Non-binary Research Articles

Mobility of non-binary and gender nonconforming individuals: A systematic literature review

The gendered nature of travel behaviours and experiences have long been recognised in research and policy making. However, research on non-binary people and their mobility is scarce, as is the acknowledgement of a spectrum nature of gender within the transportation discipline. This paper presents the first systematic literature review, using PRISMA guidelines, of the mobility and travel experiences of non-binary people. The review identified that to date the main research domains for non-binary people's mobility considered issues of harassment and violence on public transit, fear, security measures, intersectionality, and strategies to deal with discrimination. The paper highlights spatial and geographical constraints, such as immobility and inaccessibility, that non-binary people face when interacting with public transportation system. Strategies to improve mobility for the gender nonconforming community included upgrading public transport stations, increasing funding for public transportation, and providing gender diversity training for transit workers. The findings draw attention to the need for substantial further transportation research into the field. By including non-binary perspectives in transport research, a unique range of insights and experiences can be unlocked, while increasing inclusivity in transport research.

Technology-Based Interventions, with a Stepped Care Approach, for Reducing Sexual Risk Behaviors and Increasing PrEP Initiation Among Transgender and Gender Expansive Youth and Young Adults

Technology-Based Interventions, with a Stepped Care Approach, for Reducing Sexual Risk Behaviors and Increasing PrEP Initiation Among Transgender and Gender Expansive Youth and Young Adults

The Synergistic Health Threats of State Laws Targeting Marginalized Groups in the United States.

Discriminatory state laws have deleterious effects on the health of socially marginalized groups. Health care clinicians, institutions, researchers, and research funders have tended to view different discriminatory laws in isolation, focusing on particular issues or groups. In contrast, intersectionality calls attention to the overlapping and synergistic systems of oppression that discriminatory legislation promotes or upholds, warranting an integrated analysis of these laws. In this analytic essay, we assess discriminatory state laws simultaneously and discuss their implications for health care clinicians, institutions, and researchers. We present a multifunctional model of law and population health that describes how discriminatory law affects health outcomes among marginalized groups. We then draw on publicly available legislation trackers to identify 30 states that have enacted legislation since 2020 that targets Black people and other people of color; lesbian, gay, bisexual, and queer people; transgender and nonbinary people; and women and other birthing people. Finally, we call for a coordinated, multilateral, and forceful effort by health care professionals, institutions, researchers, and research funders to counter these laws and address their predictable health consequences. (Am J Public Health. 2024;114(12):1335-1343. https://doi.org/10.2105/AJPH.2024.307830).

Queer Bunny: Gender, Nostalgia, and Coloniality in Bad Bunny’s X100PRE

This paper reads Bad Bunny’s gender performance as queer in his album X100PRE. Utilising methodology proposed by Juana María Rodríguez, we focus on “queer gestures” rather than “categories of identification” to argue that Bad Bunny experiments with a markedly queer gender fluidity. We first explore the queer affect of nostalgia in the song “Como antes” and Bad Bunny’s Instagram posts, then investigate the role of fashion in the “¿Quién tú eres?” video, using Umberto Eco’s approach to clothing as a code that communicates gender, power, and social distinction. Finally, we examine how Bad Bunny’s gender performance challenges normative masculinity in the United States from the perspective of a racialised, colonised Puerto Rican subject. This analysis reveals how gender fluidity has permeated the genre of reggaetón, traditionally linked to hypermasculinity.

"They're not my daughter, and yet…they're also not my son": Parents negotiating their adult child's nonbinary gender identity.

Scholars are increasingly recognizing that substantial gender heterogeneity exists among transgender populations; that is, gender identities that defy the ubiquitous binary categories of male and female. However, the developing research base on the families of transgender adults focuses almost exclusively on the family members of transgender persons with binary gender identities, a noteworthy shortcoming considering the prevalence of nonbinary gender identities among transgender populations and the pervasive assumption that only two genders exist. To address this gap, the current study sought to uncover how the parents of transgender adults with nonbinary gender identities come to understand, make sense of, and negotiate nonbinary gender identities in their families. Fourteen parents-12 mothers and 2 fathers-completed in-depth, semi-structured interviews, and the collected data were analyzed using reflexive thematic analysis. Analyses generated three broad themes that best-described these parents' experience with their child's gender, which was heavily shaped by the pervasiveness of cisnormativity: (a) varied attempts to understand nonbinary gender; (b) a nonbinary "double-edged sword"; and (c) familial resilience. Directions for future research, clinical practice, and policy change are discussed, including the therapeutic benefit of dialectical thinking and the need for legislation that legally affirms and protects nonbinary persons.

