Experiences of Trans Women and Two-Spirit Persons Accessing Women-Specific Health and Housing Services in a Downtown Neighborhood of Vancouver, Canada

Two-Spirit Peoples' experiences accessing and receiving care from community pharmacies

Background

Two-Spirit Peoples face unique challenges in accessing and receiving health care in Canada due to health services, including community pharmacy services, being built on hetero- and cis-normative models that impede appropriate care for this group. Currently, there is limited published information on Two-Spirit Peoples' experiences accessing and receiving care in community pharmacy settings.

Methods

To address the lack of published information, 21 Two-Spirit individuals shared their experiences in a focus group setting. Four different focus groups were held across Canada, including 1 in Saskatoon, Vancouver, Edmonton, and Toronto. Informed by Indigenous methodologies, data were recorded via audio recording and notetaking, and the audio was transcribed and then analyzed for themes using the Voice-Centred Relational Method.

Results

Three major structural systems that affect the experiences of Two-Spirit Peoples in community pharmacies were identified: 1) white supremacy, 2) capitalism, and 3) heteronormativity. These 3 systemic issues presented themselves via racism, homophobia, transphobia, pharmacists' lack of knowledge about Two-Spirit individuals and their health and lack of time spent educating or building relationships with Two-Spirit Peoples. Participants provided suggestions for how community pharmacists can better serve the Two-Spirit community, such as using inclusive language, adding pronouns and preferred names to patient files, increasing knowledge about Two-Spirit health and advocating for Two-Spirit Peoples.

Discussion

The results suggest that dismantling current structures and ideologies in community pharmacy and society are required to overcome the identified issues.

Conclusion

Two-Spirit Peoples face barriers when it comes to accessing and receiving care in community pharmacies, resulting in many Two-Spirit individuals avoiding health care to save themselves from unsafe and uncomfortable interactions. Pre- and postlicensure pharmacy education about Two-Spirit Peoples is required to improve Two-Spirit Peoples' experiences accessing and receiving care in community pharmacies.

Institutional Violence Perpetrated against Transgender Individuals in Health Services: A Systematic Review of Qualitative Studies

This review aims to analyze the evidence related to violence perpetrated against transgender individuals in health services based on their narratives. This is a systematic literature review of qualitative studies. A search was carried out in the Scopus, Web of Science, Latin American and Caribbean Literature in Health Sciences (LILACS), Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, and MEDLINE databases using the descriptors "transgender people", "violence", and "health services". The eligibility criteria included original qualitative articles addressing the research question, with fully available text, reporting violence specifically by health workers, involving trans individuals aged 18 and above, and published in Portuguese, English, or Spanish. In addition, studies were included that reported experiences of violence suffered by the trans population, through their narratives, in health services. A total of 3477 studies were found, of which 25 were included for analysis. The results highlighted situations such as refusal of service; resistance to the use of social names and pronouns; barriers to accessing health services; discrimination and stigma; insensitivity of health workers; lack of specialized care and professional preparedness; and a system focused on binarism. The analysis of the studies listed in this review highlights the multiple facets of institutional violence faced by the transgender population in health services. It is evident that the forms of violence often interlink and reinforce each other, creating a hostile environment for the transgender population in health services. Thus, there is an urgent need to create strategies that ensure access to dignified and respectful care for all individuals, regardless of their gender identity.

Improving the forensic genital examination for trans and gender diverse sexual assault complainants: three case reports

Trans and gender diverse people experience high rates of sexual violence and significant barriers to healthcare, including post-sexual assault healthcare. These barriers could lead to delays in presentations to sexual assault services and a reluctance to having forensic examinations, thereby impacting genital injury assessment and evidence collection. It is therefore important that clinicians working in sexual assault services understand how to best undertake forensic genital examinations, collect forensic genital specimens, and identify and document genital injuries in this population. This case report discusses three trans and gender diverse complainants of sexual assault seen at the Sexual Assault Resource Centre in Western Australia. These cases, along with an accompanying review of the literature, have been used to change the centre's practice towards this community to improve forensic genital examinations. This has included creating specific trans and gender diverse medical and forensic notes, improving clinician knowledge around trans and gender diverse genital examinations and genital injury profiles, creating an inclusive physical environment, improving trans and gender diverse patient knowledge around sexual assault services, and providing options for genital specimen collection.

