Frequency of self-reported persistent post-treatment genital hypoesthesia among past antidepressant users: a cross-sectional survey of sexual and gender minority youth in Canada and the US.

PURPOSE: Persistent post-treatment genital hypoesthesia (PPTGH) is a primary symptom of post-SSRI sexual dysfunction (PSSD), an iatrogenic syndrome characterized by enduring sexual dysfunction following the discontinuation of some antidepressants. We aimed to estimate the frequency of PPTGH among past users of psychiatric treatments, particularly antidepressants. METHODS: We used a subsample of UnACoRN, a US/Canada survey of sexual and gender minority youth aged 15 to 29. We included participants with a history of psychiatric drug use. We excluded individuals with genital surgeries or without sexual experience. The analysis involved chi-square tests for initial group comparisons, post hoc tests for multiple comparisons, and logistic regression among those who had stopped taking medication. We exponentiated the regression to estimate the odds of PPTGH by drug type, adjusting for age, sex-assigned-at-birth, hormone treatment, and depression severity in three nested models. RESULTS: 574 of 2179 survey participants reported genital hypoesthesia. They were older and more likely to report male sex assignment at birth, hormonal therapy history, and psychiatric drug history. The frequency of PPTGH among antidepressant users was 13.2% (93/707) compared to 0.9% (1/102) among users of other medications; adjusted odds ratio: 14.2 (95% CI: 2.92 to 257). CONCLUSION: Antidepressant discontinuation is strongly associated with PPTGH in the US and Canada where SSRI/SNRI medications account for 80% of antidepressant prescriptions. We call for standardized international warnings and transparent, informed consent. Future research should expand upon our efforts to estimate the risk of PSSD by including all the proposed diagnostic criteria, including documentation of temporal changes in PSSD-related symptoms before and after treatment (≥3 months).

This study explored the long-lasting sexual side effects­specifically, reduced genital sensitivity­of certain antidepressants, even after stopping the medication, in a diverse group of young people, primarily those identifying as sexual and gender minorities. We analyzed responses from a large survey, focusing on participants with a history of psychiatric drug use but without genital surgeries. Our findings indicate that those who used antidepressants experienced a substantial increase in reports of reduced genital sensitivity­13.2% of antidepressant users compared to 0.9% of users of other medications. This symptom is more common among individuals who had used antidepressants and sedatives. Our results emphasize the necessity for clear warnings and proper consent processes about potential long-term sexual side effects, particularly for young patients, and standardization of these procedures across countries. Further research is needed to explore this condition more deeply, including studies of all related symptoms and their development over time before and after treatment.

Discontinuation of Gender-Affirming Medical Treatments: Prevalence and Associated Features in a Nonprobabilistic Sample of Transgender and Gender-Diverse Adolescents and Young Adults in Canada and the United States.

PURPOSE: This study investigated the prevalence, correlates, and reasons for discontinuing gender-affirming medical treatment (GAMT) among transgender and gender-diverse adolescents and young adults living in Canada and the United States of America. METHODS: This exploratory study used data from an online survey of sexual and gender minority adolescents and young adults aged 15-29 years living in Canada or the United States of America (March-August 2022). The analytic sample was constituted by participants who responded to questions regarding starting and stopping GAMT, as well as reasons for stopping. Correlates of discontinuing GAMT were assessed using univariate logistic regression. RESULTS: The mean age of the analytic sample (N = 3,937) was 21.1 years. Participants were predominantly nonbinary (54.2%) and assigned female at birth (80.8%). 75.5% lived in Canada and 24.5% in the United States of America. Among those who had started GAMT, 121 of 720 (16.8%) reported having ever discontinued treatment. Forty five of 121 (37.2%) who ceased GAMT reported "Yes, but I wish I hadn't." The most frequently endorsed reasons for discontinuing GAMT were health reasons (37.3%), a change in gender identity (32.0%), and cost (16.0%). Greater age; nonbinary identity, 'other' gender identity; diagnosis of or self-identifying as living with schizophrenia; residing in the United States of America (relative to Canada); and endorsing a current Christian identity were associated with discontinuation. Ninety seven of 121 (80.2%) who discontinued GAMT reported a current transgender or gender-diverse identity. DISCUSSION: Given the dearth of information about the subpopulation who discontinue GAMT, this study advances candidate factors to inform future longitudinal research to better understand the multiple reasons and contexts for stopping GAMT.

