Skip to content

STI Prevention & Sexual-Health Screening

STI risk and screening for trans-feminine bodies follows a logic distinct from cisgender screening protocols, particularly post-vaginoplasty. Neovaginal infections present atypically; routine cervical screening doesn't apply (no cervix); HIV epidemiology among trans women is meaningfully different from cis-population baselines; and many primary-care clinicians default to the wrong screening set. The skill on this page is knowing which screens you actually need, how to ask for them clearly, and when symptom presentations differ from what generic STI guidance describes.

This page covers screening logic, prevention (PrEP, DoxyPEP, barriers), infection-pattern differences, and when to escalate. For long-term sexual health monitoring see Long-Term Care → Sexual Health Long-Term. For finding an affirming PCP see Long-Term Care → Affirming Primary Care.

The shape of the problem

STI guidelines were written for cis bodies stratified by birth sex. Translating them to a trans-feminine patient — who may have a retained prostate, a urethra re-routed through a neovagina, surgical mucosa with no native lactobacillus flora, and a sexual-network exposure profile that resembles neither cis-female nor cis-male baselines — produces real diagnostic gaps. The screening question is not "which side of the binary do we apply?" but which orifices are exposed, which pathogens reach them, and which test windows remain valid.

The CDC 2021 STI Treatment Guidelines explicitly state that "transgender and gender diverse persons require a sexual-history-based, anatomy-driven approach rather than a sex-marker-driven approach." That principle frames the entire page.

Screening logic for trans-feminine bodies

vs cis-female protocols

  • No cervix. Conventional cervical Pap is irrelevant — no glandular/squamous junction biology exists in penile-inversion or peritoneal canals. See Cancer Screening → Neovaginal surveillance.
  • No native lactobacillus. Cis-vaginal flora is dominated by H₂O₂-producing lactobacilli; the neovagina (any technique) is colonized by skin, bowel, or oral flora and behaves more like a chronic surgical pocket. BV criteria (Amsel, Nugent) were derived against lactobacillus baselines and do not apply unmodified post-vaginoplasty.
  • HIV epidemiology is not cis-female. Trans-feminine HIV prevalence approximates that of high-risk MSM cohorts, not cis women — applying cis-female-baseline screening intervals undertests.
  • HPV vaccination logic carries over unchanged through age 45 (CDC recommendation).

vs cis-male protocols

  • Urethral exposure pattern differs post-vaginoplasty. The urethra is shortened and re-routed; receptive intercourse exposes it to pathogens via the neovaginal canal, not via penile insertion. Urethral GC/CT swab logic must follow the new geometry.
  • Anal exposure is more commonly receptive in trans-feminine sexual networks than in age-matched cis-male populations, per multiple US-based behavioral surveys (Reisner 2016; USTS 2015 / 2022).
  • Hepatitis B/C screening windows match general-population timing unless injection-drug or sex-work history changes the cadence.
  • Prostate retention matters for prostatitis differential, not for STI panel routing per se. See Cancer Screening → Prostate cancer.

Why "use the cis-male panel" or "use the cis-female panel" is wrong

The cis-male default omits neovaginal swabs entirely and may miss receptive oral/anal infections if the clinician doesn't ask. The cis-female default includes a Pap that has no biological substrate, omits the rectal/pharyngeal swabs needed for receptive partners, and applies BV diagnostic criteria that don't validate against neovaginal flora. Both defaults will miss infections. The correct approach is anatomy- and behavior-driven: enumerate exposed orifices, enumerate pathogens, swab each.

Anatomy-driven, not gender-driven

The default screening set is built from a sexual-history checklist, not a sex marker.

