Mitigating invalid data bias in the estimation of sexual orientation disparities in a survey of youth in US and Canada.

The current commentary explored the applicability of the methods described in "Mitigating invalid and mischievous survey responses: A registered report examining risk disparities between heterosexual and lesbian, gay, bisexual, or questioning youth" by Dr. Joseph Cimpian and colleagues to explore sexual orientation disparities in preexisting data from a nonprobability sample. Understanding Affirming Communities, Relationships, and Networks was a study of mostly White (77.4%) 9674 sexual and gender-minoritized youth aged 15-29 from the US and Canada. The influence of invalid data on the prevalence ratios of four health outcomes was assessed. The methods yielded similar effects to the original paper. The accuracy varied by outcome prevalence and was robust to misspecification of the model. Therefore, the applicability of this method to preexisting data seems feasible.

Acceptability of integrating mental health and substance use care within sexual health services among young sexual and gender minority men in Vancouver, Canada.

BACKGROUND: Despite well-established evidence showing that young sexual and gender minority (SGM) men experience disproportionate mental health and substance use inequities, few sexual health services provide mental health and substance use care. This qualitative study examined the experiences and perspectives about integrated care models within sexual health services among young SGM men experiencing mental health and substance use challenges. METHODS: Semi-structured interviews were conducted with 50 SGM men aged 18-30 years who reported using substances with sex in Vancouver, Canada. Interviews were analyzed using thematic analysis. RESULTS: Three themes were identified: 1) participants asserted that their sexual health, mental health and substance use-related health needs were interrelated and that not addressing all three concurrently could result in even more negative health outcomes. These concurrent health needs were described as stemming from the oppressive social conditions in which SGM men live. 2) Although sexual health clinics were considered a safe place to discuss sexual health needs, participants reported not being invited by health providers to engage in discussions about their mental health and substance use health-related needs. Participants also perceived how stigmas associated with mental health and substance use limited their ability to express and receive support. 3) Participants identified key characteristics they preferred and wanted within integrated care, including training for health providers on mental health and SGM men's health and connections (e.g., referral processes) between services. Participants also recommended integrating social support programs to help them address SGM-related social challenges. CONCLUSION: Our findings highlight that SGM men's sexual health, mental health and substance use-related health needs and preferences are interrelated and should be addressed together. Tailored training and resources as well as structural adaptations to improve communication channels and collaborative connections between health providers are required to facilitate the development of integrated care for young SGM men.

Cost-effectiveness of internet-based HIV screening among gay, bisexual and other men who have sex with men (GBMSM) in Metro Vancouver, Canada.

BACKGROUND: GetCheckedOnline is an internet-based screening service aiming to increase HIV testing among gay, bisexual and other men who have sex with men (GBMSM). We assessed the cost-effectiveness of GetCheckedOnline in its first implementation phase at different uptake scenarios compared to clinic-based screening services alone in Metro Vancouver, Canada. METHODS: From a healthcare payer's perspective, our cost-utility analysis used an established dynamic GBMSM HIV compartmental model estimating the probability of acquiring HIV, progressing through diagnosis, disease stages and treatment over a 30-year time horizon. The base case scenario assumed 4.7% uptake of GetCheckedOnline in 2016 (remainder using clinic-based services), with 74% of high-risk and 44% of low-risk infrequent testers becoming regular testers in five years. Scenario analyses tested increased GetCheckedOnline uptake to 10% and 15%. RESULTS: The cost per test for GetCheckedOnline was $29.40 compared to clinic-based services $56.92. Compared with clinic-based screening services, the projected increase in testing frequency with 4.7% uptake of GetCheckedOnline increased the costs by $329,600 (95% Credible Interval: -$498,200, $571,000) and gained 4.53 (95%CrI: 0, 9.20) quality-adjusted life years (QALYs) in a 30-year time horizon. The probability of GetCheckedOnline being cost-effective was 34% at the threshold of $50,000 per QALY, and increased to 73% at the threshold of $100,000 per QALY. The results were consistent in the other uptake scenarios. The probability of GetCheckedOnline being cost-effective became 80% at the threshold of $50,000 per QALY if assuming 5-year time horizon. CONCLUSIONS: GetCheckedOnline is almost half the cost of clinic-based services on a per-test basis. However, increased access to testing should be balanced with risk profiles of patients to ensure the implementation can be a cost-effective strategy for increasing HIV screening among GBMSM in Metro Vancouver. Additional analyses are needed to understand the impact of internet-based screening including screening for other STIs and in other populations.

