Finding Medical Photographs of Patients Online: Randomized, Cross-Sectional Study.

BACKGROUND: Photographs from medical case reports published in academic journals have previously been found in online image search results. This means that patient photographs circulate beyond the original journal website and can be freely accessed online. While this raises ethical and legal concerns, no systematic study has documented how often this occurs. OBJECTIVE: The aim of this cross-sectional study was to provide systematic evidence that patient photographs from case reports published in medical journals appear in Google Images search results. Research questions included the following: (1) what percentage of patient medical photographs published in case reports were found in Google Images search results? (2) what was the relationship between open access publication status and image availability? and (3) did the odds of finding patient photographs on third-party websites differ between searches conducted in 2020 and 2022? METHODS: The main outcome measure assessed whether at least 1 photograph from each case report was found on Google Images when using a structured search. Secondary outcome variables included the image source and the availability of images on third-party websites over time. The characteristics of medical images were described using summary statistics. The association between the source of full-text availability and image availability on Google Images was tested using logistic regressions. Finally, we examined the trend of finding patient photographs using generalized estimating equations. RESULTS: From a random sample of 585 case reports indexed in PubMed, 186 contained patient photographs, for a total of 598 distinct images. For 142 (76.3%) out of 186 case reports, at least 1 photograph was found in Google Images search results. A total of 18.3% (110/598) of photographs included eye, face, or full body, including 10.9% (65/598) that could potentially identify the patient. The odds of finding an image from the case report online were higher if the full-text paper was available on ResearchGate (odds ratio [OR] 9.16, 95% CI 2.71-31.02), PubMed Central (OR 7.90, 95% CI 2.33-26.77), or Google Scholar (OR 6.07, 95% CI 2.77-13.29) than if the full-text was available solely through an open access journal (OR 5.33, 95% CI 2.31-12.28). However, all factors contributed to an increased risk of locating patient images online. Compared with the search in 2020, patient photographs were less likely to be found on third-party websites based on the 2022 search results (OR 0.61, 95% Cl 0.43-0.87). CONCLUSIONS: A high proportion of medical photographs from case reports was found on Google Images, raising ethical concerns with policy and practice implications. Journal publishers and corporations such as Google are best positioned to develop an effective remedy. Until then, it is crucial that patients are adequately informed about the potential risks and benefits of providing consent for clinicians to publish their images in medical journals.

Cohort study of team-based care among marginalized people who use drugs in Ottawa.

OBJECTIVE: To describe team-based care use among a cohort of people who use drugs (PWUD) and to determine factors associated with receipt of team-based care. DESIGN: A cohort study using survey data collected between March and December 2013. These data were then linked to provincial-level health administrative databases to assess patterns of primary care among PWUD in the 2 years before survey completion. SETTING: Ottawa, Ont. PARTICIPANTS: Marginalized PWUD 16 years of age or older. MAIN OUTCOME MEASURES: Patients were assigned to primary care models based on survey responses and then were categorized as attached to team-based medical homes, attached to non-team-based medical homes, not attached to a medical home, and no primary care. Descriptive statistics and multinomial logistic regression were used to determine associations between PWUD and medical home models. RESULTS: Of 663 total participants, only 162 (24.4%) received team-based care, which was associated with high school level of education (adjusted odds ratio [AOR] = 2.18; 95% CI 1.13 to 4.20), receipt of disability benefits (AOR = 2.47; 95% CI 1.22 to 5.02), and HIV infection (AOR = 2.88; 95% CI 1.28 to 6.52), and was inversely associated with recent overdose (AOR = 0.49; 95% CI 0.25 to 0.94). In comparison, 125 (18.8%) received non-team-based medical care, which was associated with university or college education (AOR = 2.31; 95% CI 1.04 to 5.15) and mental health comorbidity (AOR = 4.18; 95% CI 2.33 to 7.50), and was inversely associated with being detained in jail in the previous 12 months (AOR = 0.51; 95% CI 0.28 to 0.90). CONCLUSION: Although team-based, integrated models of care will benefit disadvantaged groups the most, few PWUD receive such care. Policy makers should mitigate barriers to physician care and improve integration across health and social services.

