Avoidance of primary healthcare among transgender and non-binary people in Canada during the COVID-19 pandemic.

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

Journeying together: A visual exploration of "engagement" as a journey in HIV programming and service delivery.

The experiences of people living with, or impacted by HIV, who participate in research and programming are relatively-well documented. However, how stakeholders within the HIV sector understand engagement, or how it functions discursively, is undertheorized. We used a comparative case study design and photovoice to explore engagement in three community-based organizations providing HIV programs or services in Toronto, Canada. We invited stakeholders to photograph their subjective understandings of engagement. We employ a visual and thematic analysis of our findings, by focusing on participants' use of journey metaphors to discuss engagement within and across sites. Visual metaphors of journey were employed by participants to make sense of their experience, and demonstrated that for many, engagement was a dynamic, affective and relational process. Our findings illustrate how journey may be an apt metaphor to explore the relational, contingent and socio-spatial/political specificities of engagement within and across HIV organizations. We conclude with a discussion on implications for practice.

The TRANScending Love Arts-Based Workshop to Address Self-Acceptance and Intersectional Stigma Among Transgender Women of Color in Toronto, Canada: Findings from a Qualitative Implementation Science Study.

Purpose: Transgender (trans) women of color's HIV vulnerabilities are shaped by social exclusion and intersectional stigma. There is a dearth of tailored HIV prevention interventions with trans women of color in Canada. The objective of the study was to explore trans women of color's HIV prevention priorities and to pilot test an intervention developed from these priorities. Methods: We conducted a qualitative implementation science study to develop HIV intervention strategies with trans women of color in Toronto, Canada. First, we conducted a focus group with trans women of color (n=8) to explore HIV prevention priorities. Second, we held a consultation with trans women of color community leaders (n=2). Findings informed the development of the TRANScending Love (T-Love) arts-based workshop that we pilot tested with three groups of trans women of color (n=18). Workshops were directly followed by focus groups to examine T-Love products and processes. Results: Focus group participants called for researchers to shift the focus away from trans women's bodies and HIV risks to address low self-acceptance produced by intersecting forms of stigma. The community leader consultation articulated the potential for strengths-focused arts-based approaches to address self-worth. T-Love participants described how workshops fostered self-acceptance and built connections between trans women of color. Conclusions: Findings demonstrate the feasibility and acceptability of an arts-based strategy with trans women of color to elicit group-based sharing of journeys to self-acceptance, fostering feelings of solidarity and connection. Providing opportunities for dialogue and reflection about individual and collective strengths may reduce internalized stigma among trans women of color.