Exposure Sample needed
Receptive oral Pharyngeal NAAT (GC/CT)
Receptive anal Rectal NAAT (GC/CT) + visual exam
Receptive neovaginal Neovaginal swab (GC/CT) + culture
Insertive (any) Urethral NAAT or first-void urine
Any condomless partner HIV 4th-gen, syphilis, HBV/HCV
Symptoms (lesion, discharge) Site-directed culture/PCR

Site-specific swabbing

Oral / pharyngeal

Pharyngeal GC/CT NAAT. Frequently asymptomatic — the CDC 2021 guidelines estimate that more than 90% of pharyngeal gonorrhea is asymptomatic. The throat is a known reservoir for antimicrobial-resistant N. gonorrhoeae. Must be ordered explicitly — it is not included in a default urine NAAT.

Anal

Rectal GC/CT NAAT plus visual inspection for warts, fissures, ulcers. Anal Pap on a shared-decision basis in HIV-positive, multiple-partner, or symptomatic patients (UCSF Center of Excellence; ANCHOR trial 2022 supports treatment of high-grade AIN to reduce SCC incidence in HIV-positive adults ≥35).

Urethral (pre-surgery)

First-void urine NAAT (GC/CT) is preferred for asymptomatic screening; urethral swab if symptomatic or discharge present. Trichomonas NAAT on urine when indicated.

Neovaginal (post-vaginoplasty)

Direct swab of the neovaginal canal for GC/CT NAAT. Most NAAT platforms (Aptima, Xpert) are validated for vaginal swabs in cis women — neovaginal performance characteristics are extrapolated but considered acceptable in CDC 2021 and UCSF guidance. Culture is preferred for symptomatic discharge to capture mixed flora and antimicrobial sensitivity. Wet-mount microscopy is of limited value because the lactobacillus-versus-clue-cell heuristic doesn't apply.

For partnered context post-vaginoplasty see Partnered Sex Post-Vaginoplasty.

Why the routing matters

Urine NAAT alone is not a complete screen

A urine NAAT detects only urethral or — by extension in cis women — endocervical infection. It does not detect pharyngeal or rectal gonorrhea/chlamydia, which are the dominant sites in trans-feminine sexual networks with receptive oral or anal exposure.

The CDC 2021 STI Treatment Guidelines explicitly recommend extragenital NAAT at every exposed site regardless of sex marker. A clinician who orders "the STI panel" and stops at urine has missed the test that would have detected most gonorrhea or chlamydia in a receptive trans-feminine patient.

Practical bedside rule: if any oral or anal receptive exposure has occurred, pharyngeal and rectal NAAT must be ordered by site-specific name. Asking for "a full panel" is not enough — most lab requisitions default to urine.

How to ask the clinic

Concrete request language: "I'd like NAAT for gonorrhea and chlamydia at [pharyngeal / rectal / neovaginal / urethral] sites; HIV 4th-generation Ag/Ab; RPR; HBsAg, anti-HBs, anti-HCV." Patients should not have to explain biology to get correct routing — but in practice may need to. See Affirming Primary Care for clinician-finding strategies.

STI panels — what to actually request

HIV

  • 4th-generation Ag/Ab combination (HIV-1/2 antibody plus p24 antigen). Window period ~18 days. Standard of care per CDC.
  • 5th-generation tests (with HIV-1 RNA reflex) shorten the window further; not yet universal.
  • Rapid fingerstick antibody-only tests have a longer window and miss acute infection — acceptable for routine screening but not for post-incident evaluation.

Syphilis

  • RPR or VDRL (non-treponemal) for screening; reflex to treponemal-specific (TP-PA, FTA-ABS, EIA) for confirmation.
  • Or reverse-sequence: treponemal EIA first, RPR confirmation. Either pathway is CDC-acceptable.
  • Trans-feminine populations have elevated syphilis incidence in multiple US surveillance datasets — cadence should reflect that.

Gonorrhea / chlamydia by site

NAAT at every exposed site. Site-specific, not pooled. A negative urine NAAT does not exclude pharyngeal or rectal infection.

Trichomoniasis

NAAT (Aptima TV) preferred over wet mount; sensitivity ~95% vs ~50–60% for wet mount. Order on urine, vaginal swab, or neovaginal swab as appropriate. Often asymptomatic.