Mental health and structural harm: a qualitative study of sexual minority men's experiences of mental healthcare in Toronto, Canada.

Compared to the general population, sexual minority men report poorer mental health outcomes and higher mental healthcare utilisation. However, they also report more unmet mental health needs. To better understand this phenomenon, we conducted qualitative interviews with 24 sexual minority men to explore the structural factors shaping their encounters with mental healthcare in Toronto, Canada. Interviews were analysed using grounded theory. Many participants struggled to access mental healthcare and felt more marginalised and distressed because of two interrelated sets of barriers. The first were general barriers, hurdles to mental healthcare not exclusive to sexual minorities. These included financial and logistical obstacles, the prominence of psychiatry and the biomedical model, and unsatisfactory provider encounters. The second were sexual minority barriers, obstacles explicitly rooted in heterosexism and homophobia sometimes intersecting with other forms of marginality. These included experiencing discrimination and distrust, and limited sexual minority affirming options. Discussions of general barriers outweighed those of sexual minority barriers, demonstrating the health consequences of structural harms in the absence of overt structural stigma. Healthcare inaccessibility, income insecurity and the high cost of living are fostering poor mental health among sexual minority men. Research must consider the upstream policy changes necessary to counteract these harms.

Engagement in primary health care among marginalized people who use drugs in Ottawa, Canada.

BACKGROUND: There may be less primary health care engagement among people who use drugs (PWUD) than among the general population, even though the former have greater comorbidity and more frequent use of emergency department care. We investigated factors associated with primary care engagement among PWUD. METHODS: The Participatory Research in Ottawa: Understanding Drugs (PROUD) cohort study meaningfully engaged and trained people with lived experience to recruit and survey marginalized PWUD between March-December 2013. We linked this survey data to provincial-level administrative databases held at ICES. We categorized engagement in primary care over the 2 years prior to survey completion as: not engaged (< 3 outpatient visits to the same family physician) versus engaged in care (3+ visits to the same family physician). We used multivariable logistic regression to determine factors associated with engagement in primary care. RESULTS: Characteristics of 663 participants included a median age of 43 years, 76% men, and 67% living in the two lowest income quintile neighborhoods. Despite high comorbidity and a median of 4 (interquartile range 0-10) primary care visits in the year prior to survey completion, only 372 (56.1%) were engaged in primary care. Engagement was most strongly associated with the following factors: receiving provincial benefits, including disability payments (adjusted odds ratio [AOR] 4.14 (95% confidence interval [CI] 2.30 to 7.43)) or income assistance (AOR 3.69 (95% CI 2.00 to 6.81)), having ever taken methadone (AOR 3.82 (95% CI 2.28 to 6.41)), mental health comorbidity (AOR 3.43 (95% CI 2.19 to 5.38)), and having stable housing (AOR 2.09 (95% CI 1.29 to 3.38)). CONCLUSIONS: Despite high comorbidity, engagement in primary care among PWUD was low. Our findings suggest that social care (housing, disability, and income support) and mental health care are associated with improved primary care continuity; integration of these care systems with primary care and opioid substitution therapy may lessen the significant morbidity and acute care use among PWUD.

Potential use of supervised injection services among people who inject drugs in a remote and mid-size Canadian setting.