Conformity to Masculinity Norms and Mental Health Outcomes Among Gay, Bisexual, Trans, Two-Spirit, and Queer Men and Non-Binary Individuals.

Homophobia and biphobia negatively impact the mental health of gay, bisexual, trans, Two-Spirit, and queer men and non-binary individuals (GBT2Q) and sexual and gender minority men, but little is known about the impact of gender-related oppression. The current study examines the impact of pressure to conform to masculine norms in Canada-based GBT2Q individuals. Specifically, the associations between (a) gender expression and pressure to be masculine and (b) pressure to be masculine and depression, anxiety, and self-rated mental health were investigated. Drawing from an online national cross-sectional survey of 8,977 GBT2Q individuals and sexual and gender minority men living in Canada aged 15 years or older, 56.4% (n = 5,067) of respondents reported experiencing pressure to conform to masculine norms. Respondents were more likely to report masculine pressure if they were younger than 30 years, described their gender expression as fluid, identified their sexuality as queer, were an ethnoracial minority, and were trans. Pressure to be masculine was associated with increased odds of depression, anxiety, and reporting poor or fair mental health. The current study provides evidence of the detrimental impact of pressure to conform to masculine norms on the mental health of gay, bisexual, trans, Two-Spirit, and queer men and non-binary peoples.

A systematic review of the prevalence of lifetime experience with 'conversion' practices among sexual and gender minority populations.

RATIONALE: Conversion practices (CPs) refer to organized attempts to deter people from adopting or expressing non-heterosexual identities or gender identities that differ from their gender/sex assigned at birth. Numerous jurisdictions have contemplated or enacted legislative CP bans in recent years. Syntheses of CP prevalence are needed to inform further public health policy and action. OBJECTIVES: To conduct a systematic review describing CP prevalence estimates internationally and exploring heterogeneity across country and socially relevant subgroups. METHODS: We performed literature searches in eight databases (Medline, Embase, PsycInfo, Social Work Abstracts, CINAHL, Web of Science, LGBTQ+ Source, and Proquest Dissertations) and included studies from all jurisdictions, globally, conducted after 2000 with a sampling frame of sexual and gender minority (SGM) people, as well as studies of practitioners seeing SGM patients. We used the Hoy et al. risk of bias tool for prevalence studies and summarized distribution of estimates using median and range. RESULTS: We identified fourteen articles that reported prevalence estimates among SGM populations, and two articles that reported prevalence estimates from studies of mental health practitioners. Prevalence estimates among SGM samples ranged 2%-34% (median: 8.5). Prevalence estimates were greater in studies conducted in the US (median: 13%), compared to Canada (median: 7%), and greater among transgender (median: 12%), compared to cisgender (median: 4%) subsamples. Prevalence estimates were greatest among people assigned male at birth, whether transgender (median: 10%) or cisgender (median: 8%), as compared to people assigned female at birth (medians: 5% among transgender participants, 3% among cisgender participants). Further differences were observed by race (medians: 8% among Indigenous and other racial minorities, 5% among white groups) but not by sexual orientation. CONCLUSIONS: CPs remain prevalent, despite denouncements from professional bodies. Social inequities in CP prevalence signal the need for targeted efforts to protect transgender, Indigenous and racial minority, and assigned-male-at-birth subgroups.

Association between level of compliance with COVID-19 public health measures and depressive symptoms: A cross-sectional survey of young adults in Canada and France.

