Advancing Gender-Affirming Sexual Health Care: Primary Care Provider Training Gaps and Implications for Equity-Oriented Practice

Background and Purpose: Transgender and gender diverse (TGD) people experience persistent sexual health inequities, including disproportionate prevalence of HIV and other sexually transmitted infections (STIs), driven by structural stigma, cisnormativity, and inequitable health systems. Gender affirmation, defined as the recognition and support of a person’s gender identity, is a critical social determinant of health and a core principle of ethical, equity-oriented practice. Yet, access to gender-affirming sexual health care remains constrained by gaps in provider knowledge, training, and institutional support. Social work is uniquely positioned to advance gender-affirming care through its commitments to social justice, person-centered practice, and systems transformation. This study examines primary care providers’ (PCPs) practices, knowledge, and training gaps in delivering gender-affirming STI testing to inform multi-level interventions that promote equitable, affirming care for TGD communities.

Methods: We conducted a convergent parallel mixed-methods study with PCPs (physicians, nurse practitioners, physician assistants) in 2024–2025. Quantitative data were collected via an online cross-sectional survey (n=50) assessing sociodemographic and practice characteristics, prior TGD-related training, knowledge and use of STI testing guidelines, and self-reported clinical competence. Bivariable and multivariable regression analyses examined factors associated with self-reported clinical competence. Qualitative data were collected through semi-structured interviews (n=8) exploring how providers navigate sexual history taking, physical examinations, and guideline application in care with TGD patients. Qualitative data were analyzed using inductive content analysis and integrated with quantitative findings to generate a comprehensive understanding of provider-level and structural barriers to gender-affirming sexual health care.

Results: Nearly half of PCPs (46%) reported ≤5 hours of TGD-specific training, and fewer than half (48%) were aware of TGD-inclusive STI testing guidelines. In multivariable analyses, ≥6 hours of training (b=.96, p<.01) and greater clinical exposure to TGD patients (b=.81, p<.01) were significantly associated with higher self-reported competence. Providers identified key training needs, including gender-affirming sexual history taking, STI screening guidelines, gender-affirming hormone therapy, and trauma-informed approaches. Qualitative findings revealed how cisnormative assumptions shaped clinical decision-making, including selective use of inclusive language and reliance on gendered assumptions in testing practices. Providers described navigating fragmented or insufficient guidelines, particularly for preventive care (e.g., anal cancer screening), and often relied on self-directed learning or informal mentorship. Participants emphasized the need for accessible, case-based, and multimodal training, alongside organizational supports (e.g., clinical tools, decision aids) to operationalize gender-affirming care in routine practice.

Conclusions and Implications: Findings highlight how gaps in training, guideline clarity, and institutional infrastructure reproduce inequities in sexual health care for TGD populations. Advancing gender-affirming practice requires moving beyond individual-level competence toward systems-level transformation, including integration of gender-affirming sexual health into medical education, development of clear and inclusive clinical guidelines, and implementation of organizational supports that facilitate equitable care. Social work has a critical role in this transformation through interdisciplinary collaboration, advocacy, and implementation of trauma-informed, stigma-reducing, and intersectionality-informed interventions. This study contributes actionable evidence to support the development and scaling of gender-affirming health systems that promote dignity, access, and health equity for TGD communities.