Hepatitis B and C

  • HBV: HBsAg, anti-HBs, anti-HBc at baseline. Vaccinate if non-immune.
  • HCV: anti-HCV antibody once for all adults ≥18 (USPSTF 2020), with reflex to HCV RNA if positive. Repeat if ongoing risk (injection drug use, sex with HIV-positive partner, sex work, multiple partners).

Herpes

  • Routine HSV serology is not recommended for asymptomatic patients (CDC 2021, USPSTF). High false-positive rate, no clear management benefit.
  • Symptomatic: PCR or viral culture of a lesion. Type-specific (HSV-1 vs HSV-2) matters for prognosis and partner counseling.

HPV

  • Trans women without a cervix do not need cervical cytology.
  • Anal HPV is the relevant concern, particularly in HIV-positive patients and those with receptive anal exposure. Anal Pap on a shared-decision basis.
  • HPV vaccination through age 45 (CDC catch-up guidance), regardless of prior exposure.
  • Genital condyloma in penile-inversion canals is documented; visible lesions warrant treatment.

Bacterial vaginosis equivalents post-vaginoplasty

Amsel and Nugent criteria don't validate post-vaginoplasty

Cis-vaginal BV diagnosis depends on a lactobacillus-dominant baseline being disrupted by anaerobic overgrowth. The neovagina (any technique) has no native lactobacillus, so the Amsel pH cutoff (>4.5), the clue-cell finding, and the Nugent Gram-stain score are not interpretable as designed.

Symptomatic mixed-flora discharge with foul odor, change in volume, or pH shift in a neovaginal canal warrants culture, not Amsel-based diagnosis. Empirical metronidazole 500 mg PO BID × 7 d is reasonable first-line for symptomatic mixed-flora overgrowth in penile-inversion canals; clindamycin cream is an alternative. Recurrent or refractory symptoms warrant ID or sex-medicine referral, particularly in peritoneal-pull-through or sigmoid neovaginas where flora differs further.

Screening cadence

The operational table. Cadence is anatomy- plus behavior-driven; cadence acceleration on PrEP is per CDC 2021 PrEP guidance.

Trigger Cadence
Baseline (new partner, new context) Full panel before/after onset
Average-risk, partnered Annual
On PrEP Quarterly (per CDC PrEP guide)
Multiple partners or anonymous partners Quarterly
Sex work or sex-with-MSM-partners patterns Quarterly
Post-incident (condom failure, assault) Day 0, week 2, week 6, month 3
Pre-procedure (vaginoplasty, FFS, biopsy) Within 30 d of OR
Symptomatic Immediately, site-directed

CDC PrEP guidelines mandate quarterly HIV testing on PrEP; STI panel quarterly is standard practice though guideline language varies. Pre-procedure timing matters because most surgical programs require a documented negative panel within 30 days of OR — see Partnered Sex Pre-Surgery for the partnered-context side of pre-op planning.

HIV epidemiology in trans-feminine populations

The asymmetry between trans-feminine HIV prevalence and the cis-population baselines that drive most clinical screening defaults is large and well documented. It justifies its own treatment.

Why baseline rates are higher

  • CDC surveillance (2019–2021 HIV among trans people report): HIV prevalence among trans women in jurisdictions reporting transgender data ~14%, vs ~0.4% in the US adult population.
  • Becasen et al. 2019 (AJPH) meta-analysis of 88 studies: laboratory-confirmed HIV prevalence in US trans women 14.1% (95% CI 8.7–22.2%); self-report ~9.2%. Trans men ~3.2%.
  • Drivers: structural marginalization, sex-work participation rates, partner-network density, condomless receptive anal/neovaginal intercourse, delayed PrEP uptake, healthcare avoidance.

