panel representative of the U.S. household population (Wave 1: Oct-Dec 2020, n=727; Wave 2: Mar-May 2021, n=569). Respondents reporting their sexual identity as lesbian, gay, bisexual, or something else were categorized as sexual minority. Respondents reporting a gender identity different than their sex assigned at birth (e.g., assigned male at birth/identified as female, assigned female at birth/identified as male), identified as transgender, or identified as not male, female, or transgender were categorized as gender minority. Youth not identified as sexual or gender minority were categorized as non-SGM. Mental health and suicide risk were operationalized with validated measures adapted from state and local Youth Risk Behavior Surveys and the Flint Adolescent Study, including stress, mental health quality of life, symptoms of depression and anxiety, and suicide-related behaviors. Chi-square tests compared mental health and suicide outcomes across SGM status. Odds ratios (OR) and 95% confidence intervals (CI) were estimated. At wave 1, 12.4% adolescents identified as sexual minority and 3.6% as gender minority. Across both waves, SGM youth were more likely than non-SGM youth to report their mental health was not good half or more days in the prior two weeks (Wave 1: OR=3.08, 95% CI:1.68-5.66) (Wave 2: OR=3.20, 95%CI:1.74-5.88). SGM youth were more likely than non-SGM youth to report high or very high stress at home at wave 1 (OR=3.04, 95%CI:1.62-5.71), and at wave 2, the size of this difference increased (OR=4.57, 95%CI:2.60-8.03). At wave 1, SGM youth were likely than non-SGM youth to seriously consider attempting suicide within the last year (OR=4.62, 95%CI:2.50-8.52), and the size of this difference increased at wave 2 (OR=6.53, 95%CI:3.26-13.08). Findings indicate that the pandemic may have exacerbated mental health and suicide related disparities between SGM and non-SGM youth, especially stress at home and suicidal ideation. Findings provide insight for mental health professionals, educators, and communities regarding the mental health needs of SGM youth during the pandemic and can inform innovative clinic-, school-, and family-level strategies among adolescents.

Social media recruitment is no longer an uncharted avenue for survey research. The results thus far provide evidence of an engaging means of recruiting hard-to-reach populations. Questions remain, however, regarding whether the data collected using this method of recruitment produce quality data. This article assesses one aspect that may influence the quality of data gathered through nonprobability sampling using social media advertisements for a hard-to-reach sexual and gender minority youth population: recruitment design formats. The data come from the Survey of Today's Adolescent Relationships and Transitions, which used a variety of forms of advertisements as survey recruitment tools on Facebook, Instagram, and Snapchat. Results demonstrate that design decisions such as the format of the advertisement (e.g., video or static) and the use of eligibility language on the advertisements impact the quality of the data as measured by break-off rates and the use of nonsubstantive responses. Additionally, the type of device used affected the measures of data quality.

Purpose: We assessed the association of receipt of medical gender affirmation services (e.g., hormones, surgery) with HIV and other sexually transmitted disease (STD) prevention and knowledge indicators among transgender youth. Methods: A United States online sample of sexually experienced transgender youth ages 13-24 years (N = 1029) in 2018 completed a cross-sectional survey, including questions about sociodemographics, medical gender affirmation, and HIV and STD prevention outcomes (HIV testing, STD testing, pre-exposure prophylaxis [PrEP] awareness, and nonoccupational postexposure prophylaxis [nPEP] awareness). Logistic regression models were fit to assess the association of medical gender affirmation with HIV and STD prevention outcomes. Interaction terms and stratified models assessed differences in the association between medical gender affirmation and outcomes by gender identity. Results: Participants' mean age was 19.1 (standard deviation = 2.7), 45% were transgender female, 29% transgender male, 26% nonbinary, 53% were youth of color, and 19% accessed medical gender affirmation services. Medical gender affirmation was associated with increased odds of STD testing (adjusted odds ratio [aOR] = 1.90; 95% confidence interval [CI] = 1.33-2.73) with no significant interactions by gender identity. Associations between medical gender affirmation and awareness of PrEP and nPEP varied by gender identity. Among transgender male youth, medical gender affirmation was associated with awareness of PrEP (aOR = 2.65; 95% CI = 1.50-4.71) and nPEP (aOR = 2.03; 95% CI = 1.12-3.71). Among nonbinary youth, medical gender affirmation was associated with awareness of PrEP (aOR = 3.47; 95% CI = 1.26-11.27). Conclusion: Medical gender affirmation was associated with uptake and awareness of sexual health services. Bolstering medical gender affirmation for transgender youth may also bolster preventive health services broadly.

