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Introduction In the context of renewed debate about Canada’s “end demand” sex work laws, we took an intersectional approach to characterize experiences with the criminal legal system and perceived access to justice among transgender (trans) and nonbinary sex workers in Canada. Methods The Trans PULSE Canada community-based study collected multimode survey data in fall 2019. Data were cross-stratified by lifetime sex work and sex assigned at birth, ethnoracial group, or household income. Age adjustment did not meaningfully impact results. Results Of 2012 included participants (median age = 30, 66.5% assigned female at birth, 48.9% non-binary), 280 (16.1%) had ever done sex work. While access to justice was limited for trans and non-binary people overall, sex workers were more likely to anticipate (72.1% vs. 50.5%) and experience (43.2% vs. 15.7%) police mistreatment. In the previous 5 years, sex workers were more likely to experience violence for any reason (61.4% vs. 27.4% of other participants) or due to being trans or non-binary (41.4% vs. 14.0%), and to have avoided calling 911 for police (51.4% vs. 18.1%). Few sex workers trusted that they would be treated fairly by police if they experienced physical (10.8% vs. 34.9%) or sexual (4.7% vs. 20.6%) violence. Intersectional inequalities included that sex workers assigned male at birth and street-based workers were most likely to have experienced gender-based violence, and that Indigenous and racialized sex workers reported higher levels of police mistreatment and 911 avoidance. Conclusions Overall, trans and non-binary people in Canada reported high levels of violence and limited access to justice. Sex workers faced large inequities in these outcomes, which were exacerbated for transfeminine, Indigenous, racialized, and street-based workers. Policy Implications These findings challenge the notion that Canadian sex work laws protect sex workers and highlight the limitations of formal legal protections for trans people. These inequities must be addressed in sex work legal reform efforts.

Background Emerging international evidence indicates the COVID-19 pandemic has exacerbated socioeconomic and health challenges faced by transgender (trans) and non-binary populations globally. This qualitative study is among the first to characterize impacts of the pandemic on these groups in Canada. Methods Drawing on data from the Trans PULSE Canada survey (N = 820), we used thematic analysis to examine the free-form responses of 697 participants to one open-ended question on impacts of the pandemic. We first organized responses into descriptive themes, and then used this preliminary analytical process to construct more refined, higher order themes that provided a rich account of the pandemic’s impacts. Results Our results are organized into five themes that highlight the pandemic’s impacts on trans and non-binary populations in Canada. These include: (1) reduced access to both gender-affirming and other healthcare, (2) heightened financial, employment, and housing precarity, (3) strained social networks in an era of physical distancing and virtual communication, (4) an intensification of safety concerns, and (5) changes in experiences of gender affirmation. Conclusion Our findings highlight the pandemic’s systemic impacts on the lives of trans and non-binary people in domains such as healthcare, employment, and housing, and on the social networks of these groups, many of which reflect an exacerbation of pre-existing inequities. Based on our analysis, we recommend that public health researchers, policymakers, and practitioners attend to the structural impacts of the pandemic on these groups as primary sites of inquiry and intervention.

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

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

Intersectionality theoretical frameworks have been increasingly incorporated into quantitative research. A range of methods have been applied to describing outcomes and disparities across large numbers of intersections of social identities or positions, with limited evaluation.Using data simulated to reflect plausible epidemiologic data scenarios, we evaluated methods for intercategorical intersectional analysis of continuous outcomes, including cross-classification, regression with interactions, multilevel analysis of individual heterogeneity (MAIHDA), and decision-tree methods (classification and regression trees [CART], conditional inference trees [CTree], random forest). The primary outcome was estimation accuracy of intersection-specific means. We applied each method to an illustrative example using National Health and Nutrition Examination Study (NHANES) systolic blood pressure data.When studying high-dimensional intersections at smaller sample sizes, MAIHDA, CTree, and random forest produced more accurate estimates. In large samples, all methods performed similarly except CART, which produced less accurate estimates. For variable selection, CART performed poorly across sample sizes, although random forest performed best. The NHANES example demonstrated that different methods resulted in meaningful differences in systolic blood pressure estimates, highlighting the importance of selecting appropriate methods.This study evaluates some of a growing toolbox of methods for describing intersectional health outcomes and disparities. We identified more accurate methods for estimating outcomes for high-dimensional intersections across different sample sizes. As estimation is rarely the only objective for epidemiologists, we highlight different outputs each method creates, and suggest the sequential pairing of methods as a strategy for overcoming certain technical challenges.

