“I feel like I am surviving the health care system”: understanding LGBTQ health in Nova Scotia, Canada

Background Currently, there is a dearth of baseline data on the health of lesbian, gay, bisexual, transgender, and queer (LGBTQ) populations in the province of Nova Scotia, Canada. Historically, LGBTQ health research has tended to focus on individual-level health risks associated with poor health outcomes among these populations, which has served to obscure the ways in which they maintain their own health and wellness across the life course. As such, there is an urgent need to shift the focus of LGBTQ health research towards strengths-based perspectives that explore the complex and resilient ways in which LGBTQ populations promote their health. Methods This paper discusses the findings of our recent scoping review as well as the qualitative data to emerge from community consultations aimed at developing strengths-based approaches to understanding and advancing LGBTQ pathways to health across Nova Scotia. Results Our scoping review findings demonstrated the lack of strengths-based research on LGBTQ health in Nova Scotia. Specifically, the studies examined in our scoping review identified a number of health-promoting factors and a wide variety of measurement tools, some of which may prove useful for future strengths-based health research with LGBTQ populations. In addition, our community consultations revealed that many participants had negative experiences with health care systems and services in Nova Scotia. However, participants also shared a number of factors that contribute to LGBTQ health and suggestions for how LGBTQ pathways to health in Nova Scotia can be improved. Conclusions There is an urgent need to conduct research on the health needs, lived experiences, and outcomes of LGBTQ populations in Nova Scotia to address gaps in our knowledge of their unique health needs. In moving forward, it is important that future health research take an intersectional, strengths-based perspective in an effort to highlight the factors that promote LGBTQ health and wellness across the life course, while taking into account the social determinants of health.

160 the level of the individual. Based on this framing of 161 LGBTQ health, much health research has tended to 162 focus on risks for poor health outcomes among 163 LGBTQ populations, particularly rates of STI and 164 HIV infection, smoking, obesity, depression, and 165 suicidal ideation [30][31][32]. Although early health 166 research played an important role in identifying, 167 mitigating, and treating poor health outcomes among 168 LGBTQ populations as something more than an 169 individual deficit, it also served to create negative 170 perceptions of LGBTQ health and obscured the ways 171 in which these populations maintain their health. As 172 such, it is necessary to shift away from deficit-173 focused heath research toward strengths-based 174 perspectives that take a more holistic approach to 175 understanding LGBTQ health across the life course 176 [33][34][35][36]. Strengths-based perspectives do not ignore 177 health risks and challenges but rather focus on the 178 positive resources available to address these risks 179 and challenges [37]. Improving cultural competence 180 within health care systems, policies, and services in 181 Nova Scotia requires acknowledging, rendering 182 visible, and appropriately measuring the determi-183 nants of LGBTQ health and wellness across the life 184 course [38,39]. 185 Purpose 186 The purpose of this paper is to offer an overview of the 187 findings of a scoping review and community consulta-188 tions aimed at developing strengths-based approaches to 189 understanding LGBTQ pathways to health in Nova 190 Scotia. The scoping review and community consultations 191 are nested within a larger program of research aimed at 192 rendering visible the health needs, outcomes, and lived 193 experiences of LGBTQ populations in Nova Scotia in an 194 effort to improve access to, and the provision of, 195 evidence-based, culturally competent health care for 196 these populations. 197 198 The research described in this paper is informed by the 199 central tenets of community-based participatory 200 research. Community-based participatory research 201 involves "individuals and communities affected by the 202 research in all aspects of the research process, reciprocal 203 learning from the expertise of the members, shared 204 decision-making, and mutual ownership of the processes 205 and products of the research" (Van Wagenen et al.,[40], 206 p. 4). In this regard, we sought to include LGBTQ popu-207 lations and other stakeholders, such as health care 208 providers, health researchers, and policy makers, in 209 every stage of this research. 210 In an effort to gain a clearer understanding of the 211 existing health-focused LGBTQ literature, we conducted 212 a scoping review using the methodology proposed by 213 Arksey and O'Malley [41]. The purpose of our scoping 214 review was to explore the academic, peer-reviewed  that time were considered. We did not, however, limit 249 our findings to a particular start date. To ensure rigour, 250 an inter-rater reliability approach was used in the inclu- cruited through word of mouth and through existing 266 community networks in both urban and rural Nova Sco-267 tia. In total, there were twenty participants, six of whom 268 attended the rural consultation in Truro and fourteen of 269 whom attended the urban consultation in Halifax. Par-270 ticipants ranged in age from mid-20s to late 60s and the 271 majority identified as white. Prior to data collection, eth-272 ics approval was provided by the Dalhousie University 273 research ethics board (REB #2014-3291) and informed 274 consent was obtained from all participants. All data were 275 audio recorded with permission, transcribed verbatim, 276 and analyzed for key emergent themes. In addition to 277 sharing the findings of the scoping review, the overarch-278 ing purpose of these consultations was to discuss strat-279 egies for conducting strengths-based research on 280 LGBTQ health needs, outcomes, and experiences in 281 Nova Scotia. The community consultation transcripts 282 were analyzed and coded for emergent themes.

