'I don't want to have to teach every medical provider': barriers to care among non-binary people in the Canadian healthcare system.

It is well-known that trans and non-binary individuals experience worse health outcomes due to experiences of violence and discrimination. For this reason, accessible healthcare for trans and non-binary people is crucial. There is a lack of Canadian literature on the experiences of non-binary people within the healthcare system. This study sought to understand barriers to healthcare among non-binary people living in a mid-sized urban/rural region of Canada. Interviews were conducted between November 2019 to March 2020 with 12 non-binary individuals assigned female at birth, living in Waterloo Region, Ontario, Canada, as a part of a larger qualitative study exploring experiences within the community, healthcare and employment. Three broad themes were developed: erasure, barriers to access to healthcare, and assessing whether (or not) to come out. Sub-themes included institutional erasure, informational erasure, general healthcare barriers, medical transition healthcare barriers, anticipated discrimination, and assessing safety. Policy and institutional changes are needed to increase the safety and accessibility of healthcare services to non-binary individuals.

Exploring LGBT2Q+ Intracategorical Factors in Mental Health Service Utilization: Differences in Gender Modalities, Sexual Orientations, and Ethnoracial Groups in Canada.

LGBT2Q+ (lesbian, gay, bisexual, transgender, Two-Spirit, queer, plus) Canadians face minority stressors that lead to higher mental health inequalities such as worse self-reported mental health and increased risk of mental health issues when compared to their heterosexual/straight and cisgender counterparts. However, there are within-group (intracategorical) differences within a community as large as LGBT2Q+ peoples. Guided by the Andersen Model of Healthcare Utilization, we sought to explore intracategorical differences in LGBT2Q+ Canadian predisposing, enabling, and need factors in mental health service utilization within the past year. Using data from the 2020 LGBT2Q+ Health Survey (N = 1542), modified Poisson logistic regression found that more polysexual respondents and trans/gender-diverse respondents were more likely to have utilized mental health services within the past year than their gay, lesbian, and cis male counterparts. As well, compared to White respondents, Indigenous respondents were more likely to have utilized mental health services, while other racialized respondents were associated with less utilization. Backwards elimination of Andersen model of healthcare utilization factors predicting mental health service utilization retained two predisposing factors (ethnoracial groups and gender modality) and two need factors (self-reporting living with a mood disorder and self-reporting living with an anxiety disorder). Results suggest that polysexual, trans and gender-diverse, and racialized LGBT2Q+ peoples have an increased need for mental health services due to increased specific minority stressors that cisgender, White, monosexual peoples do not face. Implications for healthcare providers are discussed on how to improve service provision to LGBT2Q+ peoples.

Exploring community enabling factors associated with recent HIV testing in a regional sample of gay, bisexual, and other men who have sex with men.

HIV testing and diagnosis are the gateway into treatment and eventual viral suppression. With gay, bisexual, and other men who have sex with men (GBMSM) persistently over-representing new HIV diagnoses in Canada, combined with the evolving nature of community social connection, an exploration of factors associated with recent HIV testing is warranted. As most studies of GBMSM rely on samples obtained from larger metropolitan regions, examining HIV testing from an under-researched region is necessary. With data collected from an online survey of LGBTQ+ persons 16 or older living, working, or residing in the Region of Waterloo, Ontario, Canada, we used multinomial logistic regression to explore socio-demographic, behavioural, and psychosocial factors associated with recent HIV testing for GBMSM. In the final multivariate multinomial logistic regression model: sense of belonging was associated with more recently testing, as was having an increasing proportion of LGBT friends, app use to find sex partners in the past 12 months, access to the local AIDS service organization, and general sense of belonging to local community, among other. This analysis highlights the continued importance of enabling and need factors when accessing testing, and suggests areas for further testing promotion in physical and virtual spaces frequented by GBMSM.

Experiences of trans patients in primary care settings: findings from The OutLook Study.

