Improving prevalence estimates of mental health and well-being indicators among Sexual Minority Men: A Propensity Weighting Approach.

The prevalence and relative disparities of mental health outcomes and well-being indicators are often inconsistent across studies of Sexual Minority Men (SMM) due to selection biases in community-based surveys (non-probability sample), as well as misclassification biases in population-based surveys where some SMM often conceal their sexual orientation identities. The current paper estimated the prevalence of mental health related outcomes (depressive symptoms, mental health service use [MHSU], anxiety) and well-being indicators (loneliness and self-rated mental health) among SMM, broken down by sexual orientation using the Adjusted Logistic Propensity score (ALP) weighting. We applied the ALP to correct for selection biases in the 2019 Sex Now data (a community-based survey of SMMs in Canada) by reweighting it to the 2015-2018 Canadian Community Health Survey (a population survey from Statistics Canada). For all SMMs, the ALP-weighted prevalence of depressive symptoms is 15.96% (95% CI: 11.36%, 23.83%), while for MHSU, it is 32.13% (95% CI: 26.09, 41.20). The ALP estimates lie in between the crude estimates from the two surveys. This method was successful in providing a more accurate estimate than relying on results from one survey alone. We recommend to the use of ALP on other minority populations under certain assumptions.

" full of opportunities, but not for everyone": A narrative inquiry into mechanisms of labor market inequity among precariously employed gay, bisexual, and queer men.

BACKGROUND: This study brings lesbian, gay, bisexual, transgender (trans), and queer (LGBTQ+) populations into scholarly discourse related to precarious employment through a political economy of queer struggle. METHODS: Drawing on narrative inquiry, 20 gay, bisexual, and queer men shared stories of precarious employment that were analyzed using Polkinghorne's narrative analysis. RESULTS: Results tell an overarching narrative in three parts that follow the trajectory of participants' early life experiences, entering the labor market and being precariously employed. Part 1: Devaluation of LGBTQ+ identities and adverse life experiences impacted participants' abilities to plan their careers and complete postsecondary education. Part 2: Participants experienced restricted opportunities due to safety concerns and learned to navigate white, cis, straight, Canadian ideals that are valued in the labor market. Part 3: Participants were without protections to respond to hostile treatment for fear of losing their employment. CONCLUSIONS: These stories of precarious employment illustrate unique ways that LGBTQ+ people might be particularly susceptible to exploitative labor markets.

Geosexual Archetype, Preventive Behaviors, and Sexually Transmitted Infections Among High-Risk Men Who Have Sex With Men.

BACKGROUND: Social geography plays an important role in transmission of sexually transmitted infections (STIs) among men who have sex with men. Previous qualitative work had identified 7 "geosexual archetypes," each with distinct travel patterns for sex and potentially important differences in STI rates. The objective of this article was to explore what could be learned about STI transmission by looking at STI prevention strategies (condom use and preexposure prophylaxis use) and prevalence of STIs among these geosexual archetypes. METHODS: We analyzed data from the Sex Now 2019 online survey in Canada. Men who have sex with men who reported 3 or more partners in the past 6 months were included in the analysis (n = 3649). RESULTS: The most common archetype was "geoflexible" (sex at home, partner's home, and other places; 35.6%), followed by "privates" (sex only at own/partner's home; 23.0%); the least common archetypes was "rover" (sex not at home or partner's place; 4.0%). There were significant variations in both STI prevention strategies and prevalence of bacterial STIs in the past year by geosexual archetype. In particular, among those who were HIV negative, those who reported a geoflexible archetype and used preexposure prophylaxis but did not use condoms consistently had a 52.6% prevalence of bacterial STIs, which was much higher compared with all other groups. Within other archetypes, those living with HIV had the highest prevalence of bacterial STIs. CONCLUSIONS: Geosexual archetype together with participant's STI prevention strategies was a strong predictor of bacterial STI risk. Understanding how place is connected to bacterial STIs is key in prevention as individuals do not live in isolation.

Acceptability of bariatric surgery in people with endometrial cancer and atypical hyperplasia: A qualitative study.

