Change in Finances, Peer Access, and Mental Health Among Trans and Nonbinary People During the COVID-19 Pandemic.

Purpose: Due to structural transphobia, trans and nonbinary (TNB) individuals were particularly vulnerable to the negative effects of social isolation and financial instability resulting from COVID-19. The present study examined the effect of change in finances and access to TNB peer gatherings on anxiety and depression during the COVID-19 pandemic. Methods: Participants were 18 years and older (mean = 30) and completed prepandemic baseline (Fall 2019) and pandemic follow-up (Fall 2020) surveys. Multivariable regressions examined associations between mental health and change in (1) finances and (2) access to TNB peer gatherings (in person or online). Results: Of 780 participants, 50% reported that the COVID-19 pandemic had a negative impact on personal income and 58.3% reported negative impact on access to TNB peer gatherings. Depression and anxiety symptoms increased from prepandemic to follow-up, and most participants were above measurement cutoffs for clinical levels at both time points. Change in finances and access to TNB peer gatherings interacted with prepandemic depression scores to predict depression symptoms during the COVID-19 pandemic. For participants with high prepandemic depression scores, financial stability predicted pandemic depression scores comparable to that predicted by negative financial change. No interaction was found between these variables when predicting anxiety symptoms during the COVID-19 pandemic. Conclusion: Findings underscore the influence of inequality and prepandemic mental health when considering the impact of COVID-19 on wellbeing. Results suggest need for multifaceted programs and services, including financial support and meaningful TNB community engagement, to address barriers to health equity posed by systematic gender oppression.

Rare exemplars and missed opportunities: Intersectionality within current sexual and gender diversity research and scholarship in psychology.

Using intersectionality as our critical analytical framework, we examined 22 articles on sexual and gender diversity (SGD) published in peer-reviewed psychology journals between January and June 2022 to: (1) identify their engagement with intersectionality's core themes; and (2) highlight key findings and directions for future intersectional SGD research. Our review includes 12 theoretical and empirical articles that addressed a breadth of topics such as intersectional stigma/discrimination, gendered racism, minority stress, and intersectional ableism. This review highlights opportunities within intersectional SGD research in psychology to provide a needed corrective to the discipline's tradition of individualistic, single-axis research focused on predominantly White, cisgender and heterosexual people, and attend to intersectionality's focus on intersecting power relations and commitments to social justice.

Experiences and Stressors of Parents of Trans and Gender-Diverse Youth in Clinical Care from Trans Youth CAN!

Parents of trans and gender-diverse youth can experience challenges navigating gender-affirming (GA) care such as stigma, transphobia, and lack of support. There is little information available about stressors, worries, and positive feelings of parents as they try to support their youth accessing GA care. This article presents baseline survey data on experiences and stressors of 160 parents/caregivers in the Trans Youth CAN! cohort study, which examined medical, social, and family outcomes in youth age 16 years or younger considering puberty blockers or GA hormones. Data were collected at 10 Canadian gender clinics. Authors report on participating parents' characteristics, levels of support toward youth, stressors, worries, concerns, and positive feelings related to youth's gender. Most parent participants were White (85.1 percent), female (85.1 percent), birth or adoptive parents (96.1 percent), and reported strong support for youth's gender. Participants' concerns included their youth facing rejection (81.9 percent), generalized transphobia (74.6 percent), or encountering violence (76.4 percent). Parents also reported positive feelings about seeing their youth grow more confident. Most parental worries and stressors were situated outside the family, reflecting the systemic discrimination faced by youth and their families. Social workers could address these by developing systems-focused interventions and by further taking into account intersectional health disparities.

Quantitative methods for descriptive intersectional analysis with binary health outcomes.