Methods
283 Results 284 Scoping review findings 285 Overall, the findings of our scoping review confirmed 286 that the majority of LGBTQ health research conducted 287 to date has largely remained focused on risks and defi-288 cits, underscoring the need to shift towards strengths-289 based approaches. It is also noteworthy that very few of 290 the studies that met our inclusion criteria were con-291 ducted in Canada (n = 16) or were conducted in multiple 292 countries but included populations in Canada (n = 3) 293 (see Appendix 3) and only one study specifically in-294 cluded LGBTQ populations in Nova Scotia. This finding 295 further illustrates the need for strengths-based research 296 focused on the health needs and experiences of LGBTQ 297 populations in Nova Scotia. The included studies also 298 featured a range of study populations and terminology 299 (see Appendix 4). While some studies focused on 300 LGBTQ populations in general, others focused on spe-301 cific subpopulations. Notable subpopulations included 302 youth (n = 26), older adults (n = 14), and people of 303 colour (n = 14). Although we did not limit our studies to 304 a particular start date, the findings demonstrate that 305 strengths-based research on LGBTQ health is becoming 306 increasingly prevalent. Of the included studies, none 307 were published prior to 1990, six were published be-  The articles included in our scoping review explored a 312 wide range of protective or health promoting factors 313 with the potential to contribute to LGBTQ health, in-314 cluding, for example, social support, coping skills, and 315 positive school and/or work environments [33,[42][43][44]. 316 Further, these studies used diverse tools to measure 317 positive health factors. However, we also noted that 318 many of the measures used were not specific to LGBTQ 373 Community consultations 374 The following section offers an overview of the key con-375 cerns raised about LGBTQ health in Nova Scotia from 376 our community consultations. Our semi-structured 377 focus group guide centred around core issues to emerge 378 from our scoping review, including experiences with 379 health care systems and services, factors seen to contrib-380 ute to LGBTQ health and wellness, LGBTQ resilience, 381 improving the cultural competence of health care sys-382 tems and services, and finally, suggestions for future 383 LGBTQ health research in Nova Scotia. 384 Negative experiences with health care systems and services 385 Following the scoping review, the community consult-386 ation discussions offered a rich overview of LGBTQ ex-387 periences with health care systems and services, factors 388 that contribute to LGBTQ health and wellness, and how 389 LGBTQ pathways to health in Nova Scotia can be im-390 proved. Unsurprisingly, many of the LGBTQ participants 391 attending the consultations reported negative experi-392 ences with health care services in Nova Scotia. Several 393 participants described having negative first impressions 394 of health care settings based on their interactions with 395 medical office assistants and heteronormative, gender-396 binary language on medical intake forms. In other 397 words, intake forms and salutations required patients to 398 select gender-congruent 'male' or 'female' categories and 399 to select corresponding terms such as 'Mr.' and 'Mrs'. As 400 one participant explained, "I shouldn't have to go into a 401 doctor's office and be like I'm probably going to get mis-402 gendered and I need to prepare myself for that and put 403 on my armour. That shouldn't even be happening in the 404 first place. But it does happen and it's my reality, and I 405 have to deal with it". Similarly, participants expressed 406 concern about the challenges of communicating with 407 health service providers and being open with them re-408 garding their LGBTQ identity-both in terms of sexual 409 orientation and gender identity. One participant charac-410 terized this experience as "explaining yourself over and 411 over" when interacting with health service providers.

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Participants suggested that these negative encounters 413 serve to discourage LGBTQ populations from accessing 414 regular check-ups and preventative care, and instead, 415 waiting until they are ill before seeking health care ser-416 vices. Participants also expressed concern regarding 417 health service providers' lack of knowledge on LGBTQ 418 health issues, which may lead to inappropriate advice. 419 One participant shared the story of a friend in a rural 420 setting whose doctor threatened to involuntarily commit 421 them for psychiatric care based on their non-binary gen-422 der identification. This experience is supported by the 423 findings of a previous study on lesbian and bisexual 424 women in Nova Scotia wherein several women reported 425 being told by a physician that their sexuality was that sex education currently tends to be framed through 475 a heteronormative and gender-binary lens, thereby limit-476 ing its utility for LGBTQ youth. Self-acceptance and 477 levels or degrees of 'outness' to health service providers 478 were also described as important health promoting 479 factors. As one participant noted, "it took me a long 480 time to get to that point to be able to talk openly about 481 my own body [and] my own sex life". Most participants 482 reasoned that while not being 'out' to a health service 483 provider can potentially have negative implications for 484 health, it is also a necessary part of the process of acces-485 sing health care in order to negotiate personal safety in 486 instances where there is uncertainty or lack of trust with 487 a health care provider. Similarly, not being 'out' was seen 488 as a factor preventing LGBTQ populations from acces-489 sing certain community organizations and services for 490 fear of being identified as LGBTQ. In addition, cognitive, 491 behavioural, and emotional personal coping strategies 492 and self-care were viewed as key individual-level factors 493 contributing to the health and wellness of LGBTQ popu-494 lations in Nova Scotia.  Consistent with our scoping review findings, social 505 support was one of the most prominent determinants 506 seen as contributing to LGBTQ health and wellness. Po-507 tential sources of social support include biological family 508 or family of origin, family of choice, friends, and other 509 LGBTQ community members. Community connected-510 ness was also seen as a source of strength among partici-511 pants. Participants defined community connectedness 512 quite broadly, referencing involvement in gay-straight 513 alliances, LGBTQ communities, sports leagues, commu-514 nity activities such as Pride Week, and accessing 515 community services as potential connections. Similarly, 516 participants suggested that for LGBTQ populations for 517 whom religion or spirituality are important, belonging to 518 an affirming religious or spiritual community could play 519 a critical role in maintaining health and wellness. As one 520 participant explained,