Perceptions of prospective pharmaceutical stimulant substitution treatments among people who use illicit stimulants in Vancouver, Canada

BACKGROUND

Stimulant-involved overdose deaths are increasing, driven by polysubstance use and adulteration of the illicit drug supply. While emerging evidence for prescription stimulant substitution is promising, there are no approved treatment options for stimulant use disorder that address the realities of an unpredictable drug supply. This study explores treatment experiences of people who use illicit stimulants (PWUS) to identify gaps and perceptions of prospective pharmaceutical stimulant substitution treatments (SST).

METHODS

In-depth qualitative interviews were conducted with 86 PWUS in Vancouver, Canada. Thematic analysis focused on experiences of available treatment options for stimulant use and perceptions of prospective SST.

RESULTS

Participants identified how primarily behavioral treatment approaches do not meet the unique needs of PWUS, in contrast with the range of medical treatments available for opioid use disorder. Participants anticipated health and social benefits if they were able to access SST, including avoiding the toxic illicit stimulant supply, reduced engagement in criminalized activities, and greater economic security. Perceptions of prospective SST were informed by knowledge of existing opioid treatments. This led some participants to be unsupportive of SST, citing concerns around agency and highly regulated operational contexts that do not align with the lived realities of stimulant use.

CONCLUSION

Findings demonstrate the need for SST pilot programs in real-world settings and underscore the health and social advantages SST may offer; although drawing on existing opioid treatment models to implement SST pilots may limit success. Thus, any novel treatments for stimulant use must centre the lived realities of PWUS.

Barriers and Facilitators to Accessing Sexual and Reproductive Health Services Among Transgender People: A Meta-Synthesis

The availability and accessibility of sexual and reproductive health (SRH) services for transgender individuals are crucial. This population is deprived of health care due to rejection, stigma, gender-based discrimination, confidentiality, and violence. This review attempts to provide readers with an account of the fundamental problems that the transgender population faces regarding experiences of SRH. This meta-synthesis review applied the Social-Ecological Model (SEM) to address trans individuals' SRH factors. The databases were searched using "SRH" and "transgender" keywords. Fifty studies were finally selected. All studies were qualitative, including 36 semi-structured/ in-depth interviews, two focus group studies, and 12 interviews and focus group studies. The Social-Ecological Model application illustrates the impact of individual, interpersonal, institutional, and social factors on the condition of SRH among transgender individuals. This meta-synthesis reinforces multiple levels of factors that influence the SRH of transgender individuals. These include limited information, lack of awareness, low socioeconomic status, stigma and discrimination, and social deprivation. Interventions are urgently needed to provide better sexual and reproductive well-being for transgender individuals.

Negative changes in illicit drug supply during COVID-19: Associations with use of overdose prevention and health services among women sex workers who use drugs (2020-2021)

BACKGROUND

Women sex workers are a highly criminalized population who are over-represented amongst people who use drugs (PWUD) and face gaps in overdose prevention and harm reduction services. British Columbia, Canada continues to face a pronounced drug poisoning crisis of the illicit drug supply, which has intensified during the COVID-19 pandemic. Our objective was to examine the prevalence and structural correlates of experiencing negative changes in illicit drug supply (e.g., availability, quality, cost, or access to drugs) amongst women sex workers who use drugs during the first year of the COVID-19 pandemic.

METHODS

Cross-sectional questionnaire data were drawn from a prospective, community-based cohort of women sex workers in Vancouver (AESHA) from April 2020 to 2021. Bivariate and multivariable logistic regression was used to investigate structural correlates of negative changes in drug supply during COVID-19 among sex workers who use drugs.

RESULTS

Among 179 sex workers who use drugs, 68.2% reported experiencing negative changes to drug supply during COVID-19, 54.2% recently accessed overdose prevention sites, and 44.7% reported experiencing recent healthcare barriers. In multivariable analysis adjusted for injection drug use, women who reported negative changes in illicit drug supply had higher odds of experiencing recent healthcare barriers (AOR 2.28, 95%CI 1.12-4.62); those recently accessing overdose prevention sites (AOR 1.75, 95%CI 0.86-3.54) faced marginally higher odds also.

CONCLUSIONS

Over two-thirds of participants experienced negative changes to illicit drug supply during the first year of the COVID-19 pandemic. The association between experiencing negative changes in the illicit drug supply and accessing overdose prevention services highlights the agency of women in taking measures to address overdose-related risks. Highly criminalized women who experience structural barriers to direct services are also vulnerable to fluctuations in the illicit drug supply. Attenuating health consequences requires interventions tailored to sex workers' needs.