Intersectionality recognizes that in the context of sociohistorically shaped structural power relations, an individual's multiple social positions or identities (e.g., gender, ethnicity) can interact to affect health-related outcomes. Despite limited methodological guidance, intersectionality frameworks have increasingly been incorporated into epidemiological studies, both to describe health disparities and to examine their causes. This study aimed to advance methods in intersectional estimation of binary outcomes in descriptive health disparities research through evaluation of 7 potentially intersectional data analysis methods: cross-classification, regression with interactions, multilevel analysis of individual heterogeneity (MAIHDA), and decision trees (CART, CTree, CHAID, random forest). Accuracy of estimated intersection-specific outcome prevalence was evaluated across 192 intersections using simulated data scenarios. For comparison we included a non-intersectional main effects regression. We additionally assessed variable selection performance amongst decision trees. Example analyses using National Health and Nutrition Examination Study data illustrated differences in results between methods. At larger sample sizes, all methods except for CART performed better than non-intersectional main effects regression. In smaller samples, MAIHDA was the most accurate method but showed no advantage over main effects regression, while random forest, cross-classification, and saturated regression were the least accurate, and CTree and CHAID performed moderately well. CART performed poorly for estimation and variable selection. Sensitivity analyses examining the bias-variance tradeoff suggest MAIHDA as the preferred unbiased method for accurate estimation of high-dimensional intersections at smaller sample sizes. Larger sample sizes are more imperative for other methods. Results support the adoption of an intersectional approach to descriptive epidemiology.

Latent variable and clustering methods in intersectionality research: systematic review of methods applications.

PURPOSE: An intersectionality framework has been increasingly incorporated into quantitative study of health inequity, to incorporate social power in meaningful ways. Researchers have identified "person-centered" methods that cluster within-individual characteristics as appropriate to intersectionality. We aimed to review their use and match with theory. METHODS: We conducted a multidisciplinary systematic review of English-language quantitative studies wherein authors explicitly stated an intersectional approach, and used clustering methods. We extracted study characteristics and applications of intersectionality. RESULTS: 782 studies with quantitative applications of intersectionality were identified, of which 16 were eligible: eight using latent class analysis, two latent profile analysis, and six clustering methods. Papers used cross-sectional data (100.0%) primarily had U.S. lead authors (68.8%) and were published within psychology, social sciences, and health journals. While 87.5% of papers defined intersectionality and 93.8% cited foundational authors, engagement with intersectionality method literature was more limited. Clustering variables were based on social identities/positions (e.g., gender), dimensions of identity (e.g., race centrality), or processes (e.g., stigma). Results most commonly included four classes/clusters (60.0%), which were frequently used in additional analyses. These described sociodemographic differences across classes/clusters, or used classes/clusters as an exposure variable to predict outcomes in regression analysis, structural equation modeling, mediation, or survival analysis. Author rationales for method choice included both theoretical/intersectional and statistical arguments. CONCLUSION: Latent variable and clustering methods were used in varied ways in intersectional approaches, and reflected differing matches between theory and methods. We highlight situations in which these methods may be advantageous, and missed opportunities for additional uses.

Health care access among transgender and nonbinary people in Canada, 2019: a cross-sectional survey.

BACKGROUND: Previous Canadian studies have identified problems regarding health care access for transgender (trans) and nonbinary people, but all-ages national data have been lacking. This study describes access to care among trans and nonbinary people in Canada, and compares health care access across provinces or regions. METHODS: We conducted a bilingual, multimode cross-sectional survey (Trans PULSE Canada) from July 26 to Oct. 1, 2019. We recruited trans and nonbinary people aged 14 years and older using convenience sampling. We assessed 5 outcomes: having a primary care provider, having a primary care provider with whom the respondent was comfortable discussing trans health issues, past-year unmet health care need, medical gender affirmation status, and being on a wait-list to access gender-affirming medical care. Average marginal predictions were estimated from multivariable logistic regression models with multiply imputed data. RESULTS: The survey included 2873 participants, and 2217 surveys were analyzed after exclusions. Of the 2217 trans and nonbinary respondents, most had a primary care provider (n = 1803; 81.4%, 95% confidence interval [CI] 79.8%-83.0%), with model-predicted probabilities from 52.1% (95% CI 20.2%-84.1%) in the territories to 92.9% (95% CI 83.5%-100.0%) in Newfoundland and Labrador. Of the respondents, 52.3% (n = 1150; 95% CI 50.3%-54.2%) had a primary care provider with whom they were comfortable discussing trans health issues, and 44.4% (n = 978; 95% CI 42.3%-46.4%) reported an unmet health care need. Among participants who needed gender-affirming medical treatment (n = 1627), self-defined treatment completion ranged from an estimated 16.8% (95% CI 0.6%-32.5%) in Newfoundland and Labrador to 59.1% (95% CI 52.5%-65.6%) in Quebec. Of those who needed but had not completed gender-affirming care at the time of the study (n = 1046), 40.7% (n = 416; 95% CI 37.8%-43.6%) were on a wait-list, most often for surgery. These outcomes, with the exception of having a provider with whom one is comfortable discussing trans issues, varied significantly by province or region (p < 0.05). INTERPRETATION: Participants reported considerable unmet needs or delays in primary, general and gender-affirming care, with significant regional variation. Our results indicate that, despite efforts toward equity in access to care for trans and nonbinary people in Canada, inequities persist.