BACKGROUND: While supervised injection services (SIS) feasibility research has been conducted in large urban centres across North America, it is unknown whether these services are acceptable among people who inject drugs (PWID) in remote, mid-size cities. We assessed willingness to use SIS and expected frequency of SIS use among PWID in Thunder Bay, a community in Northwestern, Ontario, Canada, serving people from suburban, rural and remote areas of the region. METHODS: Between June and October 2016, peer research associates administered surveys to PWID. Sociodemographic characteristics, drug use and behavioural patterns associated with willingness to use SIS and expected frequency of SIS use were estimated using bivariable and multivariable logistic regression models. Design preferences and amenities identified as important to provide alongside SIS were assessed descriptively. RESULTS: Among 200 PWID (median age, IQR: 35, 28-43; 43% female), 137 (69%) reported willingness to use SIS. In multivariable analyses, public injecting was positively associated with willingness to use (Adjusted Odds Ratio (AOR): 4.15; 95% confidence interval (CI): 2.08-8.29). Among those willing to use SIS, 87 (64%) said they would always/usually use SIS, while 48 (36%) said they would sometime/occasionally use SIS. In multivariable analyses, being female (AOR: 2.44; 95% CI: 1.06-5.65) and reporting injecting alone was positively associated with higher expected frequency of use (AOR: 2.59; 95% CI: 1.02-6.58). CONCLUSIONS: Our findings suggest that SIS could play a role in addressing the harms of injection drug use in remote and mid-sized settings particularly for those who inject in public, as well as women and those who inject alone, who report higher expected frequency of SIS use. Design preferences of local PWID, in addition to differences according to gender should be taken into consideration to maximize the uptake of SIS, alongside existing health and social service provisions available to PWID.

A tale of two epidemics: gay men's mental health and the biomedicalisation of HIV prevention and care in Toronto.

There is mounting urgency regarding the mental health of gay, bisexual and other men who have sex with men (GBM). We examined how GBM are understanding the relationship between HIV and their mental health given the increasing biomedicalisation of HIV prevention and care. Our Grounded Theory analysis derived from qualitative interviews with 24 GBM living in Toronto, Canada, including both HIV-negative and HIV-positive men. Participants understood biomedical advances, such as undetectable viral load and pre-exposure prophylaxis (PrEP), as providing some relief from HIV-related distress. However, they offered ambivalent perspectives on the biomedicalisation of HIV. Some considered non-HIV-specific stressors (e.g. unemployment, racial discrimination) more significant than HIV-related concerns. These men expressed HIV-related distress as being under control due to biomedical advances or as always negligible when compared to non-HIV-specific stressors. Others emphasised the ongoing mental health implications of HIV (e.g. enduring risk and stigma). We describe a tension between optimistic responses to biomedicine's ability to ease the psychosocial burdens associated with HIV and the inability for biomedicine to address the social and economic determinants driving the dual epidemics of HIV and mental distress amongst GBM. We argue for more socio-material analysis over further sexual behavioural analysis of GBM mental health disparities.

Hepatitis C Testing, Status and Treatment among Marginalized People Who Use Drugs in an Inner City Setting: An Observational Cohort Study.

BACKGROUND: Chronic hepatitis C virus (HCV) infection is common among people who inject drugs (PWID) and is associated with morbidity and premature death. Although HCV can be cured, treatment may be inaccessible. We studied HCV testing, status and treatment among marginalized people who use drugs in Ottawa, Canada, a setting with universal insurance coverage for physician services. METHODS: We analyzed data from the Participatory Research in Ottawa: Understanding Drugs study, a cross-sectional, peer-administered survey of people who use drugs from 2012 to 2013. We linked responses to population-based health administrative databases and used multivariable Poisson regression to identify factors independently associated with self-reported HCV testing, self-reported positive HCV status, and database-determined engagement in HCV treatment. RESULTS: Among 663 participants, 562 (84.8%) reported testing for HCV and 258 (45.9%) reported HCV-positive status. In multivariable analysis, HCV-positive status was associated with female gender (RR 1.27; 95%CI 1.04 to 1.55), advancing age (RR 1.03/year; 95%CI 1.02 to 1.04), receiving disability payments (RR 1.42; 95%CI 1.06 to 1.91), injecting drugs (RR 5.11; 95%CI 2.64 to 9.91), ever injecting with a used needle (RR 1.30; 95%CI 1.12 to 1.52), and ever having taken methadone (RR 1.26; 95%CI 1.05 to 1.52). Of HCV positive participants, 196 (76%) were engaged in primary care but only 23 (8.9%) had received HCV therapy. Conclusions/Importance: Although HCV testing and positive status rates are high among PWID in our study, few have received HCV treatment. Innovative initiatives to increase access to HCV treatment for PWID are urgently needed.

Challenges with access to healthcare from the perspective of patients living with HIV: a scoping review & framework synthesis.