Disparities

Axis Pattern Source
Race Lab HIV prevalence ~44% in Black trans women, ~26% in Hispanic/Latina, ~7% in White. CDC surveillance data align. Becasen 2019; CDC NHBS-Trans
Sex work USTS 2015 and 2022 both report high lifetime sex-work prevalence among Black/Latina cohorts USTS
Geography Southern US states (esp. GA, FL, TX, LA) drive bulk of incident diagnoses CDC Surveillance
Age at HIV Median diagnosis 25–34; younger than cis-female median CDC NHBS-Trans 2021

Why this matters for PrEP indication

Population-level prevalence above ~3% is generally cited as the threshold at which universal PrEP discussion is warranted. Trans-feminine baseline far exceeds that. Every trans-feminine patient with any sexual activity should have at least one PrEP conversation; many will be candidates regardless of specific behavioral risk. The CDC 2021 PrEP clinical practice guideline now recommends discussing PrEP with all sexually active adults and adolescents, which formalizes this floor.

USTS data and CDC report

  • US Transgender Survey 2015 (n=27,715) and 2022 (n=92,329) provide self-reported HIV prevalence and PrEP uptake; both consistently below laboratory-confirmed estimates because of underdiagnosis.
  • The CDC HIV Surveillance Special Report 27 (2021) — "HIV Infection, Risk, Prevention, and Testing Behaviors Among Transgender Women — National HIV Behavioral Surveillance, 7 U.S. Cities, 2019–2020" — is the closest to a current CDC behavioral baseline.

PrEP

Indication

Per the CDC 2021 PrEP clinical practice guideline: discuss with all sexually active adults; recommend for any patient with condomless sex with a partner of unknown or positive HIV status, recent bacterial STI, or PWID risk. For trans-feminine patients, the population-prevalence floor itself supports broad indication.

Daily oral

Regimen Brand Approved exposures Trial basis
TDF/FTC (300/200 mg) Truvada Cis women, cis men, trans men, trans women iPrEx OL, IPERGAY, PROUD
TAF/FTC (25/200 mg) Descovy MSM and trans-feminine receptive partners (not cis-vaginal-only) DISCOVER
  • TDF/FTC is the long-standing default; broadest approval, broadest evidence base, lowest cost (now generic).
  • TAF/FTC is approved for MSM and trans women with receptive oral/anal/neovaginal exposure; not approved for receptive vaginal exposure in cis women because of insufficient trial data. Trans-feminine patients with receptive neovaginal exposure are typically considered eligible by analogy to MSM data, though guidance varies.
  • TAF preferred when renal function or bone density is a concern; equivalent efficacy in MSM/trans-feminine populations per DISCOVER.

Long-acting injectable

  • Cabotegravir LA (brand Apretude). Bimonthly intramuscular injection after an oral lead-in. HPTN 083 (cisgender MSM and trans women, 2020) showed superiority over daily oral TDF/FTC for HIV prevention. Preferred for patients with adherence challenges; cost and access remain limiting.

HRT interactions

Clinical-pharmacokinetic literature shows minimal interaction between TDF/FTC, TAF/FTC, or cabotegravir LA and exogenous estradiol or spironolactone. Some early concern about estradiol lowering tenofovir drug levels in trans-feminine PrEP cohorts (Hiransuthikul 2019, J Int AIDS Soc) was not borne out as clinically significant when adherence was adequate. WPATH SOC v8 and the CDC PrEP guidelines explicitly state PrEP and HRT can be coadministered without dose adjustment.

Bone-density caveat: TDF causes a small reduction in BMD; estradiol is broadly bone-protective in trans-feminine patients. Net effect on long-term fracture risk is not established but likely neutral or favorable. TAF avoids the BMD signal entirely.

Cost and access

  • ACA covers PrEP as a preventive service (no copay) for the drug itself; lab and visit costs vary.
  • Ready, Set, PrEP (federal program, getyourprep.com) provides free medication for uninsured patients meeting criteria.
  • Manufacturer copay assistance: Gilead Advancing Access for TDF/FTC and TAF/FTC; ViiV for cabotegravir.
  • State AIDS Drug Assistance Programs (ADAP) cover PrEP in many states.