Advancing Intersectional Discrimination Measures for Health Disparities Research: Protocol for a Bilingual Mixed Methods Measurement Study.

BACKGROUND: Guided by intersectionality frameworks, researchers have documented health disparities at the intersection of multiple axes of social status and position, particularly race and ethnicity, gender, and sexual orientation. To advance from identifying to intervening in such intersectional health disparities, studies that examine the underlying mechanisms are required. Although much research demonstrates the negative health impacts of perceived discrimination along single axes, quantitative approaches to assessing the role of discrimination in generating intersectional health disparities remain in their infancy. Members of our team recently introduced the Intersectional Discrimination Index (InDI) to address this gap. The InDI comprises three measures of enacted (day-to-day and major) and anticipated discrimination. These attribution-free measures ask about experiences of mistreatment because of who you are. These measures show promise for intersectional health disparities research but require further validation across intersectional groups and languages. In addition, the proposal to remove attributions is controversial, and no direct comparison has ever been conducted. OBJECTIVE: This study aims to cognitively and psychometrically evaluate the InDI in English and Spanish and determine whether attributions should be included. METHODS: The study will draw on a preliminary validation data set and three original sequentially collected sources of data: qualitative cognitive interviews in English and Spanish with a sample purposively recruited across intersecting social status and position (gender, sexual orientation, race and ethnicity, socioeconomic status, age, and nativity); a Spanish quantitative survey (n=500; 250/500, 50% sexual and gender minorities); and an English quantitative survey (n=3000), with quota sampling by race and ethnicity (Black, Latino/a/x, and White), sexual or gender minority status, and gender. RESULTS: The study was funded by the National Institute on Minority Health and Health Disparities in May 2021, and data collection began in July 2021. CONCLUSIONS: The key deliverables of the study will be bilingual measures of anticipated, day-to-day, and major discrimination validated for multiple health disparity populations using qualitative, quantitative, and mixed methods. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/30987.

Gender-concordant identity documents and mental health among transgender adults in the USA: a cross-sectional study.

BACKGROUND: Transgender (trans) people experience profound mental health disparities compared with the general population, attributable in part to the psychological effects of gender non-affirmation. Despite the barriers to legal gender affirmation for trans people, little is known about its association with mental health. We therefore sought to determine whether having gender-concordant identity documents (IDs) is associated with mental health among trans adults in the USA. We hypothesised that having an ID that reflects one's preferred name and gender marker would be associated with reduced psychological distress and suicide risk. METHODS: In this cross-sectional observational study, we obtained data from the 2015 US Transgender Survey, the largest cross-sectional survey of trans adults in the USA, with 27 715 participants. Eligible participants were adults (≥18 years), residing in a US state, territory, or overseas US military base; and considered themselves transgender, trans, genderqueer, non-binary, or similar. We excluded participants not living day-to-day in a different gender to the sex they were assigned at birth, participants who identified as crossdressers, and those missing data. The primary exposure of interest was whether all or some (vs none) of a respondent's IDs reflected their preferred name and gender marker. We examined associations with psychological distress (measured with the Kessler 6 scale) and suicide ideation, planning, and attempts in the past year, which we analysed using linear and modified Poisson regression models to examine associations with respondents' IDs. FINDINGS: Of 22 286 respondents included in our analytic sample, 10 288 (weighted percentage 45·1%) had their preferred name and gender marker on none, 9666 (44·2%) on some, and 2332 (10·7%) on all of their IDs. Compared with those with no gender-concordant ID, respondents for whom all IDs were concordant had lower prevalence of serious psychological distress (adjusted prevalence ratio 0·68, 95% CI 0·61-0·76), suicidal ideation (0·78, 0·72-0·85), and suicide planning (0·75, 0·64-0·87), adjusting for potential confounders. Having some versus no concordant ID was generally associated with smaller reductions in distress and suicidality. Gender-concordant ID was not associated with suicide attempts (eg, adjusted prevalence ratio for all vs no IDs was 0·92, 95% CI 0·68-1·24). INTERPRETATION: Possession of gender-concordant IDs might improve mental health among trans persons. Gender recognition policies should be considered structural determinants of transgender health. FUNDING: None.