Affect, gendered embodiment and sexual harassment

Sexual harassment is an affective, embodied and relational issue with distinctly gendered consequences for those who experience it. Despite a vast literature illuminating the gendered dynamics of sexual harassment, detailed analyses of the affective dimensions of such dynamics are scarce. This article analyses young women’s and nonbinary people’s experiences of sexual harassment from the perspective of affective embodiment. The analysis draws on Sara Ahmed’s theorisation on embodied hurts, orientations and emotions to trace relational, embodied and affective processes of gendering linked with sexual harassment. The analysis identifies two harassment-related embodied processes: embodied regulation and embodied resistance. Whereas embodied regulation takes the form of feminisation – a process that renders bodies vulnerable – embodied resistance includes a variety of orientations labelled here as preparedness, defeminisation and embodied critique. Thus, the analysis suggests that bodies may respond to sexual harassment in varied ways, and even though harassment contributes to the constant shaping of bodies, it does not determine them.

Associations between misgendering, invalidation, pride, community connectedness, and trauma among nonbinary adults.

Transgender and nonbinary (TNB) people experience elevated rates of posttraumatic stress (PTS) due to transphobic violence, discrimination, microaggressions, and minority stress. Nonbinary people in particular experience unique chronic minority stressors (e.g., misgendering, interpersonal invalidation) because of the assumption that gender is inherently binary. Such examples of oppression against TNB people could contribute to complex PTS (c-PTS) symptoms, which arise due to exposure to chronic, cumulative, and interpersonal trauma. This study aimed to examine how misgendering and invalidation may be associated with PTS and c-PTS symptoms among nonbinary people and whether this association is moderated by pride and community connectedness. Cross-sectional data from 610 nonbinary people living in the United States and Canada were analyzed using hierarchical linear regressions. Misgendering and invalidation had significant positive associations with PTS and c-PTS symptoms. However, pride and community connectedness were not significant moderators of these associations. Findings from this study contribute to the conceptualizations of traumatic stress among nonbinary people and provide considerations for more affirming trauma-informed care. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Unacceptable Experiences Whilst Attending University and Their Association With Student Mental Health, Well-Being and Academic Outcomes

Introduction: Unacceptable experiences (UEs) are commonly reported by undergraduate students. However, their prevalence and impact have not been rigorously studied. Objectives: To (1) estimate the prevalence of UEs, (2) identify high-risk subgroups, and (3) examine associations with mental health and academic outcomes among undergraduate students attending Queen's University. Methods: Data from the 2021/2022-2023/2024 cycles of the U-Flourish Student Well-Being Survey were collected at the beginning and completion of each academic year. Validated symptom measures included the GAD-7 (anxiety), PHQ-9 (depression), C-SSRS (suicidal thoughts and behaviours), and WEMWBS-7 (well-being). Self-reported UEs included: sexual violence or harassment, physical assault, bullying, hate crimes, and discrimination. Multivariable regression examined associations between UEs and student mental health, and grade-point average (GPA) from linked university data. Results: One-third (28.9%) of students (n=797/2,757) reported an unacceptable experience over the academic year. Sexual violence or harassment and discrimination (15%) were most frequently reported, followed by bullying/harassment (11%), hate crimes (4.6%) and physical assault (3.3%). UEs were highest in students who identified as non-binary gender (49%), 2SLGBTQIA+ sexuality (39%) or had a history of mental illness (41%). These UEs increased the risk of reporting clinically significant anxiety and depressive symptoms by 5-18% and 11-40%, respectively, and Students reporting UEs were also more likely (2-59%) to report having suicidal thoughts and behaviours over the academic year, particularly those who experienced sexual violence (RR:1.59; 95% CI:1.10-2.23). There was evidence that sexual violence, bullying, and hate crimes were associated with lower GPAs among first-year students. Conclusion: UEs are common among undergraduate students and are associated with significant negative mental health and well-being outcomes. Further research is needed to better understand the nature of these UEs and the mechanisms by which they impact student mental health and academic performance. This information is pivotal to develop evidence-informed prevention and early intervention initiatives.