"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.

Detransition Narratives Trouble the Simple Attribution of Madness in Transantagonistic Contexts: A Qualitative Analysis of 16 Canadians' Experiences.

Emerging evidence suggests that transgender individuals are more likely than cisgender peers to receive a diagnosis with a primary mental disorder. Attributions of madness, though, may serve the social function of dismissing and discrediting transgender individual's self-perceptions. The narratives of individuals who stop or reverse an initial gender transition who also identify as living with mental health conditions can sometimes amplify these socio-political discourses about transgender people. Through a critical mental health lens, this article presents a qualitative analysis of 16 individuals who stopped or reversed a gender transition and who also reported a primary mental health condition. Semi-structured, virtual interviews were conducted with people living in Canada. Applying constructivist grounded theory methodology, and following an iterative, inductive approach to analysis, we used the constant comparative method to analyse these 16 in-depth interviews. Results show rich complexity such that participants narrated madness in nuanced and complex ways while disrupting biased attitudes that madness discredited their thoughts and feelings, including prior gender dysphoria. Instead, participants incorporated madness into expanding self-awareness and narrated their thoughts and feelings as valid and worthy. Future research must consider provider's perspectives, though, in treating mad individuals who detransitioned, since alternate gender-affirming care models may better support the identification and wellness of care-seeking individuals who may be identified (in the past, present, or future) as mad.

Exploring Mediators of Mental Health Service Use Among Transgender Individuals in Ontario, Canada.

OBJECTIVES: To determine if and to what degree neighbourhood-level marginalization mediates mental health service use among transgender individuals. METHODS: This retrospective cohort study identified 2,085 transgender individuals through data obtained from 4 outpatient community and hospital clinics in 3 large cities in Ontario, which were linked with administrative health data between January 2015 and December 2019. An age-matched 1:5 comparison cohort was created from the general population of Ontario. Outcome measures were analysed from March 2020 to May 2022. The primary outcome was mental health service utilization, which included mental health-related visits to primary care providers, psychiatrists, mental health- and self-harm-related emergency department visits, and mental health hospitalizations. Mediation variables included ethnic concentration, residential instability, dependency, and material deprivation at the neighbourhood level and were derived from the Ontario Marginalization Index. RESULTS: This study identified 2,085 transgender individuals from participating outpatient community and hospital clinics, who were matched to the general population (n = 10,425). Overall, neighbourhood-level marginalization did not clinically mediate mental health service use. However, transgender individuals were more likely to be exposed to all forms of neighbourhood-level marginalization, as well as having higher rates of health service use across all outcome measures. CONCLUSIONS: In this study, mental health service use among transgender individuals was not clinically mediated by marginalization at the neighbourhood level. This study highlights the need to explore marginalization and mental health service use at the individual level to better understand the mental health disparities experienced by transgender individuals and to ensure that health-care services are inclusive and affirming.

Disruptions of sexually transmitted and blood borne infections testing services during the COVID-19 pandemic: accounts of service providers in Ontario, Canada.

