Parliamentary Standing Committee on Health LBGTIQ2S* Health And

Submitted to the:

Parliamentary Standing Committee on Health

House of Commons Government of Canada, Ottawa

Chair: MP Bill Casey ​ Vice Chairs: MP Marilyn Gladu & MP Don Davies ​ Members: MP Ramez Ayoub, MP Pam Damoff, MP Doug Eyolfson, MP Ben Lobb, MP Ron McKinnon, MP ​ Robert-Falcon Ouellette, MP Sonia Sidhu, MP Len Webber

CC’d: extensively ​

On the Issue of: LBGTIQ2S* Health and Wellness

April 30, 2019

Submitted By: Chris Shortall This submission represents the views of the author and does not reflect the views of any of his/their personal or professional affiliations

Edited by: Tamara Reynish, PhD Candidate (Medical Studies), University of Tasmania, Centre for Rural Health, BA, MA, ​ ​ MSW

Thank you for holding these meetings and the opportunity to address Lesbian Bisexual Gay Transgender Intersex Queer Two-Spirit etc. (LBGTIQ2S*) health and wellness in Canada. It has been ignored for too long (Hellquist, G. et al. versus Health Canada and the Public Health Agency of Canada, 2009). In some cases, ​ ​ ​ ​ valuable work in this area has already been lost because of delays in action in this area (Canadian Rainbow Health Coalition, 2006). Hopefully some consensus and collaborative benefit can come from these meetings.

Recommendation 1: Framing LBGTIQ2S* Health and Wellness, ​ Address Vulnerability and Susceptibility, & Standardize General Language and Terminology

Heteronormativity and cisgenderism are problematic because it forces everyone regardless of their identity, to pass as coherent, static, or as an otherwise cognizant, intentional, and foundational collection of presentations (Atkinson and DePalma, 2008; Gray et al., 1996; Ingraham, 2005; Sullivan, 2007; Wilchins, 2004). Sexually and gender diverse people are not a unified sub population; each of the letters of LBGTIQ2S* comprise of many complex, intersecting social identities, personal histories, geographies, activities, and behaviours. The richness of LBGTIQ2S* health and wellness is that it affects everyone. Thank you for removing gender markers ​ from government issued identification documents and taking this first step to addressing cisnormativity (Grabish, 2019). Many of the particular health and wellness issues facing LBGTIQ2S* people and populations have been summarized by Dean et al. (2000) in the USA, and others in Canada (Shortall 2017). Some particular holistic health and wellness issues already known to adversely affect large portions of the sexually and gender diverse populations are: problematic tobacco/drug and alcohol usage; obesity/eating disorders/body image; biological family versus family of choice; systemic heterosexism and cisgenderism; minority stress/bullying/violence/safety (school, public, home and workplace); HIV stigma; loneliness/social isolation; seniors issues; transgender/intersex participation in professional sport; anxiety/suicidality/depression/mental health issues; availability and access to supportive/knowledgeable/trained primary health and social services; sustainability of LBGTIQ2S* social support networks; housing/homelessness/poverty issues; sex work; economic security as it relates to student debt. All of these issues can impact individuals and populations throughout a lifespan and across geographic areas. Inclusive of the established social determinants of health, other issues include: reparative conversion therapy; intersex rights; (dis)abilities; the whole host of Aboriginal/Indigenous/First Nations issues (Robinson, 2014-2017). Primary and secondary school sexuality/sexual orientation and gender identity/gender expression diversity curricula and primary/secondary school GSA’s (Gay Straight Alliances) should be supported as an upstream approach to LBGTIQ2S* health and wellness. In Canada it should also include a whole host of immigrant/racial/ethnic/ethnocultural/visible minority diversity issues including tailored/targeted LBGTIQ2S* services, and be dealt with using a framework of intersectionality. Mulé, et al. (2009, figure 1) presents a useful diagrammatic to begin to frame the holistic health and wellness issues facing LBGTIQ2S* people. Often, for funding requirements LBGTIQ2S* peoples are listed as populations served, but the mainstream/universal community based organizations may not have any specific services for these populations, nor have received adequate training in the area. Federal funding is needed for the targeted LBGTIQ2S* populations outside of sexual health/STBBIs/HIV/AIDS which is incommensurate with the variety of holistic health and wellness issues facing these populations. Funding envelopes can either specifically address particular health issues or priority populations (preferred), however caution needs to be taken to ensure they have adequate framing and duration.

