Youth who are assigned female at birth (AFAB) and identify as transgender (e.g., as non-binary or as trans boys), not as girls, are at risk for negative sexual health outcomes yet are effectively excluded from sexual health programs because gender-diverse youth do not experience the cisgender, heteronormative teen sexual education messaging available to them as salient or applicable. This lack of programming is likely contributing to obstacles to sexual health: Data suggest that AFAB trans-identified youth may be less likely to use condoms when having sex with people who have penises and are at least as likely as cisgender girls to be pregnant. This health inequity must be addressed. Access to inclusive sexual education, condoms, and sexual health support can vary widely across regions of the US, and within states for those living in rural versus urban settings. This is particularly true now that states have more influence on adolescents’ access to sexual health services and gender-affirming care. Our comprehensive sexual health program will be developed nationally for maximal impact. The foundation for this R01 proposal is our work with Girl2Girl, a text messaging-based sexual health program designed for cisgender sexual minority girls 14-18 years of age. In an RCT of 948 LGB+ girls, Girl2Girl was associated with higher rates of condom-protected penile-vaginal sex (f2=.11) and use of birth control other than condoms (f2=.13) at 12 months post-intervention. We propose to adapt Girl2Girl to address social and structural influences of sexual behavior of AFAB trans-identified youth, including significant social stressors, discrimination, dysphoria and rejection. In so doing, this proposal addresses the National Institute of Nursing Research’s (NINR) research lens on HEALTH EQUITY. It also speaks to NINR’s research lens on PREVENTION AND HEALTH PROMOTION across the prevention continuum by including both sexually experienced and inexperienced youth. Specifically, we aim to: Specific Aim 1: With ongoing feedback from trans-identified youth assigned female at birth, adapt Girl2Girl for gender inclusivity to create #TranscendentHealth. First, we will conduct focus groups (n=80) to identify and give voice to the contexts that affect sexual decision making of AFAB trans-identified youth. After adapting the content, we will conduct Content Advisory Teams (CATs; n=50) to ensure that program content resonates with these youth. Finally, we will conduct a beta test (n=22) to confirm the protocol. Specific Aim 2: Test the resulting adaptation in a national RCT of 700 trans-identified AFAB youth 14-18 years of age. Our main outcome measures will be: 1) Rates of condom-protected sex, 2) use of other types of birth control methods (e.g., the shot, IUDs) other than condoms, 3) HIV/STI testing, and 4) PreP uptake for those for whom it is indicated. Secondary measures also will include pregnancy, and intentions to: 1) use condoms, 2) uptake other birth control methods, 3) test for STIs and 4) uptake PrEP.

Youth who are assigned female at birth (AFAB) and identify as transgender (e.g., as non-binary or as trans boys), not as girls, are at risk for negative sexual health outcomes yet are effectively excluded from sexual health programs because gender-diverse youth do not experience the cisgender, heteronormative teen sexual education messaging available to them as salient or applicable. This lack of programming is likely contributing to obstacles to sexual health: Data suggest that AFAB trans-identified youth may be less likely to use condoms when having sex with people who have penises and are at least as likely as cisgender girls to be pregnant. #TranscendentHealth aims to address this health inequity.