OBJECTIVE: In young individuals with obesity, infertility, and endometrial cancer, significant, sustained weight loss through bariatric surgery may result in a durable oncologic and reproductive response. However, it is not known whether bariatric surgery is acceptable to this patient population. We performed a qualitative study to understand the acceptability of bariatric surgery in young individuals with obesity and endometrial cancer or atypical hyperplasia. STUDY DESIGN: All participants were of reproductive age with body mass index [BMI] ≥ 35 and grade 1 endometrial cancer or atypical hyperplasia. Semi-structured interviews were used to explore participant perception of their weight, fertility, and the possibility of bariatric surgery as part of the treatment strategy for their endometrial cancer/atypical hyperplasia. Thematic saturation was reached after 14 interviews. RESULTS: Fourteen participants with a median age of 34 years (range 27-38) and BMI of 42 (33-64) were interviewed. Participants were reluctant to accept bariatric surgery as a treatment option due to 1) lack of knowledge about the procedure, 2) stigma attached to bariatric surgery, and 3) fear of the risks associated with bariatric surgery. Their perception towards their weight, fertility, and cancer diagnosis was characterized by concepts of 'helplessness', 'isolation', 'frustration', and 'guilt'. We observed a significant gap in participant understanding of the complex interplay between their cancer, infertility, and obesity. CONCLUSIONS: More support and resources are required, with patient-oriented counseling focused on the implication of their weight on their cancer diagnosis and fertility, before presenting bariatric surgery as a treatment option.

The impact of a stress management intervention including cultural components on stress biomarker levels and mental health indicators among indigenous women.

We examined the effectiveness of a 26-week culture-inclusive intervention on reducing salivary stress biomarker levels, and perceived stress, depressive, and post-traumatic stress disorder (PTSD) symptoms measured using scales in 53 Indigenous women in Ontario, Canada. Statistical analyses compared the average biomarker levels, and the area under the curve (AUC) of biomarkers. Differences in biomarkers and mental health scale scores pre- and post-intervention were compared using mixed models with a random intercept. Interaction terms were included between the intervention and age, education, disability, and HIV status, individually, to test for sub-group differences. Cortisol AUC post-intervention was decreased compared to pre-intervention (ß -1.29 µg/dL; 95%CI -2.35, -0.23). There was a slight decrease in perceived stress levels (aOR: -2.80; 95%CI -5.09, -0.50). The associations were stronger among women of younger age, higher education, and no disabilities. These interventions can be effective, but future interventions should target Indigenous population sub-groups to address individual needs.

Community and Health Care Provider Preferences for Bacterial Sexually Transmitted Infection Testing Interventions for Gay, Bisexual, and Other Men Who Have Sex With Men: e-Delphi Study.

BACKGROUND: Canadian clinical guidelines recommend at least annual and up to quarterly bacterial sexually transmitted infection (STI) testing among sexually active gay, bisexual, and other men who have sex with men (GBM). However, testing rates are suboptimal. Innovative solutions are needed to close the gap because there is currently limited knowledge on how best to approach this issue. OBJECTIVE: Our aim was to build consensus regarding interventions with the greatest potential for improving local STI testing services for GBM communities in Toronto, Ontario, Canada, using a web-based e-Delphi process. METHODS: The e-Delphi method involves using a panel format to conduct successive rounds of prioritization, with feedback between rounds, to determine priorities among groups. We recruited experts separately from the community (GBM who sought or underwent STI testing in the preceding 18 months; conducted between October 2019 and November 2019) and health care providers (those who offered STI testing to GBM in the past 12 months; conducted between February 2020 and May 2020). The experts prioritized 6 to 8 potential interventions on a 7-point Likert scale ranging from definitely not a priority to definitely a priority over 3 survey rounds and ranked their top 3 interventions. Consensus was defined as ≥60% within a ±1 response point. Summaries of responses were provided in successive rounds. We reported the percentage of a priority (encompassing somewhat a priority, a priority, and definitely a priority responses) at the end of the final round of the survey. RESULTS: Of the community experts (CEs), 84% (43/51) completed all rounds; 19% (8/43) were living with HIV; 37% (16/43) were HIV negative and on pre-exposure prophylaxis; and 42% (18/43) were HIV negative and not on pre-exposure prophylaxis. We reached consensus on 6 interventions: client reminders (41/43, 95%), express testing (38/43, 88%), routine testing (36/43, 84%), an online booking app (36/43, 84%), online-based testing (33/43, 77%), and nurse-led testing (31/43, 72%). The CEs favored convenient interventions that also maintain a relationship with their provider. Of the provider experts (PEs), 77% (37/48) completed all rounds; 59% (22/37) were physicians. Consensus was reached on the same 6 interventions (range 25/37, 68%, to 39/39, 100%) but not for provider alerts (7/37, 19%) and provider audit and feedback (6/37, 16%). Express testing, online-based testing, and nurse-led testing were prioritized by >95% (>37/39) of the PEs by the end of round 2 because of streamlined processes and decreased need to see a provider. CONCLUSIONS: Both panels were enthusiastic about innovations that make STI testing more efficient, with express testing rating highly in both the prioritizations and top 3 rankings. However, CEs preferred convenient interventions that involved their provider, whereas PEs favored interventions that prioritized patient independence and reduced patient-provider time. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/13801.

