Community Organizations Stand Between Canada’s Sexual and Gender-Diverse Women and Care Inequity

Across Canada, a quiet but consequential gap in the healthcare system is being bridged not by hospitals or clinics, but by small community-based organizations staffed by people who often work without stable funding, formal training pipelines, or institutional recognition. New peer-reviewed research published in BMC Health Services Research examines how these organizations build and sustain the capacity to deliver health promotion services to sexual and gender-diverse women, a population that continues to face substantial barriers to culturally competent and affirming healthcare. The study, led by Erin Ziegler of the Daphne Cockwell School of Nursing at Toronto Metropolitan University together with Yemisi Onilude, Yamini Bhatt, and Anna R. Gagliardi, offers one of the most detailed portraits to date of what frontline community staff actually need to keep these lifelines running.

The significance of the research lies in the population it centers. Sexual and gender-diverse women in Canada, including those who identify as Two Spirit, lesbian, bisexual, queer, transgender, or otherwise outside cisgender and heterosexual norms, experience documented disparities in health outcomes. These disparities are driven in large part by barriers to accessing care that is both clinically appropriate and culturally affirming. When mainstream healthcare fails these patients, whether through discrimination, lack of provider knowledge, or inflexible service models, community organizations step into the void, delivering services that range from gender-affirming care navigation to mental health support and sexual and reproductive health education. Until now, the requirements for developing and supporting this health promotion capacity among community agencies have remained largely unexamined in the health services literature.

To fill that gap, the research team conducted a qualitative descriptive study built around virtual semi-structured interviews with ten community-based staff members drawn from six Canadian provinces. Participants were purposively recruited through 2SLGBTQ+ networks, social media, and community outreach, a strategy designed to capture the perspectives of those directly embedded in service delivery rather than institutional spokespersons. The cohort reflected the diversity of roles that sustain these organizations: five health promoters, two executive directors, one therapist, one nurse practitioner, and one program coordinator, working at various career stages. Data collection took place between August and October 2024 through Zoom interviews that were audio-recorded and transcribed verbatim.

The analytical approach was methodologically rigorous. The team used NVivo 15 software to support systematic coding of the transcripts and developed themes through an iterative, consensus-driven process consistent with inductive thematic analysis. The study followed the Standards for Reporting Qualitative Research, and ethical approval was granted by the Toronto Metropolitan University Research Ethics Board under reference 2023-472, with online electronic informed consent obtained from all participants prior to participation. This level of procedural transparency matters, because qualitative findings in a politically sensitive field are only as credible as the methods behind them, and this study anchors its conclusions in a clearly documented and reproducible analytic chain.

Three overarching themes emerged from the interviews. The first concerned participants’ experiences delivering care, and it revealed the breadth of services these organizations provide. Staff emphasized the importance of delivering essential health services that include gender-affirming care, mental health support, and sexual and reproductive health education, all framed within culturally and linguistically appropriate models. In practice, this means adapting materials and encounters to the identities, languages, and lived realities of the women they serve, rather than expecting patients to conform to standardized clinical scripts. The findings underscore that cultural and linguistic appropriateness is not an optional enhancement but a core precondition for these services to work at all.

The second theme mapped the structural architecture that makes such service delivery possible. Participants identified leadership development, inter-agency partnerships, and attention to the social determinants of health as crucial components of organizational capacity. In other words, community organizations do not operate as isolated islands of care. They depend on leaders who can shepherd teams through uncertainty, on formal and informal partnerships with other agencies that extend their reach, and on programs that address the housing, income, and social conditions that shape health long before anyone walks through a clinic door. This systems-level view challenges the common caricature of community organizations as makeshift substitutes for real healthcare and reframes them as integrated nodes in a wider health promotion network.

The third theme catalogued the barriers, and it is here that the study is most sobering. Participants described inadequate and unstable funding as a chronic condition that undermines planning, retention, and service continuity. They reported shortages of trained providers, a lack of formal integration with the broader healthcare system, information gaps, language barriers, long healthcare waitlists, and persistent discrimination against the population they serve. Each of these barriers interacts with the others: unstable funding worsens workforce shortages, weak integration leaves community staff without referral pathways into hospitals and specialized care, and discrimination at the system level drives demand back onto already overstretched community services. The result is a reinforcing loop in which the organizations doing the most for a marginalized population are structurally resourced to do the least.

Against that backdrop, participants did not simply vent frustration; they proposed concrete remedies. They recommended enhancing resources, expanding staffing, strengthening education and training, intensifying advocacy efforts, deepening research engagement, and pursuing inclusive policy development to support organizational capacity. These recommendations collectively constitute a capacity-building agenda. Education and training would professionalize the workforce and improve service quality. Advocacy and policy development would address the upstream legal and institutional conditions that perpetuate inequity. Research engagement would ensure that services evolve on the basis of evidence rather than crisis response. And sustainable resourcing would give organizations the predictability they need to retain skilled staff and plan multi-year programs.

The authors conclude that several key factors may strengthen the health promotion capacity of community-based agencies serving sexual and gender-diverse women, including sustainable funding, workforce development, education, and research infrastructure. Crucially, they caution that future research should examine the broader applicability and effectiveness of these findings across diverse contexts, and they call for prioritizing structural change, intersectional approaches, and community-led solutions. That emphasis on intersectionality is significant, because sexual and gender-diverse women are not a homogeneous group; experiences of care vary by race, language, geography, disability, and socioeconomic status, and capacity-building strategies that ignore those intersecting identities risk reproducing the very exclusions they aim to fix.

The study was funded by the Canadian Institutes for Health Research, received on 11 November 2025, was accepted on 11 September 2026, and published open access on 22 September 2026. Its arrival could not be more timely. As health systems worldwide confront workforce shortages and rising demand for affirming care, the Canadian evidence offers a transferable insight: community-based organizations are not peripheral charities but essential health infrastructure, and the healthcare system’s treatment of sexual and gender-diverse women will depend on whether governments and institutions choose to fund, train, and formally integrate them. The ten staff members interviewed for this study described, in effect, a parallel health system running on commitment and improvisation. Converting that commitment into durable capacity, the research makes clear, is a policy choice that remains to be made.

Subject of Research: Health promotion capacity building in community-based organizations serving sexual and gender-diverse women in Canada.

Article Title: Building health promotion capacity for sexual and gender-diverse women: insights from staff at community-based organizations in Canada

Article References: Building health promotion capacity for sexual and gender-diverse women: insights from staff at community-based organizations in Canada. (n.d.). https://doi.org/10.1186/s12913-026-15624-6

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15624-6

Keywords: 2SLGBTQ+ health, community-based health promotion, sexual and gender-diverse women, health equity, gender-affirming care, capacity building, qualitative research, health services research, social determinants of health, workforce development, Building, health