Gender and Race/Ethnicity dynamics in anesthesiology mentorship: results of a European survey

BackgroundMentorship is crucial to career advancement, medical education, and psychosocial support, especially for women and minorities. Although anesthesia mentoring programs have shown promise, there are no survey data regarding mentor-mentee relationship dynamics. This study aimed to explore the dynamics of the anesthesia mentor/mentee relationship.MethodsA open cross-sectional web-based survey was distributed by the European Society of Anesthesiology and Intensive Care and European Society of Regional Anesthesia to European anesthesiologists. Participation was anonymous and consent was obtained. The study evaluated responses relating to preferences, facilitators, and barriers to mentorship relationships along with sociodemographic information.ResultsIn total, 543 anesthesiologists responded to the survey, and 406 (111 mentees, 49 mentors, 193 both, 53 neither) responded to questions regarding mentorship. 184 anesthesiologists identified as woman and 22 as other genders (non-binary, transgender, gender-fluid, and self-described gender). Moreover, 250 anesthesiologists identified as white. Both mentors and mentees indicated that personal compatibility was the most important factor for successful mentorship. Barriers to mentorship included time consumption and perceived lack of interest from the mentor and mentee. Both mentors and mentees benefited from this relationship. The former reported feeling helpful, and the latter supported the development of clinical skills. The mentors indicated that their participation was important for protecting against burnout/exhaustion and impostor syndrome. Participants reported a preference for mentorship programs organized at the departmental level, offered at the start of the anesthesiology education curricula. Women were more likely to feel a ‘lack of interest’ in mentoring them as a barrier (OR = 2.49, P = 0.033). Gender was a barrier for mentors of other genders (OR = 23.9, P = 0.0027) and ethnicity (OR = 48.0, P = 0.0023). White mentees found gender (OR = 0.14, P = 0.021) and ethnicity (OR = 0.11, P = 0.048) to be less important barriers to successful mentorship relationship.ConclusionWhen possible, programs should prioritize matching mentors and mentees based on personal compatibility and experience in the mentee’s area of interest. Addressing the perceived lack of interest in mentoring is essential for promoting diversity, equality, and inclusion within anesthesiology, as well as and uplifting women and minorities.Trial registrationClinicaltrials.gov identifier: NCT05968339, First posted (01/08/2023).

Non-Binary Identity Development: A Retrospective Exploration of Family Support

There is growing awareness of transgender and gender non-conforming individuals; people whose gender identity and expression are different from what is typically expected, including non-binary gender identity. Despite this increased attention, trans and non-binary youth are most at risk for negative outcomes, such as psychological distress and suicidal ideation. This, coupled with the fact that the limited studies of family acceptance of trans youth are focused primarily on binary trans youth, illustrates the need for increased understanding of family acceptance of non-binary identity, specifically. Accordingly, this phenomenology depicts the lived experience of family support for a non-binary identity. In this retrospective analysis, 336 self-identifying non-binary participants responded to open-ended questions about family support of their gender identity. Three categories of themes emerged across participant responses: 1) gendered messages, 2) explicit support, and 3) arrested development. These findings highlight the importance of increasing visibility and understanding of non-binary identity in both the family and the scholarly literature. Implications for parents, researchers, practitioners, and policymakers are discussed.

Contextualising Experiences of Co-Occurring Mental Ill-Health and Substance Use Among Trans, Non-Binary, and Gender Diverse Young People: Implications for Tailored Harm Reduction Approaches.

Though significant research highlights higher rates of mental ill-health and substance use among trans, non-binary and gender diverse (henceforth 'trans') young people, little research has considered patterns, contextual characteristics, and correlates of co-occurring experiences of mental ill-health and substance use among trans young people. Using data from the Trans Pathways study, we used prevalence ratios and age- and gender-adjusted logistic regression models to examine prevalence and differences of co-occurring substance use (past six-month cigarette use, alcohol use, and other drug use) and contextual characteristics of substance use (past six-month solitary alcohol and/or drug use, substance use for coping) by mental ill-health (depression disorder, anxiety disorder, past 12-month self-harm thoughtsand behaviours,suicidal thoughts, planning, and attempt/s). Age- and gender-adjusted models assessed associations between co-occurring depressive and anxiety disorders and recent cigarette, alcohol, and other drug use (six co-occurring items total) and 18 interpersonal stressors. Significantly increased odds of smoking or recentuse of cannabis or sedatives was observed among trans young people reporting depressive disorder, anxiety disorder (aORs ranging 1.8-3.1). Trans young people who reported recent smoking or use of cannabis, inhalants, or sedatives, had 40% to 80% reduced odds of past 12-month self-harm thoughts, self-harm behaviours,suicidal thoughts, and suicide attempt/s (aORs ranging 0.2-0.6). On the other hand, solitary alcohol and/or other drug use and substance use for coping was significantly associated with increased odds of all mental ill-health outcomes. Issues with school, secure housing, and intimate partner abuse were themost robust correlates of co-occurring mental ill-health and substance use. Trans young people using substances, especially cigarettes, cannabis, and sedatives, often so do with co-occurring experiences of depression and anxiety though limited substance use in more 'social' contexts may confer benefits for preventingself-harm and suicide thoughts and behaviours. Continued research in partnership with trans young people is warranted to conceptualise more nuanced and precise conceptualparameters of trans-affirming substance useharm reduction approaches.