Precarious Housing Associated with Unsuppressed Viral load, sub-optimal Access to HIV Treatment and Unmet Health care Needs, Among Women Living with HIV in Metro Vancouver, Canada

We investigated associations between (1) housing status (four categories measuring housing stability) and outcomes along the HIV care continuum (not currently on antiretroviral therapy [ART]; sub-optimal ART adherence [< 95% in the last 3-4 weeks]; unsuppressed viral load [> 200 copies/ml], median CD4 < 200 in the last six months), and (2) housing status and unmet primary, dental and mental health care needs in the last six months among WLWH. Housing status was defined according to the Canadian Definition of Homelessness and had four categories: unsheltered (i.e., living in ≥ 1 unsheltered location [e.g., street, abandoned buildings]), unstable (i.e., living in ≥ 1 unstable location [e.g., shelter, couch surfing]), supportive housing (i.e., only living in supportive housing), and stable housing (i.e., only living in one's own housing; reference). At baseline, in the last six months, 47.3% of participants reported unstable housing, followed by 24.4% unsheltered housing, 16.4% stable housing, and 11.9% supportive housing. Overall, 19.1% of the full sample (N = 336, 2010-2019) reported not currently on ART; among participants on ART, 28.0% reported sub-optimal ART adherence. Overall, 32.1% had recent unsuppressed viral load. Among a subsample (n = 318, 2014-2019), 15.7% reported unmet primary care needs, 26.1% unmet dental care needs, and 16.4% unmet mental health care needs. In adjusted models, being unsheltered (vs. stable housing) was associated with not currently on ART, unsuppressed viral load, and unmet primary and dental care needs. Housing and health services need to be developed with and for WLWH to address structural inequities and fulfill basic rights to housing and health.

“It's no foundation, there's no stabilization, you're just scattered”: A qualitative study of the institutional circuit of recently-evicted people who use drugs

People who use drugs (PWUD) commonly experience housing instability due to intersecting structural vulnerabilities (e.g., drug prohibition, discriminatory housing policies), and prejudicial or illegal evictions are common. In Vancouver, Canada, evictions have proliferated in the Downtown Eastside, a historically low-income neighbourhood with high rates of drug use and housing instability, resulting in many PWUD being evicted into homelessness. This study characterizes housing trajectories of recently-evicted PWUD through the lens of the institutional circuit of homelessness, and explores how wider contexts of structural vulnerability shape experiences within this. Qualitative interviews were conducted with PWUD recently evicted in the Downtown Eastside (<60 days). Peer research assistants recruited 58 PWUD through outreach activities. All PWUD participated in baseline interviews on the causes and contexts of evictions. Follow-up interviews were completed with 41 participants 3-6 months later, focusing on longer-term impacts of eviction, including housing trajectories. Most participants were evicted into homelessness, remaining so at follow-up. Participants described patterns of residential instability consisting of frequent cycling between shelters, streets, and kin-based networks. While participants normalized this cycling as characteristic of their marginalized social positions, narratives revealed how the demands of the institutional circuit deepened vulnerabilities and prolonged experiences of homelessness. Experiences were framed by participants' (in)ability to navigate survival needs (e.g., shelter, drug use), with tensions and trade-offs between needs increasing participants' and their peers' risks of harms. Constructions of agency further shaped experiences; accounts highlighted tensions between the control inherent to indoor spaces and participants' need for autonomy. Findings demonstrate how the demands of the institutional circuit foregrounded structural vulnerabilities to perpetuate cycles of instability. Interventions that address survival needs and preserve agency will be necessary to mitigate risks within the institutional circuit, in tandem with upstream interventions that target housing vulnerability and broader social-structural conditions (e.g., poverty, affordability) that entrap recently-evicted PWUD in the institutional circuit.