OBJECTIVES:We tested preliminary efficacy of a peer change agent type I network intervention to increase pre-exposure prophylaxis (PrEP) linkage to care among network members connected to young Black men who have sex with men. DESIGN:Parent study is a pragmatic randomized controlled trial with 110 weeks of total follow-up. Interim midpoint analyses are performed here using participant data before crossover assignment at 55 weeks. METHODS:We randomly assigned 423 participants in Chicago to receive the network intervention, an opinion leader workshop with telephonic booster sessions, versus a time-matched control from 2016 to 2018. The consolidated surrogate outcome was PrEP referral and linkage to clinical care among network members connected to study participants and was collected from independent administrative data. RESULTS:Each study participant in the trial (n = 423) had on average 1822 network contacts who could be eligible for PrEP referral and linkage. During the 55-week observation period, PrEP referral was most likely to occur within 3 days of an intervention session compared to control [odds ratio (OR) 0.07 (0.02-0.013); P = 0.007] resulting in 1-2 referrals of network members per session. Network members with referral or linkage were more likely to be connected to study participants in the intervention arm than the control condition [aOR 1.50 (1.09-2.06); P = 0.012]. CONCLUSIONS:A peer change agent type I network intervention is preliminarily effective at diffusing PrEP through a network of individuals highly susceptible to HIV over 55 weeks. This low-intensity intervention demonstrated network-level impact among populations that have experienced limited PrEP care engagement in the United States.

INTRODUCTION:Adolescent sexual minority males (ASMM) are at disproportionate risk of HIV infection. The purpose of this study was to assess ASMM's attitudes about sexual health, barriers/facilitators to accessing HIV prevention, and actual versus ideal interactions for receiving sexual health care and information.METHOD:Two online and two in-person focus groups were conducted with ASMM from across the United States. Qualitative data were analyzed using content analysis.RESULTS:Twenty-one racially diverse ASMM participated (average age = 16.4 years). Online focus groups were superior for reaching the target population. Four themes emerged: 1: identity formation and sources of support, 2: challenges to obtaining sexual health information, 3: attitudes/beliefs about sex and sexual behaviors, and 4: barriers to HIV prevention.DISCUSSION:These findings illustrate current gaps in sexual health knowledge, as well as barriers and facilitators to obtaining sexual health information, sexual health care, and affirming education and support for ASMM.

Men and women of color have had low pre-exposure prophylaxis (PrEP) uptake. How one's preferred source of health information shapes attitudes toward PrEP is unclear. We conducted cross-sectional surveys to assess changes in PrEP awareness, knowledge, and attitudes, trusted sources for PrEP information, and associations between trusted source of information and PrEP knowledge and attitudes. Participants were recruited from six areas served by community health centers in Chicago, IL (two health centers); Jackson, MS; Newark, NJ; Philadelphia, PA; and Washington, D.C. during June-September 2015 (n = 160) and June-September 2016 (n = 200). Participants were Black (74%), heterosexual (81%), and largely unaware of PrEP (72%). Participants who trusted health experts and community organizations for PrEP information had lower percentages of agreeing with statements indicative of negative PrEP attitudes. Interventions that increase PrEP awareness as well as knowledge and favorable attitudes might help increase PrEP use in communities with high HIV prevalence.

INTRODUCTION:HIV disproportionally burdens adolescent men who have sex with men (AMSM) and transgender youth. This study explores barriers and facilitators that professionals face in delivering HIV preventive services and education.METHODS:Adolescent health providers (nurse practitioners, physicians, and other), school nurses, youth workers, and school educators were recruited nationally for this qualitative study.RESULTS:Thirty-four professionals participated. Common categories identified across professional group were (1) effective strategies for building trust with youth, (2) perceived barriers/facilitators to sexual health communication, (3) perceived barriers/facilitators to effective HIV prevention, and (4) preferred content for HIV prevention tools.DISCUSSION:Key elements for developing multidisciplinary resources to support AMSM and transgender youth should include (1) web-based or easily accessible sexual health educational materials, (2) resources for referrals, (3) trainings to support competence in caring for sexual and gender minority youth, and (4) guidance for navigating policies or eliciting policy change.

Purpose: Sexual and gender minority youth (SGM), an umbrella term encompassing gay, bisexual, and transgender youth, experience disproportionately high rates of new HIV infections, and recent advances in biomedical HIV prevention modalities hold promise in reducing new infections. However, the extent to which SGM youth are aware of and willing to use these modalities is unknown. Methods: Using data from the Survey of Today's Adolescents Relationships and Transitions, we analyze awareness of and willingness to take HIV pre-exposure prophylaxis (PrEP), nonoccupational HIV post-exposure prophylaxis, and rectal microbicides among adolescent sexual minority males aged 13-18 years and transgender youth aged 13-24 years. Results: Overall, we found a majority of our respondents were not aware of any of these prevention modalities. Across both subsamples, age and outness to a health care provider were associated with increased PrEP awareness, and any anal sex was associated with PrEP willingness. Conclusions: These findings highlight the importance of provider education on how to discuss SGM issues with patients and educate them about HIV prevention options. Published by Elsevier Inc. on behalf of Society for Adolescent Health and Medicine.