BACKGROUND: Since the onset of the COVID-19 pandemic in March 2020 in Canada, the availability of sexual health services including sexually transmitted and blood-borne infection (STBBI) testing has been negatively impacted in the province of Ontario due to their designation as "non-essential" health services. As a result, many individuals wanting to access sexual healthcare continued to have unmet sexual health needs throughout the pandemic. In response to this, sexual health service providers have adopted alternative models of testing, such as virtual interventions and self-sampling/testing. Our objective was to investigate service providers' experiences of disruptions to STBBI testing during the COVID-19 pandemic in Ontario, Canada, and their acceptability of alternative testing services. METHODS: Between October 2020-February 2021, we conducted semi-structured virtual focus groups (3) and in-depth interviews (11) with a diverse group of sexual health service providers (n = 18) including frontline workers, public health workers, sexual health nurses, physicians, and sexual health educators across Ontario. As part of a larger community-based research study, data collection and analysis were led by three Peer Researchers and a Community Advisory Board was consulted throughout the research process. Transcripts were transcribed verbatim and analysed with NVivo software following grounded theory. RESULTS: Service providers identified the reallocation of public health resources and staff toward COVID-19 management, and closures, reduced hours, and lower in-person capacities at sexual health clinics as the causes for a sharp decline in access to sexual health testing services. Virtual and self-sampling interventions for STBBI testing were adopted to increase service capacity while reducing risks of COVID-19 transmission. Participants suggested that alternative models of testing were more convenient, accessible, safe, comfortable, cost-effective, and less onerous compared to traditional clinic-based models, and that they helped fill the gaps in testing caused by the pandemic. CONCLUSIONS: Acceptability of virtual and self-sampling interventions for STBBI testing was high among service providers, and their lived experiences of implementing such services demonstrated their feasibility in the context of Ontario. There is a need to approach sexual health services as an essential part of healthcare and to sustain sexual health services that meet the needs of diverse individuals.

Academic Productivity of Equity-Deserving Physician Scholars During COVID-19: A Scoping Review.

PURPOSE: The COVID-19 pandemic presented new barriers and exacerbated existing inequities for physician scholars. While COVID-19's impact on academic productivity among women has received attention, the pandemic may have posed additional challenges for scholars from a wider range of equity-deserving groups, including those who hold multiple equity-deserving identities. To examine this concern, the authors conducted a scoping review of the literature through an intersectionality lens. METHOD: The authors searched peer-reviewed literature published March 1, 2020, to December 16, 2021, in Ovid MEDLINE, Ovid Embase, and PubMed. The authors excluded studies not written in English and/or outside of academic medicine. From included studies, they extracted data regarding descriptions of how COVID-19 impacted academic productivity of equity-deserving physician scholars, analyses on the pandemic's reported impact on productivity of physician scholars from equity-deserving groups, and strategies provided to reduce the impact of the COVID-19 pandemic on academic productivity of physician scholars from equity-deserving groups. RESULTS: Of 11,587 unique articles, 44 met inclusion criteria, including 15 nonempirical studies and 29 empirical studies (22 bibliometrics studies, 6 surveys, and 1 qualitative study). All included articles focused on the gendered impact of the pandemic on academic productivity. The majority of their recommendations focused on how to alleviate the burden of the pandemic on women, particularly those in the early stages of their career and/or with children, without consideration of scholars who hold multiple and intersecting identities from a wider range of equity-deserving groups. CONCLUSIONS: Findings indicate a lack of published literature on the pandemic's impact on physician scholars from equity-deserving groups, including a lack of consideration of physician scholars who experience multiple forms of discrimination. Well-intentioned measures by academic institutions to reduce the impact on scholars may inadvertently risk reproducing and sustaining inequities that equity-deserving scholars faced during the pandemic.

Cisnormativity as a structural barrier to STI testing for trans masculine, two-spirit, and non-binary people who are gay, bisexual, or have sex with men.