Similarities and differences in the functions of non-suicidal self-injury (NSSI) across gender non-conforming and cisgender young adults

BackgroundNon-suicidal self-injury (NSSI) can be motivated by a broad range of functions and many individuals report multiple reasons for self-injuring. Most NSSI research has involved predominantly female samples and few studies have examined gender similarities and differences in function endorsement. MethodsWe characterise the prevalence and versatility of NSSI functions within a gender-diverse online sample of cisgender women (cis-women; n = 280), cisgender men (cis-men; n = 176), and transgender, non-binary, and other gender non-conforming young adults (TGNC; n = 80) age 18–30 (M = 23.73, SD = 3.55). The Ottawa Self-Injury Inventory (OSI-F) assessed 24 intrapersonal and social functions across nine domains: affect regulation, self-punishment, anti-dissociation, anti-suicide, sensation seeking, sexuality, interpersonal influence, and body image. ResultsTGNC participants and cis-women were significantly more likely to report intrapersonally motivated NSSI and greater function versatility than cis-men. Low mood, emotional distress, suicidality, and trauma symptomology appeared to contribute to gender differences in function endorsement. Gender similarities also emerged; across groups, intrapersonal functions were substantially more common than social functions, and the most endorsed domains were affect regulation and self-punishment. No domains were gender specific. LimitationsThe OSI-F was developed from majority female samples and may not adequately capture the experiences of other gender groups. ConclusionsInterventions which reduce distress and strengthen emotion regulation are likely to benefit individuals who self-injure regardless of gender. However, most individuals report multiple NSSI functions and person-centred interventions which address this complexity are needed. Future research should develop gender-informed treatment models which consider the unique experiences of TGNC individuals and cis-men who self-injure.

Disabled people negotiate gender, sexual identity and self-directed social care support in England: how does choice and control operate?

Putting disabled people in charge of their own support was a central component of the UK personalisation agenda. Austerity, staff recruitment difficulties and local authority retrenchment have meant that the experience for disabled people has not always lived up to the rhetorical promise. In this context, disabled people with marginalised sexual and/or gender identities face difficult choices in everyday interactions of support that trouble the idea that control routinely sits with them. In this article, we draw on two research studies with disabled people who use self-directed support in which they discuss navigating gender and sexual identity. In both studies, there are opportunities for disabled people to draw on support that is empowering, but we also hear about ‘bad bargains’ that they are sometimes forced to make. We argue that the hard-won goals of choice and control are being degraded and confronting LGBTQI+ and non-binary disabled people with sometimes impossible dilemmas.

Prioritizing Patient Perspectives: Cardiovascular Health of Transgender and Nonbinary People.

Prioritizing Patient Perspectives: Cardiovascular Health of Transgender and Nonbinary People.

The Effect of Systemic Racism and Homophobia on Police Enforcement and Sexual and Emotional Violence among Sex Workers in East London: Findings from a Cohort Study