Recommendation 2: Ensure Geographic Representation of Rural & Remote LBGTIQ2S* ​

Mulé, states “large urban centres benefit most in being able to provide direct health care services obviously in response to the larger number of LBGTIQ2S* people who have [coalesced] in these cities. Nevertheless their funding is far from adequate or guaranteed” (2015, p.36). There appears to be limited community-led initiatives in the area of LBGTIQ2S* health and wellness outside of the provinces of BC, Ontario, Quebec and Nova Scotia, where provincial and municipal public funding is more readily available (Mulé, 2015). In terms of federal funding, already disadvantaged rural and remote jurisdictions in direct competition for federal and private grants with more buoyant sites reflects poorly on the Canadian government’s approach to equality amongst and between provinces. Canadian Health Transfers (CHT) and Canadian Social Transfers (CST) need to ​ specify requirements to address LBGTIQ2S* health and wellness initiatives in numerous ways that do not only amount to lip service and tokenism. It is not surprising that all the submissions and witnesses to these Senate Standing Committee on Health meetings have been from urban and metropolitan centres in Quebec, Ontario, and British Columbia where more bouyant provincal coffiers mean that these issues are being addressed only where funds are more prevalent. I want to congratulate the funding bodies for dedicating so much money to Advancé and, while I am confident this initiative will improve the landscape in those provinces, this nationally funded initiative reiterates the notion that Canada ends in Halifax, as the Atlantic Coordinator for, is in Nova Scotia. It by no means represents all jurisdictions and further reiterates the notion that Canada is MTV (Montreal, Toronto, Vancouver). Mulé also discusses the rights of rural and remote LBGTIQ2S* people where health care services are limited; there is deeply embedded stigma, and the only possibility for LBGTIQ2S* programming has been by nonprofit community-based organizations with HIV/AIDS funding (2015). LBGTIQ2S* populations in Newfoundland & Labrador do not have access to the level of tailored/targeted services available in urban/metropolitan areas, as other witnesses have represented. To elucidate this statement, I was hired by the ​ AIDS Committee of Newfoundland & Labrador to coordinate/implement the PHAC funded Gay Urban Youth Zone (GUYZ) Project in 2006-2008. This project focused solely on St. John’s, provided direct service provision to the target population and also provided training for other mainstream/universal service providers. The ACNL GUYZ Project was successful, however it was cut short when HIV project funding was reoriented by changes in governing parties and healthcare priorities. To my knowledge, no other organization in NL has received federal funding for explicit LBGTIQ2S* health and wellness in the province since that time. Funding needs to be sustainable and the Regional Health Authorities, and Provincial Governmental Offices may not be conducive ​ places to spearhead the necessary change. Options for LBGTIQ2S* people to access tailored/targeted services in St. John’s, on the Northeast Avalon, are limited to say the least, but they are even more limited outside of the Northeast Avalon (across the island), and further afield in Labrador. While these services seem common in other jurisdictions, the only community-led primary healthcare services explicitly tailored/targeting LBGTIQ2S* people in the province is the Newfoundland & Labrador Sexual Health Centre/Planned Parenthood, who have to fundraise two-thirds of their annual budget. They do not receive enough provincial money to operate, let alone provide province-wide services. It is unknown if mainstream/universal health and social care services are indeed knowledgeable/trained in the particular holistic health and wellness issues facing LBGTIQ2S* people and populations in Newfoundland & Labrador particularly, and this notion extends to other jurisdictions in Canada. The College of Family Physicians while completely ignoring LBGTIQ2S* health and wellness, states that “people in rural areas have a higher burden of illness, reduced life expectancy, and are often older, poorer, and sicker than urban [metropolitan] populations. ...Policy decisions are often guided by urban health care models without understanding the potential negative impacts in rural communities. Rural communities need rural-based solutions and to develop regional capacity to innovate, experiment, and discover what works” (August, 2018, p.4). The resultant health and social inequalities experienced by rural and remote LBGTIQ2S* people are aggravated by their geographic location in non-metropolitan centres and constitute a possible (unexplored) contributing factor to interprovincial migration (Stats Canada, 2017). Anecdotal evidence shows that LBGTIQ2S* people relocate from rural and remote areas to more urban locales, and oftentimes to larger metropolitan centres, to reduce minority stressors, access services unavailable in rural and remote areas, and increase feelings of community connectedness, despite feelings of loss of place. Intentional steps are needed to assess and improve the migration data that is (or may become) available. LBGTIQ2S* people in rural and remote areas face increased exposure to minority stressors and lower feelings of community connectedness (Sweet, 2019; Power & Barry, 2018). Recently my PHAC application P001377 - Mental Health Promotion Innovation Fund (MHP-IF) was rejected/denied at the early letter of intent stage in spite of its focus on high-risk rural and remote LBGTIQ2S* populations, its use of established population health/public health initiatives, and a described solid connection to the target community as well as proposed knowledge brokering with university health researchers. It specifically highlighted KTE ways to address the health research enterprise alongside direct service provision. The work will have to be shelved until appropriate funding becomes available. I cite it only because it represents a missed opportunity for the current federal government to enable the changes that this committee and the LBGTQ2 Secretariat appear to support.