Trans masculine, two-spirit, and non-binary people who are gay, bisexual or otherwise have sex with men (TGBM) are under-tested for sexually transmitted infections (STI) and may face complex, intersectional barriers that prevent them from accessing STI testing. As part of a study on gay, bisexual and other men who have sex with men's (GBM) experiences of current STI testing systems in Ontario, Canada, this paper reports on the findings from TGBM participants' experiences with in-person STI testing in a range of venues (i.e. Family doctors, walk-in clinics, and community-based organizations) to explore testing barriers specific to TGBM. Using a community-based research approach, between June 2020 and December 2021 peer researchers who identified as GBM conducted focus groups and interviews with 38 cis and trans GBM, 13 of whom identified as TGBM. Data were analyzed following grounded theory. When questioned about past experiences with testing, TGBM participants reported several barriers to STI testing within current testing models in Ontario due to cisnormativity and heteronormativity. Cisnormativity is the assumption that everyone identifies as the gender they were assigned at birth, and those who do not are considered "abnormal", while heteronormativity is when it is assumed that everyone is heterosexual. From our research we identified three overarching themes concerning testing barriers among TGBM participants: (1) non-inclusive clinic environments, (2) lack of provider knowledge and competency, and (3) legal documentation. Inherent cis and heteronormativity in healthcare institutions appear to be factors shaping the historical under-testing for STI in the TGBM population. These findings suggest the relevance of implementing trans-specific clinical practices that reduce the stigma and barriers faced by TGBM in STI testing contexts, including: hosting all-gender testing hours, opening more LGBTQ+ clinics, offering training in transgender health to testing providers, and conducting a review of how gender markers on health documents can be more inclusive of trans, two-spirit, and non-binary communities.

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.

"Mental Readiness" and Gatekeeping in Trans Healthcare.

Gatekeeping refers to clinicians' strict application of eligibility criteria to determine a trans patient's "fitness" to engage in medical transition, resulting in significant barriers to gender-affirming care. Gatekeeping often uses "mental readiness" as a prerequisite to medical transition, which contributes to patient distress and systemic discrimination. Changing international trans health guidelines (the new World Professional Association for Transgender Health Standards of Care version 8) recommends clinicians shift from a gatekeeping model towards an informed consent model, which improves access to care. This commentary offers recommendations on how clinicians can reconsider existing "mental readiness" frameworks around medical transition to facilitate improved access to care.

Examining TikTok's Potential for Community-Engaged Digital Knowledge Mobilization With Equity-Seeking Groups.

Social media is increasingly being leveraged by researchers to engage in public debates and rapidly disseminate research results to health care providers, health care users, policy makers, educators, and the general public. This paper contributes to the growing literature on the use of social media for digital knowledge mobilization, drawing particular attention to TikTok and its unique potential for collaborative knowledge mobilization with underserved communities who experience barriers to health care and health inequities (eg, equity-seeking groups). Setting the TikTok platform apart from other social media are the unique audiovisual video editing tools, together with an impactful algorithm, that make knowledge dissemination and exchange with large global audiences possible. As an example, we will discuss digital knowledge mobilization with trans and nonbinary (trans) communities, a population that experiences barriers to health care and is engaged in significant peer-to-peer health information sharing on the web. To demonstrate, analytics data from 13 selected TikTok videos on the topic of research on gender-affirming medicine (eg, hormonal therapy and surgeries) are presented to illustrate how knowledge is disseminated within the trans community via TikTok. Considerations for researchers planning to use TikTok for digital knowledge mobilization and other related community engagement with equity-seeking groups are also discussed. These include the limitations of TikTok analytics data for measuring knowledge mobilization, population-specific concerns related to community safety on social media, the spread of disinformation, barriers to internet access, and commercialization and intellectual property issues. This paper concludes that TikTok is an innovative social media platform that presents possibilities for achieving transformative, community-engaged knowledge mobilization among researchers, underserved health care users, and their health care providers, all of whom are necessary to achieve better health care and population health outcomes.

Caught between HIV exceptionalism and health service integration: Making visible the role of public health policy in the scale-up of novel sexual health services.

The role of contextual factors for program implementation is well-documented; however, their changing function throughout implementation phases is less established. We conducted an institutional ethnography to understand how structural conditions for scaling up initiatives are shaped by public health policy. We conducted 25 interviews with implementers of a comprehensive sexual health testing service in Canada, 21 meeting observations, and textual analyses of key policies and reports. Our analysis revealed a disjuncture between implementers' task of scaling up programming and the actualities of working within the discursive and material confines of policies premised on HIV exceptionalism and underfunded integrated health services.