Math versus meaning in MAIHDA: A commentary on multilevel statistical models for quantitative intersectionality.

RATIONALE: Intersectionality has been increasingly adopted as a theoretical framework within quantitative research, raising questions about the congruence between theory and statistical methodology. Which methods best map onto intersectionality theory, with regard to their assumptions and the results they produce? Which methods are best positioned to provide information on health inequalities and direction for their remediation? One method, multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA), has been argued to provide statistical efficiency for high-dimensional intersectional analysis along with valid intersection-specific predictions and tests of interactions. However, the method has not been thoroughly tested in scenarios where ground truth is known. METHOD: We perform a simulation analysis using plausible data generating scenarios where intersectional effects are present. We apply variants of MAIHDA and ordinary least squares regression to each, and we observe how the effects are reflected in the estimates that the methods produce. RESULTS: The first-order fixed effects estimated by MAIHDA can be interpreted neither as effects on mean outcome when interacting variables are set to zero (as in a correctly-specified linear regression model), nor as effects on mean outcome averaged over the individuals in the population (as in a misspecified linear regression model), but rather as effects on mean outcome averaged over an artificial population where all intersections are of equal size. Furthermore, the values of the random effects do not reflect advantage or disadvantage of different intersectional groups. CONCLUSIONS: Because first-order fixed effects estimates are the reference point for interpreting random effects as intersectional effects in MAIHDA analyses, the random effects alone do not provide meaningful estimates of intersectional advantage or disadvantage. Rather, the fixed and random parts of the model must be combined for their estimates to be meaningful. We therefore advise caution when interpreting the results of MAIHDA in quantitative intersectional analyses.

Advancing quantitative intersectionality research methods: Intracategorical and intercategorical approaches to shared and differential constructs.

A range of methods have recently been proposed for incorporating intersectionality theoretical frameworks into quantitative research methodology. We published a pair of articles on methods for intercategorical intersectionality, in which we distinguished analytic from descriptive studies, identified causal mediation decomposition methods as an appropriate strategy for analytic intercategorical intersectionality, and introduced and validated a group of three new measures of major, day-to-day, and anticipated discrimination for use in intercategorical analysis (Bauer and Scheim, 2019; Scheim and Bauer, 2019). We respond to points raised in four invited commentaries on our original pair of articles-by Evans (2019); Jackson and VanderWeele (2019); Harnois and Bastos (2019); and Richman and Zucker (2019). We discuss differential constructs, which represent those that exist only for those at particular intersections, or for which meanings vary across intersections. Whereas such constructs may be studied intracategorically, in intercategorical studies they place limits on both the types of measures that may be used and the statistical analyses that can be conducted. Most quantitative intersectionality methods work has therefore focused on intracategorical measures, but intercategorical analyses. We present a preliminary agenda for continued methods development in quantitative intersectionality methods.

Methods for analytic intercategorical intersectionality in quantitative research: Discrimination as a mediator of health inequalities.

RATIONALE: Intersectionality as a theoretical framework has gained prominence in qualitative research on social inequity. Intercategorical quantitative applications have focused primarily on describing health or social inequalities across intersectional groups, coded using cross-classified categories or interaction terms. This descriptive intersectionality omits consideration of the mediating processes (e.g., discrimination) through which intersectional positions impact outcome inequalities, which offer opportunities for intervention. OBJECTIVE: We argue for the importance of a quantitative analytic intersectionality. We identify methodological challenges and potential solutions in structuring studies to allow for both intersectional heterogeneity in outcomes and in the ways that processes such as discrimination may cause these outcomes for those at different intersections. METHOD: To incorporate both mediation and exposure-mediator interaction, we use VanderWeele's three-way decomposition methodology, adapt the interpretation for application to analytic intersectionality studies, and present a step-by-step analytic approach. Using online panel data collected from Canada and the United States in 2016 (N = 2542), we illustrate this approach with a statistical analysis of whether and to what extent observed inequalities in psychological distress across intersections of ethnoracial group and sexual or gender minority (SGM) status may be explained by past-year experiences of day-to-day discrimination, assessed using the Intersectional Discrimination Index (InDI). RESULTS AND CONCLUSIONS: We describe actual and adjusted intersectional inequalities in psychological distress and decompose them to identify three component effects for each of 11 intersectional comparison groups (e.g., Indigenous SGM), versus the reference intersectional group that experienced the lowest levels of discrimination (white non-SGM). These reflect the expected inequality in outcome: 1) due to membership in the more discriminated-against group, if its members had experienced the same lower levels of discrimination as the reference intersection; 2) due to unequal levels of discrimination; and 3), due to unequal effects of discrimination. We present considerations for use and interpretation of these methods.