PurposeCOVID-related stressors associated with loss of income and community are compounded with gender minority stress among trans and non-binary people (TNB) – which may result in mental health burden. The present study examined the effect of COVID-related change in finances and TNB gathering access on anxiety and depression among TNB people.MethodsParticipants were 18 years and older (M age = 30) who completed both pre-pandemic baseline (Fall 2019) and pandemic follow-up (Fall 2020) surveys in the Trans PULSE Canada study. Multivariable regression analyses examined associations between change in (1) finances and (2) access to TNB peers and mental health during the pandemic.ResultsOf 780 participants, 50% reported that COVID had a negative effect on personal income and 58.3% reported loss in access to TNB peer or friend gatherings (in person or online). Depression and anxiety symptoms increased from pre-pandemic to follow-up, and most participants were above measurement cut-offs for clinical levels during the pandemic. Changes in finances and access to peer gatherings were associated with depression symptoms during the pandemic, but effects depended on level of pre-pandemic depression. For participants with high pre-pandemic depression, financial stability was not protective against increased depression at follow-up. Participants experiencing unprecedentedly high levels of depression during COVID may have pursued more TNB gatherings. Neither financial change nor access to TNB gatherings were associated with pandemic anxiety.ConclusionFindings suggest need for a multifaceted approach to mental health programmes and services to address structural barriers, including financial support and meaningful TNB community engagement.

Transgender (trans) and non-binary people experience barriers to culturally competent healthcare and many have reported avoiding care. COVID-19 and related mitigation strategies may have exacerbated avoidance, and poor mental health may be bidirectionally related to avoiding care. This study estimated the prevalence of primary care avoidance during the pandemic in a national sample of trans and non-binary people in Canada with a primary care provider and examined the association between poorer self-rated mental health and avoidance. In Fall 2019, Trans PULSE Canada collected multi-mode survey data from trans and non-binary people. In September to October 2020, 820 participants completed a COVID-19-focused survey. In this cross-sectional analysis, multivariable logistic regression models estimated odds ratios adjusted for confounders and weighted to the 2019 sample. The analysis included 689 individuals with a primary healthcare provider, of whom 61.2% (95% CI: 57.2, 65.2) reported fair or poor mental health and 25.7% (95% CI: 22.3, 29.2) reported care avoidance during the pandemic. The most common reason for avoidance was having a non-urgent health concern (72.7%, 95% CI: 65.9, 79.5). In adjusted analyses, those with fair or poor mental health had higher odds of avoiding primary care as compared to those with good to excellent mental health (adjusted odds ratio [AOR] = 2.37; 95% CI: 1.50, 3.77). This relationship was similar when excluding COVID-related reasons for avoidance (AOR = 2.52; 95% CI: 1.52, 4.17). Expansion of virtual communication may enhance primary care accessibility, and proactively assessing mental health symptoms may facilitate connections to gender-affirming mental health services.

