Homes of substance: Drugs and the making of home/lessness for 2S/LGBTQ+ youth.

Two-Spirit, lesbian, gay, bisexual, transgender, queer, and other sexual minority (2S/LGBTQ+) youth between the ages of 14 and 29 experience inequities in homelessness and substance use. Research in this area has explored substance use as a determinant of homelessness and/or as a coping mechanism, yet far less attention has been directed to the potentially generative role of drugs in this marginalizing context. This community-based photovoice study leverages data from 61 semi-structured interviews with 32 2S/LGBTQ+ youth experiencing homelessness and unstable housing to examine how drugs shape their practices and contexts of homemaking. Analysis followed a reflexive thematic approach and was informed theoretically by perspectives on home- and place-making, a momentum-stagnation analytical frame, and a narcofeminist ethics of care. This framing centred attention on the possibilities of what drugs can do for 2S/LGBTQ+ youth in terms of shaping selves, homes, and worlds while homeless. We inductively derived three themes: (i) chasing comforts, (ii) striking down stagnation, and (iii) producing precarity. 2S/LGBTQ+ youth consumed substances in chasing comforts including warmth, relief, and a sense of clarity and being more at ease within the context of homelessness and social and material inequity. Their substance use was also a means for striking down stagnation and engendering momentum as they worked to carve out better homes and futures for themselves Youth frequently drew attention to the temporality and limits of these benefits, however, cautioning that drugs could also turn to producing new forms of precarity that limited what they expected and experienced as possible with respect to their homemaking projects. Findings highlight the generative potential of drugs in the making of home/lessness and provide critical direction for policy and service delivery, including for supports to further consider and attend to the social contexts, meanings, and effects of 2S/LGBTQ+ youths' substance use in connection with homelessness.

Beyond the Rainbow: Advancing 2S/LGBTQ+ Health Equity at a Time of Political Volatility.

Two-Spirit, lesbian, gay, bisexual, transgender, queer and other sexual and gender minority (2S/LGBTQ+) populations continue to experience profound health disparities. In this article, we prioritize five issues in 2S/LGBTQ+ health equity and discuss policy interventions to address disparities in each area: (1) poverty in 2S/LGBTQ+ communities; (2) Two-Spirit mental health; (3) health equity issues in migrant and racialized LGBTQ+ populations; (4) challenges in implementing bans on conversion therapy; and (5) the evolving context of gender-affirming care. Multi-level policy interventions, including those in healthcare-adjacent contexts such as housing and immigration, will be critical to address the structural undercurrents driving health inequities for 2S/LGBTQ+ populations. Recognizing growing complexity and political volatility in the lives of 2S/LGBTQ+ people across Canada, we challenge healthcare policy actors to recognize the breadth of structural barriers to 2S/LGBTQ+ health equity issues and act with urgency in this area.

Achieving 2S/LGBTQ+ Health Equity Requires Grappling With the Structural Drivers of Poor Health in Sexual and Gender Minorities.

While the need for research, policy and practice addressing the health equity issues of Two-Spirit, lesbian, gay, bisexual, transgender, queer and other sexual and gender minority (2S/LGBTQ+) populations is increasingly recognized, we acknowledge that significant gaps remain in this area. As authors in this themed issue have consistently pointed out, interventions that grapple with the intersectionally varied structural drivers of 2S/LGBTQ+ health remain lacking and, in particular, warrant urgent consideration. This is especially the case during a time when structural threats to the well-being of 2S/LGBTQ+ populations are on the rise, both in Canada and in other geopolitical contexts.

"To smoke feels gender": Exploring the transformative and emancipatory capacities of cannabis among transgender, non-binary and gender non-conforming (TGNC) youth.

