Transgender and Nonbinary Young Adult-Perceived Facilitators of Parental Consent for Gender-Affirming Medical Care as a Minor.

Sexual violence perpetrated by men against women remains pervasive, with over 25% of cisgender women in the U.S. experiencing an attempted or completed rape defined as unwanted vaginal, oral, or anal penetration through the use of physical force or threats of physical harm in their lifetime (). Further, approximately 23% report unwanted sexual penetration following non-physical threats or coercion (). Sexual violence against women including non-penetration sexual contact and sexual harassment (), is associated with adverse mental and physical health, as well as negative social and behavioral outcomes (). Sexual violence and HIV among cisgender women are widely considered a syndemic, or co-occurring and mutually reinforcing epidemics (). Pathways linking sexual violence to HIV susceptibility operate through behavioral and biological mechanisms shaped by trauma-related mental health sequelae (). Behaviorally, adverse mental health is associated with high-transmission sexual behaviors (e.g., condomless penetrative sex, multiple concurrent sexual partners) () and diminished self-efficacy to negotiate prevention (). Biologically, two complementary pathways are hypothesized (): (1) dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis which causes irregularities in acute and chronic stress responses and alters systemic and mucosal immune function, and (2) from forced penetration that disrupts epithelial integrity and initiates aberrant inflammation and impaired wound healing (). [] In the , chronic activation of the HPA axis and subsequent glucocorticoid resistance can drive immune dysregulation, reflected in both heightened pro-inflammatory signaling () and elements of immune suppression (; ). Depression has been linked to increased circulating interleukin (IL)-1β, IL-6, and C-Reactive Protein (CRP) levels (i.e., increased inflammation), and to functional alterations in T cells and natural killer cells (immune suppression) (). Further, longitudinal evidence suggests trauma, depression, and PTSD symptoms predict increased inflammation (e.g., CRP) over time (). Meta-analytic reviews similarly implicate PTSD in elevated pro-inflammatory cytokines (e.g., IL-6, IL- 1β, ΤNF-α and reduced anti-inflammatory signaling (e.g., IL-10) () (). In the context of intimate partner violence (IPV), increased CRP has been reported in women diagnosed with PTSD after IPV (). Importantly, inflammation may be both a consequence and a precursor of psychological distress, with emerging data documenting that reducing inflammation can improve mental health symptoms ().