BACKGROUND: While compliance with preventive measures remains central to limit the spread of COVID-19, these measures critically affected mental health of young adults. We therefore investigated the association between the level of compliance with COVID-19 preventive measures and depressive symptoms among young adults in Canada and France. METHODS: From October to December 2020, we conducted a cross-sectional online survey of young adults ages 18-29 years in Canada (n = 3246) and France (n = 2680) to collect demographic data, experiences with COVID-19 preventive measures, and mental health. Depressive symptoms were assessed by the Patient Health Questionnaire-9 (PHQ-9). Compliance profiles were built using cluster analysis. Weighted multivariable logistic regression was used to estimate associations between compliance level and major depressive symptoms (PHQ-9 score≥15) in each country. RESULTS: One third of respondents reported major depressive symptoms (Canada: 36.4%, France: 23.4%). Four compliance profiles were identified: high (42.5%), medium-high (21.7%), medium-low (18.1%), and low (17.7%), with high levels more frequently observed in Canada compared to France. In both countries, participants in low compliance profile (Canada: Adjusted Odds Ratio (AOR) [95% Confidence Interval] 0.75 [0.58, 0.98], France: AOR 0.60 [0.46, 0.75]), in the medium-low (Canada: AOR 0.58 [0.48, 0.72], France: AOR 0.81 [0.66, 1.01]), and medium-high compliance profiles (Canada: AOR 0.78 [0.65, 0.93], France: AOR 0.77 [0.63, 0.93]) were less likely to report major depressive symptoms compared to the high compliance profile. Ethno-racial minorities, sexual and gender minority, and unemployed young adults had higher odds of reporting such symptoms. CONCLUSIONS: Major depressive symptoms were associated with high compliance with COVID-19 preventive measures among young adults. The implementation of socially-isolating measures should be coupled with mental health interventions to address mental health needs of young adults, with enhanced supports for sub-groups who are structurally disadvantaged (e.g., racialized, unemployed, sexual and gender minority).

Strong community belonging moderates poor mental health in lesbian, gay, and bisexual individuals living in Canada: an intersectional analysis of a national population-based survey.

OBJECTIVES: Lesbian, gay, and bisexual (LGB) individuals report worse mental health than heterosexuals; however, this disparity may vary across intersecting social locations and be moderated by community belonging. METHODS: We investigated these relationships using the Canadian Community Health Survey 2015-2016. Log-binomial regression models were used to estimate associations between self-rated mental health and social locations (sexual orientation, gender, race, immigration, education, income), community belonging, and interactions between explanatory variables. RESULTS: Poor mental health was 1.79 (95%CI: 1.37-2.33) times higher in lesbian/gay individuals and 3.3 (95%CI: 2.89-3.76) times higher in bisexuals when compared to heterosexuals. LGB participants across all social locations reported poorer mental health as compared with heterosexuals, with bisexuals consistently displaying worse mental health. Strong community belonging modifies this relationship, reducing disparities across all sexual orientations and social locations. CONCLUSION: The intersections of differing social locations and community belonging should be considered when addressing LGB Canadians' mental health needs.