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

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

Background Intersectionality is a theoretical framework rooted in the premise that human experience is jointly shaped by multiple social positions (e.g. race, gender), and cannot be adequately understood by considering social positions independently. Used widely in qualitative studies, its uptake in quantitative research has been more recent. Objectives To characterize quantitative research applications of intersectionality from 1989 to mid-2020, to evaluate basic integration of theoretical frameworks, and to identify innovative methods that could be applied to health research. Methods Adhering to PRISMA guidelines, we conducted a systematic review of peer-reviewed articles indexed within Scopus, Medline, ProQuest Political Science and Public Administration, and PsycINFO. Original English-language quantitative or mixed-methods research or methods papers that explicitly applied intersectionality theoretical frameworks were included. Experimental studies on perception/stereotyping and measures development or validation studies were excluded. We extracted data related to publication, study design, quantitative methods, and application of intersectionality. Results 707 articles (671 applied studies, 25 methods-only papers, 11 methods plus application) met inclusion criteria. Articles were published in journals across a range of disciplines, most commonly psychology, sociology, and medical/life sciences; 40.8% studied a health-related outcome. Results supported concerns among intersectionality scholars that core theoretical tenets are often lost or misinterpreted in quantitative research; about one in four applied articles (26.9%) failed to define intersectionality, while one in six (17.5%) included intersectional position components not reflective of social power. Quantitative methods were simplistic (most often regression with interactions, cross-classified variables, or stratification) and were often misapplied or misinterpreted. Several novel methods were identified. Conclusions Intersectionality is frequently misunderstood when bridging theory into quantitative methodology. Further work is required to (1) ensure researchers understand key features that define quantitative intersectionality analyses, (2) improve reporting practices for intersectional analyses, and (3) develop and adapt quantitative methods., Highlights • Multidisciplinary statistical methods for intersectional research were identified. • Regression with intersectional variables was the most frequently used method. • Decomposition analyses and decision trees were identified as promising methods. • Intersectionality theory and methods literature was infrequently cited in studies. • Improvements in reporting of quantitative intersectional research are needed.

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

Introduction The use of intersectionality as an explicit theoretical framework in quantitative public health research is relatively recent, and has involved a wide array of study design and statistical methods. As best practices have not been identified, guidance for research design and analysis is needed. Methods We draw on a review of the literature and our own methods publications to present an overview of key considerations in approaching public health research from an intersectional perspective. Results Key considerations differ for descriptive studies of intersectional inequalities and analytic studies of potential causes of those inequalities, as research methodologies and their strengths and limitations differ. For descriptive studies, considerations include specification of intersectional groups, multiplicative vs. additive scale for analysis of effects and interactions, limitations of data sets, whether all intersectional groups are of equal interest, and choosing statistical methods. For analytic studies, considerations include whether potential causal factors are relevant and measurable for all intersections or are specific to some, variable measurement, different options in standardization or control of confounding, and statistical analysis methods. Discussion We present considerations in incorporating intersectionality frameworks, and provide tools for conceptualizing intersectionality-informed quantitative public health research.

Introduction This study evaluated seven quantitative methods for their predictive accuracy for intersectionally defined subgroups, via a simulation study. The methods were single-level regression with interaction terms, cross-classification, multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA), and four decision tree Methods classification and regression trees (CART), conditional inference trees, chi-square automatic interaction detector, and random forest. Also evaluated was how well methods identified variables relevant to the outcome. An example analysis will be presented using data from the U.S. National Health and Nutritional Examination Survey. Methods The simulated datasets varied by outcome variable type (binary and continuous), input variable types, sample size, and size and direction of the effects. Accuracy was evaluated using mean squared error or mean absolute percentage error. The secondary outcome was evaluated via significance and confidence interval coverage of regression terms and variable selection of the machine learning methods. Results Predictive accuracy improved with increasing sample size for all methods except CART. At small sample sizes random forest and MAIHDA generally created the most precise predictions. Variable selection consistently faced a high type 1 error for CTree and CHAID. While performing well for prediction, variable selection by random forest and confidence interval coverage and power of MAIHDA main effects coefficients were suboptimal. Discussion From this study emerge recommendations for applying methods in quantitative intersectionality. Different methodologies are optimal for different purposes, for example while random forest and MAIHDA performed well for prediction, they were less reliable for variable identification. In our discussion, we will work through how to select, apply, and interpret methodologies to achieve analytic goals that align with intersectionality theory.