There is extensive qualitative evidence of violence and enforcement impacting sex workers who are ethnically or racially minoritized, and gender or sexual minority sex workers, but there is little quantitative evidence. Baseline and follow-up data were collected among 288 sex workers of diverse genders (cis/transgender women and men and non-binary people) in London (2018–2019). Interviewer-administered and self-completed questionnaires included reports of rape, emotional violence, and (un)lawful police encounters. We used generalized estimating equation models (Stata vs 16.1) to measure associations between (i) ethnic/racial identity (Black, Asian, mixed or multiple vs White) and recent (6 months) or past police enforcement and (ii) ethnic/racial and sexual identity (lesbian, gay or bisexual (LGB) vs. heterosexual) with recent rape and emotional violence (there was insufficient data to examine the association with transgender/non-binary identities). Ethnically/racially minoritized sex workers (26.4%) reported more police encounters partly due to increased representation in street settings (51.4% vs 30.7% off-street, p = 0.002). After accounting for street setting, ethnically/racially minoritized sex workers had higher odds of recent arrest (adjusted odds ratio 2.8, 95% CI 1.3–5.8), past imprisonment (aOR 2.3, 95% CI 1.1–5.0), police extortion (aOR 3.3, 95% CI 1.4–7.8), and rape (aOR 3.6, 95% CI 1.1–11.5). LGB-identifying sex workers (55.4%) were more vulnerable to rape (aOR 2.4, 95% CI 1.1–5.2) and emotional violence. Sex workers identifying as ethnically/racially minoritized (aOR 2.1, 95% CI 1.0–4.5), LGB (aOR 2.0, 95% CI 1.0–4.0), or who use drugs (aOR 2.0, 95% CI 1.1–3.8) were more likely to have experienced emotional violence than white-identifying, heterosexual or those who did not use drugs. Experience of any recent police enforcement was associated with increased odds of rape (aOR 3.6, 95% CI 1.3–8.4) and emotional violence (aOR 4.9, 95% CI 1.8–13.0). Findings show how police enforcement disproportionately targets ethnically/racially minoritized sex workers and contributes to increased risk of rape and emotional violence, which is elevated among sexual and ethnically/racially minoritized workers.

Centering the margins: Reimagining resilience and resistance for transgender and nonbinary people of color

AbstractBy centering the margins through intersectional and cross‐cultural perspectives, this article offers a reimagining of resilience by exploring individual versus collective (i.e., group‐level) approaches and strategies adopted by transgender and nonbinary people of color (TPOC) to resist oppression. We address the dynamics of multiple group membership and recognize the profound effects of culture on how TPOC communities navigate resilience and resistance. Utilizing an international perspective, we examine risk and resilience by considering proximal and distal minority stressors such as discrimination and internalized stigma. We also address the utility of current models used to address TPOC resilience (i.e., minority stress and resilience theory, transgender resilience intervention model). Finally, we address tensions associated with the characterization of resilience and resistance for TPOC within the social sciences and across cultures. This article thus serves as a critical foundation for reimagining research with TPOC by presenting potential avenues for further research, theory, and community action globally.

Social-ecological barriers and facilitators to seeking inpatient psychiatric care among transgender and nonbinary people: A qualitative descriptive study.

To assess barriers and facilitators to seeking inpatient psychiatric treatment among transgender and nonbinary people. Qualitative interview study. Semi-structured interviews were conducted from March 2019 to June 2022 with transgender and nonbinary people admitted to an inpatient psychiatric hospital in the United States during the past 5 years. Data were analysed using thematic analysis and constructed within a modified social-ecological model of stigma. Standards for Reporting Qualitative Research were used for this study. Participants (N = 15) described barriers and facilitators across all three social-ecological levels. i) Individual themes included distrust of the mental healthcare system, feeling unsafe, loss of autonomy, minimizing one's own mental health needs, and feelings of accountability to others. ii) Interpersonal themes included: lack of support for transgender/nonbinary identity, limited transgender/nonbinary knowledge among mental healthcare professionals, and allyship. iii) Structural themes included: carceral setting, financial costs, and availability of non-profit treatment options. Multi-level themes were identified as barriers and facilitators to seeking inpatient psychiatric care for transgender and nonbinary people, providing opportunities among inpatient settings to improve care delivery and engagement. Greater health equity can be achieved by addressing barriers to care. Incorporating inclusive and affirming practices in inpatient psychiatric services presents an opportunity to reduce barriers to seeking care. The present study describes the experiences of transgender and nonbinary people as they determine whether to voluntarily seek inpatient psychiatric treatment. This perspective allows nurses, health systems, and policymakers to integrate transgender and nonbinary people's needs to improve healthcare delivery. Transgender and nonbinary participants were recruited in collaboration with community organizations. Members of the transgender and nonbinary community participated in study design development and analysis and were part of the study team.

He/She/They - gender inclusivity in developing and using health-related questionnaires: a scoping review.