BACKGROUND: Relationships between primary care providers (PCP) and trans patients remain important, necessitating discussions about gender identity, health and their intersections. METHODS: Using an online survey, we explored socio-demographic and psycho-social factors associated with: (1) disclosing gender identity; (2) discussing gender identity-related health issues; and (3) comfort sharing gender identity with PCPs, among trans people (n =112) over 16years of age, sampled in Waterloo, Ontario, Canada. Bivariate and multivariate methods using modified Poisson regression generated effect estimates. RESULTS: Age, birth presumed gender, employment status, family support, and transphobia were significantly associated with disclosing gender identity, discussing gender identity-related health issues, and comfortability sharing gender identity with PCPs. CONCLUSION: Increasing PCPs' knowledge of trans-related health issues is stressed to improve access and quality for trans patients.

Barriers and facilitators to HIV and sexually transmitted infections testing for gay, bisexual, and other transgender men who have sex with men.

Transgender men who have sex with men (trans MSM) may be at elevated risk for HIV and other sexually transmitted infections (STI), and therefore require access to HIV and STI testing services. However, trans people often face stigma, discrimination, and gaps in provider competence when attempting to access health care and may therefore postpone, avoid, or be refused care. In this context, quantitative data have indicated low access to, and uptake of, HIV testing among trans MSM. The present manuscript aimed to identify trans MSM's perspectives on barriers and facilitators to HIV and STI testing. As part of a community-based research project investigating HIV risk and resilience among trans MSM, 40 trans MSM aged 18 and above and living in Ontario, Canada participated in one-on-one qualitative interviews in 2013. Participants described a number of barriers to HIV and other STI testing. These included both trans-specific and general difficulties in accessing sexual health services, lack of trans health knowledge among testing providers, limited clinical capacity to meet STI testing needs, and a perceived gap between trans-inclusive policies and their implementation in practice. Two major facilitators were identified: access to trusted and flexible testing providers, and integration of testing with ongoing monitoring for hormone therapy. Based on these findings, we provide recommendations for enhancing access to HIV and STI testing for this key population.

Intervenable factors associated with suicide risk in transgender persons: a respondent driven sampling study in Ontario, Canada.

BACKGROUND: Across Europe, Canada, and the United States, 22-43 % of transgender (trans) people report a history of suicide attempts. We aimed to identify intervenable factors (related to social inclusion, transphobia, or sex/gender transition) associated with reduced risk of past-year suicide ideation or attempt, and to quantify the potential population health impact. METHODS: The Trans PULSE respondent-driven sampling (RDS) survey collected data from trans people age 16+ in Ontario, Canada, including 380 who reported on suicide outcomes. Descriptive statistics and multivariable logistic regression models were weighted using RDS II methods. Counterfactual risk ratios and population attributable risks were estimated using model-standardized risks. RESULTS: Among trans Ontarians, 35.1 % (95 % CI: 27.6, 42.5) seriously considered, and 11.2 % (95 % CI: 6.0, 16.4) attempted, suicide in the past year. Social support, reduced transphobia, and having any personal identification documents changed to an appropriate sex designation were associated with large relative and absolute reductions in suicide risk, as was completing a medical transition through hormones and/or surgeries (when needed). Parental support for gender identity was associated with reduced ideation. Lower self-reported transphobia (10(th) versus 90(th) percentile) was associated with a 66 % reduction in ideation (RR = 0.34, 95 % CI: 0.17, 0.67), and an additional 76 % reduction in attempts among those with ideation (RR = 0.24; 95 % CI: 0.07, 0.82). This corresponds to potential prevention of 160 ideations per 1000 trans persons, and 200 attempts per 1,000 with ideation, based on a hypothetical reduction of transphobia from current levels to the 10(th) percentile. CONCLUSIONS: Large effect sizes were observed for this controlled analysis of intervenable factors, suggesting that interventions to increase social inclusion and access to medical transition, and to reduce transphobia, have the potential to contribute to substantial reductions in the extremely high prevalences of suicide ideation and attempts within trans populations. Such interventions at the population level may require policy change.

Challenges to the involvement of people living with HIV in community-based HIV/AIDS organizations in Ontario, Canada.