Background and aims Identifying typologies of social determinants of health (SDoH) vulnerability influencing drug use practices among women living with HIV (WLWH) can help to address associated harms. This research aimed to explore the association of SDoH clusters with drug use among WLWH. Design Latent class analysis (LCA) was used to identify the distinct clusters of SDoH. Inverse probability weighting (IPW) was employed to account for confounding and potential selection bias. Associations were analyzed using generalized linear model with log link and Poisson distribution, and then weighted risk ratio (RR) and 95% confidence intervals (CI) were reported. Setting and participants Data from 1422 WLWH recruited at time-point 1 of the Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS, 2013-15), with 1252 participants at 18 months follow-up (time-point 2). Measurements Drug use was defined as use of illicit/non-prescribed opioids/stimulants in the past 6 months. SDoH indicators included: race discrimination, gender discrimination, HIV stigma, social support, access to care, food security, income level, employment status, education, housing status and histories of recent sex work and incarceration. Findings LCA identified four SDoH classes: no/least SDoH adversities (6.6%), discrimination/stigma (17.7%), economic hardship (30.8%) and most SDoH adversities (45.0%). Drug use was reported by 17.5% and 17.2% at time-points 1 and 2, respectively. WLWH with no/least SDoH adversities were less likely to report drug use than those in economic hardship class (weighted RR = 0.13; 95% CIs = 0.03, 0.63), discrimination/stigma class (weighted RR = 0.15; 95% CIs = 0.03, 0.78), and most SDoH adversities class (weighted RR = 0.13; 95% CIs = 0.03, 0.58). Conclusions Social determinants of health vulnerabilities are associated with greater likelihood of drug use, underscoring the significance of addressing interlinked social determinants and drug use through the course of HIV care and treatment.

Objective This study examines the prevalence of drug and poly-drug use and their associated factors among female sex workers (FSW) in Iran. Methods We analyzed data from a bio-behavioral surveillance survey of 1347 FSW across 13 major cities in Iran in 2015. Two outcome measures were defined: i) past-month “any drug use”, a binary variable defined as none or any; and ii) a three-category past-month “poly-drug use” variable defined as none, only one drug, and more than one drug. Correlates of these two study outcomes were assessed using multivariable logistic regression and multinomial logistic regression, respectively. Adjusted odds ratios (AOR) and 95% confidence intervals (CI) were reported. Results We found that 24.9% (95% CI: 16.1, 36.4) and 13.5% (95% CI: 8.1, 21.5) of FSW reported past-month any drug use and poly-drug use, respectively. Longer sex work career (AOR 2.44 [95% CI: 1.28, 4.63]), unstable housing (AOR 2.56 [1.17, 5.64]), past-year experience of sexual violence (AOR 1.61 [1.15, 2.27]), and incarceration (AOR 2.02 [1.23, 3.32]) were positively associated with any drug use. Similarly, FSW who were unstably housed (AOR 3.4 [1.06, 10.95]), reported past-year experience of sexual violence (AOR 2.06 [95% CI: 1.24, 3.41]) and incarceration (AOR 2.82 [1.60, 4.97]) were positively associated with past-month poly-drug use. Conclusion Drug use is frequent among Iranian FSW, particularly among those who experienced sexual violence, unstable housing or incarceration. Programs to reduce harms associated with drug and poly-drug use should target FSW as a priority population.

OBJECTIVES: Visible minorities are a group categorized in health research to identify and track inequalities, or to study the impact of racialization. We compared classifications obtained from a commonly used measure (Statistics Canada standard) with those obtained by two direct questions—whether one is a member of a visible minority group and whether one is perceived or treated as a person of colour. METHODS: A mixed-methods analysis was conducted using data from an English-language online survey (n = 311) and cognitive interviews with a maximum diversity subsample (n = 79). Participants were Canadian residents age 14 and older. RESULTS: Agreement between the single visible minority item and the standard was good (Cohen’s Κ = 0.725; 95% CI = 0.629, 0.820). However, participants understood “visible minority” in different and often literal ways, sometimes including those living with visible disabilities or who were visibly transgender or poor. Agreement between the single person of colour item and the standard was very good (Κ = 0.830; 95% CI = 0.747, 0.913). “Person of colour” was more clearly understood to reflect ethnoracial background and may better capture the group likely to be targeted for racism than the Statistics Canada standard. When Indigenous participants who reported being persons of colour were reclassified to reflect the government definition of visible minority as non-Indigenous, this measure had strong agreement with the current federal standard measure (K = 0.851; 95% CI = 0.772, 0.930). CONCLUSION: A single question on perception or treatment as a person of colour appears to well identify racialized persons and may alternately be recoded to approximate government classification of visible minorities.

