Health and well-being of trans and non-binary participants in a community-based survey of gay, bisexual, and queer men, and non-binary and Two-Spirit people across Canada

Romantic relationship configurations and their correlates among LGBTQ+ persons: A latent class analysis

Research comparing monogamous and non-monogamous relationships on well-being indicators across diverse populations have yielded inconsistent findings. The present study investigates sociodemographic characteristics, as well as personal and relational outcomes, across different relationship configurations. Data were drawn from an online community-based sample of 1,528 LGBTQ+ persons aged 18 years and older in Quebec, Canada. A latent class analysis was performed based on legal relationship status, relationship agreement, cohabitation status, and the seeking of extradyadic sexual and romantic partners on the internet. Class differences on sociodemographic characteristics and well-being and relationship quality indicators were examined. A five-class solution best fit the data, highlighting five distinct relationship configurations: Formalized monogamy (59%), Free monogamy (20%), Formalized open relationship (11%), Monogamous considering alternatives (7%) and Free consensual non-monogamies (3%). Cisgender women were more likely to engage in monogamous relationships than cisgender men, who were overrepresented in open relationships. Lower levels of perceived partner support were observed in both free monogamous and consensually non-monogamous relationships, the latter of which also showed lower levels of well-being. Consensual non-monogamy researchers exploring relationship outcomes should examine relationship facets that go beyond relationship structure or agreement. Variations in monogamies and non-monogamies, both consensual and non-consensual, may be present within each broad relationship configuration, as reflected in different personal and relational needs, which can then translate to better or poorer outcomes.

Sex-Based Performance Disparities in Machine Learning Algorithms for Cardiac Disease Prediction: Exploratory Study

BACKGROUND

The presence of bias in artificial intelligence has garnered increased attention, with inequities in algorithmic performance being exposed across the fields of criminal justice, education, and welfare services. In health care, the inequitable performance of algorithms across demographic groups may widen health inequalities.

OBJECTIVE

Here, we identify and characterize bias in cardiology algorithms, looking specifically at algorithms used in the management of heart failure.

METHODS

Stage 1 involved a literature search of PubMed and Web of Science for key terms relating to cardiac machine learning (ML) algorithms. Papers that built ML models to predict cardiac disease were evaluated for their focus on demographic bias in model performance, and open-source data sets were retained for our investigation. Two open-source data sets were identified: (1) the University of California Irvine Heart Failure data set and (2) the University of California Irvine Coronary Artery Disease data set. We reproduced existing algorithms that have been reported for these data sets, tested them for sex biases in algorithm performance, and assessed a range of remediation techniques for their efficacy in reducing inequities. Particular attention was paid to the false negative rate (FNR), due to the clinical significance of underdiagnosis and missed opportunities for treatment.

RESULTS

In stage 1, our literature search returned 127 papers, with 60 meeting the criteria for a full review and only 3 papers highlighting sex differences in algorithm performance. In the papers that reported sex, there was a consistent underrepresentation of female patients in the data sets. No papers investigated racial or ethnic differences. In stage 2, we reproduced algorithms reported in the literature, achieving mean accuracies of 84.24% (SD 3.51%) for data set 1 and 85.72% (SD 1.75%) for data set 2 (random forest models). For data set 1, the FNR was significantly higher for female patients in 13 out of 16 experiments, meeting the threshold of statistical significance (-17.81% to -3.37%; P<.05). A smaller disparity in the false positive rate was significant for male patients in 13 out of 16 experiments (-0.48% to +9.77%; P<.05). We observed an overprediction of disease for male patients (higher false positive rate) and an underprediction of disease for female patients (higher FNR). Sex differences in feature importance suggest that feature selection needs to be demographically tailored.

CONCLUSIONS

Our research exposes a significant gap in cardiac ML research, highlighting that the underperformance of algorithms for female patients has been overlooked in the published literature. Our study quantifies sex disparities in algorithmic performance and explores several sources of bias. We found an underrepresentation of female patients in the data sets used to train algorithms, identified sex biases in model error rates, and demonstrated that a series of remediation techniques were unable to address the inequities present.