Spatial Access to Sexual Health Clinics Measured Through a Novel Accessibility Score in Toronto, Canada.

BACKGROUND: Understanding spatial access to sexual health services will provide the foundation for future resource planning and allocation. The purpose of this study was to evaluate the potential geographic access to sexual health services in Toronto, Canada, by developing a novel accessibility index to sexual health clinics. METHODS: We created an accessibility index using the 2-step floating catchment area method to quantify neighborhood-level access to sexual health clinics. The index assumed mixed modes of urban travel through walking and public transit, as well as through driving, and was estimated at the census tract level. RESULTS: Census tracts were grouped into quantiles by the estimated accessibility score. Census tracts with higher accessibility scores were characterized as those with greater residential instability and lower dependency and ethnic concentration. The downtown core area has all census tracts categorized as medium, high, or very high (average [SD] score, 1.320 [0.312]), whereas the noncore area has 56.98%, 302 of 530 census tracts categorized as medium, high, or very high (average [SD] score, -0.105 [0.960]). CONCLUSIONS: We demonstrated the benefit of using statistical methods to quantify the geographical access to sexual health services and identified neighborhoods with high and low levels of access. Findings from this study present an overview of the level of spatial access to sexual health clinics in Toronto based on clinic locations in 2018 and can be further used to characterize neighborhoods with a lower level of access and inform policy and planning decisions in the city.

"Conversion Therapy" Experiences in Their Social Contexts: A Qualitative Study of Sexual Orientation and Gender Identity and Expression Change Efforts in Canada.

OBJECTIVE: To describe in what forms, with whom, where, when, and why Canadians experience sexual orientation and gender identity and expression change efforts (SOGIECE). METHODS: This qualitative study is grounded in a transformative paradigm. We conducted semi-structured interviews with a purposive sample of 22 adults recruited from across Canada who have experienced "conversion therapy." Directed content analysis was used, employing deductive and inductive coding approaches, to synthesize the findings and address 5 policy-relevant questions. RESULTS: What are SOGIECE? Formal and informal methods of SOGIECE were used, including pharmacologic interventions, denial of gender-affirming care, and coaching to repress sexual orientation and/or gender identity and expression. With whom did SOGIECE occur? Practitioners included religious leaders, licenced health-care professionals (e.g., psychiatrists and psychologists), peers, and family members. Where did SOGIECE occur? SOGIECE occurred in 3 predominant settings: faith-based, health care, and social life. When did SOGIECE occur? SOGIECE rarely occurred over a restricted time frame; often, SOGIECE began while participants were adolescents or young adults and continued multiple years under various forms. Others described SOGIECE as a context in which their life was embedded for many years. Why did people attend SOGIECE? Cisheteronormative social and religious expectations taught participants that being non-cisgender or non-heterosexual was incompatible with living a good and respectable life. CONCLUSIONS: SOGIECE are not a circumscribed set of practices. Our study shows that SOGIECE are a larger phenomenon that consists of intentional and explicit change efforts as well as heterosexual- and cisgender-dominant social norms expressed and enforced across a wide range of settings and circumstances. This study provides critical context to inform contemporary social and health policy responses to SOGIECE. Policies should account for the overt, covert, and insidious ways that SOGIECE operate in order to effectively promote safety, equity, and health for sexually diverse and gender-diverse people.