Recommendation 3: Increase Implementation Science, Focus on Primary Health Care Renewal, and Target ​ Upstream Population Health/Public Health Interventions

Healthcare reform in Canada requires implementing national approaches; developing more cost-effective ways of delivering care; initiating a shift to community-based versus hospital-based care; and, the downloading/outsourcing of services to local regional health boards. However, without sufficient community-based programs, financial resources, or trained personnel, this practice places unrealistic demands on already overburdened community-based services (Brown, 2009). Newfoundland & Labrador is currently one of ​ the provinces and territories that has not been able to secure stable operational funding for a LBGTIQ2S* community centre like the other submission witnesses have access to. In Newfoundland & Labrador due to a lack of funding, all the work in this area is volunteer-based, uncoordinated, and service provision is reliant on inadequate mainstream/universal services untrained/unknowledgeable in the particular holistic health and wellness issues facing sexually and gender diverse people outside of a framework of sexual health/STBBIs/HIV/AIDS. As outlined by the Out Saskatoon submission to this committee, it would be beneficial if there was dedicated financial support to LBGTIQ2S* centres across the country, especially in underfunded areas, in order to provide front line support, sector-wide education, and, innovative interventions, policies and practices (OutSaskatoon, 2019). For approaches to the research enterprise in this matter, see the National Collaborating Centre for Determinants of Health (2014) and CIHI (2018). It is admirable that the there is a federal policy on Gender Based Analysis Plus, which depends on closing key gaps between diverse groups of women, men and non-binary people, ​ however more dedicated specific LBGTIQ2S* work needs to be done in the country (Hawe, Samis, Di Ruggiero & Shoveller, 2011). Gender Based Analysis Plus has not been extended to Newfoundland & Labrador whos provincial Women's Policy Office still cites using Gender Based Analysis and excludes/ignores transgender, intersex and non-binary people. A lack of explicit inclusion of LBGTIQ2S* people in public policy constitutes ​ further heterosexism/heteronormativity and cisgenderism/trans/biphobia, and exemplifies the problematic of non educated people representing and addressing LBGTIQ2S* issues. While all mainstream/universal primary healthcare and health/social services initiatives currently (and will continue to) provide services to LBGTIQ2S* people, few of them are specifically aware and trained/knowledgeable in the areas of LBGTIQ2S* peoples' holistic complex health and wellness needs (Clarke, 2018; Colpitts & Gahagan, 2016). As LBGTIQ2S* people face microaggressions in many mainstream/universal services, LBGTIQ2S* people can experience negative and unfavourable interactions with health and social providers who are simply unaware of the unconscious biases that they hold (Brotman et al., 2007; Harbin, Beagan, and Goldberg, 2012; Kitzinger, 2005; Mathieson, Bailey, and Gurevich, 2002). Negative experiences and unfavourable interactions with health and social service providers can result in delays in seeking care and, subsequently add more complexity in health issues. In Newfoundland & Labrador, mainstream/universal services do not necessarily have the staff, training/knowledge, and budgets for tailored/targeted programming towards the particular health and wellness issues facing LBGTIQ2S* people. There are limited funds available in my