A critical exploration of stigma interventions and programs for queer peoples across the life course in Canada: a scoping review protocol

TL;DR

This paper outlines a scoping review protocol to explore stigma interventions for queer people in Canada across their lifespan.

Contribution

The study introduces a critical, intersectional approach to examining queer stigma interventions across the life course in Canada.

Findings

The review will use intersectional queer theory and socioecological models to analyze stigma interventions.

Findings will inform future research and practical resources for queer communities in Canada.

The protocol includes rigorous methods to identify gaps and strengths in current stigma reduction programs.

Abstract

Queer populations (sexual and gender diverse people, including two-spirit, lesbian, gay, bisexual, trans, and queer) in Canada face significant health disparities, largely driven by stigma related to sexual and gender identities. These inequities are associated with adverse health outcomes. Although a growing body of literature examines stigma reduction, interventions often focus on specific types of queer stigma rather than considering the broader, intersectional experiences of queer people. This scoping review aims to critically explore the current state of queer stigma across the life course in Canada, with an emphasis on understanding their impact, successes, and gaps.

This review will include studies that address interventions aimed at reducing queer-related stigma in Canada. Eligible studies must focus on queer populations and measure outcomes related to stigma reduction. Studies of any design (qualitative, quantitative, mixed methods), published in English or French, and from any year will be considered. A systematic search will be conducted across multiple databases, including Medline-R (Ovid), Embase (Ovid), APA PsycInfo (Ovid), CINAHL (EBSCO), Social Services Abstracts (ProQuest), Social Science Abstracts (ProQuest), and Social Science Citation Index (Web of Science), along with grey literature sources. Two reviewers will independently assess potential articles against the inclusion criteria through two stages: titles and abstracts as well as full-text screening. Data extraction will focus on study characteristics, intervention details, and outcomes related to stigma reduction. Findings will be reported in tables and narrative summaries, guided by the socioecological model and intersectional queer theories. Data will be analyzed to identify trends and gaps in current interventions aimed at addressing queer stigma.

Using an intersectional queer approach and the socioecological model, this review will identify gaps and strengths in queer stigma programming and interventions across the life course. The broad inclusion criteria and a rigorous approach will account for academic and grey literature, highlighting ongoing treatments, measurement tools, and resources. This extensive data collection will inform future research on queer peoples’ resource and programming needs in Canada. Findings will contribute to workshops development, training modules, and community reports for healthcare providers and community organizations serving queer communities.

https://doi.org/10.6084/m9.figshare.28523621.v1.

Full text

Introduction

The alarming health inequities experienced by two-spirit, lesbian, gay, bisexual, trans, and queer (2S/LGBTQ+; herein queer) people are a significant human rights and public health issue. Queer peoples in Canada experience higher rates of mental health issues, psychological distress, substance abuse, suicidality, physical and sexual abuse, and sexually transmitted infections compared to cisgender and heterosexual counterparts [1–8]. It is generally understood that these health disparities are both the direct and indirect result of stigma associated with queer identities [9]. For example, a recent report by the Standing Committee on Health commissioned by the Canadian House of Commons notes that the health inequities experienced by queer peoples is in part due to the stigmatizations of minoritized gender and sexual identities in Canadian society and the subsequent discrimination they experienced [7]. In an effort to promote the wellbeing of queer peoples, queer health practitioners, scholars, and institutions are increasingly calling for the design, implementation, and assessment of interventions that address stigma experienced by queer peoples [7, 10, 11].

A stigmatized identity is a discrediting attribute or a marker of inferiority that is socially constructed and driven through various social processes by advantaged social groups. As Parker and Aggleton argue: “Stigma plays a key role in producing and reproducing relations of power and control. It causes some groups to be devalued and others to feel that they are superior in some way” (p.16) [12]. Stigma processes comprise stereotypes, or negative connotations about a marginalized group, which lead to prejudice and discrimination [13, 14]. These processes are multifaceted, with various mechanisms that operate intrapersonally (e.g., perceived or internalized stigma), interpersonally (e.g., enacted stigma), and structurally (e.g., institutional policies) [15–17]. Herek uses the terms sexual stigma and gender stigma to refer to all facets of stigma associated with sexual identity and gender identity, respectively [9]. Recognizing that the experiences of queer peoples are diverse, different, and overlapping, the proposed review employs the term queer stigma to refer generally to all stigma directed at queer populations, including sexual and gender stigma.