Accessing healthcare can be difficult but the barriers multiply for people living with HIV (PLHIV). To improve access and the health of PLHIV, we must consider their perspectives and use them to inform standard practice. A better understanding of the current literature related to healthcare access from the perspective of PLHIV, can help to identify evidence gaps and highlight research priorities and opportunities. To identify relevant peer-reviewed publications, search strategies were employed. Electronic and grey literature databases were explored. Articles were screened based on their title and abstract and those that met the screening criteria, were reviewed in full. Data analysis was conducted using a collaborative approach that included knowledge user consultation. Initial concepts were extracted, summarized and through framework synthesis, developed into emerging and final themes. From 20,678 articles, 326 articles met the initial screening criteria and 64 were reviewed in full. The final themes identified, in order of most to least frequent were: Acceptability, Availability, Accessibility, Affordability, Other Barriers, Communication, Satisfaction, Accommodation, Preferences and Equity in Access. The most frequently discussed concepts related to negative interactions with staff, followed by long wait times, limited household resources or inability to pay fees, and fear of one's serostatus being disclosed. Knowledge users were in agreement with the categorization of initial concepts and final themes; however, some gaps in the literature were identified. Specific changes are critical to improving access to healthcare for PLHIV. These include improving availability by ensuring staff and healthcare professionals have proper training, cultivating acceptability and reducing stigma through improving HIV awareness, increasing accessibility through increased HIV information for PLHIV and improved dissemination of this information to increase patient knowledge and health awareness. Finally, ensuring proper protocols are implemented and followed to guarantee patient confidentiality and overall satisfaction with healthcare services are recommended.

Open Availability of Patient Medical Photographs in Google Images Search Results: Cross-Sectional Study of Transgender Research.

BACKGROUND: This paper focuses on the collision of three factors: a growing emphasis on sharing research through open access publication, an increasing awareness of big data and its potential uses, and an engaged public interested in the privacy and confidentiality of their personal health information. One conceptual space where this collision is brought into sharp relief is with the open availability of patient medical photographs from peer-reviewed journal articles in the search results of online image databases such as Google Images. OBJECTIVE: The aim of this study was to assess the availability of patient medical photographs from published journal articles in Google Images search results and the factors impacting this availability. METHODS: We conducted a cross-sectional study using data from an evidence map of research with transgender, gender non-binary, and other gender diverse (trans) participants. For the original evidence map, a comprehensive search of 15 academic databases was developed in collaboration with a health sciences librarian. Initial search results produced 25,230 references after duplicates were removed. Eligibility criteria were established to include empirical research of any design that included trans participants or their personal information and that was published in English in peer-reviewed journals. We identified all articles published between 2008 and 2015 with medical photographs of trans participants. For each reference, images were individually numbered in order to track the total number of medical photographs. We used odds ratios (OR) to assess the association between availability of the clinical photograph on Google Images and the following factors: whether the article was openly available online (open access, Researchgate.net, or Academia.edu), whether the article included genital images, if the photographs were published in color, and whether the photographs were located on the journal article landing page. RESULTS: We identified 94 articles with medical photographs of trans participants, including a total of 605 photographs. Of the 94 publications, 35 (37%) included at least one medical photograph that was found on Google Images. The ability to locate the article freely online contributes to the availability of at least one image from the article on Google Images (OR 2.99, 95% CI 1.20-7.45). CONCLUSIONS: This is the first study to document the existence of medical photographs from peer-reviewed journals appearing in Google Images search results. Almost all of the images we searched for included sensitive photographs of patient genitals, chests, or breasts. Given that it is unlikely that patients consented to sharing their personal health information in these ways, this constitutes a risk to patient privacy. Based on the impact of current practices, revisions to informed consent policies and guidelines are required.

Clinical ethics issues in HIV care in Canada: an institutional ethnographic study.