Stigma, Mental Health, and Health care Use Among Rural Sexual and Gender Minority Individuals

Sexual and gender minorities (SGM) frequently experience depression and health care-related stigma. Health care satisfaction is important for seeking care, but little is known about SGM health care satisfaction, and especially as it relates to depression among rural SGM. From May 25 to July 2, 2021, we surveyed rural Illinois (IL) individuals aged ≥18 years on the topics of demographics, depression, health care satisfaction, past health care experiences, internalized stigma, and victimization. Among the 398 respondents, the gender identity distribution included cisgender males and females (171 and 203, respectively) and transgender males and females (8 and 7, respectively), while sexual orientation included heterosexuals (114), gay/lesbians (143), and other orientations (141). Analyses were conducted with respect to both identity and orientation (and their interaction). In univariate analysis, transgender individuals were more likely than cisgender to screen positive for depression and less likely to report feeling accepted by their medical provider. Compared to heterosexual respondents, gay/lesbians and other orientations were more likely to screen positive for depression. In logistic regression, factors associated with increased risk of depression included nonheterosexual orientation and past poor health care experiences. In linear regression, factors most commonly associated with the seven satisfaction subscales include: sexual orientation, past poor experiences, and employment. There were significant differences in depression across both sexual orientation and gender identity, and in health care satisfaction by sexual orientation. Rural SGMs are more vulnerable to depression and less likely to report satisfactory care. As health care engagement is critical for screening and care adherence, engaging rural SGM in a routine and satisfactory fashion is needed.

Healthcare Service Utilization and Perceived Gaps: The Experience of French-Speaking 2S/LGBTQI+ People in Manitoba

Ethnolinguistically diverse 2S/LGBTQI+ (two-spirit, lesbian, gay, bisexual, transgender, queer and intersex) populations have unique healthcare needs and experience health inequities compared to their cisgender or heterosexual peers. This community-based participatory study sought to describe the profile and healthcare needs and experiences of official language minority French-speaking 2S/LGBTQI+ adults in Manitoba. Participants (N = 80) reported that gender and sexual identity were often concealed from service providers; many respondents faced discrimination based on their ethnolinguistic and sexual identities. Service gaps are identified pertaining to mental and sexual health; locating 2S/LGBTQI+-friendly, patient-centred care in French is difficult. Policy and practice should address systemic inequity and discrimination experienced by this equity-seeking population.

'I turn to my closest friends for support': queer youth navigating mental health during COVID-19

The objectives of this in-depth qualitative study were to identify how COVID-19 impacted the mental health experiences of queer youth in Vancouver, Canada. Between November 2020 and June 2021, fifteen queer youth aged 15 to 25 were enrolled in the study. They participated in semi-weekly, solicited digital diary entries and semi-structured intake and follow-up interviews about COVID-19, social distancing protocols, and mental health. Using thematic analysis, two major themes were identified. First, participants described how COVID-19 impacted social support by highlighting the limitations of their existing social networks and feelings of disconnect from others in the local queer community. Second, participants described how public health guidance and the offloading of responsibility for COVID-19 risk-management onto the individual was a significant source of anxiety and stress, and how they moralised the struggle to balance compliance with the desire to connect with others. These findings highlight the need to understand the negative mental health outcomes arising from moralising approaches to public health that offload risk-management onto the individual, isolate queer youth, and hamper their identity-development processes.

Monosexism as an Additional Dimension of Minority Stress Affecting Mental Health among Bisexual and Pansexual Individuals in Hong Kong: The Role of Gender and Sexual Identity Integration

Monosexism has been increasingly recognized as a minority stressor uniquely experienced by plurisexual individuals. The present study investigated the effects of monosexist discrimination on mental health and examined the moderating role of gender and sexual identity integration (i.e., negation, authenticity, and disclosure). In a sample of 314 bisexual and pansexual individuals in Hong Kong (73.9% women and 26.1% men), the results showed that monosexist discrimination was associated with higher levels of depression and anxiety symptoms, above and beyond heterosexist discrimination. The association between monosexist discrimination and depression symptoms was stronger among bisexual and pansexual men than women, despite there being no gender differences in vulnerability to monosexist discrimination. Moreover, sexual identity negation, authenticity, and disclosure moderated the associations of monosexist discrimination with depression and anxiety symptoms, such that the associations were not significant among those with more positive integration of sexual identity (i.e., lower levels of sexual identity negation as well as higher levels of sexual identity authenticity and disclosure). This study provides insight into the deleterious impact of monosexism and the protective role of sexual identity integration. Implications for plurisexual-affirming psychological intervention, public policy, and community practice are discussed.