RéSUMé: OBJECTIFS: Les lesbiennes, les hommes gais et les personnes bisexuelles (LGB) déclarent une moins bonne santé mentale que les personnes hétérosexuelles, mais cette disparité peut varier selon l'emplacement social, et elle peut être modérée par l'appartenance communautaire. MéTHODE: Nous avons examiné ces relations à l'aide de l'Enquête sur la santé dans les collectivités canadiennes de 2015­2016. Nous avons utilisé des modèles de régression log-binomiaux pour estimer les associations entre la santé mentale autoévaluée et les emplacements sociaux (l'orientation sexuelle, le genre, la race, l'immigration, l'instruction, le revenu), l'appartenance communautaire et les interactions entre les variables explicatives. RéSULTATS: La mauvaise santé mentale était 1,79 fois (IC de 95% : 1,37­2,33) plus élevée chez les lesbiennes et les hommes gais et 3,3 fois (IC de 95% : 2,89­3,76) plus élevée chez les personnes bisexuelles que chez les personnes hétérosexuelles. Les participantes et les participants LGB de tous les emplacements sociaux ont déclaré une moins bonne santé mentale que les personnes hétérosexuelles, et les personnes bisexuelles ont systématiquement fait état d'une moins bonne santé mentale. Une forte appartenance communautaire modifie cette relation en réduisant les disparités pour toutes les orientations sexuelles et tous les emplacements sociaux. CONCLUSION: Les croisements entre les différents emplacements sociaux et l'appartenance communautaire devraient être pris en compte lorsqu'on aborde les besoins de santé mentale des Canadiennes et des Canadiens LGB.

Cost-related avoidance of oral health service utilization among lesbian, gay, and bisexual individuals in Canada.

OBJECTIVES: This study estimates the frequency of cost-related oral health service avoidance (CROHSA) among lesbian, gay, and bisexual (LGB) individuals in Canada relative to heterosexual persons. METHODS: Heterosexual and sexual minority individuals in Canada were compared using the national probability-based Canadian Community Health Survey 2017-2018. Logistic regression was used to quantify associations between LGB status and CROHSA. Mediators were tested following Andersen's behavioral model of health service utilization and included partnership status, oral health status, presence of dental pain, educational attainment, insurance status, smoking status, general health status, and personal income. RESULTS: From our sample of 103,216 individuals, 34.8% of LGB individuals reported avoiding oral health care due to cost compared to 22.7% of heterosexual persons. Disparities were most pronounced among bisexual individuals (odds ratio [OR] 2.29 95% confidence interval [CI] 1.42, 3.49). Disparities persisted despite adjustment for confounding using age, gender/sex, and ethnicity (OR 2.23 95% CI 1.42, 3.49). Disparities were fully mediated by eight hypothesized mediators namely, educational attainment, smoking status, partnership status, income, insurance status, oral health status, and the presence of dental pain (OR 1.69 95% CI 0.94, 3.03). In contrast, lesbian/gay individuals did not have elevated odds of experiencing CROHSA compared to heterosexual individuals (OR 1.27 95% CI 0.84, 1.92). CONCLUSION: CROHSA is elevated for bisexual individuals relative to heterosexual individuals. Targeted interventions should be explored to improve oral healthcare access among this population. Future research should assess the role of minority stress and social safety on oral health inequities among sexual minority groups.

Geosexual Archetype, Preventive Behaviors, and Sexually Transmitted Infections Among High-Risk Men Who Have Sex With Men.

BACKGROUND: Social geography plays an important role in transmission of sexually transmitted infections (STIs) among men who have sex with men. Previous qualitative work had identified 7 "geosexual archetypes," each with distinct travel patterns for sex and potentially important differences in STI rates. The objective of this article was to explore what could be learned about STI transmission by looking at STI prevention strategies (condom use and preexposure prophylaxis use) and prevalence of STIs among these geosexual archetypes. METHODS: We analyzed data from the Sex Now 2019 online survey in Canada. Men who have sex with men who reported 3 or more partners in the past 6 months were included in the analysis (n = 3649). RESULTS: The most common archetype was "geoflexible" (sex at home, partner's home, and other places; 35.6%), followed by "privates" (sex only at own/partner's home; 23.0%); the least common archetypes was "rover" (sex not at home or partner's place; 4.0%). There were significant variations in both STI prevention strategies and prevalence of bacterial STIs in the past year by geosexual archetype. In particular, among those who were HIV negative, those who reported a geoflexible archetype and used preexposure prophylaxis but did not use condoms consistently had a 52.6% prevalence of bacterial STIs, which was much higher compared with all other groups. Within other archetypes, those living with HIV had the highest prevalence of bacterial STIs. CONCLUSIONS: Geosexual archetype together with participant's STI prevention strategies was a strong predictor of bacterial STI risk. Understanding how place is connected to bacterial STIs is key in prevention as individuals do not live in isolation.