BACKGROUND: This is a study involving three HIV clinics in the Canadian provinces of Newfoundland and Labrador, and Manitoba. We sought to identify ethical issues involving health care providers and clinic clients in these settings, and to gain an understanding of how different ethical issues are managed by these groups. METHODS: We used an institutional ethnographic method to investigate ethical issues in HIV clinics. Our researcher conducted in-depth semi-structured interviews, compiled participant observation notes, and studied health records in order to document ethical issues in the clinics, and to understand how health care providers and clinic clients manage and resolve these issues. RESULTS: We found that health care providers and clinic clients have developed work processes for managing ethical issues of various types: conflicts between client-autonomy and public health priorities ("treatment as prevention"), difficulties associated with the criminalization of nondisclosure of HIV positive status, challenges with non-adherence to HIV treatment, the protection of confidentiality, barriers to treatment access, and negative social determinants of health and well-being. CONCLUSIONS: Some ethical issues resulted from structural disadvantages experienced by clinic clients. The most striking findings in our study were the negative social determinants of health and well-being experienced by some clinic clients - such as experiences of violence and trauma, poverty, racism, colonization, homelessness, and other factors affecting well-being such as problematic substance use. These negative determinants were at the root of other ethical issues, and are themselves of ethical concern.

A cohort study examining emergency department visits and hospital admissions among people who use drugs in Ottawa, Canada.

BACKGROUND: The health of people who use drugs (PWUD) is characterized by multimorbidity and chronicity of health conditions, necessitating an understanding of their health care utilization. The objective of this study was to evaluate emergency department (ED) visits and hospital admissions among a cohort of PWUD. METHODS: We used a retrospective observational design between 2012 and 2013. The population was a marginalized cohort of PWUD (the PROUD study) for whom survey data was linked (n = 663) to provincial health administrative data housed at the Institute for Clinical Evaluative Sciences. We constructed a 5:1 comparison group matched by age, sex, income quintile, and region. The main outcomes were defined as having two or more ED visits, or one or more hospital admissions, in the year prior to survey completion. We used multivariable logistic regression analyses to identify factors associated with these outcomes. RESULTS: Compared to the matched cohort, PWUD had higher rates of ED visits (rate ratio [RR] 7.0; 95% confidence interval [95% CI] 6.5-7.6) and hospitalization (RR 7.7; 95% CI 5.9-10.0). After adjustment, factors predicting more ED visits were receiving disability (adjusted odds ratio [AOR] 3.0; 95% CI 1.7-5.5) or income assistance (AOR 2.7; 95% CI 1.5-5.0), injection drug use (AOR 2.1; 95% CI 1.3-3.4), incarceration within 12 months (AOR 1.6; 95% CI 1.1-2.4), mental health comorbidity (AOR 2.1; 95% CI 1.4-3.1), and a suicide attempt within 12 months (AOR 2.1; 95% CI 1.1-3.4). Receiving methadone (AOR 0.5; 95% CI 0.3-0.9) and having a regular family physician (AOR 0.5; 95% CI 0.2-0.9) were associated with lower odds of having more ED visits. Factors associated with more hospital admissions included Aboriginal identity (AOR 2.4; 95% CI 1.4-4.1), receiving disability (AOR 2.4; 95% CI 1.1-5.4), non-injection drug use (opioids and non-opioids) (AOR 2.2; 95% CI 1.1-4.4), comorbid HIV (AOR 2.4; 95% CI 1.2-5.6), mental health comorbidity (AOR 2.4; 95% CI 1.3-4.2), and unstable housing (AOR 1.9; 95% CI 1.0-3.4); there were no protective factors for hospitalization. CONCLUSIONS: Improved post-incarceration support, housing services, and access to integrated primary care services including opioid replacement therapy may be effective interventions to decrease acute care use among PWUD, including targeted approaches for people receiving social assistance or with mental health concerns.

The ethics of community-based research with people who use drugs: results of a scoping review.