Housing Instability and Evictions Linked to Elevated Intimate Partner and Workplace Violence Among Women Sex Workers in Vancouver, Canada: Findings of a Prospective, Community-Based Cohort, 2010-2019

Objectives. To model the relationship of unstable housing and evictions with physical and sexual violence perpetrated against women sex workers in intimate and workplace settings. Methods. We used bivariate and multivariable logistic regression with generalized estimating equations to model the association of unstable housing exposure and evictions with intimate partner violence (IPV) and workplace violence among a community-based longitudinal cohort of cisgender and transgender women sex workers in Vancouver, Canada, from 2010 through 2019. Results. Of 946 women, 85.9% experienced unstable housing, 11.1% eviction, 26.2% IPV, and 31.8% workplace violence. In multivariable generalized estimating equation models, recent exposure to unstable housing (adjusted odds ratio [AOR] = 2.04; 95% confidence interval [CI] = 1.45, 2.87) and evictions (AOR = 2.45; 95% CI = 0.99, 6.07) were associated with IPV, and exposure to unstable housing was associated with workplace violence (AOR = 1.46; 95% CI = 1.06, 2.00). Conclusions. Women sex workers face a high burden of unstable housing and evictions, which are linked to increased odds of intimate partner and workplace violence. Increased access to safe, women-centered, and nondiscriminatory housing is urgently needed. (Am J Public Health. 2023;113(4):442-452. https://doi.org/10.2105/AJPH.2022.307207).

Canadian School Psychology and Indigenous Peoples: Opportunities and Recommendations

School psychologists play important roles in working alongside Indigenous Peoples within Canada; however, a large gap exists between the discipline’s actions and the recommendations set forth by Indigenous Nations and governmental working groups. In this conceptual article, we seek to highlight the need for further Indigenous representation and engagement in the field of school psychology, as well as present key areas of relevance. We first briefly contextualize the relationship between Indigenous Peoples and school psychology, followed by the results of a brief survey concerning Indigenous representation and engagement across five school psychology doctoral programs in Canada. Next, we discuss nine key areas of consideration for school psychologists based on the Calls to Action of the Truth and Reconciliation Commission of Canada and the Calls for Justice of the National Inquiry into Missing and Murdered Indigenous Women and Girls. Each area of consideration provides school psychologists with a starting point for concrete actions when working with Indigenous students, families, and communities.

Pathways From Recent Incarceration to Antiretroviral Therapy Adherence: Opportunities for Interventions to Support Women Living With HIV Post Release From Correctional Facilities

ABSTRACT

Women living with HIV are increasingly incarcerated and experience suboptimal HIV health outcomes post release from incarceration. Drawing on cohort data with cisgender and trans women living with HIV (Sexual Health and HIV/AIDS: Women's Longitudinal Needs Assessment), we used path analysis to investigate pathways from recent incarceration to optimal antiretroviral therapy (ART) adherence. We tested direct effects between recent incarceration, mediating variables, and ART adherence, along with indirect effects between incarceration and ART adherence through each mediator. We assessed model fit using chi-square, root-mean-square error of approximation (RMSEA), and comparative fit index (CFI). Our hypothesized model fit well to the data (χ2(1)=1.100; p=.2943; CFI = 1.000; RMSEA = 0.007). Recent experiences of homelessness, criminalized substance use, and gender-based violence each fully mediated the pathway between recent incarceration and optimal ART adherence. Findings highlight the need for safe and supportive housing, supports for criminalized substance use, and trauma and violence-informed care and practice post release from incarceration.

The prevalence and social-structural correlates of housing status among women living with HIV in Vancouver, Canada

Background

Women living with HIV (WLWH) experience numerous social and structural barriers to stable housing, with substantial implications for access to health care services. This study is the first to apply the Canadian Definition of Homelessness (CDOH), an inclusive national guideline, to investigate the prevalence and correlates of housing status among WLWH in Metro Vancouver, Canada.

Methods

Our study utilized data from a longitudinal open cohort of cisgender and trans WLWH aged 14 years and older, in 2010–2019. Cross-sectional descriptive statistics of the prevalence of housing status and other social and structural variables were summarized for the baseline visits. Bivariate and multivariable logistic regression analyses were conducted using generalized linear mixed models (GLMM) for repeated measures to investigate the relationship between social and structural correlates and housing status among WLWH.

Results

The study included 336 participants with 1930 observations over 9 years. Housing status derived from CDOH included four categories: unsheltered, unstable, supportive housing, and stable housing (reference). Evidence suggested high levels of precarious housing, with 24% of participants reporting being unsheltered, 47% reporting unstable housing, 11.9% reporting supportive housing, and 16.4% reporting stable housing in the last six months at baseline. According to the multivariable models, living in the Downtown Eastside (DTES) neighbourhood of Metro Vancouver, hospitalization, physical/sexual violence, and stimulant use were associated with being unsheltered, compared to stable housing; DTES residence, hospitalization, and physical/sexual violence were associated with unstable housing; DTES residence and stimulant use were associated with living in supportive housing.