province to engage in provider and policy maker training/education to make these mainstream/universal services and their programs tailored/targeted to LBGTIQ2S* populations (Government of NL, 2017). Physicians; nurses; community and school-based psychologists; teachers; counsellors; and, social workers, are some of the health professions that encompass primary health care and social services providers who work with LBGTIQ2S* populations, but who are often untrained to do so. It remains, that without a trained and knowledgeable health and social provider workforce, LBGTIQ2S* people will continue to interact with a healthcare system that is unable to provide adequate care. For example, nursing education rubrics are lacking (Shortall, 2019). On top of primary health care tertiary curricular reform, there needs to be a particular focus on practical training for Allied Health Practitioners currently in the workforce; review of electronic medical records; standardization of health and wellness documentation; adequacy of insured services; and a variety of activities undertaken within the rubric of institutional policy (and procedure audits) using queer lens analysis frameworks. Initiatives designed to reform professional education need to be designed and delivered in collaboration with LBGTIQ2S* content experts. The capacity exists to do this work in Newfoundland & Labrador, however without adequate funding we cannot measure the economic and social benefits of supporting the health and wellness of LBGTIQ2S* people in rural and remote areas (Banks, 2001; Banks, 2003; Thurlow, 2018). For myself, as a graduate of Applied Health Services Research, I investigated Canadian English Baccalaureate Nursing curricula -and related curricular policy- for LBGTIQ2S* inclusion (Shortall, 2017). I subsequently received a small CIHR IGH Community Support Grant to work with nurses in Ontario to develop a national online educational module to help educate and inform midcareer nurses about heterosexism and cisgenderism (Pendergast, 2018). We are not adequately training our health care workforce to be responsive to the health and wellness needs of the sexually and gender diverse (Shortall, 2017). As one of the nursing online educational module CIHR grant holders I am a content expert, however I cannot draw a salary or stipend from my work on the project, and the project funding is short term and has no built in sustainability, in spite of its readiness for commercialization. At some point it was recognized that more Applied Health Services and Policy Researchers were needed in the Canadian context with specialty knowledge and the ability to work towards upstream population health goals, which is what I am doing. However, I am unable to secure employment in this field in my province. The work I am doing is volunteer, including writing this submission. Capacity for creating and administering population health/public health research initiatives are limited to those that have the specialized knowledge, skills, and abilities to develop, implement, and evaluate these particular healthcare interventions (Colpitts & Gahagan, 2016). In Ontario, the provincially mandated Re:Searching for LBGTIQ2S* health (Ross, 2019), is a research group at the UofT School of Public Health, and ​ while another metropolitan centre, provides much capacity needed for that province. There needs to be support for this capacity across Canada, and possibly consider it to be community based with solid connections to universities.

Recommendation 4: Unify Data Collection, Promote Data Sharing and Dissemination, ​ Invest in Unique & Creative Initiatives