Reasons for not using pre-exposure prophylaxis for HIV and strategies that may facilitate uptake in Ontario and British Columbia among gay, bisexual and other men who have sex with men: a cross-sectional survey

BACKGROUND

Pre-exposure prophylaxis (PrEP) for HIV is underutilized. We aimed to identify barriers to use of PrEP and strategies that may facilitate its uptake.

METHODS

Gay, bisexual and other men who have sex with men, aged 19 years or older and living in Ontario and British Columbia, Canada, completed a cross-sectional survey in 2019-2020. Participants who met Canadian PrEP guideline criteria and were not already using PrEP identified relevant barriers and which strategies would make them more likely to start PrEP. We described the barriers and strategies separately for Ontario and BC.

RESULTS

Of 1527 survey responses, 260 respondents who never used PrEP and met criteria for PrEP were included. In Ontario, the most common barriers were affordability (43%) and concern about adverse effects (42%). In BC, the most common reasons were concern about adverse effects (41%) and not feeling at high enough risk (36%). In Ontario, preferred strategies were short waiting time (63%), the health care provider informing about their HIV risk being higher than perceived (62%), and a written step-by-step guide (60%). In BC, strategies were short waiting time (68%), people speaking publicly about PrEP (68%), and the health care provider counselling about their HIV risk being higher than perceived (64%), adverse effects of PrEP (65%) and how well PrEP works (62%).

INTERPRETATION

Concern about adverse effects and not self-identifying as having high risk for HIV were common barriers, and shorter waiting times may increase PrEP uptake. In Ontario, the findings suggested lack of affordability, whereas in BC, strategies involving health care providers were valued.

Social Support and Mental Health Among Transgender and Nonbinary Youth in Quebec

Purpose: Transgender and nonbinary (TNB) youth face elevated levels of discrimination, stigma, mental health disorders, and suicidality when compared with their cisgender counterparts. Family and school support may mitigate some of the effects of the stressors facing TNB youth. This study aimed to better understand the impact of each of these sources of support on TNB youths' mental health and wellbeing. Methods: We used data collected between 2018 and 2019 as part of the Canadian Trans Youth Health Survey, a bilingual online survey to measure social support, physical health, and mental health in a sample of 220 TNB youth aged 14-25 living in Québec, Canada. We examined the relationships among different sources of support, and mental health and wellbeing outcomes using logistic regression. Analyses were conducted on the full sample and according to linguistic groups (French and English). Results: Participants reported high levels of mental health symptoms, self-harm, and suicidality, and mental health symptoms were higher in the English-speaking group (p = 0.005). In models controlling for age, family connectedness was associated with good/excellent self-reported mental health (odds ratio [OR] = 2.62, p = 0.001) and lower odds of having considered suicide (OR = 0.49, p = 0.003) or attempted suicide (OR = 0.43, p = 0.002), whereas school connectedness was associated with higher odds of good/very good/excellent general (OR = 2.42, p = 0.013) and good/excellent mental (OR = 2.45, p = 0.045) health. Conclusion: Family and school support present consistent associations with TNB youths' health and may constitute key areas for intervention for those supporting them.

Age-specific determinants of psychiatric outcomes after the first COVID-19 wave: baseline findings from a Canadian online cohort study

BACKGROUND

Canadians endured unprecedented mental health (MH) and support access challenges during the first COVID-19 wave. Identifying groups of individuals who remain at risk beyond the acute pandemic phase is key to guiding systemic intervention efforts and policy. We hypothesized that determinants of three complementary, clinically actionable psychiatric outcomes would differ across Canadian age groups.