Perceived influence of alcohol consumption, substance use, and mental health on PrEP adherence and condom use among PrEP-prescribed gay, bisexual, and other men-who-have-sex-with-men: a qualitative investigation.

BACKGROUND: Gay, bisexual, and other men-who-have-sex-with-men (GBMSM) continue to be disproportionately affected by Human Immunodeficiency Virus (HIV). Although HIV pre-exposure prophylaxis (PrEP) offers an effective means of reducing incident HIV among this population, the HIV-preventive success of oral-based PrEP is contingent upon regimen adherence. Elevated rates of alcohol-, substance use-, and mental health-related issues among GBMSM potentially hinder PrEP-taking efforts, however the evidence for this remains mixed. Accordingly, the present study entailed a comprehensive qualitative investigation to explore PrEP-prescribed GBMSM's perceptions surrounding the influence of alcohol, substance use, and mental health on PrEP adherence. METHODS: PrEP-prescribed GBMSM (age ≥ 18 years; prescribed PrEP for ≥ 3 months) were recruited from two PrEP-delivery clinics in Toronto, Canada for focus groups as part of the formative phase of an alcohol-, substance use-, and mental health-focused randomized controlled intervention trial. Focus group discussions qualitatively explored perceived strengths and barriers associated with adherence to PrEP treatment; with an emphasis on alcohol, substance use, and mental health concerns. Condom use among PrEP-prescribed GBMSM within the context of these concerns was also discussed. RESULTS: A total of five focus groups involving 35 GBMSM were conducted (4-10/group; mean age = 42.4; white = 71.4%). Although participants themselves generally reported successfully adhering to their PrEP regimens-resulting from a strong, underlying motivation for self-care-they recognized the detrimental impact that alcohol, substance use, and mental health had on adherence among their peers. In this regard, alcohol and substances were perceived as detracting from adherence only when consumption was excessive or temporally linked to PrEP dosing. Pronounced mental health issues (e.g., severe depression) were also seen as hindering adherence, although these effects were nuanced and perceived as person-dependent. Alcohol and substances were linked to condomless sex, regardless of PrEP use, and PrEP was therefore viewed as an HIV-protective 'safety net.' CONCLUSIONS: Overall, findings suggest that PrEP adherence can often be successfully achieved in the presence of alcohol-, substance use-, and mental health-related issues. Augmenting self-care, and addressing pronounced addictions- and mental health-related concerns, may enhance PrEP treatment among GBMSM.

Community perspectives on ideal bacterial STI testing services for gay, bisexual, and other men who have sex with men in Toronto, Canada: a qualitative study.

BACKGROUND: Innovation is needed to produce sustained improvements in bacterial sexually transmitted infections (STI) testing given suboptimal access and uptake among sexually active gay, bisexual or other men who have sex with men (GBM). Yet, the STI testing processes and technologies that best address local testing barriers among GBM in Toronto is unknown. We aimed to explore men's perspectives regarding STI testing services for GBM to identify and prioritize new STI testing interventions in Toronto, Ontario, Canada. METHODS: We conducted four focus groups with twenty-seven GBM in 2017: two with cisgender men living with HIV, one with cisgender HIV-negative men, and one with transgender men. Twenty-seven men participated in the focus groups with 40% 18-30 years of age, 48% self-identifying as white, and the remainder self-identifying as Middle Eastern, Latino/Hispanic, Asian/Pacific Islander, South Asian, First Nations, African/Caribbean/Black, or mixed race. 59% of participants self-identified as living with HIV. Participants were asked about their STI testing experiences in Toronto, barriers and facilitators to testing, and ideal STI testing process. Focus groups were audio recorded, transcribed verbatim, and analyzed using thematic analysis. RESULTS: Core concepts included how clinical context, bacterial STI testing delivery, and interactions with healthcare providers can create barriers and recommendations for ways to improve. Regarding clinical context, participants desired more clinics with accessible locations/hours; streamlined testing that minimized use of waiting rooms and wait times; and improved clinic ambience. Bacterial STI testing delivery recommendations included standardization to ensure consistency in sexual history intake, tests offered, follow-up and public health reporting between clinics. Men also recommended reducing the multistep process testing by offering components such as lab requisitions and results online. Participants also recommended interactions with healthcare providers be professional and non-judgmental, offer compassionate and competent care with destigmatizing and lesbian, gay, bisexual and trans (LGBT) affirming communication. CONCLUSION: Concrete and practical solutions for improving existing sexual health services and facilitating optimal STI testing include streamlining testing options and providing patient-centred, LGBT-affirming care to enable optimal STI testing.