Little is known about youth accessing gender-affirming care in Canada. Trans Youth CAN! is a prospective 24-month cohort study of youth referred for puberty suppression/gender affirming hormones, examining pathways to care, medical, social, and family outcomes. Eligible participants were pubertal, aged

HIV infection and substance use synergistically impact health outcomes of people with HIV. In this study, we assessed the prevalence of substance use among women living with HIV (WLWH) and compared them with expected values from general data.Cigarette smoking, frequency of alcohol consumption, last-month non-prescribed cannabis use (vs. last-year use), and last 3 months regular (≥once/week) and occasional (once/week) use of crack/cocaine, speed (amphetamine), and heroin (vs. last-year use) were examined in WLWH from the 2013-2015 Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS; N = 1422) and compared with general population women from the 2013-2014 Canadian Community Health Survey (CCHS; N = 46,831). Age/ethnoracial-standardized prevalence differences (SPD) and 95% confidence intervals (CI) were reported.Compared to expected estimates from general population women, a higher proportion of WLWH reported daily cigarette smoking (SPD: 26.8% [95% CI: 23.9, 29.7]), smoking ≥20 cigarettes/day (SPD: 11.6% [9.8, 13.6]), regular non-prescribed cannabis use (SPD: 8.0% [4.1, 8.6]), regular crack/cocaine use (SPD: 16.7% [13.1, 20.9]), regular/occasional speed use (SPD: 2.4% [1.2, 4.7]), and heroin use (SPD: 11.2% [8.3, 15.0]). However, WLWH reported lower frequencies of alcohol consumption and binge drinking than their counterparts in the general population.Cigarette smoking and illicit drug use, but not alcohol use or binge drinking, were more prevalent in WLWH than would be expected for Canadian women with a similar age and ethnoracial group profile. These findings may indicate the need for women-centered harm reduction programs to improve health outcomes of WLWH in Canada.

Background: Associations between HIV-related stigma and reduced antiretroviral therapy (ART) adherence are widely established, yet the mechanisms accounting for this relationship are underexplored. There has been less attention to HIV-related stigma and its associations with ART initiation and current ART use. We examined pathways from HIV-related stigma to ART initiation, current ART use, and ART adherence among women living with HIV in Canada. Methods: We used baseline survey data from a national cohort of women living with HIV in Canada (n = 1425). Structural equation modeling using weighted least squares estimation methods was conducted to test the direct effects of HIV-related stigma dimensions (personalized, negative self-image, and public attitudes) on ART initiation, current ART use, and 90% ART adherence, and indirect effects through depression and HIV disclosure concerns, adjusting for sociodemographic factors. Results: In the final model, the direct paths from personalized stigma to ART initiation (β = −0.104, P < 0.05) and current ART use (β = −0.142, P < 0.01), and negative self-image to ART initiation (β = −0.113, P < 0.01) were significant, accounting for the mediation effects of depression and HIV disclosure concerns. Depression mediated the pathways from personalized stigma to ART adherence, and negative self-image to current ART use and ART adherence. Final model fit indices suggest that the model fit the data well [χ2(25) = 90.251, P < 0.001; comparative fit index = 0.945; root-mean-square error of approximation = 0.044]. Conclusions: HIV-related stigma is associated with reduced likelihood of ART initiation and current ART use, and suboptimal ART adherence. To optimize the benefit of ART among women living with HIV, interventions should reduce HIV-related stigma and address depression.

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

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

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

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

BackgroundWomen living with HIV (WLWH) continue to experience poorer outcomes across the HIV care cascade and overall health, an appreciable proportion of which may not be disease-related but due to socio-structural barriers that impact health. We compared socio-structural determinants of health and self-rated health between WLWH and expected general population values.MethodsPrevalences of socio-structural determinants and self-rated health were estimated from 1,422 WLWH aged 16+ in the 2013-2015 Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS). Prevalences were also estimated from 46,831 general population women (assumed HIV-negative) in the 2013-2014 Canadian Community Health Survey (CCHS), standardized to the age/ethnoracial group distribution of WLWH. Standardized prevalence differences (SPDs) and 95% confidence intervals (CI) were reported.ResultsCompared to general population women, a higher proportion of WLWH reported annual personal income ConclusionsSignificant socio-structural inequalities and lower self-rated health were found among WLWH compared to general population women. Such inequities support the integration of a social-determinants approach, social service delivery, and programming into HIV care, with additional resource allocation tailored to the particular needs of WLWH.