The Intersectional Discrimination Index: Development and validation of measures of self-reported enacted and anticipated discrimination for intercategorical analysis.

BACKGROUND AND OBJECTIVE: Although intersectional approaches have gained traction in population health research, quantitative discrimination and health studies have tended to focus on a single axis of discrimination (e.g., racism, homophobia). As few discrimination measures function across multiple social identities or positions, we developed the Intersectional Discrimination Index (InDI) for intercategorical intersectionality research, including measures of Anticipated (InDI-A), Day-to-Day (InDI-D), and Major (InDI-M) discrimination that do not require attribution to particular grounds. METHODS: We conducted a validity and reliability study with 2016 online survey panel data from Canada and the United States (n = 2583). Internal consistency and dimensionality of the InDI-A were evaluated with exploratory and confirmatory factor analyses. Construct validation included known-groups comparisons, associations with psychological distress, and convergence with existing discrimination measures. Test-retest reliability was examined in a subgroup (n = 150). RESULTS: We found support for use of the InDI-A as a unidimensional scale. As hypothesized, racial and sexual/gender minorities reported higher frequencies of all discrimination types (all p < 0.001), and discrimination varied across intersectional categories. Each InDI component was significantly positively associated with psychological distress after controlling for potential confounders. Frequency scores were strongly positively correlated with existing scales. Intraclass correlation coefficients for test-retest reliability of anticipated, lifetime day-to-day, and lifetime major discrimination ranged from 0.70 to 0.72. CONCLUSIONS: Final InDI measures include the 9-item InDI-A, 9-item InDI-D, and 13-item InDI-M, for which we have found initial evidence of construct validity and reliability. In combination with sociodemographic information, the InDI measures can be used to evaluate the role of discrimination as a mediator of intersectional health inequalities, and to monitor the prevalence and impacts of discrimination in heterogeneous populations.

Transgender-inclusive measures of sex/gender for population surveys: Mixed-methods evaluation and recommendations.

Given that an estimated 0.6% of the U.S. population is transgender (trans) and that large health disparities for this population have been documented, government and research organizations are increasingly expanding measures of sex/gender to be trans inclusive. Options suggested for trans community surveys, such as expansive check-all-that-apply gender identity lists and write-in options that offer maximum flexibility, are generally not appropriate for broad population surveys. These require limited questions and a small number of categories for analysis. Limited evaluation has been undertaken of trans-inclusive population survey measures for sex/gender, including those currently in use. Using an internet survey and follow-up of 311 participants, and cognitive interviews from a maximum-diversity sub-sample (n = 79), we conducted a mixed-methods evaluation of two existing measures: a two-step question developed in the United States and a multidimensional measure developed in Canada. We found very low levels of item missingness, and no indicators of confusion on the part of cisgender (non-trans) participants for both measures. However, a majority of interview participants indicated problems with each question item set. Agreement between the two measures in assessment of gender identity was very high (K = 0.9081), but gender identity was a poor proxy for other dimensions of sex or gender among trans participants. Issues to inform measure development or adaptation that emerged from analysis included dimensions of sex/gender measured, whether non-binary identities were trans, Indigenous and cultural identities, proxy reporting, temporality concerns, and the inability of a single item to provide a valid measure of sex/gender. Based on this evaluation, we recommend that population surveys meant for multi-purpose analysis consider a new Multidimensional Sex/Gender Measure for testing that includes three simple items (one asked only of a small sub-group) to assess gender identity and lived gender, with optional additions. We provide considerations for adaptation of this measure to different contexts.

Health care availability, quality, and unmet need: a comparison of transgender and cisgender residents of Ontario, Canada.

