The social, mental, physical and sexual health of diverse Two-Spirit, lesbian, gay, bisexual, transgender, queer and other sexual and gender minority (2S/LGBTQ+) populations across Canada and globally is under threat. In Canada, we are not immune to the rise in divisive and regressive policies and rhetoric that is negatively impacting the lives of 2S/LGBTQ+ people in the US and across the world (HRC Staff 2023; United Nations 2022). Make no mistake, the threats to the human rights and health of 2S/LGBTQ+ communities are growing in Canada as well (Benchetrit 2023). Health systems leaders and scholars can play a critical role in learning about, addressing and advocating for health equity for 2S/LGBTQ+ communities. This themed issue focuses on the urgency of addressing the social and structural determinants of health inequity for 2S/LGBTQ+ communities in a context of political volatility.

In this issue, Kia et al. (2024) provide a comprehensive and nuanced essay outlining a wide array of health equity concerns impacting the everyday lives of 2S/LGBTQ+ communities. These issues include the detrimental impacts of poverty for 2S/LGBTQ+ communities and the multi-level action needed to redress socio-economic precarity. The authors centre Two-Spirit mental health concerns within a history of ongoing colonialism and the urgent need for Indigenous self-governing healthcare systems. Structural racism is explored as a health determinant for migrant and racialized LGBTQ+ people, along with a call to action for partnership, program development and structural reform. Legislative bans on “conversion therapy” (Kia et al. 2024: 10) are discussed as a crucial 2S/LGBTQ+ health equity issue, including the need to support those who have survived “sexual orientation and gender identity and expression change efforts” (p.16). Finally, Kia et al. (2024) discuss the ideological discourses and regressive policies surrounding gender-affirming care and the dangers of Canadian complacency within the global context of anti-trans rhetoric and policy reform. These conservative policies include those that propose limiting access to trans healthcare for minors (Tasker 2023).

An array of thoughtful respondents – academic and community leaders in 2S/LGBTQ+ health – critically engage with this essay, each largely focusing on one (or more) of the five key issues outlined by Kia et al. (2024). The six responses further open up and complicate these issues within a historical and political context, often underscoring the intersectional forces that produce differential health outcomes for 2S/LGBTQ+ communities and the stigmas and oppressions that persist for many of those who live under the rainbow. Taken together, the message that emerges from this collection is clear: “Urgent action is needed to support the health of 2S/LGBTQ+ communities.” Advancing the health of 2S/LGBTQ+ peoples requires an unwavering commitment to equity-focused, anti-racist, anti-oppressive and intersectional action – with attention to sexual orientation, gender and gender expression, race and ethnicity, Indigeneity, language, disability, co-morbidities, socio-economic status, geography and immigration status. 2S/LGBTQ+ people are a heterogenous group, and no single policy or healthcare intervention will address the significant and differential health determinants impacting these diverse communities.

Acting on the structural determinants can seem daunting. And it is. What this collection proposes is a guide to consider the multiple and intersecting areas of policy action that are needed to help heterogenous 2S/LGBTQ+ communities thrive. It also offers hope – pointing to community-led actions that are happening across Canada to move the needle in advancing health equity. The areas of policy action discussed are numerous and include the need for a national 2S/LGBTQ+ housing strategy that addresses race and racism and intersectional social determinants of health (Friends of Ruby 2024). Indigenous-led initiatives that challenge colonial systems and directly work to advance the health of Two-Spirit and other Indigenous populations must be supported (2 Spirits in Motion Society 2022; Robinson 2022; Sylliboy 2022). Funding comprehensive services that support the health of LGBTQ+ migrants and racialized people is necessary (Udemnovelles 2024). Kia et al. (2024) also make explicit the importance of improving and sustaining gender-affirming healthcare in Canada amid a context of global volatility. This requires all health professions to clearly indicate their support for providing this care and to ensure that care processes and requirements are updated to reflect the WPATH SOC-8 [World Professional Association for Transgender Health Standards of Care Version 8] guidelines and help increase equitable access to services across Canada (Kia et al. 2023).

This collection makes clear the need for community-driven solutions. This requires health leaders to be responsive to, and supportive of, the bold and necessary policy actions proposed by 2S/LGBTQ+ communities themselves.

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