BACKGROUND: Transgender, non-binary and gender non-conforming (herein, "TGNC") youth (15-24 years old) face overlapping minority stressors (e.g., gender discrimination, lack of access to gender-affirming care, rejection, violence) that contribute to mental health inequities. TGNC youth also use substances at higher rates when compared to cisgender youth, including some of the highest rates of cannabis use in Canada. METHODS: This community-based participatory research study provides an in-depth qualitative, photovoice-based analysis examining how cannabis use features within the gender experiences of a sample of TGNC youth in British Columbia (BC). We conducted in-depth, semi-structured interviews with 27 TGNC youth (15-24 years old) from across British Columbia. Interviews were designed to elicit discussions about the photos youth had taken as well as various gender and mental health experiences related to their cannabis use. Analysis and identification of emergent themes was guided by social constructivist grounded theory as well as queer and trans theorizing and informed by community-based research approaches through regular meetings with our team's Substance Use Beyond the Binary Youth Action Committee comprised of TGNC youth who use substances. RESULTS: Three overarching themes pertaining to cannabis use and gender experiences amongst TGNC youth in our study were generated. First, participants used cannabis purposefully and strategically to enact diverse gender expressions and embodiments. Second, participants leveraged cannabis to support introspection whilst mobilizing identity discovery and development. Finally, participants mobilized cannabis as a vehicle for accessing moments of gender euphoria and affirmation. CONCLUSIONS: These findings identify how some TGNC youth use cannabis to purposefully and strategically facilitate their mental health, well-being, identity development and self-expression. This research reveals critically important experiential and embodied dimensions of cannabis use that have not historically been considered in cannabis-related policy and the provision of care, including mental health and substance use-related care.

Self-Perceived Reasons for Suicide Attempts in Sexual and Gender Minorities in Canada.

The aim of this study was to examine the self-perceived reasons of suicide attempts among sexual and gender minorities (SGM). We surveyed SGM living in Canada (n = 2778) and respondents who had attempted suicide answered open-ended questions about their perceived reason(s) of their first/only attempt (FOA) and last attempt (LA) (for those who attempted multiple times). Responses were double-coded and categorized as discrete findings. A quarter (25%, n = 695) of the total sample reported a history of suicide attempt, of whom 72% reported multiple attempts. Respondents described a wide variety of reasons for their suicide attempts, with an important number of individuals reporting multiple reasons (corresponding to 47.5% of FOA and 43% of LA). Emotional issues (FOA:42.1%, LA:44.0%) were the most prevalent category of reasons for suicide attempts followed by experience of mental illness (FOA:30.1%, LA:36.1%). Other common reasons included violence (FOA:23.2%, LA:10.2%), interpersonal conflict (FOA:13.4%, LA:6.0%), stress related to life circumstances (FOA:9.5%, LA:16.7%), relationship issues (FOA:7.9%, LA:13.3%), and minority stress related to sexuality (FOA:11.1%, LA:6.2%) and gender identity (FOA:5.0%, LA:6.8%). SGM assessments of the reasons underlying their suicide attempts yielded a variety of factors, many of which were absent from the literature on SGM suicide but amenable to tailored interventions.

Protocol of a drug-drug interaction study between bictegravir/emtricitabine/tenofovir alafenamide and feminizing hormones in trans women living with HIV.