METHODS

The Personal Impacts of COVID-19 Survey (PICS) was iteratively developed with stakeholder feedback, incorporating validated, age-appropriate measures. Baseline, cross-sectional online data collected between November 2020-July 2021 was used in analyses. Age group-specific determinants were sought for three key baseline MH outcomes: (1) current probable depression, generalized anxiety disorder, obsessive-compulsive disorder and/or suicide attempt during COVID-19, (2) increased severity of any lifetime psychiatric diagnosis, and (3) inadequate MH support access during COVID-19. Multivariable logistic regression models were constructed for children, youth (self- and parent-report), young adults (19-29 years) and adults over 29 years, using survey type as a covariate. Statistical significance was defined by 95% confidence interval excluding an odds ratio of one.

RESULTS

Data from 3140 baseline surveys were analyzed. Late adolescence and early adulthood were identified as life phases with the worst MH outcomes. Poverty, limited education, home maker/caregiver roles, female and non-binary gender, LGBTQ2S + status and special educational, psychiatric and medical conditions were differentially identified as determinants across age groups.

INTERPRETATION

Negative psychiatric impacts of COVID-19 on Canadians that include poor access to MH support clearly persisted beyond the first wave, widening pre-existing inequity gaps. This should guide policy makers and clinicians in current and future prioritization efforts.

Sampling Sexual and Gender Minority Youth With UnACoRN (Understanding Affirming Communities, Relationships, and Networks): Lessons From a Web-Based Survey

BACKGROUND

Periodic surveys of sexual and gender minority (SGM) populations are essential for monitoring and investigating health inequities. Recent legislative efforts to ban so-called conversion therapy make it necessary to adapt youth surveys to reach a wider range of SGM populations, including those <18 years of age and those who may not adopt an explicit two-spirit, lesbian, gay, bisexual, transgender, and queer (2S/LGBTQ) identity.

OBJECTIVE

We aimed to share our experiences in recruiting SGM youth through multiple in-person and online channels and to share lessons learned for future researchers.

METHODS

The Understanding Affirming Communities, Relationships, and Networks (UnACoRN) web-based survey collected anonymous data in English and French from 9679 mostly SGM respondents in the United States and Canada. Respondents were recruited from March 2022 to August 2022 using word-of-mouth referrals, leaflet distribution, bus advertisements, and paid and unpaid campaigns on social media and a pornography website. We analyzed the metadata provided by these and other online resources we used for recruitment (eg, Bitly and Qualtrics) and describe the campaign's effectiveness by recruitment venue based on calculating the cost per completed survey and other secondary metrics.

RESULTS

Most participants were recruited through Meta (13,741/16,533, 83.1%), mainly through Instagram; 88.96% (visitors: 14,888/18,179) of our sample reached the survey through paid advertisements. Overall, the cost per survey was lower for Meta than Pornhub or the bus advertisements. Similarly, the proportion of visitors who started the survey was higher for Meta (8492/18,179, 46.7%) than Pornhub (58/18,179, 1.02%). Our subsample of 7037 residents of Canada had a similar geographic distribution to the general population, with an average absolute difference in proportion by province or territory of 1.4% compared to the Canadian census. Our US subsample included 2521 participants from all US states and the District of Columbia. A total of CAD $8571.58 (the currency exchange rate was US $1=CAD $1.25) was spent across 4 paid recruitment channels (Facebook, Instagram, PornHub, and bus advertisements). The most cost-effective tool of recruitment was Instagram, with an average cost per completed survey of CAD $1.48.

CONCLUSIONS

UnACoRN recruited nearly 10,000 SGM youth in the United States and Canada, and the cost per survey was CAD $1.48. Researchers using online recruitment strategies should be aware of the differences in campaign management each website or social media platform offers and be prepared to engage with their framing (content selection and delivery) to correct any imbalances derived from it. Those who focus on SGM populations should consider how 2S/LGBTQ-oriented campaigns might deter participation from cisgender or heterosexual people or SGM people not identifying as 2S/LGBTQ, if relevant to their research design. Finally, those with limited resources may select fewer venues with lower cost per completed survey or that appeal more to their specific audience, if needed.

Feasibility of communication platforms to empower transgender cultural competence among human immunodeficiency virus screeners: A qualitative analysis

Background

Human immunodeficiency virus (HIV) screeners have limited experience of interacting with trans people. The application of communication platforms between them to empower HIV screeners' trans-related cultural competence remains unknown.