Uptake of Mpox vaccination among transgender people and gay, bisexual and other men who have sex with men among sexually-transmitted infection clinic clients in Vancouver, British Columbia.

OBJECTIVES: As the primary public health strategy for controlling the 2022 Mpox outbreak, it is critical to evaluate the impact of Mpox vaccination campaigns for transgender people and gay, bisexual and other men who have sex with men (T/GBM). We measured vaccine uptake and associated factors among T/GBM clients of an urban STI clinic in British Columbia (BC). METHODS: We conducted a cross-sectional online survey between August 8-22, 2022 of clients who had attended the STI clinic, 5-7 weeks following the first-dose Mpox vaccination campaign in BC. We drew on a systematic review of factors associated with vaccine uptake to develop survey questions, and measured vaccine uptake among vaccine-eligible T/GBM. RESULTS: Overall, 51% of T/GBM had received the first dose of the vaccine. The sample (331 participants) was majority White and university educated, identified as a man and gay, 10% had trans experience, and 68% met eligibility criteria for vaccination. Among vaccine-eligible participants identifying as T/GBM, 66% had been vaccinated; being unvaccinated was more common among participants identifying as bisexual or heteroflexible/mostly straight, and who spent less time with other T/GBM. Eligible yet unvaccinated participants had lower perceived susceptibility, and reported fewer cues to action (e.g., fewer saw information promoting the vaccine), and increased constraints to vaccine access; vaccine barriers related to accessing clinics and privacy were common. The majority (85%) of those eligible and unvaccinated at time of survey were willing to receive the vaccine. CONCLUSION: In this sample of STI clinic clients, vaccine uptake among eligible T/GBM was high in the initial weeks following a Mpox vaccination campaign. However, uptake was patterned on social gradients with lower uptake among T/GBM who may be less effectively engaged by available promotion channels. We recommend early, intentional and diverse engagement of T/GBM populations in Mpox and other targeted vaccination programs.

Sexual Orientation and Gender Identity and Expression Change Efforts and Suicidality: Evidence, Challenges, and Future Research Directions.

Sexual orientation and gender identity and expression change efforts (SOGIECE) aim to deny or suppress nonheterosexual and transgender identities. SOGIECE, including "conversion practices," are controversial and remain prevalent despite contemporary legislative bans and denouncement of these harmful practices from numerous health profession organizations. Recent work has questioned the validity of epidemiological studies associating SOGIECE with suicidal thoughts and suicide attempts. This perspective article addresses such critiques, arguing that the balance of available evidence indicates SOGIECE contribute to suicidality, while proposing methods to better account for structural context and the multitude of factors that may explain both SOGIECE attendance and suicidality.

Moderation of the association between COVID-19-related income loss and depression by receipt of financial support: Repeated cross-sectional surveys of young adults in Canada and France (2020-2021).

Background: To mitigate the adverse effects of the COVID-19 pandemic on financial resources, governments and family/friends mobilized financial support interventions (e.g., emergency aid funds) and assistance. However, little is known about how financial assistance alleviated mental health problems. This study aimed to investigate the moderating effect of financial support from the government or from family/friends on the association between income loss and depression among young adults. Methods: Two online cross-sectional surveys among young adults ages 18-29 living in Canada and France were conducted in 2020 (n = 4,511) and 2021 (n = 3,329). Moderate-to-severe depressive symptoms were measured using the Patient Health Questionnaire-9 (cut-off score: ≥10). Two logistic regression models were performed for each survey with an interaction term between income loss and financial support (government or family/friends modeled separately), controlling for demographics. Results: Overall, half reported depressive symptoms (2020/2021: 53.5%/45.6%), and over a third lost income (2020/2021: 10.2%/11.6% all income, 37.7%/21.6% some income). In 2020, 40.6% received government financial support (17.7% in 2021) while family/friends support was received by 12% (in both surveys). In both surveys, among those who received governmental financial support, income loss was associated with depression, whether participants lost all their income (e.g., 2020: Adjusted Odds Ratios (AOR) 1.75, 95% Confidence Interval [1.29-2.44]), or some of their income (e.g., 2020: AOR 1.45 [1.17-1.81]). However, among those who received family/friends financial support, income loss was no longer significantly associated with depression in both cycles, whether participants lost all their income (e.g., 2020: AOR 1.37 [0.78-2.40]), or some of their income (e.g., 2020: AOR 1.31 [0.86-1.99]). Conclusions: Association between income loss and depression was moderated by receipt of family/friends financial support but not by receipt of government financial support. Financial support interventions may help to mitigate the negative effects of income loss on young adults mental health during periods of economic crisis.