AIMS: Trans/transfeminine women are disproportionally affected by HIV. Concerns regarding negative drug-drug interactions (DDIs) between ART drugs and gender-affirming hormone therapy (GAHT), specifically feminizing hormone therapy (FHT), may contribute to the lower ART uptake by trans women with HIV compared with their cis counterparts. The aim of this study is to investigate the bidirectional pharmacokinetic effects of components of FHT regimens (oral oestradiol and androgen-suppressing medications) with the ART regimen (bictegravir/emtricitabine/tenofovir alafenamide [B/F/TAF)]. METHODS: We present a protocol for a three-armed, parallel-group, longitudinal (6-month), DDI study. Group 1 includes 15 3trans women with HIV taking FHT and ART; group 2 includes 15 premenopausal cis women with HIV taking ART; group 3 includes 15 trans women without HIV taking FHT. Women with HIV must be on or switch to B/F/TAF at baseline and be virally suppressed for ≥3 months. Trans women must be taking a stable regimen of ≥2 mg daily oral oestradiol and an anti-androgen (pharmaceutical, and/or surgical, and/or medical) for ≥3 months. Plasma ART drug concentrations will be sampled at Month 2 and compared between groups 1 and 2. Serum oestradiol concentrations will be sampled at baseline and Month 2 visits and compared between groups 1 and 3. The primary outcomes are B/F/TAF pharmacokinetic parameters (Cmin, Cmax and AUC) and oestradiol concentrations (Cmin, C4h, Cmax and AUC) at month 2. DISCUSSION: This study is of global importance as it provides critical information regarding safe coadministration of B/F/TAF and FHT, both of which are life-saving therapies for trans women with HIV.

"You kind of blame it on the alcohol, but. . .": A discourse analysis of alcohol use and sexual consent among young men in Vancouver, Canada.

There is growing awareness about issues of sexual consent, especially in autonomy-compromising or "non-ideal" contexts, including sex involving alcohol. Understanding the conditions needed for consensual sex to occur in this emergent milieu is critically important, especially for young men (ages 18-30 years) who normatively combine drinking alcohol with sex and are most often perpetrators of sexual violence. This study offers a discourse analysis of young men's alcohol use and sexual consent. Data are drawn from qualitative interviews with 76 young men (including gay, bisexual, queer, and straight men) in Vancouver, Canada, from 2018 to 2021. Informed by Kukla's non-ideal theory of sexual consent and critical and inclusive masculinities, this analysis identified three discursive frames: careful connections, watering it down, and blurred lines. In careful connections young men discussed their efforts to actively promote sexual and decisional autonomy for themselves and their sexual partners when drinking. Yet, in watering it down young men invoked discourses of disinhibition, deflection, and denial to normalize alcohol use as being somewhat excusatory for sexual violence, downplaying the role and responsibility of men. Lastly, men operationalized blurred lines through a continuum of consent and of "meeting (masculine) expectations" when discussing sexual violence and victimization while intoxicated. Together, these discursive frames provide insights into the gendered nature of sexual violence and the extent to which idealized notions of sexual consent play out in the everyday lives of young men who use alcohol with sex. Findings hold philosophical and pragmatic implications for contemporary efforts to scaffold sexual consent.

"Nowhere else to be found": Drawing on peer support experiences among transgender and gender-diverse people to substantiate community-driven gender-affirming care.

Increasingly, applied social scientists and clinicians recognize the value of engaging transgender and gender-diverse (TGD) people, particularly TGD individuals with lived experience as care recipients (peers), to inform the provision of gender-affirming care. Despite this trend, few researchers have systematically examined how this group can contribute to and enhance the development and delivery of interventions intended to affirm gender diversity. In this article, we address limitations in the literature by drawing on a secondary analysis of qualitative data - originally collected to examine the peer support experiences of TGD individuals - to explore the potential that TGD peers hold for elevating gender-affirming care. The study was informed methodologically by an abductive approach to grounded theory, and conceptually by critical resilience and intersectional scholarship. Data collection involved virtual, semi-structured interviews with 35 TGD individuals in two Canadian cities who indicated having experiences of seeking, receiving, and/or providing peer support. Data analysis comprised an iterative, abductive process of cross-referencing participant accounts with relevant scholarship to arrive at an account of how TGD peers may contribute to the growth of gender-affirming care. Our findings suggest, broadly, that TGD peers may enhance gender-affirming care by: (1) validating a growing diversity of embodiments and experiences in healthcare decision-making, (2) nurturing and diversifying relevant networks of safety, community support, and advocacy outside formal systems of care, and (3) strengthening possibilities for resisting and transforming existing healthcare systems. After outlining these findings, we briefly consider the implications of our analysis and leverage our inferences to substantiate the notion of community-driven gender-affirming care, meaning care that is intentional in its incorporation of relevant community stakeholders to shape governance and service provision. We conclude with reflections on the promise of community-driven care at a time of heightened volatility across systems serving TGD populations.