Objective

This study aims to qualitatively explore the follow-up interviews of HIV screeners regarding their opinions on the feasibility of an online platform group discussion and web page to enhance communication between them and trans people and to explore their perspectives on how these components enhanced their promotion of cultural competence.

Methods

This study was conducted between October 2020 and June 2021. Purposive and snowball sampling were applied to recruit 6 trans persons and 11 HIV screeners. Six online platform group discussions were held on weekday evenings, each group meeting for 60 min, 360 min in total within 3 months, via a video chat room of Google Meet; this was supplemented by a closed web page. The major results were presented through content analysis of the HIV screeners' follow-up interviews.

Results

The HIV screeners identified the facilitators of participating in the communication platforms, which included a reminder message, easy-to-use interface, visible-audible and readable interaction, recalled and reviewable content and group belonging; the barriers included time and space limitation, device restrictions and operation problem. Two categories of trans-related cultural competence - trans awareness and action taken - were revealed, from which five major themes emerged: provoked to ask questions, improved cognition, reflection, trans-sensitive communication and self-enhancement.

Conclusion

The results revealed that the communication platforms could facilitate the mutual and vivid discussion between HIV screeners and trans people and empower the trans-related cultural competence of HIV screeners. The highly feasible intervention design of this research can be applied to digital training courses related to gender diversity issues.

Gender Binaries in Nursing: A Critical Shift to Postgenderism

Gender binaries refer to grouping systems that label individuals as male or female. Societal shifts in what defines gender have evolved over the past decade; however, nursing practice remains grounded in these traditional gender binaries. The negative impacts of these practices, specifically in reproductive care, are detrimental for individuals who do not identify within traditional gender binaries. Gender binaries and stereotypes persist because of the prevalence of attitudes; nursing education development; and biases within care areas-specifically, reproductive care-because of issues such as gendered theories and language. Nurses can play a role in enhancing inclusivity by encouraging reflective practice, implementing gender-informed concepts into curricula, and encouraging the use of a postgenderism lens in policy and practice. Improvements in these areas can help foster health care access and safety.

"Doing it on my own terms": Transgender and nonbinary adults' experiences with HPV self-swabbing home testing kits

The human papillomavirus (HPV) carries a significant health risk for people with a cervix. Among transgender and nonbinary people, however, testing and treatment for HPV can pose difficulties, and even be traumatic at times. This current study is part of a larger mixed methods study conducted in Michigan in 2020, and it explores the experiences of transmasculine and nonbinary people with at-home self-swabbing HPV test kits and knowledge of HPV transmission/screenings. Phenomenological methods were used by conducting virtual qualitative interviews with ten transmasculine and nonbinary individuals with cervixes, ages 23-59. Interviews were independently coded by members of the research team and a tabletop theming method was used. Four themes were generated from the data: 1) Multilevel barriers; 2) "Get it done, so I know that I am safe"; 3) Contrasting preferences for care; and 4) Community calls for change. The discussion focuses on the implications of these findings for improving sexual health care for the transgender and nonbinary community, along with directions for further research.

Dismantling Barriers and Transforming the Future of Pre-Exposure Prophylaxis Uptake in Young Black and Latinx Sexual Minority Men and Transgender Women

Pre-exposure prophylaxis (PrEP) has the potential to transform HIV in young Black and Latinx sexual minority men (SMM) and transgender women (TW). Addressing low PrEP uptake in this population depends on the better understanding of barriers to PrEP use. This article uses an ecological framework to explore barriers to daily oral PrEP in a sample of young Black and Latinx SMM and TW in three geographically prioritized cities in the United States. In-depth interviews were completed with 33 young Black and Latinx SMM and TW (22 at risk for and 11 recently diagnosed with HIV), aged 17-24, participating in a randomized trial aimed at increasing PrEP and antiretroviral therapy (ART) uptake and adherence. Interviews were recorded and transcribed, and then analyzed using inductive and deductive coding. Coded transcripts were organized into individual, interpersonal, community, and structural categories, by PrEP use and HIV status. Among participants, nine reported having been prescribed PrEP, with five actively or recently taking PrEP, whereas only one participant diagnosed with HIV had been prescribed PrEP. Major themes related to barriers emerged across the individual, family, community, and structural level. Limited barriers related to partners, instead partners with HIV encouraged PrEP use. Participants commonly reported low perceived HIV risk, fear of disclosure, barriers relating to insurance/cost, and medication use as reasons for nonuse of PrEP. For youth to remain on a healthy life course, HIV preventative measures will need to be adopted early in adolescence for those at risk of HIV acquisition. Interventions need to simultaneously address multilevel barriers that contribute to nonuse in adolescents. Clinical trials registry site and number: ClinicalTrials.gov Identifier: NCT03194477.