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

Changes in gay and bisexual men's connectedness to the gay community are related to the declining public visibility of HIV/AIDS and greater acceptance for homosexuality and bisexuality in mainstream society. Little work, however, has focused on perceived acceptance for subgroups within the gay community or broader society. Using interviews (n = 20) and a survey (n = 202) of gay and bisexual men in a mid-sized Canadian city, we find perceived hierarchies of acceptance for the various subgroups as well as an age effect wherein middle-aged men perceive the least acceptance for all groups. These differences are linked with the uneven impact of social, political, and institutional changes relevant to gay and bisexual men in Canada.

Recent estimates suggest that as many as 1 in 200 adults may be trans (transgender, transsexual, or transitioned). Knowledge about dimensions of sex and gender in trans populations is crucial to development of inclusive policy, practice, and research, but limited data have been available, particularly from probability samples. The Trans PULSE community-based research project surveyed trans Ontarians (n = 433) in 2009–2010 using respondent-driven sampling. Frequencies were weighted by recruitment probability to produce estimates for the networked Ontario trans population. An estimated 30% of trans Ontarians were living their day-to-day lives in their birth gender, and 23% were living in their felt gender with no medical intervention. In all, 42% were using hormones, while 15% of male-to-female spectrum persons had undergone vaginoplasty and 0.4% of female-to-male spectrum persons had had phalloplasty. Of those living in their felt gender, 59% had begun to do so within the past four years. A minority of trans Ontarians reported a linear transition from one sex to another, yet such a trajectory is often assumed to be the norm. Accounting for this observed diversity, we recommend policy and practice changes to increase social inclusion and service access for trans persons, regardless of transition status.

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

Purpose – Despite health inequities experienced by Aboriginal and transgender (trans) communities, little research has explored the well-being of Aboriginal trans (gender-diverse) people. This paper aims to describe barriers to well-being in a sample of Aboriginal gender-diverse people in Ontario, Canada. Design/methodology/approach – In 2009-2010, 433 trans people in Canada's most populous province participated in a multi-mode health survey. In all, 32 participants identified as First Nations, Métis, or Inuit (Aboriginal); unweighted frequencies were calculated to describe their characteristics. Findings – Participants expressed diverse gender identities; 44 per cent identified with the pan-Aboriginal term two-spirit. High levels of poverty (47 per cent), homelessness or underhousing (34 per cent), and ever having to move due to being trans (67 per cent) were reported. In all, 61 per cent reported at least one past-year unmet health care need. Most participants had experienced violence due to being trans (73 per cent) and had ever seriously considered suicide (76 per cent). One-fifth had been incarcerated while presenting in their felt gender. Aboriginal spirituality was practiced by 44 per cent, and 19 per cent had seen an Aboriginal Elder for mental health support. Research limitations/implications – Action is needed to address the social determinants of health among Aboriginal gender-diverse people. Using principles of self-determination, there is a need to increase access to health and community supports, including integration of traditional culture and healing practices. Larger study samples and qualitative research are required. Originality/value – These first published data regarding the health of Aboriginal gender-diverse Ontarians illustrate both their heterogeneity and all-too-common experiences of individual and systemic discrimination, and barriers to care. Results highlight potential impacts of colonialism and social exclusion, and suggest priorities for ameliorative action.

Newer forms of community-based participatory research (CBPR) prioritize community control over community engagement, and articles that outline some of the challenges inherent in this approach to CBPR are imperative in terms of advancing knowledge and practice. This article outlines the community control strategy utilized by Trans PULSE, an Ontario-wide research initiative devoted to understanding the ways in which social exclusion, cisnormativity (the belief that transgender (trans) identities or bodies are less authentic or ‘normal’), and transphobia shape the provision of services and affect health outcomes for trans people in Ontario, Canada. While we have been successful in building and supporting a solid model of community control in research, challenges have emerged related to: power differentials between community and academic partners, unintentional disempowerment of community members through the research process, the impact of community-level trauma on team dynamics, and differing visions about the importance and place of anti-racism work. Challenges are detailed as ‘lessons learned’ and a series of key questions for CBPR teams to consider are offered.