Canada is in a good position to take intentional steps to be a global leader in LBGTIQ2S* health and wellness, as much of the current research is from the USA and beyond. The Pan-Canadian Health Inequities Data Tool (PHAC, et al. 2017) needs to be updated to reflect intersectionality including LBGTIQ2S* and other populations. Unfortunately, the Stats Canada document Difficulty Accessing Health Care Services in Canada ​ ​ (2016) does not include data on LBGTIQ2S* people, who face many barriers to accessing equitable health care services. It would be beneficial to have provincial and federal demographic and statistical information accurately and specifically report on sex, and the sexually and gender diverse populations (LBGTIQ2S*), and outside of a simplistic framework on sexual health/STBBIs/HIV/AIDS (Richters et al. 2008). While increasing population-level data is useful, it must be worded appropriately to capture the variety of sexual activities, physical and emotional attraction, as well as sex assigned at birth, gender expression, and gender identity (Shortall 2017, Appendix A). There is no population-level data that addresses sexuality/sexual orientation and or gender identity/gender expression available for Newfoundland & Labrador, and I can only hazard that there are many other regional jurisdictions outside of metropolitan areas that are in the same situation (personal communication, NLCHI). Qualitative research produces rich, reliable data that enhances quantitative data, if conducted correctly. While Stats Canada work is underway nationally in the area of safety (Stats Canada, 2018), there are interesting knowledge mobilization/knowledge translation opportunities to synthesize existing research. Consolidating data from funded SSHRC, PHAC & CIHR projects, in conjunction with the various community surveys and university student projects around the country could be beneficial. The funding bodies (SSHRC, ​ CIHR and PHAC) could be positioned to champion analytics of the impact and progress of these innovative public/population health interventions. Furthermore, partnerships in research and intervention initiatives are often contingent on peoples/organizations ability to add them to their current workload or rely heavily on volunteers/personal passions, and ultimately are directed towards priority areas based on funding pockets. Particular issues are therefore addressed/studied more avidly and completely, while others are completely neglected based on funding directives. Take for example, CIHR Foundation Grant which favoured biomedical work, or my local group of LBGTIQ2S* health advocates who have recently requested the Newfoundland & Labrador Aging Research Centre to complete a provincial Survey, Needs Assessment and Environmental Scan pertaining to the health and community services of LBGTIQ2S* older adults. If the Aging Research Centre can find an interested and qualified researcher to undertake the work, it will provide baseline information, however there is no guarantee that the Aging Research Centre will be able to conduct the research requested by the community. To reiterate, my recently denied PHAC proposal to implement and evaluate a collection of innovative, equitable, and culturally safe population health interventions to promote mental health through the development of individual protective factors among young LBGTIQ2S* people. Included upstream interventions to address the policy environment, mainstream/universal service provision, and knowledge brokering regarding the health and wellness of LBGTIQ2S* people in Newfoundland & Labrador. Without that funding there is a missed opportunity. It was denied because it appeared that it was not supported by well-documented evidence that demonstrated the effectiveness and appropriateness of the proposed interventions. A circular argument that keeps us entrenched in status quo curative interventions. Without evidence of the efficacy of intervention, the intervention cannot be implemented, yet without implementing the intervention, the evidence cannot be collected. We need to break the cycle and invest in locally incepted, community based health population/public research interventions for and about LBGTIQ2S* individuals that focus on the holistic health and wellness issues they face, as well as, provide services for these at risk and vulnerable populations, in an effort to improve the health and wellbeing of all Canadians, in the face of heterosexism and cisgenderism.

About the Author: Chris Shortall, St. John’s, Newfoundland & Labrador ​ ​

I am a queer-identified, cisgender male of white-settler, upper-middle-class background. I acknowledge my privilege and pledge to work towards achieving improved health and equity for diverse (vulnerable) people. B.Sc.H (Psychology/Sociology) Acadia. M.Sc. (Medicine) Applied Health Services Research, MUN. ​ ​ ​ Membership Affiliations: Canadian Association for Health Services and Policy Research (CAHSPR) ​ Canadian Public Health Association (CPHA) CIHR IGH Recipient: Hacking the Knowledge Gap:Trainee Award for Innovative Thinking to Support ​ LGBTQI2S* Health and Wellness : Queering Nursing Education. ​ ​ * CIHR funded visiting researcher, NL Centre for Applied Health Research, MUN. ​ ​ BoD Member -Quadrangle LBGTIQ2S* Community Centre ​ *Quadrangle only exists on paper - no funding available Executive Director, Rainbow Health Consulting Ltd. ​

References / Works Cited

Atkinson, E., & DePalma, R. (2008). Imagining the homonormative: Performative subversion in education for social justice. British Journal of Sociology of Education, 29(1), 25-35. ​ ​ ​ ​

Banks, C. (2001). The Cost of Homophobia: Literature Review on the Economic Impact of Homophobia on ​ Canada. Saskatoon, SK: Gay and Lesbian Health Services. ​

Banks, C. (2003). The Cost of Homophobia: Literature Review on the Human Impact of Homophobia In Canada. ​ ​ Saskatoon, SK: Gay and Lesbian Health Services. Retrieved from: https://cuisr.usask.ca/documents/publications/2000-2004/The%20Cost%20of%20Homophobia%20Literat ure%20Review%20on%20the%20Human%20Impact%20of%20Homophobia%20On%20Canada.pdf