Where to get PrEP

Primary care, ID specialist, sexual-health clinic, Planned Parenthood, LGBTQ-focused community health centers, telehealth PrEP services. No specialty gating — any prescriber can initiate after baseline labs (HIV, renal, HBV, STI panel).

DoxyPEP

Recent evidence

Luetkemeyer et al. 2023 (NEJM; DoxyPEP trial) enrolled MSM and trans women on PrEP or living with HIV; 200 mg doxycycline within 72 h of condomless sex produced ~65% reduction in chlamydia, ~55% in gonorrhea, ~80% in syphilis. French and other follow-up studies confirm the syphilis and chlamydia effect; gonorrhea reduction varies with local tetracycline-resistance prevalence.

Indication and dosing

  • 200 mg doxycycline (typically two 100 mg caps) PO within 72 hours of condomless oral, anal, or vaginal/neovaginal sex.
  • CDC 2024 draft DoxyPEP guidance recommends offering DoxyPEP to MSM and trans women with bacterial STI in the prior 12 months.

Trans-femme inclusion in trial data

The Luetkemeyer trial enrolled trans women alongside MSM but the trans-feminine subgroup was small and not separately powered. Inference is by analogy. Subsequent observational cohorts (San Francisco, NYC) include trans-feminine participants but published subgroup-specific effect sizes are still emerging.

Effectiveness summary

Pathogen DoxyPEP reduction Notes
Syphilis ~70–80% Largest effect, durable
Chlamydia ~65% Consistent across sites
Gonorrhea ~55%, variable Lower where TetR is prevalent
Mycoplasma genitalium Possible benefit Resistance concern significant

When DoxyPEP is appropriate

  • High-risk partner pattern, recent bacterial STI, on PrEP, or multiple condomless exposures.

When it isn't

  • Very low exposure frequency (NNT becomes large).
  • Tetracycline allergy.
  • Concerns about antimicrobial-resistance selection — particularly doxycycline-resistant N. gonorrhoeae, S. aureus, and intestinal flora. Population-level resistance surveillance is ongoing.
  • Pregnancy (not clinically applicable here but flagged in CDC text).

Barrier methods

External condoms

Latex or polyisoprene preferred; polyurethane second-line. Effective barrier for insertive exposures and for performing oral on a partner with a penis. For lubricant compatibility see Sex Toys, Lubrication & Hygiene.

Internal condoms

Formerly "female condoms"; the FC2 device. Inserted into receptive vagina, neovagina, or anus. Useful for receptive trans-feminine partners because they enable barrier protection without requiring partner cooperation. Not ideal for the smaller-caliber neovaginal canal in some patients — fit should be checked.

Dental dams

Latex or polyurethane sheets for oral-vaginal/neovaginal/anal contact. Reduce oral exposure to GC/CT/HSV/HPV. Adoption is low in practice; cut-up condom or non-microwavable plastic wrap are commonly used substitutes.

Gloves

Nitrile or latex gloves for digital penetration reduce transmission of HSV, HPV, and bacterial pathogens, and reduce minor abrasions that increase HIV acquisition risk. Useful particularly with longer fingernails or in any context where mucosal trauma is plausible — and standard for impact-adjacent or fisting play, see Kink, BDSM & Aftercare.

When barriers are most useful

  • New partner before STI status is established.
  • Anonymous or transactional partners.
  • Partner with known untreated STI.
  • High-bleeding context (menstruation in partner, post-procedure, abrasion).
  • Pregnancy prevention is not relevant for most trans-feminine patients (azoospermia is typical on long-term GAHT) but is for those still producing sperm or considering fertility windows.

Post-vaginoplasty infection patterns

Distinct from cis-vaginal patterns

  • No native lactobacillus; flora is mixed skin (penile inversion), bowel (sigmoid), or peritoneal/oral (peritoneal pull-through) origin.
  • Hair follicles in incompletely depilated grafts are a common source of recurrent folliculitis and abscess.
  • Granulation tissue in the first 6–12 months can mimic infection.