Conclusion

Complex social-structural inequities are associated with housing instability among WLWH. In addition to meeting basic needs for living, to facilitate access to housing among WLWH, housing options that are gender-responsive and gender-inclusive and include trauma- and violence-informed principles, low-barrier requirements, and strong connections with supportive harm reduction services are critical.

COVID-19 and the opportunity for gender-responsive virtual and remote substance use treatment and harm reduction services

The COVID-19 pandemic has increased the uptake of virtual and remote service delivery in the substance use field, which was previously uncommon. This swift uptake of virtual services provides an opportunity to improve service design to meet the diverse needs of women and gender-diverse people. Such services have the potential to better meet the needs of women and gender-diverse people by allowing for increased choice, control, and autonomy, enabling empowerment, facilitating greater considerations of power relations, violence, childcare responsibilities, and fostering greater inclusion of trans and non-binary people. This commentary aims to identify how virtual and remote delivery of substance use treatment and harm reduction services can be gender-responsive. We highlight the role gender transformative services play in meeting the unique needs of women and gender-diverse people who use drugs both during and after the COVID-19 pandemic. By using the unique window of opportunity COVID-19 has created to develop and deliver gender-transformative programs, we can help address the detrimental gaps in service accessibility and effectiveness that have persistently been experienced by women and gender-diverse people who use drugs.

Violence, policing, and systemic racism as structural barriers to substance use treatment amongst women sex workers who use drugs: Findings of a community-based cohort in Vancouver, Canada (2010-2019)

BACKGROUND

Despite a high prevalence of substance use among women sex workers (SWs), rigorous social epidemiologic data on substance use treatment experiences among SWs remains limited. Given these gaps and the disproportionate burden of criminalization borne by Indigenous SWs, we evaluated (1) structural correlates of unsuccessful attempts to access substance use treatment; and (2) the interaction between policing and Indigenous ancestry on unsuccessful attempts to access treatment among SWs who use drugs.

METHODS

Prospective data were from an open community-based cohort of women SWs (2010-2019) in Vancouver, Canada. Bivariate and multivariable logistic regression with generalized estimating equations(GEE) assessed correlates of unsuccessful attempts to access treatment. A multivariable GEE confounder model examined the interaction between Indigenous ancestry and policing on unsuccessful attempts to access treatment.

RESULTS

Amongst 645 SWs who used drugs, 32.1 % reported unsuccessful attempts to access substance use treatment during the 9.5-year study. In multivariable GEE analysis, unsuccessful substance use treatment access was associated with identifying as a sexual/gender minority (AOR: 1.90, 95 %CI:1.37-2.63), opioid use (AOR: 1.43, 95 %CI: 1.07-1.91), and exposure to homelessness (AOR: 1.72; 95 %CI:1.33-2.21), police harassment (AOR: 1.48, 95 %CI:1.03-2.13), workplace violence (AOR: 1.80, 95 %CI: 1.31-2.49) and intimate partner violence (AOR: 2.11, 95 %CI:1.50-2.97). In interaction analysis, Indigenous SWs who experienced police harassment faced the highest odds of unsuccessful attempts to access substance use treatment (AOR: 2.59, 95 %CI:1.65-4.05).

CONCLUSION

Findings suggest a need to scale-up culturally-safe, trauma-informed addictions, gender-based violence, and sex worker services, alongside dismantling of systemic racism across and beyond health and addictions services.

"This isn't a fairy tale we're talking about; this is our real lives": Community-orientated responses to address trans and gender diverse homelessness

Globally, trans and gender diverse people contend with day-to-day exclusion, discrimination, and marginalisation, often culminating in experiences of poverty and homelessness. In this discussion article, we outline a bricolage research orientation rooted in liberation and Indigenous approaches brought into dialogue with the broader cannon of community psychology for meaningful research with homeless trans and gender diverse people. Such an approach transcends rigid disciplinary divides and shapes a framework for collaborative action, advocacy, and social change. We argue that scholar-activism, social justice, and relationality and collaboration should inform every stage of the research process and beyond when engaging with minoritized communities.