Stigma towards queer individuals in Canada has deep historical roots, stemming from colonial-era impositions of heteronormative and cisnormative values. British colonial laws criminalized homosexuality until 1969, and this legal framework has entrenched negative societal attitudes that persist today [18]. Authors have argued that the decriminalization of homosexuality in Canada is a myth, and has rather been reintroduced through other polices, including indecency laws which today are still used to criminalize queer peoples [18, 19]. Although systemic barriers and queer stigma persists, Canada has made significant policy advances to promote the inclusion and rights of queer peoples, including the “decriminalization” of homosexuality, introducing anti-discrimination protections, [20] and legalizing same-sex marriage in 2005 [21]. There is an urgent need to understand stigma-mitigating efforts in Canada to address systemic issues and promote the wellbeing of queer peoples across the life course.

Defining stigma

Scholars have highlighted the inconsistent and varied definitions of stigma across studies and disciplines [22, 23]. Many researchers provide no explicit definition, relying instead on dictionary definitions or related concepts like stereotyping or rejection. When explicit definitions are provided, they often vary considerably [22].

The socioecological model has been widely used in stigma research as an organizing framework [24, 25]. This model accounts for how stigma manifests at different levels that impact behaviour, from the individual to the structural, and can be a useful framework to study queer stigma and design interventions to overcome it. Scholars have also underscored the intersectional nature of stigma, including how its effects are compounded for individuals with multiple stigmatized identities across the life course [26–30]. While there is a growing body of literature exploring stigma interventions for queer peoples, few studies have explored queer stigma dimensions broadly [30]. Instead, existing research on interventions has focused on specific types of queer stigma, such as sexual minority stigma, [31] stigma against queer youth, [10] and HIV stigma [29]. Stigmatized identities seldom operate alone, yet interventions for stigma have often been studied in isolation [13, 29].

For the purpose of the following scoping review, stigma refers to socially constructed negative beliefs, stereotypes, and discriminatory actions directed at queer identities, resulting in marginalization and devaluation by dominant social groups. It operates at multiple levels—individual, interpersonal, and structural—and encompasses the overlapping impacts of sexual and gender stigmas, which intersect with other stigmatized identities across the life course. This definition was developed from a review of the literature and through discussions with stigma experts on the research team. The subsequent research approach, search strategy, and methodology will continue to use this definition to guide the development, completion, and reporting of this scoping review.

Research team social location and theoretical position

Link and Phelan [22] argue that social scientists studying stigma, despite not belonging to stigmatized groups themselves, approach their research through theoretical frameworks that lack insight from the lived experiences of the populations they examine. To this end, the research team completing the proposed scoping review comprise queer scholars (with multiple intersecting identities, including non-binary and trans persons, women, and people of color), stigma experts, queer health experts, methods (qualitative, quantitative, and mixed methods) experts, implementation science and public health interventions experts, search experts, and systematic and scoping review experts. Further, this research is being conducted in collaboration with the 2S/LGBTQ+ Health Hub. The Hub is a national platform for training, mentorship, networking, and capacity-building for diverse early career researchers, trainees, healthcare professionals and service providers, and government and community-based stakeholders. The Hub aims to tackle a major training and capacity gap in intersectional and community-informed queer health and community interventions, including stigma reduction programs and health promoting interventions with and for diverse queer communities.

Our proposed study adopts a transformative paradigm, which is an activist-oriented perspective offering a framework for addressing social justice. We examine power, privilege, voice, and cultural complexity throughout the research process [32]. The axiological assumptions are respect for communities, beneficence to promote human rights and social justice, and explicit connection of research outcomes to improve social justice. A strong understanding of the community’s history and a close relationship, or integration within the community, are essential. This paradigm aligns with the review’s objectives to interrogate injustices faced by queer peoples and promote well-being through a queer-oriented approach.

Both queer theory and intersectionality theory are critical theories that align with a transformative paradigm and have been widely used in health research to promote the wellbeing of marginalized populations [33, 34]. Queer theory is an anti-normative approach that critiques essentialist definitions of identities as well as understandings of categories and concepts [35]. Intersectionality theory is a framework that aims to understand how multiple systems of oppression intersect and interact to affect individuals and groups [33, 36, 37]. Queer theories and intersectionality have been used together in health research offering insights into the ways that health outcomes are related to complex interactions between structures of power and oppression as well as interconnected aspects of identity and social location [38, 39]. An intersectional queer approach will elucidate how queer stigma manifest as a product of a normative visions of the world that other peoples across multiple axes of identity. This focus allows for richer understandings of inequity in our social world, while illuminating experiences of stigma across the life course as products of complex systems of power, penalty, and privilege. This theoretical approach has and will inform all aspects of the research process, including conceptualization, analysis, extraction, interpretation, and reporting.