BACKGROUND: Evidence suggests that transgender (trans) individuals in Canada are a medically underserved population; barriers range from lack of provider knowledge on trans issues to refusal of care. This paper provides the first formal estimation of health care inequalities between trans and cisgender individuals in Ontario, Canada. METHODS: Weighted statistics from the Ontario-wide Trans PULSE Project (n = 433) were compared with age-standardized Ontario data from the Canadian Community Health Survey (n = 39,980) to produce standardized prevalence differences (SPDs). Analysis was also conducted separately for trans men and trans women, each compared to the age-standardized Ontario population. RESULTS: An estimated 33.2% (26.4,40.9) of trans Ontarians reported a past-year unmet health care need in excess of the 10.7% expected based on the age-standardized Ontario population. Inequality was greatest comparing trans with cisgender men (SPD = 34.4% (23.0, 46.1). While trans Ontarians evaluated health care availability in Ontario similarly to the broader population, they were significantly more likely to evaluate availability in their community as fair or poor. CONCLUSIONS: Trans Ontarians experience inequalities in perception and reported experiences of health care access, with 43.9% reporting a past-year unmet health care need.

Understanding sexual orientation and health in Canada: Who are we capturing and who are we missing using the Statistics Canada sexual orientation question?

OBJECTIVE: Public health research on inequalities in Canada depends heavily on population data sets such as the Canadian Community Health Survey. While sexual orientation has three dimensions - identity, behaviour and attraction - Statistics Canada and public health agencies assess sexual orientation with a single questionnaire item on identity, defined behaviourally. This study aims to evaluate this item, to allow for clearer interpretation of sexual orientation frequencies and inequalities. METHODS: Through an online convenience sampling of Canadians ≥14 years of age, participants (n = 311) completed the Statistics Canada question and a second set of sexual orientation questions. RESULTS: The single-item question had an 85.8% sensitivity in capturing sexual minorities, broadly defined by their sexual identity, lifetime behaviour and attraction. Kappa statistic for agreement between the single item and sexual identity was 0.89; with past year, lifetime behaviour and attraction were 0.39, 0.48 and 0.57 respectively. The item captured 99.3% of those with a sexual minority identity, 84.2% of those with any lifetime same-sex partners, 98.4% with a past-year same-sex partner, and 97.8% who indicated at least equal attraction to same-sex persons. CONCLUSION: Findings from Statistics Canada surveys can be best interpreted as applying to those who identify as sexual minorities. Analyses using this measure will underidentify those with same-sex partners or attractions who do not identify as a sexual minority, and should be interpreted accordingly. To understand patterns of sexual minority health in Canada, there is a need to incorporate other dimensions of sexual orientation.

Sexual Orientation Disclosure in Primary Care Settings by Gay, Bisexual, and Other Men Who Have Sex with Men in a Canadian City.

PURPOSE: Sexual orientation affects individuals' health histories and is fundamental to providers' understanding of patients as a whole. Gay, bisexual, and other men who have sex with men (GB-MSM) are vulnerable to certain health conditions, including HIV. The aim of this exploratory analysis was to examine factors associated with sexual orientation disclosure and communication with providers about GB-MSM health issues and to discuss implications. METHODS: We conducted a cross-sectional internet survey of GB-MSM (n = 202) in London-Middlesex, Ontario, Canada; analyses were limited to those with a regular primary care provider (n = 173). Blockwise regression models explored demographic, psychosocial, and healthcare-related factors associated with sexual orientation disclosure and physician-patient communication about GB-MSM-related health. RESULTS: Just over seventy-one percent (71.1%) of participants reported that their primary care provider (PCP) knew their sexual orientation, and 44.5% had talked to them about GB-MSM health. Overt negative comments or being refused care based on sexual orientation occurred infrequently, although 26.6% reported their provider had assumed they were heterosexual. Being married to or living common-law with another man, more frequent experiences of homosexual prejudice, and higher quality assessment of provider's communication skills were associated with the PCP knowing respondents' sexual orientation. Greater internalized homonegativity was associated with not talking to a PCP about GB-MSM-related health issues. More frequent experiences of homosexual prejudice, higher assessment of provider communication, and having prior negative experiences with a PCP were significantly associated with talking to a PCP about GB-MSM health. CONCLUSION: The majority of our sample disclosed their sexual orientation; however, not all patients voluntarily disclose. Medical training and education in Canada, where specific rights protections exist for sexual orientation minority populations, should emphasize awareness of essential patient health information. Training should include information about GB-MSM health and building a foundation on how to speak with GB-MSM patients nonjudgmentally.