Purpose: The purpose of this study was to assess the feasibility and efficacy of using advertisements (ads) on Facebook, Instagram, and Snapchat to recruit a national sample of adolescent sexual minority males ages 13-18 and transgender youth ages 13-24 for a web survey. Methods: The Survey of Today's Adolescent Relationships and Transitions (START) used targeted ads as survey recruitment tools. We assessed the efficacy of these varied forms of recruitment ads in reaching our target population. To understand how our sample differed from a national probability sample targeting the general adolescent population, we compared START respondents with sexual minority men identified from the 2017 Youth Risk Behavior Survey (YRBS). Results: The use of targeted language produced higher rates of completes per click compared with ads without targeted language. Video ads (compared with static images) were more effective at recruiting younger respondents. START and YRBS samples differed along lines of sexual identity, race and ethnicity, and age. The START sample had a greater percentage of Hispanic/Latino and Other/Multiracial respondents relative to the YRBS sample, thus providing additional data on these underserved sexual minority youth. Conclusion: The factors associated with design decisions for a hard-to-reach, non-probability sample impact the likelihood that respondents engage in and complete a survey. The ads proved to be effective and efficient at recruiting the targeted population.

This online focus group study captures transgender youth experiences and perspectives related to HIV preventive support and services. BrightcoveDefaultPlayer10.1542/6135486389001PEDS-VA_2019-2204 Video Abstract BACKGROUND: In the United States, transgender youth are at especially high risk for HIV infection. Literature regarding HIV prevention strategies for this vulnerable, often-hidden population is scant. Before effective, population-based HIV prevention strategies may be adequately developed, it is necessary to first enhance the contextual understanding of transgender youth HIV risk and experiences with HIV preventive services. METHODS: Two 3-day, online, asynchronous focus groups were conducted with transgender youth from across the United States to better understand participant HIV risk and experiences with HIV preventive services. Participants were recruited by using online advertisements posted via youth organizations. Qualitative data were analyzed by using content analysis. RESULTS: A total of 30 transgender youth participated. The average age was 18.6 years, and youth reported a wide range of gender identities (eg, 27% were transgender male, 17% were transgender female, and 27% used ≥1 term) and sexual orientations. Four themes emerged: (1) barriers to self-efficacy in sexual decision-making; (2) safety concerns, fear, and other challenges in forming romantic and/or sexual relationships; (3) need for support and education; and (4) desire for affirmative and culturally competent experiences and interactions (eg, home, school, and health care). CONCLUSIONS: Youth discussed experiences and perspectives related to their gender identities, sexual health education, and HIV preventive services. Findings should inform intervention development to improve support and/or services, including the following: (1) increasing provider knowledge and skills to provide gender-affirming care, (2) addressing barriers to services (eg, accessibility and affordability as well as stigma and discrimination), and (3) expanding sexual health education to be inclusive of all gender identities, sexual orientations, and definitions of sex and sexual activity.

Traditional probability-based sampling strategies are impractically expensive for surveying rare populations because of the large scale in-field screening required to find sufficient numbers of eligible persons. As a result, rare or hidden populations are often studied using versions of convenience samples, including non-probability Web panels, for which selection probabilities are unknown, designbased inference is not applicable, and study results not necessarily projectable to the target population. In an effort to improve methods for surveying rare or hidden population, NORC conducted a pilot study which tested a cost-effective alternative that combines probability sampling and Respondent-Driven Sampling (RDS) which we refer to as Web-based RDS. The initial, or seed, probability sample source for the pilot study is NORC’s AmeriSpeak Panel®, which is a household, multi-client panel that uses the NORC National Frame to construct an address-based nationally representative sample panel of US households. The non-probability sample in the pilot study is generated from the seed sample using RDS methods in which respondents nominate/refer friends and family to take the survey. The target subpopulations for the pilot study are lesbian, gay, bisexual, and transgender (LGBT) Americans. We will present results from applying alternative estimation techniques to the Web-based RDS sample obtained in the pilot study, comparing the point estimates and their associated variances for health outcomes under each alternative to each other. NORC has been investigating various methods to combine probability and non-probability samples and of those a propensity approach and a small area estimation approach appear to be the most applicable to apply to the problem at hand. We will also compare estimates using an RDS estimator to the alternative estimators that combine probability and nonprobability based samples.