Research question

Our search of the extant literature revealed a paucity of reviews exploring queer stigma interventions across the life course, and notably, no studies have focused on a Canadian context. Several reviews have explored approaches to mitigating stigma and its health impacts among sexual and gender minorities. For example, Huang et al. examined intersectionality theory integration into mental health interventions for sexual minorities, highlighting a gap in addressing intersecting forms of stigma [40]. Many interventions focus on sexuality-based stigma without considering other layers like race or gender. Layland et al. reviewed psychological and behavioural health interventions, noting that while many target internalized and anticipated stigma, there is a lack of intersectionality [30]. Stangl et al. focused on reducing intersectional stigma in HIV, emphasizing the complexity of addressing multiple intersecting stigmas [41]. While interventions improved health outcomes, reducing stigma was less successful. Fowler et al. reviewed digital mental health interventions for LGBTQIA+ individuals, emphasizing community engagement in content design [42]. Digital interventions hold promise, but more targeted approaches are needed to address specific mental health challenges within the LGBTQIA+ community. These reviews underscore the importance of intersectional frameworks and addressing stigma at multiple levels to enhance health interventions for queer people. There is, however, an urgent need to explore the successes, failures, and gaps of stigma interventions and programming in Canada through an intersectional lens. Using an interdisciplinary approach within a transformative paradigm and guided by the socioecological model as an organizing framework, the proposed scoping review will aim to critically answer the question: what is the current state of queer stigma interventions across Canada? The objectives are to:

1. Map the current state of the literature describing interventions and programs seeking to reduce stigma across the life course for queer peoples across Canada.
2. Understand the successes and failures of interventions and programs seeking to reduce stigma across the life course for queer people.

Methods

This review will follow the scoping review framework by Arksey and O’Malley and further developed by the JBI institute [43, 44]. The findings will be reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) and PRISMA for Searching (PRISMA-S) [45, 46]. The following protocol and completed scoping review will be reported according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocol (PRISMA-P); see Appendix 1 I [47]. The review has been registered on FigShare (https://doi.org/10.6084/m9.figshare.28523621.v1).

Inclusion criteria

The modified PICOS will be used to guide inclusion criteria and data extraction, to accommodate qualitative and mixed methods research [48]. In a scoping review, where the goal is to map evidence broadly, PICOS elements guide inclusion criteria without necessarily limiting studies to a single type of intervention or outcome measure. This flexibility allows for a more comprehensive exploration of how stigma reduction efforts are tailored and evaluated across various populations and life stages.

Population

Studies must focus on queer individuals at any life stage who have experienced some form of queer related stigma. The research team will highlight intersectional queer experiences, including multiple social locations, related to stigma interventions and stigma reduction.

Intervention

We will include studies that describe interventions or programs targeting the reduction of queer-related stigma. (i.e., stigmas experienced by queer peoples). These interventions, which must seek to reduce stigma, may include educational programs, media campaigns, social support initiatives, policy interventions, community-based programs, or therapeutic approaches, and digital interventions. The socioecological model will organize findings according to whether interventions directly target individuals, communities, or broader societal levels.

Comparison

Scoping reviews often do not require a strict comparator. However, if comparisons are made within studies, they may include no intervention control groups, standard care of alternative interventions aimed at stigma reduction, or different approaches/delivery methods for reducing stigma.

Outcome

Studies should measure at least one outcome related to stigma reduction. Primary outcomes may include reductions in a form of queer-related stigma (e.g., internalized, anticipated, enacted). Secondary outcomes might involve improvements in strength-based factors, mental health, social support, knowledge, attitudes, and overall well-being.

Study design

There will be no restrictions based on study design, as this scoping review aims to map the breadth of literature on queer stigma interventions across the life course. All relevant empirical studies (qualitative, quantitative, or mixed methods) and grey literature that provide evidence about queer stigma interventions and their impact will be included. Conceptual or theoretical papers will also be considered if they contribute to understanding the interventions' theoretical underpinnings. Reviews and editorials are excluded.

Geographic location

Only studies conducted in Canada, or those where Canadian data can be extracted, will be included.

Language

Only publications in English or French will be included.

Search Strategy

Two members of the research team who are social science librarians (JL, JC) have designed the database search strategy in consultation with the rest of the team. The search comprises three components: stigma, queer identities, and Canada. Interventions will be identified through the screening process. A primary search was designed in Medline-R (Ovid) using both textwords and subject headings drawing on published search filters [49–51]. This search has been shared with a librarian colleague external to the team to peer review using the PRESS framework [52]. Once revisions are made, the search will be translated to the remaining databases: Embase (Ovid), APA PsycInfo (Ovid), CINAHL (EBSCO), Social Services Abstracts (ProQuest), Social Science Abstracts (ProQuest), and Social Science Citation Index (Web of Science). All databases will be searched from inception with no limits or additional filters. Search results will be downloaded on a single day and uploaded to Rayyan.AI for deduplication. The primary Medline search strategy is available in Appendix II. Supplementary search strategies will include citation searching, grey literature searching, and a journal hand search.