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.

Young Adults' Mental Health and Unmet Service Needs in the Context of the COVID-19 Pandemic Across Canada and France.

While young adults experienced mental health challenges during the COVID-19 pandemic, little is known about how their mental health needs were subsequently met through access to mental health services (MHS). From October to December 2020, we conducted an online survey of young adults (18-29 years) living in Canada and France to investigate factors associated with unmet MHS needs. Of the 3222 participants expressing a need to access MHS (50.7% of the total sample), 58.2% in Canada and 74.8% in France reported unmet MHS needs. In both countries, those who identified as men and those who lost income due to COVID-19, were more likely to report unmet MHS needs. In Canada, participants from Quebec, those living in rural areas, and those who experienced ethno-racial discrimination had higher odds of reporting such unmet needs. Urgent investments are needed to improve access to MHS for young adults during and after the COVID-19 pandemic.

Using photovoice to understand experiences of opioid use among sexual and gender minority youth in Vancouver, Canada.

In Canada, sexual and gender minority youth use opioids at disproportionately high rates. Yet, little is known about the distinct contexts of opioid use within this group, challenging capacity to develop well founded policy and practice supports. This case study aims to examine - in depth - the experiences and contexts of opioid use among a sample of four sexual and gender minority youth in Vancouver, Canada. Qualitative data from photovoice methods and in-depth, semi-structured interviews were collected in 2019. Analysis adopted a reflexive thematic approach from a critical interpretive standpoint, informed by minority stress theory. Three interconnected themes were constructed: (i) minoritised contexts of entry into and continuation of opioid use; (ii) mental health-maintaining and stress-mitigating effects of opioid use in the context of minoritisation; and (iii) intersections of stigma, violence and poverty with opioid use and minoritisation. Findings suggest that the health of sexual and gender minority youth who use opioids is shaped by minority stress and overlapping forms of structural marginalisation. They signal the need for responsive strategies that hold promise in supporting this population, including advancing integrated approaches to substance use and mental health care alongside interventions targeted towards the social and structural determinants of health.

Geographic distribution of conversion therapy prevalence in Canada. Findings from a national cross-sectional survey, 2020.

BACKGROUND: Conversion therapy practices (CTPs) are discredited efforts that target lesbian, gay, bisexual, trans, queer, Two-Spirit, or other (LGBTQ2S+) people and seek to change, deny, or discourage their sexual orientation, gender identity, and/or gender expression. This study aims to investigate the prevalence of CTPs across Canadian provinces and territories and identify whether CTP bans reduce the prevalence of CTPs. METHODS: We collected 119 CTPs from 31 adults (18+) in Canada who have direct experience with CTPs, know people who have gone to CTPs, or know of conversion therapy practitioners using a 2020 anonymous online survey. Mapping analysis was conducted using ArcGIS Online. CTP prevalence was compared between provinces/territories with and without bans using chi-square tests. RESULTS: Three provinces and eleven municipalities had CTP bans. The prevalence of CTPs in provinces/territories with bans was 2.34 per 1,000,000 population (95% CI 1.65, 3.31). The prevalence of CTPs in provinces/territories without bans was 4.13 per 1,000,000 population (95% CI 3.32, 5.14). Accounting for the underlying population, provinces/territories with the highest prevalence of CTPs per 1,000,000 population were New Brunswick (6.69), Nova Scotia (6.50), and Saskatchewan (6.37). CONCLUSIONS: Findings suggest only 55% of Canadians were protected under CTP bans. The prevalence of CTPs in provinces/territories without bans was 1.76 times greater than provinces/territories with bans. CTPs are occurring in most provinces/territories, with higher prevalence in the west and the Atlantic. These findings and continued efforts to monitor CTP prevalence can help inform policymakers and legislators as society is increasingly acknowledging CTPs as a threat to the health and well-being of LGBTQ2S+ people.