Bowen, S. (no year). A Guide to Evaluation in Health Research. Ottawa, ON: Canadian Institutes of Health ​ ​ Research. Retrieved from: http://www.cihr-irsc.gc.ca/e/documents/kt_lm_guide_evhr-en.pdf ​

Brotman, S., Ryan, B., Collins, S., Chamberland, L., Cormier, R., Julien, D., Meyer, E., Peterkin, A., & Richard, B. (2007). Coming out to care: Caregivers of gay and lesbian seniors in Canada. The Gerontologist, 47(4), ​ ​ ​ ​ 490-503.

Browne, A. (2009). Issues Affecting Access to Health Services in Northern, Rural and Remote Regions of Canada. ​ ​ Prince George, BC: School of Northern Studies. Retrieved from: http://www.unbc.ca/assets/northernstudies/northern/issues_affecting_access_to_heal th_services_in_northern.pdf

Canadian Association of Schools of Nursing. (2018). National Research Priorities for Nursing. Ottawa, ON: ​ ​ Author. Retrieved from: https://www.casn.ca/wp-content/uploads/2018/12/Research-Priorities-2018-EN.pdf

Canadian Nursing Students’ Association [CNSA]. (2017). Resolution Statement: Incorporating ​ LBGTTIIPQQ2SAA+ Education into Nursing Curriculum in Canada. Ottawa, ON: Author. Retrieved ​ from http://cnsa.ca/wp-content/uploads/2017/02/IncorporatingLGBTTIIPQQ2SAA-Education-into-Nursing-Cu rriculum-in-Canada.pdf

Canadian Rainbow Health Coalition (2006). Rainbow Health Improving Access to Care. Ottawa, ON: Health ​ ​ Canada Primary Health Care Transition Fund. Retrieved from: http://www.apps.hc-sc.gc.ca/hcs-sss/phctf-fassp.nsf/WebProject/0025?OpenDocument&lang=eng&

CBC Ideas. (March, 15, 2019). Lonely Together: The plight of urban isolation. CBC. Retrieved from: ​ ​ https://www.cbc.ca/radio/ideas/lonely-together-the-plight-of-urban-isolation-1.5057995

CIHI. (2018). In Pursuit of Health Equity: Defining Stratifiers for Measuring Health Inequality — A Focus on ​ Age, Sex, Gender, Income, Education and Geographic LocationI. Ottawa, ON: Canadian Institut for ​ Health Information. Retrieved from: https://www.cihi.ca/sites/default/files/document/defining-stratifiers-measuring-health-inequalities-2018-e n-web.pdf

The College of Family Physicians of Canada (August, 2018). Investing in Rural Health Care: An Economic ​ Stimulus for Canada: 2019 Pre-Budget Submission to House of Commons Standing Committee on Finance. Mississauga, ON: Author. Retrieved from: ​ https://www.ourcommons.ca/Content/Committee/421/FINA/Brief/BR10006555/br-external/CollegeOfFa milyPhysiciansOfCanada-e.pdf

Clarke, B. (2018). Addressing Cisgender Bias in Health Care to Improve Services for Transgender ​ Youth.Vancouver, BC: UBC. Retrieved from: https://www.grad.ubc.ca/psi/blog/18/beth-clark ​ ​

Colpitts, E., & Gahagan, J. (2016). ‘I feel like I am surviving the health care system’: Understanding LGBTQ health in Nova Scotia, Canada. BMC Public Health, 16, 1005. https://doi.org/10.1186/s12889-016-3675-8 ​ ​ ​

Community Health Nurses of Canada. (March, 2019) LGBTQ2 Health in Canada Study Brief for the Standing ​ Committee on Health. Midland, ON: Author. Retrieved from: ​ http://www.ourcommons.ca/Content/Committee/421/HESA/Brief/BR10397544/br-external/CommunityH ealthNursesOfCanada-e.pdf

Dean, L., Meyer, I., Robinson, K., Sell, R., Sember, R., Silenzio, V., Bowen, D., Bradford, J., Rothblum, E., White, J., Dunn, P., Lawrence, A., Wolfe, D., & Xavier, J. (2000). Lesbian, gay, bisexual, and transgender health: findings and concerns. Journal of the Gay and Lesbian Medical Association, 4(3), ​ ​ ​ ​ 102-151. https://doi.org/10.1023/A:1009573800168 ​