The Greater Involvement of People Living with HIV/AIDS Principle (GIPA) has been a core commitment for many people involved in the community-based HIV/AIDS movement. GIPA refers to the inclusion of people living with HIV/AIDS in service delivery and decision-making processes that affect their lives. Despite its central importance to the movement, it has received little attention in the academic literature. Drawing on focus group discussions among staff members and volunteers of AIDS service organizations, activists, and community members, we explore challenges to the implementation of the GIPA principle in community-based HIV/AIDS organizations in Ontario, Canada. Our findings reveal ways in which implementing GIPA has become more complicated over recent years. Challenges relating to health, stigma and disclosure, evolving HIV/AIDS organizations, and GIPA-related tensions are identified. This paper considers our findings in light of previous research, and suggests some implications for practice.

Minority Stressors, Social Provisions, and Past-Year Suicidal Ideation and Suicide Attempts in a Sample of Sexual Orientation and Gender Identity/Expression Minority People in Canada.

Purpose: Mental health disparities in sexual orientation and/or gender identity and/or expression (SOGIE) minority groups are well-documented, with research consistently showing higher levels of suicidality, even in Canada, considered one of the world's most accepting countries of SOGIE minority groups. Adverse outcomes in these groups are often framed using minority stress theory, with social support frequently studied as an integral buffer to these outcomes. This analysis explores facets of minority stress and social support associated with past-year suicidal ideation and suicide attempts. Methods: A cross-sectional internet survey of SOGIE diverse people in Canada (n = 1542) was conducted. Binary logistic regression calculated bivariate and multivariate factors associated with past-year suicidal ideation and suicide attempts. Backward elimination (retaining sociodemographic factors and self-rated mental health) identified salient minority stress and social support (provisions) factors. Results: Over half (56.72%) of participants had ever thought of dying by suicide, with 24.84% having attempted suicide. During the past year, 26.80% had thought of dying by suicide, with 5.32% having attempted suicide. Victimization events, and guidance (e.g., someone to talk to about important decisions) and attachment (e.g., close relationships providing emotional security) social provision subscales remained salient after backward elimination procedures. Conclusion: Our findings emphasize that a fulsome, multilevel approach considering structural, community, and individual strategies to address overt discrimination, integrating social connections and guidance, is necessary to prevent dying by suicide.

Nonprescribed hormone use and self-performed surgeries: "do-it-yourself" transitions in transgender communities in Ontario, Canada.

OBJECTIVES: We examined the extent of nonprescribed hormone use and self-performed surgeries among transgender or transsexual (trans) people in Ontario, Canada. METHODS: We present original survey research from the Trans PULSE Project. A total of 433 participants were recruited from 2009 to 2010 through respondent-driven sampling. We used a case series design to characterize those currently taking nonprescribed hormones and participants who had ever self-performed sex-reassignment surgeries. RESULTS: An estimated 43.0% (95% confidence interval = 34.9, 51.5) of trans Ontarians were currently using hormones; of these, a quarter had ever obtained hormones from nonmedical sources (e.g., friend or relative, street or strangers, Internet pharmacy, herbals or supplements). Fourteen participants (6.4%; 95% confidence interval = 0.8, 9.0) reported currently taking nonprescribed hormones. Five indicated having performed or attempted surgical procedures on themselves (orchiectomy or mastectomy). CONCLUSIONS: Past negative experiences with providers, along with limited financial resources and a lack of access to transition-related services, may contribute to nonprescribed hormone use and self-performed surgeries. Promoting training initiatives for health care providers and jurisdictional support for more accessible services may help to address trans people's specific needs.

Scrolling Through the COVID-19 Pandemic: Exploring the Perceived Effects of Increased Social Media Use on the Mental Health of Undergraduate University Students.

Social media has become increasingly integrated into the lives of students for the past decade; however, the public health restrictions associated with the COVID-19 pandemic have led to a sharp increase in social media use in a short period of time. The purpose of this study was to investigate the effects of social media use on university students during the COVID-19 pandemic. Fifteen students from a mid-sized Canadian city were interviewed to share their experiences with social media during the COVID-19 pandemic. Purposive sampling was conducted to gather a diverse sample of participants, including individuals of various ages, gender and sexual identities, and ethnicities. Thematic analysis on the 15 interviews was completed using NVivo (version 12). Participants experienced both advantages and disadvantages associated with social media use. Ease of communication and stress relief were acknowledged as the strongest benefits. Social comparison, loneliness, development of bad habits, and lack of focus were cited as major disadvantages to social media use during the pandemic. Cost-benefit analysis of social media was common, and participants expressed the importance of using social media with moderation, balance, and awareness. Our study indicates that the focus on health with respect to the pandemic should not be solely based on physical health, rather the potential mental health risks associated with social media use during the pandemic should be recognized and addressed by healthcare providers.