Patient perspectives on the implementation of routinised syphilis screening with HIV viral load testing: Qualitative process evaluation of the Enhanced Syphilis Screening Among HIV-positive Men trial.

BACKGROUND: Syphilis infections have been on the rise, affecting men living with HIV in urban centres disproportionately. Since individuals in HIV care undergo routine blood testing, HIV clinics provide practical opportunities to conduct regular and frequent syphilis testing. Following the implementation of a routine syphilis testing intervention in HIV outpatient clinics, we conducted a qualitative process evaluation of patient experiences to measure patient acceptability, barriers to implementation, and facilitators of successful uptake. METHODS: Upon completion of the trial, which took place at four HIV outpatient clinics in Toronto and Ottawa, Canada, we recruited male patients attending these clinics from November 2017 to April 2018. Interviews were conducted on-site and were audio-recorded and transcribed verbatim. All participants provided written informed consent. Interview data were analyzed using grounded theory, assessing qualitative modulators of effective uptake of routinised syphilis testing. RESULTS: A total of 21 male patients were interviewed. Overall, interviewees found the clinical intervention acceptable, endorsing the practice of routinising syphilis testing alongside regular viral load bloodwork. Some men preferred, based on their self-assessment of syphilis risk, to opt out of testing; we considered this as a potential barrier to uptake of population-wide routinised syphilis testing. Interviewees also identified multiple facilitators of successful uptake, including the de-stigmatising of STI testing as a consequence of the universal nature of routinised testing. Participants recommended a routinised syphilis screening intervention to give patients peace of mind surrounding their sexual health. Participants identified HIV care clinics as comfortable and efficient locations to offer testing. CONCLUSIONS: Overall, most men were in support of implementing routinised syphilis testing as part of standard HIV care. From the patient perspective, HIV care clinics are convenient places to be tested for syphilis, and the routine approach was viewed to have a de-stigmatisng effect on syphilis testing. TRIAL REGISTRATION: ClinicalTrials.gov NCT02019043; registered December 23, 2013.

Peer support as a protective factor against suicide in trans populations: A scoping review.

RATIONALE: There is a growing body of research involving transgender (trans) individuals that foregrounds elevated rates of suicidality in trans populations. Although peer support is increasingly studied as a protective factor against suicide among trans persons, the scholarship in this area continues to be limited and has yet to be synthesized and appraised. OBJECTIVE: In this paper, we address this existing gap in the literature by presenting the results of a scoping review of the literature examining the significance and function of peer support in mitigating suicide risk in trans populations. METHODS: This scoping review is based on an analysis of 34 studies that were included following the execution of a methodical search and selection process. Drawing on scoping review methodology, along with PRISMA-P guidelines, we selected peer-reviewed empirical works, published between 2000 and 2020, which examined relationships between providing, seeking, and/or receiving peer support and suicide risk in trans populations. RESULTS: Our findings, which are conceptualized using the minority stress model as a guiding theoretical framework, reveal that while the literature generally substantiates the protective significance of peer support for trans persons, a small body of work also uncovers novel and unanticipated sources of peer support, including social support offered by trans peers online, which are infrequently and inconsistently examined in this body of scholarship. CONCLUSIONS: Using our appraisal of the literature, we outline the need for future research to further elucidate the significance and function of peer support in protecting against suicide among trans persons. In particular, we discuss the need for exploratory inquiry to inform a conceptualization and operationalization of peer support that more fully and consistently accounts for how such support (including online and community-based support) is sought, received, and experienced among trans persons in the context of suicide.

Integrating trans health knowledge through instructional design: preparing learners for a continent - not an island - of primary care with trans people.