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.

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

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.

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

Background Drawing on a survey of transgender people in Canada’s most populous province, we estimate the frequency of heavy episodic drinking (HED), compare HED prevalence to the age-standardized background population, and examine associations with socio-demographics, gender transition, and social exclusion. Methods 433 transgender persons aged 16+ completed a respondent-driven sampling survey in 2009–2010. Analyses were weighted using RDS II methods, including frequencies and prevalence ratios. Overall and sex-specific estimates of HED among Ontario residents in the 2009–2010 Canadian Community Health Survey (n = 39,980) were standardized to the overall and gender-specific transgender age distributions. Results Estimated prevalence of HED at least monthly among transgender Ontarians was 33.2% (95% CI: 26.3, 40.1), 1.5 times greater than expected based on the age-standardized Ontario population. Transmasculine (female-to-male spectrum) persons were more likely than transfeminine persons to report HED (42.2% versus 22.7%), an effect robust to covariate adjustment. Current sex work was associated with greater HED, but gender transition and social exclusion factors were not. Conclusion Gendered pathways to alcohol misuse, particularly among transmasculine persons, warrant further research and intervention development.

This article explains the report from the work group of WPATH charged to consider whether a diagnosis for gender identity disorder should be included in the revised DSM; whether distress is inherent, a result of social stigma, or both; and what the implications of this are for the diagnosis in the revised DSM. Suggestions are made to remove gender identity disorder from the next revision of DSM and to find a place in the nonmental disorder section of the ICD, using the more broadly defined and less stigmatizing term gender dysphoria. Alternative suggestions are also put forward to incorporate distress within Criterion A of a diagnosis of Gender Dysphoria (formerly Gender Identity Disorder) in the revised DSM, which will make the condition correspond more closely to its description in the ICD.

BACKGROUND: Despite knowledge that some people engage in same-sex sexuality without espousing a sexual minority identity, this has rarely been studied in women. METHODS: Heterosexual women aged 20 to 44 who indicated one or more female sex partners in the past year were compared to those with less recent female sex partners, and to bisexual, homosexual, and exclusively heterosexual women using 2002 US National Survey of Family Growth data. RESULTS: Compared to exclusively heterosexual women, heterosexual women with a past-year female sex partner were significantly more likely to smoke tobacco (46% vs. 19%), binge drink (34% vs. 11%), use marijuana (58% vs. 11%), and use cocaine (19% vs. 2%). Substance use was high in this group overall, but they did not differ significantly from bisexuals on tobacco use or from homosexual or bisexual women on regular alcohol consumption. Most heterosexual women with a past-year female sex partner had only one in their lifetime. They had 10 median lifetime male partners versus 1 to 7 for other groups. Whereas similar to heterosexual women with less recent female sex partners and to bisexual women on some sexual risk measures, these women were more likely than any other group to have had a non-monogamous male partner (40%) or to have engaged in sex while high (69%). Differences in sexual risk and substance use were not explained by demographic differences. CONCLUSIONS: Results suggest same-sex behavior in heterosexual-identified women is a marker for a substance use and sexual risk profile distinct from that of bisexual, lesbian, or exclusively heterosexual women.

For people who are transgender, transsexual, or transitioned (trans), access to primary, emergency, and transition-related health care is often problematic. Results from Phase I of the Trans PULSE Project, a community-based research project in Ontario, Canada, are presented. Based on qualitative data from focus groups with 85 trans community members, a theoretical framework describing how erasure functions to impact experiences interacting with the health care system was developed. Two key sites of erasure were identified: informational erasure and institutional erasure. How these processes work in a mutually reinforcing manner to erase trans individuals and communities and produce a system in which a trans patient or client is seen as an anomaly is shown. Thus, the impetus often falls on trans individuals to attempt to remedy systematic deficiencies. The concept of cisnormativity is introduced to aid in explaining the pervasiveness of trans erasure. Strategies for change are identified.