Exploring the gender care experiences and perspectives of individuals who discontinued their transition or detransitioned in Canada.

BACKGROUND: Those who detransition have received increased public and scholarly attention and their narratives are often presented as evidence of limitations with contemporary gender-affirming care practices. However, there are scant empirical studies about how this population experienced their own process of gaining access to gender-affirming medical/surgical interventions, or their recommendations for care practice. AIMS: To qualitatively explore the care experiences and perspectives of individuals who discontinued or reversed their gender transitions (referred to as detransition). METHODS: Between October 2021-January 2022, Canadian residents aged 18 and older with experience of stopping, shifting, or reversing a gender transition were invited to participate in semi-structured, one-on-one, virtual interviews. A purposive sample of 28 was recruited by circulating study adverts over social media, to clinicians in six urban centres, and within participants' social networks. Interviews ranged between 50-90 minutes, were audio-recorded, and transcribed verbatim. Following constructivist grounded theory methodology, interview data were analyzed inductively and thematically following a two-phase coding process to interpret participants' experiences of, and recommendations for, gender care. RESULTS: Participants were between the ages of 20-53 (71% were between 20-29). All participants identified along the LGBTQ2S+ spectrum. Twenty-seven out of 28 of the participants received medical/surgical interventions (60% were ages 24 and younger). A majority (57%) reported three or more past gender identities, with 60% shifting from a binary transgender identity at the time of initiating transition to a nonbinary identity later in their transition journey. To access medical/surgical interventions, most participants were assessed via the gender-affirming care model pathway and also engaged in talk therapy with a mental healthcare provider such as a psychologist or psychiatrist. Some participants experienced their care as lacking the opportunity to clarify their individual treatment needs prior to undergoing medical/surgical transition. Decisional regret emerged as a theme alongside dissatisfaction with providers' "informed consent" procedures, such that participants felt they would have benefitted from a more robust discussion of risks/benefits of interventions prior to treatment decision-making. Overall, participants recommended an individualized approach to care that is inclusive of mental healthcare supports. CONCLUSIONS: To optimize the experiences of people seeking and receiving gender care, a thorough informed consent process inclusive of individualized care options is recommended, as outlined by the World Professional Association of Transgender Health, standards of care, version 8.

A systematic review of the prevalence of lifetime experience with 'conversion' practices among sexual and gender minority populations.

RATIONALE: Conversion practices (CPs) refer to organized attempts to deter people from adopting or expressing non-heterosexual identities or gender identities that differ from their gender/sex assigned at birth. Numerous jurisdictions have contemplated or enacted legislative CP bans in recent years. Syntheses of CP prevalence are needed to inform further public health policy and action. OBJECTIVES: To conduct a systematic review describing CP prevalence estimates internationally and exploring heterogeneity across country and socially relevant subgroups. METHODS: We performed literature searches in eight databases (Medline, Embase, PsycInfo, Social Work Abstracts, CINAHL, Web of Science, LGBTQ+ Source, and Proquest Dissertations) and included studies from all jurisdictions, globally, conducted after 2000 with a sampling frame of sexual and gender minority (SGM) people, as well as studies of practitioners seeing SGM patients. We used the Hoy et al. risk of bias tool for prevalence studies and summarized distribution of estimates using median and range. RESULTS: We identified fourteen articles that reported prevalence estimates among SGM populations, and two articles that reported prevalence estimates from studies of mental health practitioners. Prevalence estimates among SGM samples ranged 2%-34% (median: 8.5). Prevalence estimates were greater in studies conducted in the US (median: 13%), compared to Canada (median: 7%), and greater among transgender (median: 12%), compared to cisgender (median: 4%) subsamples. Prevalence estimates were greatest among people assigned male at birth, whether transgender (median: 10%) or cisgender (median: 8%), as compared to people assigned female at birth (medians: 5% among transgender participants, 3% among cisgender participants). Further differences were observed by race (medians: 8% among Indigenous and other racial minorities, 5% among white groups) but not by sexual orientation. CONCLUSIONS: CPs remain prevalent, despite denouncements from professional bodies. Social inequities in CP prevalence signal the need for targeted efforts to protect transgender, Indigenous and racial minority, and assigned-male-at-birth subgroups.