Survey of Health Care Providers' Practices and Opinions Regarding Bacterial Sexually Transmitted Infection Testing Among Gay, Bisexual, and Other Men Who Have Sex With Men.

BACKGROUND: Rates of bacterial sexually transmitted infections (STIs) continue to rise among gay, bisexual, and other men who have sex with men (GBMSM) globally. Testing and treatment can prevent morbidity and transmission. However, testing rates remain suboptimal. METHODS: In 2018, we conducted an online cross-sectional survey to explore STI testing ordering practices, 14 potential barriers for testing and 11 possible ways to improve testing from the perspective of health care providers in Toronto, Ontario. An estimated 172 providers were invited from primary care and sexual health clinic settings. Providers were eligible to complete the survey if they provided care for ≥1 GBMSM per week and were involved in the decision-making process in providing STI tests. We used descriptive statistics to summarize survey responses. RESULTS: Ninety-five providers (55% response rate) participated, of whom 68% worked in primary care and 32% in sexual health settings. Most (66%) saw ≤10 GBMSM clients per week. In primary care (65%) and sexual health (40%) clinic settings, insufficient consultation time was the most common barrier to STI testing. In primary care, other common barriers included difficulty introducing testing during unrelated consultations (53%), forgetting (47%), and patients being sexually inactive (31%) or declining testing (27%). The following were most likely to improve testing: express/fast-track testing services (89%), provider alerts when patients are due for testing (87%), patient-collected specimens (84%), nurse-led STI testing (79%), and standing orders (79%). CONCLUSIONS: Promising interventions to improve bacterial STI testing included initiatives that simplify and expedite testing and expand testing delivery to other health care professionals.

Age, period, and cohort patterns in the epidemiology of suicide attempts among sexual minorities in the United States and Canada: detection of a second peak in middle adulthood.

PURPOSE: Sexual minority adults experience fivefold greater risk of suicide attempt, as compared with heterosexuals. Establishing age-specific epidemiological patterns of suicide is a prerequisite to planning interventions to redress the sexual orientation suicide inequity, and such patterns must be carefully interpreted in light of correlated period and cohort effects. We, therefore, combined US and Canadian data (1985-2017) from primary (two pooled multi-year national surveys, N = 15,477 and N = 126,463) and secondary (published, meta-analytic, N = 122,966) sources to separately estimate age, period, and cohort trends in self-reported suicide attempts among sexual minorities. METHODS: Age- and gender-stratified cross-sectional data were used to infer age and cohort effects. Age-collapsed meta-analyzed data were used to infer period effects among sexual minorities of all genders. RESULTS: We identified a bimodal age distribution in recent suicide attempts for sexual minorities across genders, though more pronounced among sexual minority men: one peak in adolescence (18-20 years of age for both genders) and one peak nearing mid-life (30-35 years of age for men; 35-40 years of age for women). This pattern was also apparent using recall data within birth cohorts of sexual minority men, suggesting it is not an artifact of birth cohort effects. Finally, we observed decreasing trends in lifetime suicide attempt prevalence estimates for both sexual minorities and heterosexuals, though these decreases did not affect the magnitude of the sexual orientation disparity. CONCLUSION: In the context of exclusively adolescent-focused suicide prevention interventions for sexual minorities, tailored suicide prevention for sexual minority adults should be pursued throughout the life course.

Sexual Health Knowledge, Attitudes, and Perceptions Among Men Who Have Sex With Men During Co-Occurring Sexually Transmitted Infection Epidemics in Toronto, Canada: A Qualitative Study.