BACKGROUND: Drug user networks and community-based organizations advocate for greater, meaningful involvement of people with lived experience of drug use in research, programs and services, and policy initiatives. Community-based approaches to research provide an opportunity to engage people who use drugs in all stages of the research process. Conducting community-based participatory research (CBPR) with people who use drugs has its own ethical challenges that are not necessarily acknowledged or supported by institutional ethics review boards. We conducted a scoping review to identify ethical issues in CBPR with people who use drugs that were documented in peer-reviewed and grey literature. METHODS: The search strategy focused on three areas; community-based research, ethical issues, and drug use. Searches of five academic databases were conducted in addition to a grey literature search, hand-searching, and consultation with organizational partners and key stakeholders. Peer reviewed literature and community reports published in English between 1985 and 2013 were included, with initial screening conducted by two reviewers. RESULTS: The search strategy produced a total of 874 references. Twenty-five references met the inclusion criteria and were included in our thematic analysis. Five areas were identified as important to the ethics of CBPR with people who use drugs: 1) participant compensation, 2) drug user perspectives on CBPR, 3) peer recruitment and representation in CBPR, 4) capacity building, and 5) participation and inclusion in CBPR. CONCLUSIONS: We critically discuss implications of the emerging research in this field and provide suggestions for future research and practice.

The ethical case for providing cost-free access to lifesaving HIV medications in Canada: Implications of a qualitative study.

Antiretroviral therapy for HIV can be expensive if paid for out of pocket. In Canada, there are a variety of federal, provincial, and private prescription drug plans that lower the cost of these lifesaving medications for people living with HIV, and in some cases, these plans result in cost-free access. However, many people living with HIV must contend with high deductibles for their antiretroviral therapies, and many experience difficulty managing the administrative requirements of their drug plans. This article comments on some of the results of a qualitative study into ethical issues in HIV care. Access to antiretrovirals was a theme that emerged in this study. We argue on ethical grounds that provincial drug plans should guarantee cost-free access to antiretroviral therapies for people living with HIV with minimal administrative requirements.

Establishing a community-based participatory research partnership among people who use drugs in Ottawa: the PROUD cohort study.

BACKGROUND: Grounded in a community-based participatory research (CBPR) framework, the PROUD (Participatory Research in Ottawa: Understanding Drugs) Study aims to better understand HIV risk and prevalence among people who use drugs in Ottawa, Ontario. The purpose of this paper is to describe the establishment of the PROUD research partnership. METHODS: PROUD relies on peers' expertise stemming from their lived experience with drug use to guide all aspects of this CBPR project. A Community Advisory Committee (CAC), comprised of eight people with lived experience, three allies and three ex-officio members, has been meeting since May 2012 to oversee all aspects of the project. Eleven medical students from the University of Ottawa were recruited to work alongside the committee. Training was provided on CBPR; HIV and harm reduction; and administering HIV point-of-care (POC) tests so that the CAC can play a key role in research design, data collection, analysis, and knowledge translation activities. RESULTS: From March-December 2013, the study enrolled 858 participants who use drugs (defined as anyone who has injected or smoked drugs other than marijuana in the last 12 months) into a prospective cohort study. Participants completed a one-time questionnaire administered by a trained peer or medical student, who then administered an HIV POC test. Recruitment, interviews and testing occurred in both the fixed research site and various community settings across Ottawa. With consent, prospective follow-up will occur through linkages to health care records available through the Institute for Clinical and Evaluation Sciences. CONCLUSION: The PROUD Study meaningfully engaged the communities of people who use drugs in Ottawa through the formation of the CAC, the training of peers as community-based researchers, and integrated KTE throughout the research project. This project successfully supported skill development across the team and empowered people with drug use experience to take on leadership roles, ensuring that this research process will promote change at the local level. The CBPR methods developed in this study provide important insights for future research projects with people who use drugs in other settings.

Transgender and Nonbinary Individuals' Perceptions Regarding Gender-Affirming Hormone Therapy and Cardiovascular Health: A Qualitative Study.