Barriers in care pathways and unmet mental health needs in LGBTIQ + communities

Lesbian, gay, bisexual, transgender, intersex, queer people and minority gender identities and sexualities (LGBTIQ+) are often stigmatized and experience discrimination in health care settings, leading to poorer mental health outcomes and unmet needs compared to heterosexual and cisgendered peers. It is thus imperative that mental health providers consider and address structural challenges in order to reduce mental health inequalities of this population. This narrative review assessed the barriers that may prevent access to care and the pathways for care in LGBTIQ + communities. PubMed, PsycInfo, Embase, and Scopus were searched for papers published between December 2021 and February 2022. A total of 107 papers were included with studies reflecting five themes: (1) Unmet mental health needs; (2) Young people; (3) Substance abuse and addiction; (4) Barriers and pathways to care; and (5) Interventions. Findings demonstrate that LGBTIQ + people experience stigmatization and higher rates of substance misuse and mental ill health, which may lead to barriers in accessing health care services, and fewer tailored interventions being provided. These findings have implications for policy, health care screening, and how specialist services are structured. Substantial gaps in the evidence-base exist, and future research should examine how mental health care providers can challenge social issues that maintain discriminatory and stigmatizing practices, and support LGBTIQ + individuals to sustain their resilience.

Association of Discrimination, Violence, and Resilience with Depressive Symptoms Among Transgender Women in Rio de Janeiro, Brazil: A Cross-Sectional Analysis

Transgender women experience violence and discrimination that lead to stress responses and contribute to poor mental health. In this analysis of baseline data from Transcendendo, a trans-specific open cohort in Rio de Janeiro, Brazil, we hypothesized that the experience of discrimination and violence would be associated with depressive symptoms and that resilience could mitigate this association. Results showed that prior experiences with discrimination and sexual and physical violence were associated with depressive symptoms, while resilience was inversely associated with depressive symptoms. Resilience did not moderate nor mediate the strong effects of discrimination and violence on depressive symptoms in adjusted models.

Trans Adults Amidst the COVID-19 Pandemic: Quality of Life, Pandemic Impact, and Vaccine Preferences

The ongoing COVID-19 pandemic is disproportionately impacting marginalized communities, such as Black, Indigenous, and people of color (BIPOC), disabled individuals, and transgender/nonbinary (i.e., trans) individuals. As trans individuals may be multiply marginalized, it is necessary to examine within group differences among trans individuals of different genders, races, socioeconomic statuses, and abilities. This study examines the following research questions: (1) What is the quality of life of trans adults during the COVID-19 pandemic? (2) How does the self-reported impact of the pandemic vary across groups within the trans community? (3) What preferences do trans adults have regarding receiving a COVID-19 vaccine? Survey data were collected in August/September of 2020. Among a sample of 449 trans adults, findings suggest that the profound impact of the pandemic was not consistent across all community members. Being a woman predicted a higher self-reported impact of the pandemic while being a masc(uline) white respondent tended to predict a lower impact of the pandemic. Higher income was associated with a higher quality of life and being a disabled white respondent predicted a lower quality of life. The majority (99%) of the sample reported wanting to receive a COVID-19 vaccine should one become available. Implications for practice include the importance of considering the holistic experiences of clients and community members, as opposed to having homogenized perspectives of even subsets of the trans community. Future research related to barriers faced when attempting to access a vaccine is needed to inform future public health responses to epidemics/pandemics impacting this community.