BACKGROUND: Our objective was to explore the sexual health knowledge, attitudes, and perceptions of men who have sex with men (MSM). METHODS: In-depth interviews were conducted with 31 MSM who lived, worked, or socialized in Toronto in June and July 2016. Participants were asked about concepts of risky sex and knowledge of, and attitudes toward, sexually transmitted infections (STIs), especially syphilis, and potential interventions. Thematic analysis was used to analyze interview transcripts. RESULTS: The prevention of STI relied on HIV prevention strategies. No one used condoms for oral sex, nor did they intend to. Pre-exposure prophylaxis was perceived as both threatening and liberating. Concepts of risky sex included emotional risk. Conversations with partners about STI testing were easier than STI status. Stigma and concealment of sexual identity were barriers to sexual health care. None of the participants recommended sexual behavior or sexual health interventions. Instead, recommendations centered on social changes to reduce or eliminate shame, embarrassment, stigma, and discrimination around both STIs and sexual orientation. CONCLUSION: Participants were thinking about sexual risk and using a variety of ways to prevent STI transmission, although most relied on HIV prevention strategies, possibly because they knew little about other STIs, and other STIs were perceived as curable, especially syphilis. Interventions promoting conversations about STI testing may be promising and will also reduce stigma as STI testing is normalized. Social and clinic interventions focused on creating psychologically safe spaces to disclose sexual identity and providing sexual orientation affirming health care may reduce STIs and improve sexual health for MSM.

Impact of climate and public health interventions on the COVID-19 pandemic: a prospective cohort study.

BACKGROUND: It is unclear whether seasonal changes, school closures or other public health interventions will result in a slowdown of the current coronavirus disease 2019 (COVID-19) pandemic. We aimed to determine whether epidemic growth is globally associated with climate or public health interventions intended to reduce transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). METHODS: We performed a prospective cohort study of all 144 geopolitical areas worldwide (375 609 cases) with at least 10 COVID-19 cases and local transmission by Mar. 20, 2020, excluding China, South Korea, Iran and Italy. Using weighted random-effects regression, we determined the association between epidemic growth (expressed as ratios of rate ratios [RRR] comparing cumulative counts of COVID-19 cases on Mar. 27, 2020, with cumulative counts on Mar. 20, 2020) and latitude, temperature, humidity, school closures, restrictions of mass gatherings, and measures of social distancing during an exposure period 14 days previously (Mar. 7 to 13, 2020). RESULTS: In univariate analyses, there were no associations of epidemic growth with latitude and temperature, but weak negative associations with relative humidity (RRR per 10% 0.91, 95% confidence interval [CI] 0.85-0.96) and absolute humidity (RRR per 5 g/m3 0.92, 95% CI 0.85-0.99). Strong associations were found for restrictions of mass gatherings (RRR 0.65, 95% CI 0.53-0.79), school closures (RRR 0.63, 95% CI 0.52-0.78) and measures of social distancing (RRR 0.62, 95% CI 0.45-0.85). In a multivariable model, there was a strong association with the number of implemented public health interventions (p for trend = 0.001), whereas the association with absolute humidity was no longer significant. INTERPRETATION: Epidemic growth of COVID-19 was not associated with latitude and temperature, but may be associated weakly with relative or absolute humidity. Conversely, public health interventions were strongly associated with reduced epidemic growth.

The Social Geography of Partner Selection in Toronto, Canada: A Qualitative Description of "Convection Mixing".

The geographic distribution of sexually transmitted infections reflects the underlying social process of sexual partner selection. This qualitative study explored the social geography of partner selection among sexual minority men and used the results to develop a mid-range theory of STI transmission. In-depth interviews with 31 sexual minority men who lived, worked, or socialized in Toronto, Canada, occurred in June and July 2016. Participants were asked how they found sexual partners and reconstructed their egocentric sexual networks for the previous 3 months. Participants described an iterative process of partner selection involving intention (sex versus dating), connecting with community, and selecting a partner based on intersecting partner characteristics (external, internal, and emergent feelings when interacting with potential partners) and personal preferences. Geography influenced partner selection three ways: (1) participant search patterns maximized the number of potential partners in the shortest distance possible; (2) the density of sexual minority men in a participant's community directly impacted participant's social and sexual isolations; and (3) geosexual isolation influenced sexual mixing patterns. Participants described "convection mixing," where assortative urban mixing nested within disassortative suburban mixing resulted in movement from the suburbs to downtown and back to the suburbs. We theorize that convection mixing may be contributing to the persistence of STI epidemics in core and outbreak areas by creating STI reservoirs outside of, and connected to, core and outbreak areas.

