This implementation study assessed provider and patient acceptability of rectal self-collection and feasibility of offering self-collection during a medical visit. We found that incorporating self-collection for rectal chlamydia and gonorrhea screening among MSM and transgender women was effective, efficient, highly acceptable, and preferred by patients and clinicians. Our findings are in line with other studies indicating that patients prefer self-collection [17,18] and provide additional insight into how to integrate self-collection into routine primary care at a large FQHC serving the general population. Self-collection in FQHCs, which care for patients in the healthcare safety-net, many of whom are racial and ethnic minorities who are disproportionately affected by STIs relative to non-Hispanic white patients,  is a potential strategy to overcome access barriers.
Neglecting extra-genital testing in MSM and transgender women leads to missed diagnoses and can contribute to persistent disparities in STIs among sexual and gender minorities. Rectal mucosa is vulnerable to STIs and symptomatic or asymptomatic extra-genital chlamydia and gonorrhea infections are associated with increased risk of HIV transmission among MSM. [7,13,21] Identifying rectal infections, especially those without symptoms, provides an opportunity to discuss HIV risk and offer prevention strategies, such as HIV pre-exposure prophylaxis (PrEP). Since MSM and transgender women, especially those of color, may not have access to LGBT-focused health centers and are the most vulnerable to acquiring HIV, offering rectal self-collection in FQHCs may be the first critical step to STI and HIV prevention. [1,13]
The Centers for Disease Control and Prevention’s Recommendations for Providing Quality Sexually Transmitted Disease Clinical Services (2020) note that STIs are increasingly treated in primary care  and recommend that basic STI services should be made available in these settings. However, primary care community health centers, including FQHCs, have only recently (January 2018) been required to collect SOGI data , and often do not conduct risk-based sexual health screening.  Though our pilot study demonstrates the feasibility of offering rectal STI screening during a primary care visit, further studies are needed to determine how primary care clinics can increase their capacity to offer comprehensive STI clinical services including sexual risk assessment, risk reduction counseling, and partner-services, which are commonly available in specialty STI clinics. 
Nevertheless, continued emphasis on SOGI data collection in primary care health centers is critical. SOGI information must be recorded in the electronic health record in a systematic manner that allows for effective patient-level use by clinical teams and organization-level use for population health. The majority of our sample (n=1191, 88.6%) had SOGI data on file. We found that 7.3% (n=87) of these patients self-identified as MSM or transgender female, which exceeds the estimated percentage of U.S. adults who self-report any sexual and gender minority identity (4.5%).  This illustrates the crucial role that FQHCs can play in tackling the STI burden that many members of sexual and gender minority populations carry, and which fuels the STI epidemic.
Clinical dashboards using SOGI data can thus identify patients with potential risks for STIs and consequently trigger any member of the clinical team to offer rectal self-collection, standardize and normalize STI screening, and provide opportunities to offer PrEP and maximize HIV prevention efforts. As this study demonstrated, MAs were able to facilitate patient rectal self-collection. Since nurses and MAs are already able to collect pharyngeal and urine specimens, rectal self-collection can shift the burden of STI testing from PCPs to clinical support staff by extending capability for MAs to assist with screening and for nurses to conduct comprehensive assessment and screening under standing orders from a PCP.
Limitations of our findings include a small sample size concentrated in a primary care FQHC which may affect generalizability and lack of a clinician-collection comparison group. Future studies should draw conclusions about the amount of time saved through specimen self-collection and whether it presents significant additional workload for non-PCP members of the primary care team. The FQHC where this study was conducted began routinely collecting SOGI in 2016, which helped provide PCPs with the information necessary to identify potential at-risk individuals and to offer appropriate extra-genital STI screening. We did not capture specific data on the number of individuals with a missed opportunity for screening. Future studies should assess extra-genital screening rates before and after introduction of SOGI collection and determine whether systematic use of SOGI data from the electronic health record could improve rates. Our pilot study was conducted in a U.S. state and at a medical practice that provided above-average acceptance, support, and affirmation of sexual and gender minority people, which may limit generalizability of these findings to other settings where patients may feel less accepted and potentially uncomfortable disclosing sexual behaviors with their primary care team.