BACKGROUND: HIV pre-exposure prophylaxis (PrEP) has been found to be an effective prevention strategy for high-risk adults, curtailing the spread of new infections. In response to this success, in May of 2018, PrEP was given FDA-approval for use among adolescents. Yet, the barriers to medication uptake for this population are somewhat unique when compared to adult populations, as parents may be just as likely as prescribers to be gatekeepers to access. Many adolescents who may want to be on PrEP may meet structural barriers, all of which could be dramatically reduced by parental involvement (e.g., navigation of health care systems, transportation to providers). The key problems are getting parents of high-risk teens aware of PrEP, motivated to assess their teen’s interest in it, and committed to partnering with their teen to adhere to a regimen. Given how recently PrEP was approved for this population, these problems, and potential solutions for them, are only just beginning to be identified. METHODS: Starting in April of 2018, we surveyed 460 AMSM ages 13-18 regarding their perceived barriers to PrEP access, as it relates to their parents. Additionally, we asked qualitatively to describe aspects of how teens’ parents might react to them taking PrEP . RESULTS: A majority of AMSM (54.2%) had heard of PrEP prior to being surveyed; 4.0% reported having taken it in their lifetime. One in five (21.9%) claimed to know at least one person (i.e., friend, sex partner) currently on PrEP. In turning to parents as barriers to PrEP uptake, the overwhelming majority (59.4%) reported their parents would be somewhat or very unsupportive. We followed and asked if it were possible to go on PrEP without parental involvement, would you want your parents to know you were taking PrEP? Two-thirds (62.4%) reported they would not want their parents to know. It should be noted that 67.5% of this sample reported they would probably or definitely go on PrEP if it were free; 81.9% said that they would probably or definitely go on PrEP if it were free and their parents would not find out. Finally, when asked why the participants did not use PrEP, 60.4% attributed it to worry that their parents would find out. Qualitative evidence from the study explained these findings. Even among those already out, embarrassment/awkwardness about having to talk with parents about sex was a driving concern; also, many mentioned that they feared being bombarded with questions from their parents. DISCUSSION: The strength of findings make it almost certain that, from the adolescent perspective, parents play a negative role in PrEP uptake among teens. What remains uncertain is the degree to which parents might be able to play a protective role over their teens’ PrEP use, particularly if they are proactive about PrEP discussions. Given the paucity of research on PrEP attitudes among parents of at-risk teens, studies that assess how best to increase parental awareness of PrEP and develop strategies to promote better parental-child communication are paramount.

Background: Transgender and non-binary (TNB) youth face barriers in accessing health information, including gender affirming information on sexual anatomy and health. At present, most sex education curricula are not designed to fit the needs of TNB youth, who are likely to face unique challenges and sexual risks as they navigate social transition and puberty compared to their cisgender peers. Because of these barriers, it is important for the parents of TNB youth to have access to information about gender and sexual health and develop a broader understanding of how to support their child. This study aimed to understand the unique education needs and knowledge deficits in parents of TNB youth and elucidate content youth and parents deemed important to include in a sexual health curriculum aimed at parents. Methods: We conducted 22 qualitative, semi-structured interviews with 6 caregivers of TNB youth, 11 TNB youth ages 18 and older, and 5 providers associated with Seattle Children’s Gender Clinic to identify the sexual health education needs of TNB youth and their parents. We used theoretical thematic analysis to analyze transcribed interviews, and consensus coding was conducted by three independent team members. Results: Parents of TNB youth self-reported a number of key knowledge deficits regarding sexual health for their children that would impact their ability to effectively support their child’s psychological, physical, and sexual wellbeing. TNB youth also provided insight into the information they believed their parents and the parents of TNB youth should know. In general, parents tended to be more concerned about long-term considerations (HRT, fertility options, how often is identifying as TNB a “phase”), whereas youth were more concerned that their parents understand gender/sexuality, how to access gender-affirming healthcare, and learn how to support them throughout their transition. Youth and parents also identified content areas for inclusion in a curriculum: basics of gender and sexuality, appropriate/inclusive language, dysphoria, body changes on HRT, surgical options/outcomes, pregnancy risk on HRT, health risks of HRT, and safety concerns regarding gender-affirming techniques (ie. binding, tucking). Both youth and parents emphasized the importance of curricular content that helps parents facilitate conversations with youth in an informed, non-judgmental manner. Participants also identified the use of diverse personal narratives as an important tool for normalizing TNB identities, gaining a broader understanding of the TNB experience, and soothing parental concerns about their child’s future. Discussion: This study demonstrates that the parents of TNB youth have unique educational needs in regards to supporting their child. Because TNB youth as a population disproportionately face sexual health risks compared to the cisgender population, it is important that the parents and caregivers of these youth are able to access accurate information that allows them to best support their child. In addition to increasing access to health information, a curriculum aimed at parents would provide a contextually appropriate space to disrupt cisnormative and binary assumptions about gender, anatomy, and sexuality. Curriculum recommendations from this study are broadly applicable to clinical and community-based settings.

