Transgender and gender diverse individuals experience pervasive invalidation and discrimination
in our society. Gender-minority stressors, including gender-related stigma and discrimination,
increase vulnerability to health problems (as compared with cisgender peers) resulting
in disparities in virtually every domain of life, from higher rates of victimisation
and mental health problems, including suicidality, to inadequate access to public
accommodations, housing, and necessary health care.
1
Although the full effects of the COVID-19 pandemic will take years to elucidate, especially
as we face waves of multiple SARS-CoV-2 variants (eg, delta [B.1.617.2]), it is apparent
that the pandemic has resulted in exacerbated disparities for transgender and gender
diverse people across several crucial determinants of health.
2
Thankfully, necessity has bred ingenuity, including the widespread adoption of telehealth,
a practice that can better meet the needs of transgender and gender diverse people
beyond the scope of the current public health crisis. Building on previous correspondence,
2
we review lessons learned from 2020 to see how health care for transgender and gender
diverse individuals might be improved in the coming years.
For transgender and gender diverse individuals with intersecting marginalised identities
(eg, transgender women of colour), structural or systemic inequity and discrimination
became particularly pronounced during the COVID-19 pandemic: higher proportions of
individuals in unstable housing and employment, and greater financial difficulties
were reported.
3
In a US poll of 7000 lesbian, gay, bisexual, transgender, and queer adults from April
to May, 2020, the Human Rights Campaign found 19% of transgender and gender diverse
people and 26% of minority ethnic transgender and gender diverse people of colour
became unemployed due to the pandemic, compared with 12% of the general population.
4
Economic hardship disproportionately affected minority ethnic transgender and gender
diverse people, with 59% of transgender and gender diverse people and 67% of minority
ethnic transgender and gender diverse people stating they were very concerned they
could not pay their bills, compared with 15% of the general population. Recent policy
efforts, such as the Fair Housing Act in the USA, are intended to reduce housing discrimination
related to transgender and gender diverse individuals, yet the impact remains to be
seen.
Although the COVID-19 pandemic compounded many existing disparities, the most notable
was markedly reduced access to expert clinical care. As public health authorities
called for appropriate measures to mitigate the spread of COVID-19, delays occurred
in accessing gender-affirming health services. For example, the cessation of non-emergent
surgeries in the USA and many other countries effectively closed the door on all gender-affirming
procedures and further delayed access to medically necessary procedures for transgender
and gender diverse people.
5
Additionally, access to even the most basic health services became difficult. Finding
a new health-care clinician for evaluation for gender-affirming hormone therapy became
more challenging as health-care systems had limited enrolment and prioritised patients
already established in their system. While the pandemic severely curtailed access
for existing patients within health systems, it left many new patients without recourse.
As health-care systems adapted to the new realities of care and integrated telemedicine,
transgender and gender diverse people newly seeking gender-affirming health care were
faced with a patchwork of practice approaches. Given limited guidance across practice
settings, health professionals adept at gender-affirming care either adapted their
approach to hormone initiation, forgoing in-person physical examinations, or were
adamant that a physical examination was essential before prescribing. Without clear
guidance from transgender health societies and organisations, clinicians were not
able to provide congruent policies and messaging across clinics, leaving new patients
to search for clinicians who felt most comfortable initiating gender-affirming medical
interventions while foregoing in-person assessment.
Mental health disparities experienced by transgender and gender diverse people were
notably exacerbated during the pandemic, as COVID-19 precautions reduced access to
social support.
6
For transgender and gender diverse people, this reduced access meant losing a crucial
source of resilience against the effects of gender-minority stress. A Washington Post
review of calls to Trans Lifeline—a crisis telephone line staffed by transgender and
gender diverse people—indicated that 24% of calls from March to July, 2020, specifically
mentioned the absence of a transgender community during this time.
7
Relatedly, transgender and gender diverse people had fewer opportunities to spend
time socially acknowledged in their affirmed gender during the COVID-19 pandemic when
in-person gatherings were forbidden. In response to reduced access to care and decreased
social connectedness, mental health indicators among transgender and gender diverse
people worsened, with increased rates of depression, anxiety, and suicidality.
6
Coping with the treatment of and recovery from COVID-19 itself might be challenging
for transgender and gender diverse individuals given decreased in-person support during
this time and worsened mental health indicators. In addition to persistent physical
symptoms (breathlessness, early fatigue, etc), COVID-19 often also involves a psychological
toll including mental health impairments (cognitive impairment, post-traumatic stress
disorder, and anxiety), which might compound existing stressors.
8
Furthermore, after diagnosis with COVID-19, one must often undergo an isolation process
at home or in a hospital room while contemplating questions about recovery and coping
with the impact of limited in-person social support.
As the USA continues to recognise the destabilising effects of the COVID-19 pandemic,
the health-care system is challenged to learn from these temporary fixes to best address
longstanding as well as pandemic-related barriers to delivery and access of equitable
health care for transgender and gender diverse people. As such, while ongoing efforts
need to be focused on reducing structural, systemic, and interpersonal gender-minority
stress, racism, and other forms of oppression, continuing insurance coverage of telemedicine
and improving necessary infrastructure (eg, high-speed internet) would allow people
in rural areas, older people, and people with restricted mobility and transport to
have access to quality health care.
9
Additionally, updating cross-state licensing regulations to allow expanded forms of
interstate practice would demonstrate clear benefits in improving access to gender-affirming
health care. There are already free-market solutions using existing efforts to reduce
barriers to interstate licensing regulations and telemedicine: private health technology
companies such as Plume and Solace have gained momentum as a mechanism of obtaining
health information and gender-affirming hormone therapy virtually.
The COVID-19 pandemic continues to stress health-care systems and underscores systematic
deficiencies that transgender and gender diverse individuals face in seeking care.
With the rapid proliferation of telemedicine in this time of need as well as innovative
virtual resources, patients and clinicians have experienced a system that can more
equitably serve patients where they live. Rather than return to that status quo of
patchwork systems with numerous coverage and access barriers to gender-affirming care,
there is an opportunity to create a novel, improved standard to ensure everyone, especially
transgender and gender diverse people, can benefit from increased access to quality
and compassionate health care, inclusive of primary, mental, and specialty care.
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2021
AWB declares the National Institute on Drug Abuse/National Institutes of Health (K23DA043418-04)
supported her salary. CGS declares that the National Heart, Lung, and Blood Institute/National
Institutes of Health (1K01HL151902-01A1), American Heart Association (20CDA35320148),
and Boston University School of Medicine Department of Medicine Career Investment
Award supported his salary. CGS is an unpaid board member of the US Professional Association
for Transgender Health. CMB, MI, and CAS declare no competing interests. The views
reflected herein are those of the individual authors and are not those of the respective
institutional affiliations of the authors or the US Government.