BACKGROUND: Transgender and nonbinary individuals face substantial cardiovascular health uncertainties. The use of gender-affirming hormone therapy can be used to achieve one's gender-affirming goals. As self-rated health is an important predictor of health outcomes, an understanding of how this association is perceived by transgender and nonbinary individuals using gender-affirming hormone therapy is required. The objective of this research was to explore transgender and nonbinary individuals' perceptions of cardiovascular health in the context of using gender-affirming hormone therapy. METHODS: In this qualitative study, English-speaking transgender and nonbinary adults using gender-affirming hormone therapy for 3 months or more were recruited from across Canada using purposive and snowball sampling methods. Semistructured interviews were conducted through videoconference to explore transgender and nonbinary individuals' perceptions of the association between gender-affirming hormone therapy and cardiovascular health between May and August 2023. Data were transcribed verbatim, and transcripts were analyzed independently by 3 reviewers using thematic analysis. RESULTS: Twenty-one participants were interviewed (8 transgender women, 9 transgender men, and 3 nonbinary individuals; median [range] age, 27 [20-69] years; 80% White participants). Three main themes were identified: cardiovascular health was not a primary concern in the decision-making process with regard to gender-affirming hormone therapy, the improved well-being associated with gender-affirming hormone therapy was felt to contribute to improved cardiovascular health, and health care provider knowledge and attitude facilitate the transition process. CONCLUSIONS: Gender-affirming hormone therapy in transgender and nonbinary individuals is perceived to improve cardiovascular health. Given the positive associations between care aligned with patient priorities, self-rated health, and health outcomes, these findings should be considered as part of shared decision-making and person-centered care.

'I was just doing what a normal gay man would do, right?': The biopolitics of substance use and the mental health of sexual minority men.

Drawing on 24 interviews conducted with gay, bisexual, queer and other men who have sex with men (GBM) living in Toronto, Canada, we examined how they are making sense of the relationship between their mental health and substance use. We draw from the literature on the biopolitics of substance use to document how GBM self-regulate and use alcohol and other drugs (AODC) as technologies of the self. Despite cultural understandings of substance use as integral to GBM communities and subjectivity, GBM can be ambivalent about their AODC. Participants discussed taking substances positively as a therapeutic mental health aid and negatively as being corrosive to their mental wellbeing. A fine line was communicated between substance use being self-productive or self-destructive. Some discussed having made 'problematic' or 'unhealthy' drug-taking decisions, while others presented themselves as self-controlled, responsible neoliberal actors doing 'what a normal gay man would do'. This ambivalence is related to the polarizing binary community and scientific discourses on substances (i.e. addiction/healthy use, irrational/rational, uncontrolled/controlled). Our findings add to the critical drug literature by demonstrating how reifying and/or dismantling the coherency of such substance use binaries can serve as a biopolitical site for some GBM to construct their identities and demonstrate healthy, 'responsible' subjectivity.

'I'm not interested in research; i'm interested in services': How to better health and social services for transgender women living with and affected by HIV.

This paper presents results of a research priority setting process focused on trans women living with and affected by HIV across Canada. It features data from semi-structured interviews and focus groups conducted with a diverse group of 76 trans women in five urban centers across the country on how they have navigated health and social service programming within their geographic context. The results focus on the structure and types of services. Respondents offered simple, yet creative ways to address barriers to vital services based on their individual and collective experiences. Notably, participants stressed the need for 1) trans-friendly and trans-specific services, 2) integrated health services, and aid in navigating complex, overlapping systems, and 3) comprehensive community-based services. They also suggest employing trans women as care coordinators or case managers in order to foster more trans-friendly environments and empower community members. We identify concrete ways to improve health and social services at the level of service delivery and program design, as well as recommendations for future participatory research. We close with an interrogation of trans people, and trans women living with and affected by HIV in particular, as 'hard to reach' populations.

Transgender data collection in the electronic health record: Current concepts and issues.

There are over 1 million transgender people living in the United States, and 33% report negative experiences with a healthcare provider, many of which are connected to data representation in electronic health records (EHRs). We present recommendations and common pitfalls involving sex- and gender-related data collection in EHRs. Our recommendations leverage the needs of patients, medical providers, and researchers to optimize both individual patient experiences and the efficacy and reproducibility of EHR population-based studies. We also briefly discuss adequate additions to the EHR considering name and pronoun usage. We add the disclaimer that these questions are more complex than commonly assumed. We conclude that collaborations between local transgender and gender-diverse persons and medical providers as well as open inclusion of transgender and gender-diverse individuals on terminology and standards boards is crucial to shifting the paradigm in transgender and gender-diverse health.