To ensure the recognition and participation of all potential respondents in health research, surveys and care, including LGBTQIA + broadly, and trans people, specifically, the use of inclusive language should be considered. This scoping review aimed to identify and describe strategies considered for gender inclusivity in development and use of health questionnaires and Patient Reported Outcomes Measures (PROMs). A systematic search of peer reviewed publications between January 2000 and September 2022 was conducted in Scopus, ProQuest Central, Ovid Medline (PubMed and EBSCO). Two reviewers independently screened identified publications titles and abstracts, followed by full text screening and data extraction from eligible articles. The search of over 5000 publications, retained 18; most acknowledged gaps in representation and advocated for gender-inclusive language. Eight articles discussed exclusion from health care and health research for gender minority groups due to the use of gendered language. Improved reliability, validity and response rates were associated with the use of gender-neutral language in seven articles. Only one article reported finding irritation among cisgender males when non-binary gender response options were used. One paper, focussing on instruments for Rheumatoid Arthritis, discussed gaps in representation if diverse gender identities were not considered when developing PROMs. This scoping review points to the importance of adopting gender-inclusive language in health questionnaires and surveys to reduce the risk of excluding gender minority groups. Despite finding very few specific examples of how others have used gender-inclusive language in health questionnaires, many strengths of gender-inclusive language usage were identified.

Ömer Seyfettin’s Short Story “The Rainbow”: A Precursor of Transgender Narratives

Ömer Seyfettin, the founder of the modern Turkish short story and a widely read literary figure, published “The Rainbow” (“Eleğimsağma”) in 1917 in a magazine. The story revolves around a ten-year-old girl, Ayşe, and her gender transformation as part of a struggle against masculine hegemony and suppression. Although this transformation takes place through the protagonist’s dream, Seyfettin successfully showcases how gender roles and stereotypes become central in building respectful, acceptable, and powerful personas in society. The story also helps to question the so-called domestic roles of women by juxtaposing the responsibilities of the two genders based on existing cultural norms. To this end, this study aims to investigate how established gender roles in a patriarchal society are called into question and how gender fluidity defies stereotypical understanding of gender representation in a male-dominated society. The analysis of this gender transformation in the story will be made through the concept of performativity which has been introduced by Judith Butler. Though biologically female, Ayşe enjoys activities such as riding, wrestling, shooting, and playing in the streets, which are almost always associated with the male gender. Furthermore, she is subjugated to societal and religious pressure to act like a girl and cover her body. In this respect, Ömer Seyfettin’s “The Rainbow” can be hailed as a leading narration that puts gender performativity in the limelight at the beginning of twentieth-century Turkish literature.

How does online postal self-sampling (OPSS) shape access to testing for sexually transmitted infections (STIs)? A qualitative study of service users

BackgroundSexually transmitted infections (STIs) are a serious public health issue in many countries. Online postal self-sampling (OPSS) is increasingly used to test for STIs, a trend accelerated by the COVID-19 pandemic. There remains limited understanding of how service users experience OPSS and what leads them to access it over clinic-based services, or vice versa. This research seeks to address these gaps, by undertaking a large qualitative study which sits within the ASSIST study, a mixed-methods, realist evaluation of OPSS.MethodsParticipants were recruited via clinic-based and online sexual health services in three case study areas in England. Purposive sampling was used to over-represent populations disproportionately affected by poor sexual health: young people; people of colour; men who have sex with men; and trans and non-binary people. Semi-structured interviews were analysed using Levesque’s conceptual framework of access to healthcare.ResultsWe interviewed 100 service users. Participants typically became aware of OPSS from sexual health services, the internet or word of mouth. Acceptability of OPSS was facilitated by the perceived privacy it offered over clinic-based services, which some participants found embarrassing to access. OPSS also enabled participants to overcome barriers to reaching clinic-based services, such as a lack of appointment availability, although difficulty obtaining OPSS kits in some areas undermined this. As all services in our case study areas were free to use, affordability did not significantly shape access, although OPSS enabled some participants to avoid costs associated with travelling to clinic-based services. Participants were usually able to engage with OPSS, finding it easy to use and reliable, although blood self-sampling was challenging for most. Participants valued the support offered by clinic-based services beyond STI testing, including the opportunity to access contraception or ask staff questions, and felt this was more appropriate when they had specific concerns about their sexual health, such as STI symptoms.ConclusionsOur findings constitute one of the largest qualitative studies to have explored OPSS and offer valuable insights to providers. OPSS shapes access to STI testing in a number of ways, including facilitating access in many circumstances, but users also want to retain access to clinic-based services, particularly for when they believe they need support beyond STI testing.