Global Affairs Canada. (2017). The Human Rights of LBGTI persons. Ottawa, ON: Author. Retrieved from: ​ ​ https://international.gc.ca/world-monde/issues_development-enjeux_developpement/human_rights-droits _homme/rights_lgbti-droits_lgbti.aspx?lang=eng; ​ https://www.canada.ca/en/privy-council/campaigns/free-to-be-me.html

Government of Newfoundland and Labrador (2019). Women's Policy Office. St. John's, NL: Author. Retrieved ​ ​ from: https://www.exec.gov.nl.ca/exec/wpo/genderbased/index.html ​

Government of Newfoundland and Labrador (2017). Towards Recovery: The Mental Health and Addictions ​ Action Plan for Newfoundland and Labrador. St. John’s, NL: Author. Retrieved from: ​ https://www.health.gov.nl.ca/health/mentalhealth/towards_recovery_action_plan_and_updates.html

Grabish, A. (April 1, 2019). Human rights hearing told sex should be scrapped entirely from birth certificates. ​ ​ Winnipeg, Manitoba: CBC. Retrieved from: https://www.cbc.ca/news/canada/manitoba/gender-neutral-birth-certificate-hearing-1.5080481

Gray, P., Kramer, M., Minick, P., McGehee, L., Thomas, D., & Greiner, D. (1996). Heterosexism in nursing education. Journal of Nursing Education, 35(5), 204-210. ​ ​ ​ ​

Harbin, A., Beagan, B., & Goldberg, L. (2012). Discomfort, judgement, and healthcare for queers. Bioethical ​ Inquiry, 9, 149-160. https://doi.org/10.1007/s11673-012-9367-x ​ ​ ​ ​

Hawe, P.; Samis, S.; Di Ruggiero, E.; & Shoveller, JA. (2011) Population Health Intervention Research Initiative for Canada: progress and prospects. NSW Public Health Bulletin, 22(1-2), 27-32. ​ ​ https://doi.org/10.1071/NB10072

Hellquist, G., Rochon, C., McConnell, S. M., Banks, P., Lanouette, D., and Zoccole, A. versus Health Canada and the Public Health Agency of Canada (2009). Human Rights Complaint Against the Government of ​ Canada. ​

Kitzinger, C. (2005). Heteronormativity in action: Reproducing the heterosexual nuclear family in after-hours medical calls. Social Problems, 52(4), 477-498. ​ ​ ​ ​

Mathieson, C., Bailey, N., & Gurevich, M. (2002). Health care services for lesbian and bisexual women: Some Canadian data. Health Care for Women International, 23, 185-196. ​ ​ ​ ​

Mulè, N. Ross, L., Deeprose, B., Jackson, B., Daley, A., Travers, A., & Moore, D. (2009). Promoting LBGT health and wellness through inclusive policy development. International Journal for Equity in Health, ​ ​ 8(18). https//doi.org/10.1186/1475-9276-8-18 ​ ​

Mulé, N. (2015). Much to be desired: LGBT health Inequalities and inequities in Canada. In J. Fish and K. Karban (Eds.), Lesbian, Gay, Bisexual and Trans Health Inequalities: International Perspectives in ​ Social Work (pp. 27 – 43). Bristol: Policy Press. [Peer Reviewed] ​

National Collaborating Centre for Determinants of Health. (2014). Let’s Talk: Moving Upstream. Antigonish, NS: ​ ​ Author, St. Francis Xavier University.

Newfoundland and Labrador Centre for Health Information (2019, April, 16). Aggregate Level Information Request on Sexual Orientation, Sexuality, Gender Identity, Gender Expression. Personal Email Communication.