This article presents the results of a pilot feasibility study comparing two alternative recruitment approaches based on Respondent Driven Sampling using initial seeds selected from a US nationally representative panel, AmeriSpeak, to augment the number of lesbian, gay, bisexual, and transgender (LGBT) respondents to a short web survey on smoking, discrimination, and health. In the nomination condition after completing the survey both LGBT and non-LGBT seeds were invited to share the names and email address of up to four LGBT persons they knew. In the recruitment condition, seeds were given four unique PINs and links to the survey to distribute to LGBT persons. Both conditions were successful in producing new LGBT respondents. The recruitment condition was much more productive. LGBT seeds (and their recruits) were much connected to and willing to contact other LGBT people they knew to participate in a survey. Comparisons of characteristics and responses from the initial samples and the LGBT referrals as well as comparisons to LGB samples from a large national survey are presented. Results demonstrate the promise of this hybrid technique for increasing the number of LGBT respondents through referrals from an initial probability based sample.

This study explored perceived barriers to HIV prevention, care, and treatment by conducting focus groups with adolescent health care providers and sexual or gender minority (SGM) youth, with the purpose of gathering input for a series of comprehensive HIV prevention tools and strategies. Providers and youth were recruited from across the United States. Among providers, online synchronous focus groups were conducted in June and July 2017. Among youth, three-day asynchronous blogs were conducted in April of 2018 for both males attracted to males and those who identified as transgender. Descriptive statistics and content analysis were performed. Data were analyzed for providers and youth separately and synthesized for commonalities and differences. In total, 17 providers (6 physicians, 3 nurse practitioners and 8 school nurses) and 46 youth [16 gay males (mean age 16.3 years) and 30 transgender youth (mean age 18.6 years)] participated in these online discussions. The providers were predominantly female (75%) and White non-Hispanic (68.8%); the youth were more diverse in race/ethnicity (58.7% White non-Hispanic, 15.2% multiracial, 13.0% Hispanic, 13.0% Black), and they represented a wide spectrum of gender identities including: male, female, transgender, genderqueer, and gender nonconforming. All participants largely focused on barriers to care. Adults and SGM youth reported: 1) limited HIV pre-exposure prophylaxis (PrEP) and HIV prevention knowledge among youth, 2) difficulties in access to care (i.e., cost, transportation), 3) real and perceived risks to confidentiality, and 4) stigma. Facilitators included: 1) open and supportive adults, 2) SGM affirming care and environments, and 3) access to referrals and resources. Because few youth had access to comprehensive sexual information, and many experienced negative interactions with providers, they voiced a strong desire for providers to initiate open and inclusive conversations about HIV prevention. Findings from this study of a diverse group of providers and SGM youth provide a framework for developing interventions that provide culturally competent and effective HIV preventative care. Results will inform development and testing of a series of HIV prevention tools, including webinars, to enhance provider skills and competence in providing SGM affirming care, initiating and maintaining PrEP, and implementing strategies to ensure adolescent patient confidentiality as appropriate. Other tools could focus on novel uses of technology to enhance access to care and health educational resources designed specifically for SGM youth.

ObjectiveYoung black men who have sex with men (YBMSM) in the USA represent a subgroup that has the highest HIV incidence among the overall population. In the USA, pre-exposure prophylaxis (PrEP) is an effective prevention intervention to prevent HIV acquisition when taken regularly. Neighbourhood and network factors may relate to PrEP awareness, but have not been studied in YBMSM. This study aimed to examine the relationship of neighbourhood and network characteristics with PrEP awareness among YBMSM.MethodsWe used data collected from a sample of 618 YBMSM in Chicago (2013–2014). Home addresses were collected for participants and enumerated network members. Administrative data (eg, 2014 American Community Survey, Chicago Department of Public Health) were used to describe residence characteristics. Network member characteristics were also collected (eg, sexual partners’ sex-drug use, confidant network members who were also MSM). Multilevel analysis was performed to examine the relationships of neighbourhood and network characteristics to PrEP awareness.ResultsHigher neighbourhood-level educational attainment (adjusted odds ratio (aOR) 1.02, p=0.03) and greater primary care density (aOR 1.38, p=0.01) were associated with greater PrEP awareness; greater neighbourhood alcohol outlet density (aOR 0.52, p=0.004) was associated with less PrEP awareness. Sexual network members residing in the same neighbourhood as the participants (aOR 2.58, p=0.03) and discussions around avoiding HIV acquisition with confidants (aOR 2.26, p=0.04) were associated with greater PrEP awareness.ConclusionsThe results suggest that neighbourhood and network characteristics can influence PrEP awareness in YBMSM. Additional studies are needed to understand the influences of neighbourhood (eg, MSM serving venues) and network (eg, peer to peer communication) characteristics on dissemination of PrEP information, uptake and adherence and the related mechanisms behind the associations.