High heterogeneity of HIV-related sexual risk among transgender people in Ontario, Canada: a province-wide respondent-driven sampling survey.

BACKGROUND: Studies of HIV-related risk in trans (transgender, transsexual, or transitioned) people have most often involved urban convenience samples of those on the male-to-female (MTF) spectrum. Studies have detected high prevalences of HIV-related risk behaviours, self-reported HIV, and HIV seropositivity. METHODS: The Trans PULSE Project conducted a multi-mode survey using respondent-driven sampling to recruit 433 trans people in Ontario, Canada. Weighted estimates were calculated for HIV-related risk behaviours, HIV testing and self-reported HIV, including subgroup estimates for gender spectrum and ethno-racial groups. RESULTS: Trans people in Ontario report a wide range of sexual behaviours with a full range of partner types. High proportions - 25% of female-to-male (FTM) and 51% of MTF individuals - had not had a sex partner within the past year. Of MTFs, 19% had a past-year high-risk sexual experience, versus 7% of FTMs. The largest behavioural contributors to HIV risk were sexual behaviours some may assume trans people do not engage in: unprotected receptive genital sex for FTMs and insertive genital sex for MTFs. Overall, 46% had never been tested for HIV; lifetime testing was highest in Aboriginal trans people and lowest among non-Aboriginal racialized people. Approximately 15% of both FTM and MTF participants had engaged in sex work or exchange sex and about 2% currently work in the sex trade. Self-report of HIV prevalence was 10 times the estimated baseline prevalence for Ontario. However, given wide confidence intervals and the high proportion of trans people who had never been tested for HIV, estimating the actual prevalence was not possible. CONCLUSIONS: Results suggest potentially higher than baseline levels of HIV; however low testing rates were observed and self-reported prevalences likely underestimate seroprevalence. Explicit inclusion of trans people in epidemiological surveillance statistics would provide much-needed information on incidence and prevalence. Given the wide range of sexual behaviours and partner types reported, HIV prevention programs and materials should not make assumptions regarding types of behaviours trans people do or do not engage in.

'Getting shut down and shut out': Exploring ACB patient perceptions on healthcare access at the physician-patient level in Canada.

PURPOSE: The experiences of African, Caribbean and Black (ACB) Canadians are seldom explored in the Canadian context. Family physicians act as a gateway to the rest of the healthcare system and are necessary to provide proper patient care. However, Canada's history with colonialism may impact the socio-cultural context in which patients receive care. METHOD: 41 participants from Waterloo Region, Ontario, were engaged in eight focus groups to discuss their experiences in the healthcare system. Data were analysed following thematic analysis. RESULTS: Style of care, racism and discrimination and a lack of cultural competence hindered access. oor Inadequate cultural competence was attributed to western and biomedical approaches, poor understanding of patients' context, physicians failing to address specific health concerns, and racism and discrimination. Participants highlighted that the two facilitators to care were having an ACB family physician and fostering positive relationships with physicians. CONCLUSION: Participants predominantly expressed dissatisfaction in physicians' approaches to care, which were compounded by experiences of racism and discrimination. Findings demonstrate how ACB patients are marginalized and excluded from the healthcare syste Iimplications for better access to care included utilizing community healthcare centres, increasing physicians' capacity around culturally inclusive care, and increasing access to ACB physicians.

Experiences of Transgender Participants in Emergency Departments: Findings from the OutLook Study.