Oestradiol concentrations in trans women with HIV suppressed on unboosted integrase inhibitor regimens versus trans women without HIV taking oral oestradiol: a pilot study.

BACKGROUND: Feminizing hormone therapy (FHT) is essential to many trans women. Concern about negative drug interactions between FHT and ART can be an ART adherence barrier among trans women with HIV. OBJECTIVES: In this single-centre, parallel group, cross-sectional pilot study, we measured serum oestradiol concentrations in trans women with HIV taking FHT and unboosted integrase strand transfer inhibitor (INSTI)-based ART versus trans women without HIV taking FHT. METHODS: We included trans women with and without HIV, aged ≥18 years, taking ≥2 mg/day of oral oestradiol for at least 3 months plus an anti-androgen. Trans women with HIV were on suppressive ART ≥3 months. Serum oestradiol concentrations were measured prior to medication dosing and 2, 4, 6 and 8 h post-dose. Median oestradiol concentrations were compared between groups using Wilcoxon rank-sum tests. RESULTS: Participants (n = 8 with HIV, n = 7 without) had a median age of 32 (IQR: 28, 39) years. Among participants, the median oral oestradiol dose was 4 mg (range 2-6 mg). Participants had been taking FHT for a median of 4 years (IQR: 2, 8). Six trans women with HIV were taking bictegravir/emtricitabine/tenofovir alafenamide and two were taking dolutegravir/abacavir/lamivudine. All oestradiol concentrations were not significantly different between groups. Eleven (73%) participants had target oestradiol concentrations in the range 200-735 pmol/L at C4h (75% among women with HIV, 71% among those without HIV). CONCLUSIONS: Oestradiol concentrations were not statistically different in trans women with HIV compared with those without HIV, suggesting a low probability of clinically relevant drug-drug interactions between FHT and unboosted INSTI-based ART.

Examining the Influence of Pre-HAART Experiences on Older, Self-Identifying Gay Men's Contemporary Constructions of Quality of Life (QOL).

Some older gay men (50+) experience diminished quality of life (QOL) due to historical and ongoing discrimination in addition to living through a collective trauma-the pre-HAART era of the HIV/AIDS epidemic-characterized by the absence of treatment and rampant discrimination targeting gay men. A growing body of literature, however, illustrates that older gay men demonstrate remarkable resilience but little is known about how QOL is conceptualized and how these conceptualizations are potentially shaped by pre-HAART experiences. The current study drew on constructivist grounded theory methods to examine how QOL is conceptualized in light of the sociohistorical relevance of pre-HAART. Twenty Canadian based gay men aged 50+ participated in semi-structured interviews via Zoom. Ultimately, QOL is understood as experiencing contentment, which is made possible by the development and implementation of three key processes: (1) developing and cultivating meaningful connections, (2) growing into and embracing identity, and (3) appreciating the capacity to do what brings joy. QOL for this group is greatly informed by a context of disadvantage, and the demonstrated resilience warrants further investigation to meaningfully support the overall well-being of older gay men.

Between two pandemics: Older, gay men's experiences across HIV/AIDS and COVID-19.