Preventable mortality among sexual minority Canadians.

Background: Epidemiologic studies point to multiple health inequities among sexual minority people, but few studies have examined mortality. Some causes of death are more preventable than others, and access to prevention is theorized to follow patterns of access to social and material resources. The objective of this study is to compare estimates of preventable mortality between sexual minority (SM)-i.e., bisexual, lesbian, gay-and heterosexual adults in Canada. Methods: A population-based retrospective cohort with 442,260 (unweighted N) Canadian adults, ages 18-59 years, was drawn from the Canadian Community Health Survey/Canadian Mortality Database linked database (2003-2017). The Rutstein preventability rating index was used to classify cause-specific mortality (low/high). Longitudinal analyses were conducted using Cox proportional hazards models. Results: SM respondents had higher hazard of all-cause mortality (unadjusted hazard ratio [uHR] 1.28, 95% CI 1.06, 1.55). The uHR increased when the outcome was limited to highly-preventable causes of mortality (uHR 1.43, 95% CI 1.14, 1.80). The uHR further increased in sensitivity analyses using higher thresholds of the Rutstein index. SM respondents had higher hazard of cause-specific mortality for heart disease (uHR 1.53, 95% CI 1.03, 2.29), accidents (uHR 1.97, 95% CI 1.01, 3.86), HIV (uHR 75.69, 95% CI 18.77, 305.20), and suicide (uHR 2.22, 95% CI 0.93, 5.30) but not for cancer (uHR 0.86, 95% CI 0.60, 1.25). The adjusted HR (aHR) for highly-preventable mortality was not attenuated by adjustment for confounders (aHR 1.57, 95% CI 1.20, 2.05) but was reduced by adjustment for hypothesized mediators relating to access to social and material resources (marital status, children, income, education; aHR 1.11, 95% CI 0.78, 1.58). Conclusions: Preventable mortality was elevated for SM Canadians compared to heterosexuals. Early and broad access to sexual minority-affirming primary and preventive healthcare should be expanded.

Cisheteronormativity, Conversion Therapy, and Identity Among Sexual and Gender Minority People: A Narrative Inquiry and Creative Non-fiction.

Sexual and gender minorities (SGMs) navigate systems of oppression that reify cisgender and heterosexual norms (cisheteronormativity) while developing their identities. 'Conversion therapy' represents a particularly prominent and harmful threat in this landscape. We explore how SGM who experienced conversion therapy develop their identities to understand antecedents to mental health struggles in this population. In-depth interviews were conducted with 22 people in Canada. A 'master narratives' framework combined with Polkinghorne's narrative analysis were used to explore individual-structural relations that affect identity in settings where cisheteronormative master narratives are amplified (i.e., conversion therapy). We present research findings through a creative non-fiction, which includes learning cisheteronormative master narratives; internalizing master narratives; feeling broken and searching for alternatives; and embracing self-love amidst pain. The amplification of master narratives through conversion therapy leads to conflict and delays in adopting a coherent identity. Health professionals should enact institutional practices that affirm SGM and thereby deemphasize cisheteronormativity.

Health Care Experiences of Patients Discontinuing or Reversing Prior Gender-Affirming Treatments.