Experiences of LGBTQ Adults Who Have Accessed Emergency Shelters in a Large Urban City in Canada

This study examines the experiences of adults who identify as LGBTQ (lesbian, gay, bisexual, transgender, queer) and who have accessed emergency shelters in an urban Canadian city. Twenty LGBTQ adults who were currently or formerly homeless participated in one qualitative interview. The interview protocol included questions on the participants' experiences accessing emergency shelters, with a focus on interactions with other emergency shelter residents. Data was analyzed using an iterative coding process. The results demonstrated that participants engage in various identity management strategies and encounter both positive and negative interactions with other emergency shelter residents. The results are discussed in terms of strategies to improve emergency shelter policies to be more inclusive of LGBTQ adults.

Engagement in Care and Housing Instability Influence HIV Screening Among Transgender Individuals in South Florida

Purpose: HIV screening is a critical step in the HIV care continuum to lowering incidence and achieving viral load suppression among at-risk populations. Few studies assess factors associated with HIV screening among transgender individuals living in the southeast region of the United States. This study was conducted to determine factors that influence HIV screening among transgender individuals in South Florida. Methods: During Fall 2016, 68 participants were recruited to complete a questionnaire as part of a pilot pre-exposure prophylaxis study. Correlations were examined between sociodemographic factors, HIV risk, and access to and engagement in care. Significant correlations were entered into one logistic regression model to estimate predictors of HIV screening and knowledge of HIV status. Results: Almost half (48.5%) of the respondents were Latinx, 38.2% Black, 10.3% non-Latinx White, and 3% other. Seventy-eight percent reported access and routine engagement in care within the past year, 25% had not screened for HIV in the past year, and of those who knew their status, 16.7% reported living with HIV. Regression analysis revealed that participants with routine engagement in care were twice as likely to screen for HIV (p=0.02). Unstable housing was associated with no HIV screening in the past year (p=0.05). Conclusion: Stable housing is linked to engagement in routine care that can increase the likelihood of an at-risk transgender individual screening for HIV. Further research is needed to develop interventions to improve engagement in care among transgender individuals who do not have adequate housing or access to care.

Holistic Health of Two Spirit People in Canada: A Call for Nursing Action

Purpose: In response to item 7.1 from the Missing and Murdered Indigenous Women and Girls Report (2019), calling on health service providers to recognize the importance in inclusive services with and for Indigenous peoples including Two Spirit, lesbian, bisexual, transgender, queer, questioning, intersex, and asexual (2SLGBTQQIA) peoples, we undertook a review of the literature to identify the gaps in understanding and to better situate the health and resiliencies of Two Spirit people in Canada. Method: We conducted a review of 13 articles related to the health and wellness of the Canadian Two Spirit community. Overall, there was a dearth of Two Spirit specific health-related information. Results: Identified themes were grounded in the holistic Medicine Wheel teachings. These themes directly parallel holistic nursing in their demonstration that health is complex, and that there are many facets that make up an individuals’ health. Conclusion: Assessing the impact that colonization has had on the intersections of gender, race, sexuality, class, culture, and spirituality, Two Spirit people face unique health concerns. Considering the intersections of identity and structural barriers in place for this community, more research led by and in collaboration with the Two Spirit community is needed.

Evaluation of an e-Learning Curriculum for Forensic Nurses on Trans-Affirming Postsexual Assault Care

Trans survivors of sexual assault have called for the development and implementation of training for care providers. To answer this call, we developed and evaluated an innovative e-learning curriculum for forensic nurses working across Ontario, Canada, on the provision of trans-affirming care. The e-learning curriculum, developed in Storyline 360 by Articulate, was launched in August 2019. The competence of nurses (N=65) completing the curriculum improved significantly from pre- to post-training across all content domains (Initial assessment, Medical care, Forensic examination, and Discharge and referral). This e-learning curriculum could be of utility in training forensic nurses worldwide.

Improving "Life Chances": Surveying the Anti-Transgender Backlash, and Offering a Transgender Equity Impact Assessment Tool for Policy Analysis

Transgender inclusion within policy is critical yet often missing. We propose a policy tool to assesses human rights, access to resources and opportunities, language, and implications for transgender and nonbinary individuals. Acknowledging trans communities as standard policy practice can serve as an essential practice to shift dialogue and norms.

'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.

Healthcare: action research with trans people living on the streets

OBJECTIVES

to analyze the representations of healthcare provided to trans people living on the streets.