Study selection

The study selection process will be performed in two stages in Rayyan.AI, which is an AI-powered systematic review software designed to assist researchers in screening and selecting studies for inclusion in systematic reviews and scoping reviews [53]. The software uses active learning, which means it continuously learns from reviewer decisions and improves its accuracy in suggesting relevant studies. This tool helps to reduce the time and effort required for manual screening while maintaining high levels of reliability. Rayyan.AI will not be used to screen on behalf of the research team, instead, the advanced filtering and highlighting feature will be used to streamline the screening process. Following a pilot test, titles and abstract screening will be independently conducted by two members of the research team (JS and another reviewer) [53]. This will be followed by a full-text review by the same reviewers. Any conflicts at either stage will be resolved through discussion or by a third reviewer (DG). The final decision for inclusion will be based on the abovementioned criteria.

Data extraction

All selected studies will be documents and key characteristics will be recorded. Data extraction will be completed in Elicit.AI by one reviewer (JS) and peer reviewed by another team member [54]. Elicit.AI, an AI-powered tool, supports researchers in systematic and scoping reviews, particularly with data extraction and synthesis. The program automates and streamlines data extraction, collecting information such as intervention types, outcomes, and study design, from studies. It analyzes large volumes of studies and organizes extracted data into structured tables for further analysis and synthesis. This significantly reduces manual data extraction time, especially in large reviews. Elicit.AI learns from researcher inputs, improving its extraction capabilities over time. Researchers can train the AI by manually labeling data points, and it will automatically extract similar information from other studies. Additionally, Elicit.AI generates tables summarizing extracted data, making it easier to visualize and compare key study characteristics. This feature aids in organizing and presenting data for meta-analysis or narrative synthesis, enhancing the review process’s efficiency. All data extracted by Elicit.AI will be independently confirmed and reviewed by at least one member of the research team. The data extracted will include study characteristics (author, year, etc.), population (location, sample, demographic characteristics, etc.), intervention characteristics (type, effectiveness, etc.), outcomes measured (including measurement tools), socioecological level, theoretical underpinnings of intervention, and key findings related to the review objective. A draft data extraction tool is provided (Appendix III), which may be modified during data extraction as needed. Details of changes will be documented in the final publication. If needed, authors of articles will be contacted for missing or additional data.

Data analysis and presentation

Articles will not be assessed for quality as is normal for scoping reviews. Extracted data will be analyzed and synthesized to align with the objectives of the scoping review. We will present the findings in two tables. Table 1 will describe key study characteristics (e.g., author, year of publication, geographic location within Canada, and study design). Table 2 will categorize studies based on primary outcome measures related to queer stigma reduction, organized according to the socioecological model, and will describe secondary outcomes such as community support, mental health, and well-being. We will also describe the type of intervention (e.g., community-based, policy-oriented, educational) and any intersectional considerations (e.g., gender identity, age, race, sexual orientation). A narrative summary will be provided alongside the tabulated results to explain how the findings contribute to the review's objectives and address the research questions. The structure for presenting the results may be refined as the review progresses. Where possible, a visual representation (i.e., “mapping”) of the data will accompany findings. This may include showing distribution of interventions and studies across Canada, across socio-ecological levels, and/or social locations. Throughout the scoping review process, the research team will leverage the varying expertise of the scholars associated with this project to inform the direction and outcomes of the research.

Discussion

To improve resources, supports, and interventions for queer people related to stigma and wellbeing, the landscape of current programming needs to be better elucidated. The proposed scoping review seeks to map the current state of stigma interventions for queer people across the life course in Canada. By using an intersectional queer approach and the socioecological model, this research will uncover gaps and strengths of current stigma interventions across Canada, aiming to identify key trends, effectiveness, and areas for improvement. The broad inclusion criteria and rigorous approach will allow us to account for current and past interventions documented in the academic and grey literature, highlighting successful existing treatments, measurement tools, and resources at specific socioecological levels and for particular stigmas. This extensive data collection will further inform future research studies seeking to understand the resource and programming needs of queer peoples in Canada. While there will not be any patient and public involvement in the completion of this scoping review, findings will be disseminated to trainees, community members, and researchers within the 2S/LGBTQ+ Health Hub; the findings will further contribute to the development of workshops, training modules, and community reports to be made available to health care providers and community organization staff serving queer communities.

Limitations

For pragmatic reasons, this scoping review has been conceptualized as a review of stigma interventions for queer peoples. We have purposefully excluded search terms focusing on broader stigmas that may be overwhelmingly experienced by said population, such as HIV/AIDS stigma. Similarly, we have excluded search terms focusing on strength-based factors, including community connectedness and resilience. Studies that explore these topics will be included in the review provided they include queer populations and stigma interventions, but we recognize that this approach my omit relevant literature focusing on general populations or strength-based interventions.