Pandemics are a component of human life, and have had great bearing on the trajectory of human evolution. Historically, the biomedical aspects of pandemics have been overrepresented, but there is growing recognition of the degree to which pandemics are socially and culturally embedded, highlighting how virus perception is socially and politically informed. Older (50+), gay men represent a population who have experienced two global pandemics in their lifespans: HIV/AIDS and COVID-19. Although governments and health officials largely failed gay men during the HIV/AIDS pandemic, gay men represent an important source of pandemic information and their experiences have much to offer health professionals and policymakers. As such, a small but growing body of literature has compared gay men's experiences amidst the two pandemics. The current study drew on constructivist grounded theory methods to examine how living through the HIV/AIDS pandemic has influenced older gay men's perspectives of COVID-19. Twenty Canadian-based gay men aged 50+ participated in semi-structured interviews via Zoom. Analysis revealed three key processes: (1) uncertainty and the familiarity of loss, (2) witnessing pandemic inequities, and, (3) navigating constantly evolving (mis)information. We highlight the utility of this knowledge to informing future pandemic planning and policies.

"A Double-Edged Sword": Health Professionals' Perspectives on the Health and Social Impacts of Gay Dating Apps on Young Gay, Bisexual, Trans and Queer Men.

Gay dating apps (GDAs) play a central role in partner-seeking for many men. The purpose of the present study was to explore health professionals' perceptions of the effects of GDAs on young gay, bisexual, trans and queer men (YGBTQM). Because health professionals have access to privileged information about YGBTQM's experiences with GDAs, they can provide unique insights about their impacts on YGBTQM health and well-being. This study drew on 28 in-depth semi-structured qualitative interviews with health professionals who provide services to YGBTQM in British Columbia, Canada. Using thematic content analysis, we identified three themes showing participants' conflicting perceptions of GDAs' impacts on YGBTQM: (1) the accessibility of sex on GDAs as either transactional or pleasurable; (2) the building of community and increased safety, which at times corresponds with increased exposure to rejection and discrimination; and (3) a perceived escalation in sexual and drug-related risk-taking in conjunction with the opportunity for education, prevention and intervention. In response to the often polarizing literature on GDAs, this study is among the first to contribute empirical evidence into the perceptions of health professionals working with YGBTQM who use GDAs, while simultaneously providing actionable insights and strategies to help identify potential harms and maximize benefits.

Health Care Experiences of Patients Discontinuing or Reversing Prior Gender-Affirming Treatments.

Importance: Medical education, research, and clinical guidelines are available to support the initiation of gender-affirming care for transgender and nonbinary people. By contrast, little is known about the clinical experiences of those who discontinue or seek to reverse gender-affirming medical or surgical interventions due to a change in gender identity, often referred to as detransition. Objective: To examine the physical and mental health experiences of people who initiated medical or surgical detransition to inform clinical practice. Design, Setting, and Participants: Using constructivist grounded theory as a qualitative approach, data were collected in the form of in-depth interviews. Data were analyzed using an inductive 2-stage coding process to categorize and interpret detransition-related health care experiences to inform clinical practice. Between October 2021 and January 2022, individuals living in Canada who were aged 18 years and older with experience of stopping, shifting, or reversing a gender transition were invited to partake in semistructured virtual interviews. Study advertisements were circulated over social media, to clinicians, and within participants' social networks. A purposive sample of 28 participants who discontinued, shifted, or reversed a gender transition were interviewed. Main Outcomes and Measures: In-depth, narrative descriptions of the physical and mental health experiences of people who discontinued or sought to reverse prior gender-affirming medical and/or surgical interventions. Results: Among the 28 participants, 18 (64%) were assigned female at birth and 10 (36%) were assigned male at birth; 2 (7%) identified as Jewish and White, 5 (18%) identified as having mixed race and ethnicity (which included Arab, Black, Indigenous, Latinx, and South Asian), and 21 (75%) identified as White. Participants initially sought gender-affirmation at a wide range of ages (15 [56%] were between ages 18 and 24 years). Detransition occurred for various reasons, such as an evolving understanding of gender identity or health concerns. Participants reported divergent perspectives about their past gender-affirming medical or surgical treatments. Some participants felt regrets, but a majority were pleased with the results of gender-affirming medical or surgical treatments. Medical detransition was often experienced as physically and psychologically challenging, yet health care avoidance was common. Participants described experiencing stigma and interacting with clinicians who were unprepared to meet their detransition-related medical needs. Conclusions and Relevance: This study's results suggest that further research and clinical guidance is required to address the unmet needs of this population who discontinue or seek to reverse prior gender-affirming interventions.