METHODS

ten women (three trans) and three cisgender men participated in this action research. Popular health education groups, focus groups, seminars and interviews were held, the data of which were organized in the software Nvivo®, submitted to content analysis and interpreted in the light of intersectionality theory.

RESULTS

healthcare was represented by the technical, relational, structural and citizenship dimensions. The relationship between gender and poverty determines the specific health needs of trans people living on the streets.

FINAL CONSIDERATIONS

the need to expand conceptions and practices on healthcare to meet the specific health needs of trans people living on the streets was evidenced. Nursing, with competence and cultural sensitivity, can contribute to positive health outcomes and, consequently, break with the logic of exclusion, illness and poverty.

Poverty in Lesbian, Gay, Bisexual, Transgender, Queer, Two-Spirit, and Other Sexual and Gender Minority (LGBTQ2S+) Communities in Canada: Implications for Social Work Practice

In this article, we draw on a recent review of the Canadian literature on poverty in lesbian, gay, bisexual, transgender, queer, two-spirit, and other sexual and gender minority (LGBTQ2S+) communities to conceptualize social work interventions that may be used to address material inequities among these groups. Our literature review, which was based on a total of 39 works, revealed distinctive expressions of poverty among younger and older LGBTQ2S+ groups, as well as racialized, newcomer, and Indigenous sexual and gender minorities. Drawing on these insights, together with theoretical frameworks grounded in intersectionality and relational poverty analysis, we conceptualize these expressions of material inequity as salient sites of social work practice and propose interventions targeting these manifestations of LGBTQ2S+ poverty at various levels. Given the centrality of anti-poverty work as part of the social work profession's commitment to social justice, and the dearth of social work literature on LGBTQ2S+ poverty, this article promises to make significant contributions to social work scholarship and professional practice.

Social and Structural Barriers to Primary Care Access Among Women Living With HIV in Metro Vancouver, Canada: A Longitudinal Cohort Study

ABSTRACT

This study examines correlates of being unable to access primary care in the past 6 months among cisgender (cis) and trans women living with HIV (WLWH). Data were drawn from a longitudinal community-based cohort study of WLWH (ages 14+) in Metro Vancouver, Canada (2014-2017). Of 291 participants contributing 914 observations, 15.5% reported being unable to access primary care at baseline. In multivariable analysis, increased odds of being unable to access primary care was associated with (a) having im/migrated to Canada, and, in the past 6 months, (b) identifying as gender minority, (c) experiencing physical or sexual violence, (d) having suicidal ideation or attempts. Decreased odds were associated with recently accessing HIV-specific resources. Our findings suggest that primary health care for WLWH should address high levels of violence and mental health conditions as well as barriers to services for gender minority and im/migrant WLWH.

Having a voice and saving lives: a qualitative survey on employment impacts of people with lived experience of drug use working in harm reduction

Background

Ongoing legal and social discrimination, and stigmatization of people with lived experience of drug use (PWLE) continues to contribute to overdose-related deaths in Canada. The involvement of PWLE working in harm reduction services has proven effective in decreasing drug-related harms among PWLE; however, there exist unintended negative impacts. PWLE working in harm reduction services risk overextending themselves beyond employment parameters (e.g., emotional labor) with few systems in place (e.g., employment advocacy) for support. While meaningful participation of PWLE in harm reduction programs is critical to addressing the overdose crisis, their labor in Canada’s overdose response commands further investigation and recognition. This paper examines some of the benefits and negative aspects of working in harm reduction among PWLE.

Methods

Fifty qualitative surveys were completed by PWLE working in harm reduction services from across Canada at the National 2018 Stimulus conference held in Edmonton, Alberta. The surveys focused on the benefits and negatives of ‘peer’ employment and recommendations for organizational transformation through short answer written sections. Surveys were analyzed thematically using NVivo, informed by critical perspectives on substance use, with attention to key re-occurring themes on employment equity.

Results

While participants described multiple benefits of working in harm reduction services, such as the valuing of their expertise by fellow ‘peers,’ growing skill sets, countering stigma, and preventing overdose deaths, issues of workplace equity were significantly identified. Stigma, tokenism, workplace discrimination, including power and pay inequities, as well as lack of worker compensation and benefits were identified as key factors persisting in the everyday experiences of participants.