Importance: Medical education, research, and clinical guidelines are available to support the initiation of gender-affirming care for transgender and nonbinary people. By contrast, little is known about the clinical experiences of those who discontinue or seek to reverse gender-affirming medical or surgical interventions due to a change in gender identity, often referred to as detransition. Objective: To examine the physical and mental health experiences of people who initiated medical or surgical detransition to inform clinical practice. Design, Setting, and Participants: Using constructivist grounded theory as a qualitative approach, data were collected in the form of in-depth interviews. Data were analyzed using an inductive 2-stage coding process to categorize and interpret detransition-related health care experiences to inform clinical practice. Between October 2021 and January 2022, individuals living in Canada who were aged 18 years and older with experience of stopping, shifting, or reversing a gender transition were invited to partake in semistructured virtual interviews. Study advertisements were circulated over social media, to clinicians, and within participants' social networks. A purposive sample of 28 participants who discontinued, shifted, or reversed a gender transition were interviewed. Main Outcomes and Measures: In-depth, narrative descriptions of the physical and mental health experiences of people who discontinued or sought to reverse prior gender-affirming medical and/or surgical interventions. Results: Among the 28 participants, 18 (64%) were assigned female at birth and 10 (36%) were assigned male at birth; 2 (7%) identified as Jewish and White, 5 (18%) identified as having mixed race and ethnicity (which included Arab, Black, Indigenous, Latinx, and South Asian), and 21 (75%) identified as White. Participants initially sought gender-affirmation at a wide range of ages (15 [56%] were between ages 18 and 24 years). Detransition occurred for various reasons, such as an evolving understanding of gender identity or health concerns. Participants reported divergent perspectives about their past gender-affirming medical or surgical treatments. Some participants felt regrets, but a majority were pleased with the results of gender-affirming medical or surgical treatments. Medical detransition was often experienced as physically and psychologically challenging, yet health care avoidance was common. Participants described experiencing stigma and interacting with clinicians who were unprepared to meet their detransition-related medical needs. Conclusions and Relevance: This study's results suggest that further research and clinical guidance is required to address the unmet needs of this population who discontinue or seek to reverse prior gender-affirming interventions.

How do sexual and gender minority people acquire the capability for suicide? Voices from survivors of near-fatal suicide attempts.

Despite well-documented disparities by sexual and gender minority (SGM) status in suicide attempt and mortality rates, few studies have investigated the lived experiences that contribute to SGM people's disproportionate risk of suicide. Having a history of at least one near-fatal (or medically serious) suicide attempt serves as a proxy for suicide mortality, but no known study has involved SGM people who have made such an attempt. Ideation-to-action theories of suicide posit that individuals acquire the capability for suicide through repeated exposure to painful and provocative events - namely, traumatic, threatening, and risky experiences - that can diminish the pain and fear of death. Yet whether identity-specific features of acquired capability for suicide contribute to SGM people's disproportionate risk of suicide remains unknown. Drawing upon interviews with 22 SGM people who experienced a recent near-fatal suicide attempt, the current study sought to identify specific determinants of how SGM individuals acquire the capability to kill themselves, a potentially powerful, and modifiable, pathway to suicide. Results identified three SGM-specific contributors to the acquired capability for suicide: (1) identity invalidation during developmentally sensitive periods of childhood and adolescence that left participants feeling erased, invisible, and, in some cases, non-existent; (2) normalization of suicide within SGM social networks that increased acceptability and reduced the fear of suicide; and (3) structural stigma and SGM community trauma as habituating sources of pain that engendered feelings of exhaustion and positioned suicide as a reprieve from pervasive anti-SGM norms. This study demonstrates that dominant suicidology theories might need to be refined to account for the stigma-related determinants of SGM suicide. Further, this study reinforces the importance of qualitative methods for understanding the lived experience of suicide and calls for SGM-specific suicide prevention efforts to respond to stigma to support those SGM people who contemplate suicide.