Background Representing approximately 0.5% of the population, transgender (trans) persons in Canada depend on family physicians for both general and transition-related care. However, physicians receive little to no training on this patient population, and trans patients are often profoundly uncomfortable and may avoid health care. This study examined factors associated with patient discomfort discussing trans health issues with a family physician in Ontario, Canada. Methods 433 trans people age 16 and over were surveyed using respondent-driven sampling for the Trans PULSE Project; 356 had a family physician. Weighted logistic regression models were fit to produce prevalence risk ratios (PRRs) via average marginal predictions, for transmasculine (n = 184) and transfeminine (n = 172) trans persons. Results Among the 83.1% (95% CI = 77.4, 88.9) of trans Ontarians who had a family physician, approximately half reported discomfort discussing trans health issues. 37.2% of transmasculine and 38.1% of transfeminine persons reported at least one trans-specific negative experience. In unadjusted analysis, sociodemographics did not predict discomfort, but those who planned to medically transition sex, but had not begun, were more likely to report discomfort (transmasculine: PRR = 2.62 (95% CI = 1.44, 4.77); transfeminine: PRR = 1.85 (95% CI = 1.08, 3.15)). Adjusted for other factors, greater perceived physician knowledge about trans issues was associated with reduced likelihood of discomfort, and previous trans-specific negative experiences with a family physician with increased discomfort. Transfeminine persons who reported three or more types of negative experiences were 2.26 times as likely, and transmasculine persons 1.61 times as likely, to report discomfort. In adjusted analyses, sociodemographic associations differed by gender, with being previously married or having higher education associated with increased risk of discomfort among transfeminine persons, but decreased risk among transmasculine persons. Conclusions Within this transgender population, discomfort in discussing trans health issues with a family physician was common, presenting a barrier to accessing primary care despite having a regular family physician and “universal” health insurance.

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 (10th versus 90th 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 10th 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.

The association of phenotypic zidovudine resistance with perinatal transmission was evaluated in 74 zidovudine-treated mothers enrolled in the Women and Infants Transmission Study through September 1994. Women in the sample had moderately advanced disease, with a median CD4+ cell count of 271/microL and a median plasma HIV-1 RNA level of 39,811 copies/mL. Factors independently associated with zidovudine resistance at delivery (50% inhibitory concentration [IC50], >/=0.1 microM) in multiple logistic regression included prepregnancy zidovudine use, high log plasma HIV-1 RNA level, and low CD4+ cell count. Of 74 mothers, 16 (22%) transmitted HIV-1 to their infants. After adjustment for duration of membrane rupture and CD8+ cell count, zidovudine resistance (IC50 range, 0.01-2.2 microM) was associated with an increased odds of transmission (ORadj, 1.25 per 0.1 microM; 95% confidence interval, 1.01-1.54), suggesting a decreased effect of prenatal zidovudine on preventing transmission in mothers infected with zidovudine-resistant virus. However, when the analysis was limited only to those mothers infected with virus containing zidovudine resistance mutations, no association between phenotypic resistance and transmission remained, indicating that phenotype may not provide significant additional information in predicting transmission where resistance genotype is known.

This controlled prospective study assessed the effectiveness of a sexual health approach to HIV prevention for men who have sex with men (MSM). Participants (N = 422 Midwestern MSM) were randomly assigned to the intervention group, who participated in a 2-day comprehensive human sexuality seminar designed to contextually address long-term risk factors and cofactors, or to the control group, who watched 3 hours of HIV prevention videos. Risk behavior during the preceding 3 months was measured at baseline, 3-month follow-up, and 12-month follow-up. Any unprotected anal intercourse outside a long-term seroconcordant relationship was the dependent variable. Of the total, 14%-24% of the participants were considered at risk of acquiring or transmitting HIV. At the 12-month follow-up, the control reported a 29% decrease in the use of condoms during anal intercourse; the intervention group reported an 8% increase (t = 2.546; p = .015). The sexual health seminars appear a promising new intervention at significantly reducing unprotected anal intercourse between men.