Conclusion

Continued exposure to stigma, workplace discrimination, and/or power imbalances, combined with the impact of high stakes employment (e.g., dealing with overdose deaths), can have significant consequences for PWLE working in harm reduction, including burn out. Policy recommendations include large-scale structural changes that address inequities of hierarchical ‘peer’ employment for PWLE, including increased leadership roles for diverse PWLE, pay equity and benefits, unionization, as well as more supportive working environments attentive to the intersecting social-structural factors (poverty, criminalization, racism, gendered violence) impacting the everyday lives of PWLE working in harm reduction.

Homeless experiences and support needs of transgender people: A systematic review of the international evidence

AIM

To examine the experiences and support needs of homeless transgender people by synthesizing the existing evidence.

BACKGROUND

Transgender people face many challenges in society in terms of people's knowledge, understanding and acceptance of a person's gender identity. Evidence regarding the homelessness experiences and available supports to transgender people remains sparse.

METHODS

A systematic review was undertaken and included qualitative and quantitative studies. A total of twelve papers were included in the review, utilizing the PRISMA method. Methodological quality was evaluated using the Mixed Methods Assessment Tool (MMAT).

RESULTS

Following analysis, the themes that emerged were (a) pathways into homelessness, (b) experiences whilst homeless and (c) routes out of homelessness.

CONCLUSION

It has become increasingly clear that the distinct needs of this group are complex and multifaceted. In order to adequately address the issues and concerns comprehensively, coordinated and effective collaborations need to be in place.

IMPLICATIONS FOR NURSING MANAGEMENT

Clinical nurses need to recognize and respond to the distinct needs of trans homeless people. Nurse managers need to provide leadership to promote the needs of homeless trans people and ensure that policies and procedures are in place that are responsive to issues and concerns.

Home and health among people living with HIV who use drugs: A qualitative study

INTRODUCTION

Housing is a critical determinant of HIV-related outcomes among people living with HIV (PLHIV) who use drugs, including on HIV treatment adherence. Research shows that sense of home may have important implications for mitigating harms associated with low-income housing environments among PLHIV who use drugs, but how this shapes treatment is poorly understood.

METHODS

Semi-structured interviews were conducted with 31 PLHIV who use drugs recruited from an ongoing prospective cohort in Vancouver, Canada. Recruitment was targeted towards individuals living in single room occupancy housing who had previously reported low treatment adherence. Interviews were co-led with a peer research assistant, and focused on housing conditions, drug use patterns, and HIV management. Interviews were transcribed, analyzed thematically, and interpreted by drawing on concepts of home and place-making.

RESULTS

The ability to exert control over housing environments contributed to participants' perceptions of home by fostering feelings of safety and allowing for creation of personalized space. Participants readily identified the importance of housing stability and quality in maintaining health (e.g. food storage, pest-free), including HIV care. However, informed by social-structural mechanisms that undermined agency, negative experiences of home adversely impacted treatment adherence.

CONCLUSIONS

Findings indicate that sense of home may enable ability to manage HIV care, and is promoted through feelings of security within, and control over, housing environments. Supports in navigating competitive housing markets are needed to address the role that home plays in HIV treatment adherence.

Intersectional Discrimination Is Associated with Housing Instability among Trans Women Living in the San Francisco Bay Area

Trans women face numerous structural barriers to health due to discrimination. Housing instability is an important structural determinant of poor health outcomes among trans women. The purpose of this study was to determine if experiences of intersectional anti-trans and racial discrimination are associated with poor housing outcomes among trans women in the San Francisco Bay Area. A secondary analysis of baseline data from the Trans *National study (n = 629) at the San Francisco Department of Public Health (2016-2018) was conducted. Multivariable logistic regression was used to analyze the association between discrimination as an ordered categorical variable (zero, one to two, or three or more experiences) and housing status adjusting for age, years lived in the Bay Area, and gender identity. We found that the odds of housing instability increased by 1.25 for every categorical unit increase (1-2, or 3+) in reported experiences of intersectional (both anti-trans and racial) discrimination for trans women (95% CI = 1.01-1.54, p-value < 0.05). Intersectional anti-trans and racial discrimination is associated with increased housing instability among trans women, giving some insight that policies and programs are needed to identify and address racism and anti-trans stigma towards trans women. Efforts to address intersectional discrimination may positively impact housing stability, with potential for ancillary effects on increasing the health and wellness of trans women who face multiple disparities.