In recent years the need to teach primary care providers to better care for transgender and non-binary (trans) patients has garnered significant scholarly and public attention. The alarming why motivating this surge in trans health primary care education has already been firmly established and needs no further comment. Instead, we offer new perspectives on how to do trans health primary care education. From treasured 'trans 101' educational interventions to trans health 'clinical pearls', the prevailing model used to teach primary care learners represents time-limited cultural competency-based education, which we argue creates an isolated education 'island'. In rethinking this approach, we present an introduction to the concepts of knowledge integration and the transfer of learning and apply them to show how trans health knowledge and skills should be structured within existing curricula to support effective learning and application. These instructional design considerations have yet to be extensively explored when teaching primary care learners trans health content and may be critical to building pedagogy that ultimately improves healthcare delivery. We conclude that trans health - and trans patients themselves - must not be treated as an isolated education island of knowledge and practice. Rather, it is the responsibility of educators to design instruction that encourages learners to integrate this knowledge with foundational principles of primary care; building bridges across a continent of primary care practice landscapes in turn.

Patient involvement in medical education: To what problem is engagement the solution?

CONTEXT: Patient and public engagement is gaining momentum across many domains of health care, inclusive of education and research. In this framing, engagement is offered as a solution to a myriad of problems. Yet, the way problems and solutions are linked together may be assumed, rather than made explicit. In the absence of clarity, there is a risk that solutions that may have worked in one domain of health care could falter, or even create new problems, in another. METHODS: We use a model from organisational studies as a way to make sense of the relationships between the problems, solutions and stakeholders operating in the name of patient and public engagement in health care. The 'garbage can model' is a playfully phrased but meaningful attempt to decipher the complex world of decision making in organisations. We use this model to guide our framing of the solutions of patient engagement practice and the wide range of problem statements that animate all of this activity. RESULTS: Following a discussion of the complexity of the field of patient engagement, we identify strategies for educators to conceptually weave problem statements, solutions and stakeholders together in mosaics of engagement activity. We further suggest a movement away from considering problems to be solved to thinking about polarities to be navigated. CONCLUSIONS: As patient engagement becomes more embedded in decision-making spaces in health professions education, we need a better understanding of how decisions are actually made in these organisations. We also need to consider that our most treasured solutions may have an uneasy fit, and some unintended consequences, as they enter new domains of health care. Finally, we advocate for critical approaches not just to the solutions of patient engagement, but to understand problem statements as they are defined, upheld and disrupted through all of this work.

Pay to skip the line: The political economy of digital testing services for HIV and other sexually transmitted infections.

The value of digital healthcare has been lauded in Canada at local, provincial, and national levels. Digital medicine is purported to enhance patient access to care while promising cost savings. Using institutional ethnography, we examined the potential for publicly funded digital testing for HIV and other sexually transmitted infections (STI) in Ontario, Canada. Our analyses draw from 23 stakeholder interviews with healthcare professionals conducted between 2019 and 2020, and textual analyses of government documents and private, for-profit digital healthcare websites. We uncovered a "two-tiered" system whereby private digital STI testing services enable people with economic resources to "pay to skip the line" queuing at public clinics and proceed directly to provide samples for diagnostics at local private medical labs. In Ontario, private lab corporations compete for fee-for-service contracts with government, which in turn organises opportunities for market growth when more patient samples are collected vis-à-vis digital testing. However, we also found that some infectious disease specimens (e.g., HIV) are re-routed for analysis at government public health laboratories, who may be unable to manage the increase in testing volume associated with digital STI testing due to state budget constraints. Our findings on public-private laboratory funding disparities thus discredit the claims that digital healthcare necessarily generates cost savings, or that it enhances patients' access to care. We conclude that divergent state funding relations together with the creeping privatisation of healthcare within this "universal" system coordinate the conditions through which private corporations capitalise from digital STI testing, compounding patient access inequities. We also stress that our findings bring forth large scale implications given the context of the global COVID-19 pandemic, the rapid diffusion of digital healthcare, together with significant novel coronavirus testing activities initiated by private industry.