OutSaskatoon (2019) Recommendations to the Standing Committee on Health: LBGTQ2 Health in Canada. ​ ​ Saskatoon, SK: Author. Retrieved from: http://www.ourcommons.ca/Content/Committee/421/HESA/Brief/BR10380322/br-external/OUTSaskatoo n-revised-e.pdf

Pendergast, L. (2018) Chris Shortall: A Q&A about LGBTQI2S health and wellness St. John’s, NL: The Gazette. ​ ​ Retrieved from: https://gazette.mun.ca/campus-and-community/alumni-spotlight/ ​

PHAC, the Pan-Canadian Public Health Network, Stats Canada, and CIHI (2017). Pan-Canadian Health ​ Inequalities Data Tool. Ottawa, ON: Author. Retrieved From: https://infoba ​ ​ se.phac-aspc.gc.ca/health-inequalities/

Power, LA. & Barry, G. (December 5, 2018). Anti-gay bullying at Botwood school like a civil war. St. John’s, ​ ​ NL: CBC. Retrieved from: https://www.cbc.ca/news/canada/newfoundland-labrador/botwood-gsa-students-bullying-1.4931992

Richters, J., de Visser, R., Rissel, C., Grulich, A., & Smith, A.M.A. (2008). Demographic and psychosocial features of participants in bondage and discipline, ‘sadomasochism’ or dominance and submission (BDSM): Data from a national survey. Journal of Sexual Medicine, 5(7), 1660-1668. ​ ​ https://doi.org/10.1111/j.1743-6109.2008.00795.x

Robinson, M. (2014-2017). Two-Spirited Roundtable Discussion Series. Retrieved from: http://lgbtqhealth.ca/projects/two-spiritedroundtablediscussionseries.php

Ross, L. (2019). Re:searching for LGBTQ2S+ Health. Ontario Retrieved from http://lgbtqhealth.ca/ ​ ​ ​

Shortall, C. (2017). Queering Baccalaureate Nursing Education in Canada: A Survey and Qualitative Content ​ Analysis of Curriculum and Policy Documents (Master’s thesis, Memorial University of Newfoundland, ​ St. John’s, NL). Retrieved from: http://research.library.mun.ca/id/eprint/12885

Shortall, C. (2019) Teaching and Evaluation/Assessment Requirements for LGBTQI2S+ Health and Wellness: A Call to Include LGBTQI2S+ Content in Canadian English Baccalaureate Nursing Curricula / Exigences en matière d’enseignement et d’évaluation pour la santé et le bien-être des personnes LGBTQI2S+: un appel pour inclure du contenu dans les programmes de baccalauréat en sciences infirmières de langue anglaise au Canada. Quality Advancement in Nursing Education - Avancées en formation infirmière,5(1), ​ ​ ​ ​ Article 7. https://doi.org/10.17483/2368-6669.1169 ​

Stats Canada (2016). Difficulty accessing health care services in Canada. Ottawa, ON: Author. Retrieved from: ​ ​ https://www150.statcan.gc.ca/n1/pub/82-624-x/2016001/article/14683-eng.htm

Stats Canada (2017). From east to west: 140 years of interprovincial migration. Ottawa, ON: Author. Retrieved ​ ​ from: https://www150.statcan.gc.ca/n1/pub/11-630-x/11-630-x2017002-eng.htm ​

Stats Canada (2018). Survey of safety in public and private spaces. Ottawa, ON: Author. ​ ​ https://www.statcan.gc.ca/eng/survey/household/5256

Stroh, P. (January, 19, 2019). Feeling lonely? You're not alone — and it could be affecting your physical health. ​ ​ CBC. Retrieved from: https://www.cbc.ca/news/health/national-dealing-with-loneliness-1.4828017 ​

Sullivan, N (2007). A critical introduction to queer theory. New York, New York: New York University Press. ​ ​

Sweet, B. (February 12, 2019). Newfoundland and Labrador government was blasted for allowing same-sex ​ marriage. St. John’s, NL: Telegram Newspaper. Retrieved from: ​ https://www.thetelegram.com/news/local/newfoundland-and-labrador-government-was-blasted-for-allowi ng-same-sex-marriage-283936/

Thurlow, C. (2018). The Economic Cost of Homophobia. London, England: Peter Tatchell Foundation. Retrieved from: https://www.petertatchellfoundation.org/wp-content/uploads/2018/06/report-a4-lo-res-1.pdf ​

Wilchins, R. (2004). Queer theory, gender theory: An instant primer. California: Alyson Publications. ​ ​