Purpose: Even in cases of medical emergency, mistreatment and negative experiences in life or in medical settings can deter trans patients from seeking necessary care. The purpose of this study was to identify factors associated with trans persons' emergency department (ED) avoidance in the mixed urban-rural Region of Waterloo, Ontario, Canada. Methods: The OutLook Study was a community-based partnership that created an online, cross-sectional questionnaire for lesbian, gay, bisexual, transgender, and other sexual and gender minority community members. Participants in this analysis were 16 years of age or older, lived, worked, or attended school in Waterloo Region, and identified as trans (n=112). Binary logistic regression was used to test associations between sociodemographic, resilience, and risk variables, and ED avoidance. Sociodemographic variables statistically significant at p<0.05 at the bivariate level were included as controls to explore different combinations of resilience and risk factor in multivariable models. Results: Participants reporting complete or partially complete medical transitions were more likely to report ED avoidance, compared to those who had not initiated medical transition. Elevated transphobia was associated with greater likelihood of avoidance. However, increasing levels of social support decreased the likelihood of avoidance. In multivariable models, social support, support from a special person, and transphobia were always significant, regardless of controlled variables. Conclusion: Transphobia-enacted in the contexts of everyday life and health care-can deter patients from seeking care. Patient-centered care requires careful attention to trans identity and health needs, especially in emergency settings. In the absence of structural changes, providers can take steps to mitigate the erasure and discrimination trans patients experience and anticipate when accessing EDs.

What do people living with HIV/AIDS expect from their physicians? Professional expertise and the doctor-patient relationship.

This qualitative study identifies the types of professional expertise that physicians are seen to possess in clinical encounters from the perspective of people living with HIV/AIDS (PLWHA). Respondents looked to their physicians for expert knowledge in 3 key areas: medical/clinical; legal/statutory; and ethical/moral. Physicians were seen to be authorities in each of these areas and their judgments, though not always agreed with, were taken seriously and influenced the health care decisions made by PLWHA. The authority that comes with professional expertise in each of the areas identified was experienced both positively and negatively by PLWHA. Understanding the expectations of patients in the medical encounter can assist physicians in providing optimal care in the management of HIV/AIDS.

Survey design from the ground up: collaboratively creating the Toronto Teen Survey.

The Toronto Teen Survey is a community-based participatory research study whose aim is to gather information on the accessibility and relevance of sexual health services for diverse groups of urban youth (13 to 17 years of age). This information will be used to develop a proactive, citywide strategy to improve sexual health outcomes for Toronto adolescents. In this article, the authors focus on the processes of collaboratively developing a survey tool with youth, academics, and community stakeholders. An overview of the project and examples from the design stage are provided. In addition, recommendations are given toward developing best practices when working with young people on research and survey design.

Community-based research in AIDS-service organizations: what helps and what doesn't?

BACKGROUND: Community-based research (CBR) approaches have become commonplace in many North American HIV communities. In many large urban centers, AIDS-service organizations (ASOs) have become active research hubs, advocating for research dollars in community settings. While ASOs have historically integrated local knowledge into their prevention, care and advocacy initiatives, many are now initiating or collaborating in research which addresses emerging issues encountered in practice with clients. OBJECTIVES: To investigate barriers and facilitating factors for ASO engagement in CBR. METHODS: We conducted a survey (n=39) and one-on-one semi-structured telephone interviews (n=25) with executive directors and CBR coordinators from ASOs in Ontario, Canada. The survey queried four major areas of interest (organizational demographics, ASO CBR activities, potential barriers and facilitators for CBR engagement, and what roles stakeholders play in CBR initiatives). The interviews focused on exploring these issues in greater depth as well as understanding barriers and facilitating factors to people living with HIV/AIDS engaging in CBR. RESULTS: ASOs in Ontario are moderately supportive of CBR in their organizations. However, our survey and one-on-one interviews indicate that funding and organizational resources are both important barriers and facilitators to ASO involvement in CBR projects. Attaining access to research ethics boards and concerns that CBR results will not be acted upon also emerged as barriers to CBR, particularly once funds and organizational resources have been attained. Initiatives designed to enhance the skills of research team members emerged as an another important facilitator. CONCLUSION: Increasing emphasis from program funders on more rigorous evaluation and accountability, coupled with pull from increasingly empowered communities demanding much more active roles in setting research agendas, means that CBR is likely here to stay. Attending to barriers and facilitators will help with enhanced ASO engagement in CBR.

Overlooked and Invisible: Everyday Experiences of Microaggressions for LGBTQ Adolescents.