Bacterial overgrowth

  • Most common post-vaginoplasty complaint is foul-smelling discharge; usually mixed anaerobic overgrowth.
  • Empirical metronidazole 500 mg PO BID × 7 d is reasonable first-line; clindamycin cream is alternative.
  • Recurrent or refractory cases: culture, ID consult, consider surgical evaluation for retained suture, fistula, or granulation tissue.

Yeast

  • Candida is less common in penile-inversion canals than in cis vaginas (lower glycogen substrate without estrogen-driven vaginal epithelium) but occurs, particularly post-antibiotic and in immunocompromised patients.
  • Diagnosis: KOH prep on swab; culture if recurrent.
  • Treatment: standard topical or oral azole therapy.

Normal vs not

Finding Normal?
Small seroserosanguinous discharge in first 6 weeks post-op Normal
Keratin debris ("smegma equivalent") in penile-inversion canal Normal
Small ongoing mucus production in peritoneal-pull-through canal Normal
Foul odor, change in color, frank pus Not
Blood beyond initial healing window, or with associated pain/fever Not
New deep pelvic pain outside expected dilation soreness Not
Pain with urination Not

Escalation

  • Surgeon: any concern related to anatomy, suture line, fistula, prolapse, stenosis.
  • PCP: routine STI workup, uncomplicated UTI, mixed-flora discharge.
  • ID: recurrent or resistant infection, suspected pelvic abscess, atypical organism.

Atypical presentation

Why STIs present differently

  • The re-routed urethra changes urethritis presentation; classic discharge may be intermittent or absent.
  • Neovaginal mucosa lacks the inflammatory response cis vaginal epithelium mounts; some infections smolder.
  • Rectal exposure dominates in many trans-feminine sexual networks but is the least symptomatic site for GC/CT.

Asymptomatic pharyngeal and rectal infection is the rule, not the exception

The most common patient (and clinician) failure mode is "I'd know if I had it." For pharyngeal and rectal gonorrhea/chlamydia, the data say otherwise:

  • Pharyngeal gonorrhea: >90% asymptomatic (CDC 2021)
  • Rectal gonorrhea/chlamydia: 70–85% asymptomatic (CDC 2021)
  • Neovaginal infection may smolder for weeks to months before symptom onset, longer than the days-to-weeks classic for cis-vaginal infection

The throat is also a major reservoir for antimicrobial-resistant N. gonorrhoeae; an undetected pharyngeal infection both transmits and breeds resistance. Default to test, not symptom triage. If exposure occurred at a site, that site needs a swab.

Pharyngeal gonorrhea

More than 90% asymptomatic. The throat reservoir is a major driver of antimicrobial-resistant gonorrhea spread. Test the pharyngeal site if any oral exposure occurred.

Anal infections

Rectal GC/CT is asymptomatic in 70–85% of infections (CDC 2021). Rectal chlamydia, including LGV serovars, can cause proctitis indistinguishable from IBD on initial presentation.

Neovaginal infection timeline

Symptoms may appear weeks to months after exposure rather than the days-to-weeks classic for cis-vaginal infection. Clinicians unfamiliar with this often discount the diagnostic relevance of older exposures.

"I'd know if I had it" is wrong

Site-specific and asymptomatic-infection data make this assumption obviously false but it remains common in both patients and clinicians. Default to test.

Communication with clinicians

Affirming-PCP screening conversations

Bring an explicit list: anatomy retained, surgery type, exposures, last full panel date. The Affirming Primary Care page covers clinician-finding strategy; this is the in-room script.

When the clinician runs the wrong panel

Most common failure mode: urine NAAT only, no extragenital sites. Request specific add-ons by name and site. Ask for the order to be reviewed before phlebotomy or swab collection. If the clinic refuses extragenital testing without justification, the request is supported by current CDC standard of care and a different clinician is the answer.