Methods Used and Topics Addressed in Quantitative Health Research on Gay, Bisexual and Other Men Who Have Sex With Men: A Systematic Review of the Literature.

Research on sexual minority men (gay, bisexual, and other men who have sex with men) was examined with regard to the measures of sexual orientation used, the methods of research, and the main health outcomes under study. A systematic review of English-language quantitative studies was conducted focused on the health of sexual minority men published in 2010 (n = 250). The results provide a snapshot of the literature and revealed that research on sexual minority men overwhelmingly focused on HIV, STIs, and sexual health for which sexual orientation was most commonly defined behaviorally. For topics of mental health or body/fitness outcomes, sexual orientation was most commonly defined by identity. Most study samples were venue-based, and only 8.8% of published papers drew data from population-based samples. The findings suggest that there exists a need for research on sexual minority men's health beyond STIs and HIV that will examine mental and physical health outcomes beyond sexual risk, uses probability-based samples, and addresses intersectional concerns related to race/ethnicity and age.

Bisexuality, poverty and mental health: A mixed methods analysis.

Bisexuality is consistently associated with poor mental health outcomes. In population-based data, this is partially explained by income differences between bisexual people and lesbian, gay, and/or heterosexual individuals. However, the interrelationships between bisexuality, poverty, and mental health are poorly understood. In this paper, we examine the relationships between these variables using a mixed methods study of 302 adult bisexuals from Ontario, Canada. Participants were recruited using respondent-driven sampling to complete an internet-based survey including measures of psychological distress and minority stress. A subset of participants completed a semi-structured qualitative interview to contextualize their mental health experiences. Using information regarding household income, number of individuals supported by the income and geographic location, participants were categorized as living below or above the Canadian Low Income Cut Off (LICO). Accounting for the networked nature of the sample, participants living below the LICO had significantly higher mean scores for depression and posttraumatic stress disorder symptoms and reported significantly more perceived discrimination compared to individuals living above the LICO. Grounded theory analysis of the qualitative interviews suggested four pathways through which bisexuality and poverty may intersect to impact mental health: through early life experiences linked to bisexuality or poverty that impacted future financial stability; through effects of bisexual identity on employment and earning potential; through the impact of class and sexual orientation discrimination on access to communities of support; and through lack of access to mental health services that could provide culturally competent care. These mixed methods data help us understand the income disparities associated with bisexual identity in population-based data, and suggest points of intervention to address their impact on bisexual mental health.

Social and Proximate Determinants of the Frequency of Condom Use Among African, Caribbean, and Other Black People in a Canadian City: Results from the BLACCH Study.

African, Caribbean, and other Black (ACB) people are a priority group for HIV prevention in Canada, but little is known about condom use in this population. This exploratory community-based research project addresses this gap in knowledge. 125 sexually active ACB people completed a questionnaire covering condom use and social determinants of health. The data were analyzed using ordinal logistic regression and mediation analyses. 20.5 % of sexually active ACB adults used condoms consistently. Male gender, wealth, unstable immigration classes, and unsecure employment statuses were independently associated with more frequent condom use. Proximate determinants mediating these relationships included: not having a cohabiting regular partner, not disliking condoms, and having a history of unwanted sex. The proximate determinants mediated 85.7-97.6 % of the effects of the social determinants. These results link social context and proximate factors with condom use. They can be used to design evidence-informed interventions for ACB people.

Sociodemographic Differences by Survey Mode in a Respondent-Driven Sampling Study of Transgender People in Ontario, Canada.

PURPOSE: To describe survey mode uptake and sociodemographic differences by mode among respondents to a respondent-driven sampling survey of transgender people in Ontario, Canada. Survey mode was left to participant choice. METHODS: Data were collected from 433 transgender Ontarians in 2009-2010 through a self-administered questionnaire, available online, by paper copy, or by telephone with language interpretation. RESULTS: Paper respondents (9.5%) were significantly more likely to be Aboriginal or persons of color, underhoused, sex workers, and unemployed or receiving disability benefits. CONCLUSION: In Canada and similar high-income countries, sampling transgender populations that are diverse with respect to social determinants of health may be best carried out with multimode surveys.