Background: Transgender and gender diverse (TG/GD) youth are more likely to experience adverse health outcomes related to violence victimization, substance use, suicide, and sexual health compared to cisgender youth. Parental support is a known protective factor that may help foster resilience in this population. However, limited research has characterized parental support specifically for TG/GD youth. To address this gap in the literature, we conducted a thematic analysis of 33 in-depth interviews with TG/GD youth in metro Atlanta. Methods: Interviews were conducted as part of a formative research study with the aim of identifying protective factors for TG/GD youth. In order to be eligible for the study, youth had to identify with a gender that was different from their sex assigned at birth. We used a multistage, thematic approach to code and analyze the data. We characterized parental support as proposed by social support theory (i.e., emotional, instrumental, informational, and appraisal); we also identified and coded emergent themes within the data. Results: Participants’ ages ranged from 16 to 25 years old (mean=21.7). Approximately half of the participants were assigned female at birth (n=16) and half were assigned male at birth (n=17). Fourteen participants identified as female or transgender women, 11 as male or transgender men, and eight as non-binary, non-conforming, fluid, or agender. Over half (n=18) identified as Black, 13 identified as White, and two identified as multiracial. Two participants identified as Latinx. Parental support was either general or gender identity specific. Nearly every participant received some form of general parental support. In terms of emotional support, parents expressed love, affection, caring, and trust, shared emotions, and showed empathy for mental health issues. For instrumental support, parents provided financial support and basic needs such as food and housing, and helped their children access health services. Informational support from parents centered on provision of sexual health education and general advice (i.e., what to do and how to do things). For appraisal, parents gave feedback (e.g., parents told youth whether or not they were doing a good job) as well as affirmations, motivation, and encouragement. Some TG/GD youth also received gender identity specific parental support. Participants describe parents as accepting/supporting, not accepting/supporting, or working toward accepting/supporting their gender identity. As examples of accepting/supporting gender identity, parents provided support in relation to coming out as transgender, the correct use of names and pronouns, and transitioning (e.g., helping with paperwork for name changes and gender markers and providing transition related information). When asked what they wish their parents had done differently, participants desired more communication and emotional, informational, appraisal, and transition-related support. Discussion: This analysis highlights key dimensions of parental support of TG/GD youth. Particularly, almost all participants described general parental support similar to parental support reported by general samples of youth. In order to enhance TG/GD youth health, parents may benefit from resources and programming to facilitate parental acceptance and support of gender identity, particularly in relation to coming out, correct use of name and pronouns, and transition related activities.

As research about transgender (trans) health grows, approaches like community based participatory research (CBPR) are crucial to incorporate the community’s needs into the formulation of research questions. CBPR, however, is currently underused in research with trans persons. We conducted a CBPR project with transmasculine young people (TYP) in a small city in the Midwest. Via interviews about their health, participants identified exercise and body image as connected primary health concerns in need of attention. There is a dearth of research about TYP’s health behaviors but research that does exist concludes we need to know more about the meaning of and motivation for exercise among trans people. A community-researcher collaborative team resulted in a project, at TYP’s request, that allowed TYP to talk openly about their health priorities. The team created an interview guide, and the first author conducted semi-structured one-hour interviews with 16 TYP. Example questions included: “When I say the word “healthy” what comes to your mind – what does a healthy TYP act like, look like, do?” “How are you healthy?” “If you could change any one of your health behaviors what would it be?” “What goals do you have for your health?” We used strategies of theme analysis to capture key patterns in health priorities according to participants. TYP were between the ages of 19-25 years old. Fourteen identified as White, one as Hispanic, and one as Black. TYP identified exercise and body image and the relationship between them as primary health concerns. They discussed these issues in terms of three themes, 1. Body shape as motivation for exercise; 2. Poor body image, stigma and fear as exercise barriers, and 3. Exercise or lack of, as destructive. In brief, participants wanted to exercise to achieve a body shape, not for health or as stress relief. They wanted more muscle, a “Dorito shape” and to minimize breasts and hips. Despite expressing a desire to exercise, they cited gyms as unwelcoming. They worried about stigma and discrimination, and did not feel sufficiently comfortable with their bodies to exercise. When they could not exercise, they resorted to harmful behaviors, like restricted eating, to achieve a traditional male shape. Many TYP also saw exercise as a potential substitute to medical transitioning with hormones or surgery. Using participatory methods allowed us to understand the priorities of a group of TYP in a small city. Our findings support that these issues are important and need to be addressed in future research and practice. It is important to continue to explore motivations for exercise and understand the balance between exercise as a positive coping mechanism and health behavior and a potentially harmful one for TYP. Although new research suggests that medical interventions can enhance trans people’s body image, this may not be an option for TYP in smaller cities. Findings also suggest that solutions are needed on multiple levels. Individually, TYP need support in body and self-acceptance. They also, however, need spaces to exercise free of discrimination and fear.