Asking for site-specific swabs

Patients should not need to justify a pharyngeal or rectal NAAT — current CDC guidance supports site-specific testing as standard. Concrete script: "Per CDC 2021 STI treatment guidelines, please order extragenital NAAT at [sites]." For ongoing relationship-side context (disclosure, partner notification) see Partnered Sex Pre-Surgery and Partnered Sex Post-Vaginoplasty.

When to escalate

Persistent symptoms

Discharge, dysuria, lesion, or pelvic pain unchanged after appropriate empirical therapy — culture, repeat NAAT, refer.

Symptoms after treatment

Test of cure for pharyngeal gonorrhea is recommended at 7–14 days (CDC 2021). Persistent symptoms warrant resistance testing and ID consult.

When to consult ID

Recurrent neovaginal infection, treatment failure, suspected drug-resistant gonorrhea, syphilis with neurologic or ocular signs, or acute HIV.

When to consult sex-medicine

Recurrent dyspareunia, chronic neovaginal pain, suspected pelvic-floor dysfunction layered on infection, or refractory recurrent BV-equivalents. See Sexual Health Long-Term for the non-infectious differential.

Sources

  • Centers for Disease Control and Prevention. "Sexually Transmitted Infections Treatment Guidelines, 2021." MMWR Recomm Rep. 2021;70(4):1–187. https://www.cdc.gov/std/treatment-guidelines/
  • Centers for Disease Control and Prevention. "Preexposure Prophylaxis for the Prevention of HIV Infection in the United States — 2021 Update: A Clinical Practice Guideline." 2021. https://www.cdc.gov/hiv/clinicians/prevention/prep.html
  • Centers for Disease Control and Prevention. "HIV Infection, Risk, Prevention, and Testing Behaviors Among Transgender Women — National HIV Behavioral Surveillance, 7 U.S. Cities, 2019–2020." HIV Surveillance Special Report 27, 2021. https://www.cdc.gov/hiv/library/reports/hiv-surveillance.html
  • Coleman E, Radix AE, Bouman WP, et al. "Standards of Care for the Health of Transgender and Gender Diverse People, Version 8" (WPATH SOC-8). Int J Transgend Health. 2022;23(sup1):S1–S259. https://www.wpath.org/soc8
  • Deutsch MB, ed. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People. UCSF Center of Excellence for Transgender Health, 2nd ed., 2016, with updates. https://transcare.ucsf.edu/guidelines
  • Reisner SL, Poteat T, Keatley J, et al. "Global health burden and needs of transgender populations: a review." Lancet. 2016;388(10042):412–436. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)00684-X/fulltext
  • Becasen JS, Denard CL, Mullins MM, Higa DH, Sipe TA. "Estimating the Prevalence of HIV and Sexual Behaviors Among the US Transgender Population: A Systematic Review and Meta-Analysis, 2006–2017." Am J Public Health. 2019;109(1):e1–e8. https://ajph.aphapublications.org/doi/10.2105/AJPH.2018.304727
  • Luetkemeyer AF, Donnell D, Dombrowski JC, et al. "Postexposure Doxycycline to Prevent Bacterial Sexually Transmitted Infections" (DoxyPEP). N Engl J Med. 2023;388:1296–1306. https://www.nejm.org/doi/full/10.1056/NEJMoa2211934
  • James SE, Herman JL, Rankin S, et al. The Report of the 2015 U.S. Transgender Survey. National Center for Transgender Equality, 2016. https://transequality.org/USTS
  • James SE, Herman JL, Durso LE, Heng-Lehtinen R. Early Insights: A Report of the 2022 U.S. Transgender Survey. National Center for Transgender Equality, 2024. https://transequality.org/USTS
  • Hiransuthikul A, Janamnuaysook R, Himmad K, et al. "Drug-drug interactions between feminizing hormone therapy and pre-exposure prophylaxis among transgender women." J Int AIDS Soc. 2019;22(7):e25338. https://onlinelibrary.wiley.com/doi/full/10.1002/jia2.25338
  • Klein A, et al. — trans-feminine sexual-health and surgical-mucosa case literature; cited where the cohort/case context is load-bearing rather than as a primary epidemiological source.