Prevalence of Exposure to Sexual Orientation Change Efforts and Associated Sociodemographic Characteristics and Psychosocial Health Outcomes among Canadian Sexual Minority Men.

OBJECTIVE: Sexual orientation change efforts (SOCE), or "conversion therapy," are pseudoscientific practices intended to suppress or deny sexual attraction to members of the same gender/sex. There are currently no data available to inform estimates of the prevalence of SOCE exposure in Canada. The objective of this study is therefore to describe the prevalence, social-demographic correlates, and health consequences of SOCE among Canadian sexual minority men. METHODS: Sex Now 2011 to 2012 was a cross-sectional nonprobability survey of Canadian sexual minority men. Respondents were asked about lifetime SOCE exposure. We estimated prevalence of SOCE exposure by sociodemographic characteristics and examined psychosocial health outcomes among those exposed to SOCE. RESULTS: Of N = 8,388 respondents, 3.5% (95% confidence interval, 3.2% to 4.1%) reported having ever been exposed to SOCE. Exposure to SOCE was higher among gay men (as compared with bisexual men), transgender respondents (as compared with cisgender respondents), those who were "out" about their sexuality (as compared with those who were not "out"), Indigenous men (as compared with White men), other racial minorities (as compared with White men), and those earning a personal income <$30,000 (as compared with those earning ≥$60,000 CAD). Exposure to SOCE was positively associated with loneliness, regular illicit drug use, suicidal ideation, and suicide attempt. CONCLUSIONS: SOCE exposure remains prevalent and associated with substantial psychosocial morbidity among sexual minority men in Canada. All levels of government in Canada should consider action to ban SOCE. SOCE survivors likely require intervention and support from the Canadian health-care system.

Applying core theory and spatial analysis to identify hepatitis C virus infection "core areas" in British Columbia, Canada.

"Core areas" of transmission for bacterial sexually transmitted infections have been identified. However, it is unclear whether core areas apply to viral infections, such as hepatitis C virus (HCV). We used geographic mapping and spatial analysis to identify distinct core areas of HCV infection in British Columbia (BC) using the BC Hepatitis Testers Cohort (BC-HTC), 1990-2013. The BC-HTC includes all BC residents tested for HCV (~1.5 million; 1990-2013). Core HCV infection areas were identified spatially and temporally for five time periods (1990-1993, 1994-1998, 1999-2003, 2004-2008 and 2009-2013) through thematic mapping, Kernel Density Estimation, Hotspot analysis and cluster analysis at the Census dissemination area level in ArcGIS and SatScan. HCV infection core areas were consistently identified. HCV core areas expanded from the downtown of major cities in different regions of BC (Metro Vancouver, Vancouver Island, and Northern BC; 1990-1998), to smaller cities in Metro Vancouver and Interior BC (2000 onwards). Statistically significant clusters, or hotspots, were also observed for downtown Vancouver, Northern BC (Prince George) and Vancouver Island from 1990 to 2008 with expansion to other urban areas in Metro Vancouver from 1990-2013. Statistically significant clusters persisted after adjustment for injection drug use, number of HCV tests, age, sex, material and social deprivation. Persistence of areas with high HCV diagnoses rates in Vancouver and Prince George supports the theory of core areas of HCV transmission. Identification of core areas can inform prevention, care and treatment programme interventions and evaluate their impact over time.

Spatial-Temporal Epidemiology of the Syphilis Epidemic in Relation to Neighborhood-Level Structural Factors in British Columbia, 2005-2016.