Lesbian, gay, bisexual, transgender, and queer (LGBTQ) adolescents face a number of challenges in their lives related to heterosexism and cissexism. Drawing on the microaggressions framework, we conducted two focus groups with LGBTQ adolescents (n = 11; ages 14-18, six trans/genderfluid, one person of color) to (1) explore the type and nature of microaggressions experienced by LGBTQ adolescents; (2) assess the relevance of existing LGBTQ microaggression taxonomies for this group; and (3) understand the impact of microaggressions on LGBTQ adolescents. Participants' experiences of microaggressions reflected complex forms of discrimination emerging from the intersections of sexual and gender identity.

Hearing "That's So Gay" and "No Homo" on Campus and Substance Use Among Sexual Minority College Students.

Sexual orientation microaggressions are common on college campuses and can contribute to negative outcomes; yet little is known about their relationship with substance use outcomes. Among a convenience sample of cisgender sexual minority college students (n= 574; 57.0% female, 24.9% people of color, 50.7% gay/lesbian; 72.4% public school) from 37 states (67.8% Midwest), this analysis investigates the association between hearing "that's so gay" and "no homo" on campus and hazardous alcohol use and the frequency of illicit drug use. Using multivariable regression analyses, the commonly heard phrases "that's so gay" and "no homo" were each found to significantly increase the risk for hazardous drinking and the frequency of drug use among students. Efforts should be made to create more welcoming campus climates for sexual minority students by reducing the use of these microaggressions and, in the meantime, offering supports to mitigate their harmful effects.

Identifying and strengthening the structural roots of urban health in Canada: participatory policy research and the urban health agenda.

An urban health research agenda for health promoters is presented. In Canada, urban issues are emerging as a major concern of policy makers. The voices raising these issues are from the non-health sectors, but many of these issues such as increasing income inequality and poverty, homelessness and housing insecurity, and social exclusion of youth, immigrants, and ethno-racial minorities have strong health implications as they are important social determinants of health. Emphasis on these and other social determinants of health and the policy decisions that strengthen or weaken them is timely as the quality of Canadian urban environments has become especially problematic. We argue for a participatory urban health research and action agenda with four components: (a) an emphasis on health promotion and the social determinants of health; (b) community-based participatory research; and (c) drawing on the lived experience of people to influence (d) policy analysis and policy change. Urban health researchers and promoters are urged to draw upon new developments in population health and community-based health promotion theory and research to identify and strengthen the roots of urban health through citizen action on public policy.

HIV-Related Sexual Risk Among Transgender Men Who Are Gay, Bisexual, or Have Sex With Men.

BACKGROUND: This study is among the first to examine factors associated with HIV-related sexual risk among transgender men and other transmasculine persons who are gay, bisexual, or have sex with men (T-GBMSM). METHODS: In 2009-2010, 433 transgender people in Ontario, Canada, participated in a multimode respondent-driven sampling survey, including 158 T-GBMSM. Analyses were weighted using respondent-driven sampling II methods to adjust for differential recruitment probabilities; confidence intervals (CI) were adjusted for clustering by shared recruiter. Prevalence ratios (PR) for associations with past-year high sexual risk (condomless intercourse outside a seroconcordant monogamous relationship) were estimated using average marginal predictions from logistic regression. RESULTS: Of T-GBMSM (mean age = 29.8; 52% living full time in felt gender; 25% Aboriginal or persons of color; 0% self-reported HIV positive), 10% had high sexual risk activity in the past year. Among the 34% with a past-year cisgender (non-transgender) male sex partner, 29% had high sexual risk. In multivariable analyses, older age, childhood sexual abuse (adjusted PR, APR = 14.03, 95% CI: 2.32 to 84.70), living full time in one's felt gender (APR = 5.20, 95% CI: 1.11 to 24.33), and being primarily or exclusively attracted to men (APR = 5.54, 95% CI: 2.27 to 13.54) were each associated with sexual risk. Of psychosocial factors examined, past-year stimulant use (APR = 4.02, 95% CI: 1.31 to 12.30) and moderate depressive symptoms (APR = 5.77, 95% CI: 1.14 to 29.25) were associated with higher sexual risk. CONCLUSIONS: T-GBMSM seem to share some HIV acquisition risk factors with their cisgender counterparts. HIV prevention interventions targeting T-GBMSM who are predominantly attracted to men and interventions addressing sequelae of childhood sexual abuse may be warranted.