Impacts of COVID-19 on trans and non-binary people in Canada: a qualitative analysis of responses to a national survey.

BACKGROUND: Emerging international evidence indicates the COVID-19 pandemic has exacerbated socioeconomic and health challenges faced by transgender (trans) and non-binary populations globally. This qualitative study is among the first to characterize impacts of the pandemic on these groups in Canada. METHODS: Drawing on data from the Trans PULSE Canada survey (N = 820), we used thematic analysis to examine the free-form responses of 697 participants to one open-ended question on impacts of the pandemic. We first organized responses into descriptive themes, and then used this preliminary analytical process to construct more refined, higher order themes that provided a rich account of the pandemic's impacts. RESULTS: Our results are organized into five themes that highlight the pandemic's impacts on trans and non-binary populations in Canada. These include: (1) reduced access to both gender-affirming and other healthcare, (2) heightened financial, employment, and housing precarity, (3) strained social networks in an era of physical distancing and virtual communication, (4) an intensification of safety concerns, and (5) changes in experiences of gender affirmation. CONCLUSION: Our findings highlight the pandemic's systemic impacts on the lives of trans and non-binary people in domains such as healthcare, employment, and housing, and on the social networks of these groups, many of which reflect an exacerbation of pre-existing inequities. Based on our analysis, we recommend that public health researchers, policymakers, and practitioners attend to the structural impacts of the pandemic on these groups as primary sites of inquiry and intervention.

Processes underpinning survival in gay men living with HIV and a history of suicidality.

Gay men living with HIV represent a particularly high risk group for suicide; however, little is known about suicidality, specifically, resiliencies in the context of suicidality among this particular group of men. The current study draws on photovoice and grounded theory methods to examine the processes that underpin survival for gay men living with HIV who have experienced suicidality. Twenty-two Canadian-based gay men participated, taking photographs to depict and discuss their perspectives on resiliencies. Analyses revealed three processes that supported men's survival: (1) connecting to key supports, (2) finding sanctity in the outdoors, and (3) giving help as purposeful value-adding. Connecting to key supports highlighted the utility of connection and therapeutic communication, listening and support provided by friends, family and professionals. Finding sanctity in the outdoors emphasised the healing capacity of outdoor green spaces, and giving help as purposeful value-adding illustrated the meaning and purpose men derived from supporting others. These findings can inform public health and primary care interventions to foster gay men's resilience and coping, and ultimately suicide prevention efforts.

"You Could Tell I Said the Wrong Things": Constructions of Sexual Identity Among Older Gay Men in Healthcare Settings.

Older gay men commonly conceal their sexual identity in healthcare settings due to past experiences and expectations of encountering stigma and discrimination in these contexts. Although insights on how older gay men construct their sexual identity in healthcare may help contextualize this phenomenon, this question remains under-explored. Accordingly, we present the findings of a secondary grounded theory analysis of individual interview data, which we originally collected to examine the healthcare experiences of 27 gay men ages 50 and over, to explore constructions of sexual identity among the group. Our findings broadly reveal that older gay men's varying exposure to intersecting systems of oppression, together with their perceptions of different healthcare settings, may be critical in shaping their constructions of sexual identity in these contexts. Our research supports the need for healthcare policies and practices that address stigma and discrimination as salient barriers to sexual identity disclosure among older gay men.