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LGBTQ resilience 560 We also asked participants in the community consulta- non-modifiable determinants discussed above, including 582 social support, pride, self-acceptance, community con-583 nectedness, and personal coping skills. 584 Improving the cultural competence of health care systems 585 and services in Nova Scotia 586 In addition to determinants that contribute to promot-587 ing the health and wellness of LGBTQ populations in 588 Nova Scotia, participants also discussed ways in which 589 the cultural competence of health care systems and ser-590 vices in Nova Scotia could be improved. One of the key 591 areas of improvement noted was making health care en-592 vironments safer and more inclusive and welcoming for 593 LGBTQ populations. Participants argued that making 594 small changes within health and social systems such as 595 removing heteronormative and gender-binary language 596 from intake forms and posting visible symbols like a 597 pride flag or an LGBTQ ally card would contribute to 598 improving pathways to health for LGBTQ populations.  Additionally, education and training for health care 607 providers on how to provide culturally competent health 608 care services for LGBTQ populations was seen as a 609 major area for improvement. A nurse attending one of 610 the consultations stated that, in her experience, nurses 611 are not taught "how to make an equitable presentation 612 for an experience in health care whatsoever. It's just not 613 there. We might be given one session one afternoon in 614 our undergrad, and that's it. And this was 2 years ago 615 when I graduated". This feeling echoes the views of 616 physicians interviewed in a previous study on queer and 617 trans women's health care in Nova Scotia who felt that 618 they lacked knowledge, particularly with regards to 619 providing care for trans populations [10]. Another 620 participant felt that the only way to ensure positive expe-621 riences of 'coming out' to health service providers is 622 through additional education and training. This finding 623 is supported by the conclusions of a previous study that 624 found that nurses in Nova Scotia "take a 'don't ask, don't 625 tell' approach, trusting that quality care can be provided 626 without acknowledging LGBTQ identities and that the 627 ways in which marginalization and oppression may 628 shape LGBTQ patients' health and health care" (Beagan 629 et al. p.60 [67]). Beyond improving communication 630 between health service providers and LGBTQ 631 populations, educating health service providers on 632 LGBTQ-specific health needs and issues was also seen "what did that look like?", and "how did that make a dif- Scotia also warrants further exploration. Finally, given 792 that we were only able to conduct community consulta-793 tions in two regions, there is a need for additional 794 research on LGBTQ health in Nova Scotia that captures 795 the perspectives of LGBTQ populations across the 796 province.
797 Limitations 798 Although our scoping review and the community con-799 sultations provide important information for conducting 800 strengths-based LGBTQ health research, there are sev-801 eral limitations to note. The scoping review only in-802 cluded peer-reviewed, academic articles published in 803 English and in academic journals and, as such, may not 804 reflect the perspectives of non-peer reviewed or grey lit-805 erature. Further, given the diversity of identities and 806 terms related to LGBTQ populations (see Appendix 4), 807 there may be identities or populations that were not ad-808 equately captured by the search terms, such as men who 809 have sex with men (MSM) but do not identify as gay or 810 bisexual, for example. While scoping reviews are a useful 811 approach to retrieving literature related to a specific 812 topic of interest and identifying gaps in the existing lit-813 erature, they do not assess the quality of the evidence or 814 synthesize the findings presented in the retrieved litera-815 ture in the way that systematic reviews do [41]. As such, 816 future research on this topic should consider including 817 systematic reviews which provide a more rigorous meth-818 odology. In addition, the community consultations were 819 limited by time and budgetary constraints which only 820 allowed for two consultations, one in rural and one in 821 urban Nova Scotia. Moreover, although we sought to 822 make the consultations safe, inclusive, and respectful 823 spaces, we invited both LGBTQ populations and health 824 service providers to attend. This may have deterred 825 LGBTQ individuals who have had negative health care 826 experiences from attending. While we have highlighted 827 the importance of intersectionality in LGBTQ health re-828 search, the majority of our community consultation par-829 ticipants identified as white and, as such, do not 830 necessarily represent the diversity of LGBTQ popula-831 tions in Nova Scotia. Future research should consider 832 using alternative recruitment strategies that may result 833 in greater diversity among participants.