BACKGROUND: Spatial clusters of syphilis have been observed within several jurisdictions globally; however, the degree to which they are predicted by the spatial distributions of gay, bisexual, and other men who have sex with men (GBM) and testing remains unknown. We sought to describe the spatial-temporal epidemiology of infectious syphilis and identify associations between neighborhood-level factors and rates of syphilis, in British Columbia, Canada. METHODS: We used ArcGIS to map infectious syphilis cases among men (2005 to 2016), SaTScan to detect areas with significantly elevated rates of syphilis, and spatial regression to identify associations between neighborhood-level factors and rates of syphilis. RESULTS: Five clusters were identified: a core in downtown Vancouver (incidence rate ratio [IRR], 18.0; 2007-2016), 2 clusters adjacent to the core (IRR, 3.3; 2012-2016; and IRR, 2.2; 2013-2016), 1 cluster east of Vancouver (IRR, 2.1; 2013-2016), and 1 cluster in Victoria (IRR, 4.3; 2015-2016). Epidemic curves were synchronized across cluster and noncluster regions. Neighborhood-level GBM population estimates and testing rates were both associated with syphilis rates; however, the spatial distribution of syphilis was not fully explained by either of these factors. CONCLUSIONS: We identified two novel ecologic correlates of the spatial distribution of infectious syphilis-density of GBM and rates of syphilis testing-and found that these factors partially, though not entirely, explained the spatial distribution of clusters. Residual spatial autocorrelation suggests that greater syphilis testing coverage may be needed and low-barrier GBM-affirming testing should be expanded to regions outside the core.

Perspectives on restoring health shared by Cree women, Alberta, Canada.

The purpose of this study was to explore nehiyaw iskwêwak (Cree women's) perceptions and beliefs about how to restore balance to health. Fifteen indigenous women from Northern Alberta, Canada, participated in a 3-day cultural retreat on beauty and art in British Columbia, Canada, in May 2015. At the end of the retreat, these women were invited to participate in a talking circle and asked, 'What does restoring balance look like?' A constructivist grounded theory approach was used to explore individual and collective perspectives on restoring health. Nehiyaw iskwêwak provided a vision of health using metaphors from the natural environment. Starting points and core characteristics of health were grounded in relationship with self, others, place and the land, suggesting interventions grounded in land-based pedagogy and focused on restoring relationship and secure attachment might be effective for this population. Nehiyaw iskwêwak also said interventions should start at the individual level; as the individual restores balance mentally, emotionally, physically and spiritually, a long-term ripple effect can be initiated through the generations and community when these women in turn support the strengthening and nurturing of relations (e.g. parents, siblings, friends, children, grandchildren) for the next seven generations.

An Application of Syndemic Theory to Identify Drivers of the Syphilis Epidemic Among Gay, Bisexual, and Other Men Who Have Sex With Men.

BACKGROUND: We applied syndemic theory to explore the degree to which syndemic conditions explain the syphilis epidemic affecting Canadian gay and bisexual men who have sex with men (GBMSM). METHODS: Data from a national survey comprising 7872 GBMSM were analyzed using multivariable logistic regression to measure associations between recent syphilis diagnosis (RSD; in previous 12 months) and the following variables: (1) sociodemographic information (sexuality, HIV status, age, income, ethnicity, relationship status), (2) antigay stigma (bullying, physical violence, sexual violence, career discrimination, health care discrimination), (3) syndemic conditions (suicidality, intimate partner violence, depression, illicit substance use, binge drinking), (4) sexual behaviors, (5) health care discrimination, and (6) the cumulative count of antigay experiences and syndemic conditions. RESULTS: Three percent (n = 235) of GBMSM surveyed reported an RSD. Men were more likely to report an RSD if they were HIV positive (adjusted odds ratio [AOR], 6.27; 95% confidence interval [CI], 4.66-8.43). Recent syphilis diagnosis was also positively associated with career discrimination, health care discrimination, substance use, and intimate partner violence. Furthermore, prevalence of RSD increased with each additional form of stigma or syndemic condition. The odds of reporting RSD was 5.2 (95% CI, 1.0-25.9) times higher for men who reported experiencing all 4 forms of antigay stigma compared with those who reported no stigma, after adjusting for sociodemographics. Similarly, the adjusted odds of reporting RSD was 12.2 (95% CI, 2.0%-74.8%) times higher for GBMSM experiencing 5 syndemic conditions compared with those reporting no syndemic conditions. CONCLUSIONS: Evidence from this large cross-sectional study suggests that the Canadian syphilis epidemic among GBMSM is being driven by a syndemic constituted by multiple social and psychological conditions. Interventions addressing specific psychosocial health outcomes that increase the risk for syphilis should be developed and integrated within targeted sexual health services and syphilis prevention initiatives.