Gender-affirming care, mental health, and economic stability in the time of COVID-19: a global cross-sectional study of transgender and non-binary people

Abstract

Background Transgender and non-binary people are disproportionately burdened by barriers to quality healthcare, mental health challenges, and economic hardship. This study examined the impact of the novel coronavirus disease (COVID-19) pandemic and subsequent control measures on gender-affirming care, mental health, and economic stability among transgender and non-binary people globally. Methods We collected global cross-sectional data from 964 transgender and non-binary adult users of the Hornet and Her apps from April to August 2020 to characterize changes in gender-affirming care, mental health, and economic stability as a result of the COVID-19 pandemic. We conducted Poisson regression models to assess if access to gender-affirming care and ability to live according to one's gender were related to depressive symptoms, anxiety, and changes in suicidal ideation. Results Individuals resided in 76 countries, including Turkey (27.4%,n=264/964) and Thailand (20.6%,n=205). A majority were non-binary (66.8%,n=644) or transfeminine (29.4%,n=283). Due to the COVID-19 pandemic, 55.0% (n=320/582) reported reduced access to gender-affirming resources, and 38.0% (n=327/860) reported reduced time lived according to their gender. About half screened positive for depression (50.4%,442/877) and anxiety (45.8%,n=392/856). One in six (17.0%,n=112/659) expected losses of health insurance, and 77.0% (n=724/940) expected income reductions. The prevalence of depressive symptoms, anxiety, and increased suicidal ideation were 1.63 (95% CI: 1.36-1.97), 1.61 (95% CI: 1.31-1.97), and 1.74 (95% CI: 1.07-2.82) times higher for individuals whose access to gender-affirming resources was reduced versus not. Discussion The COVID-19 pandemic has reduced access to gender-affirming resources and the ability of transgender and non-binary people to live according to their gender worldwide. These reductions may drive the increased depressive symptoms, anxiety, and suicidal ideation reported in this sample. To improve transgender and non-binary health globally, increased access to gender-affirming resources should be achieved through policies (e.g., digital prescriptions), flexible interventions (e.g., telehealth), and support for existing transgender health initiatives.

Well-being during COVID-19 pandemic: A comparison of individuals with minoritized sexual and gender identities and cis-heterosexual individuals

“…These findings mirror the existing literature on mental health disparities of trans* and gender non-conforming people. For example, a recent study confirmed that due to the COVID-19 pandemic, access to gender-affirming resources and the ability of transgender and non-binary people to live according to their preferred gender has been reduced [ 56 ]. While gender-affirming care has repeatedly been found to improve physical and mental health of people with minoritized gender identities [ 57 , 58 ], access to it was already difficult for many individuals.…”

COVID-19 Vaccine Acceptance among an Online Sample of Sexual and Gender Minority Men and Transgender Women

“…Stigma, stress, and discrimination that contribute to health inequities among SGM likely impact vulnerability during the COVID-19 pandemic [ 7 , 8 ]. Structural factors such as high rates of unemployment and lack of health insurance among SGM that contributed to health inequity prior to COVID-19 are now worsening [ 12 , 13 , 44 ]. SGM are also more likely to experience homelessness that may increase exposure to COVID-19.…”

“…Studies across international settings have demonstrated that SGM communities have experienced increased depression and anxiety as a result of social distancing measures and worrying about health status related to COVID-19 [ 10 , 11 ]. Studies examining global sample of SGM using a smart-phone based “Gay Social Networking” app found that since the beginning of the COVID-19 pandemic SGM have been more likely to experience job loss, income reduction, and decreased access to gender affirming resources [ 12 , 13 ]. In the United States, Latinx SGM have experienced increased personal violence due to stay-at-home orders, and racial/ethnic minority status has been associated with increased risk of severe COVID-19 [ 9 , 14 , 15 ].…”

“…Thus, COVID-19 related vulnerability likely varies across intersectional racial/ethnic, sexual, and gender minority identities. COVID-19 restrictions have been associated with decreased access to healthcare and decreased perceived social support, which may weaken resilience to minority stressors [ 13 , 16 , 17 , 18 ]. The confluence of disproportionate psychosocial and economic burdens with increased vulnerability to minority stressors among SGM may decrease COVID-19 vaccine uptake and further deepen health inequities.…”

Experiences and Perceptions of Trans and Gender Non-Binary People Regarding Their Psychosocial Support Needs: A Systematic Review of the Qualitative Research Evidence

“…More than half screened positive for depression and 45% for anxiety. Suicidal ideation was also experienced by a significant number of study respondents [ 14 ].…”