The Impact of the COVID-19 Pandemic on the Transgender Community, and What You Can Do About It
Transgender people are resilient. In the face of pervasive transphobia, we persist, we come together, and we create change. However, despite the strength and passion of our community, decades of discrimination have taken their toll. According to the 2015 U.S. Transgender Survey, of the more than 1 million transgender people in the U.S., 29 percent currently live in poverty, 30 percent have faced gender-related employment discrimination in the past year, and 30 percent have experienced homelessness in their lifetime. Transgender people also face barriers to health care, mental health challenges, and economic vulnerabilities as the result of stigma and discrimination, which are magnified for those with intersecting marginalized identities.
These factors, along with extraordinarily high rates of violence and discrimination, contribute to drastic health disparities that have been widened by the COVID-19 pandemic. The transgender community has been disproportionately impacted by COVID-19 due to disrupted access to gender-affirming care that stems from disruptions in all health care, restrictions on certain surgeries, and increased economic disparities. As medical students and members of the transgender community ourselves, we consulted trans community organizers in Baltimore and reviewed published literature to assess how COVID-19 has impacted the health of our community and what we can do about it now.
To better understand challenges facing the broader transgender community during the pandemic, we connected with a local organization supporting the community. Baltimore Safe Haven (BSH) is a trans-led organization that supports trans people struggling in Baltimore. Their services include a low-barrier shelter, a care facility, case management, job placement services, legal assistance, HIV testing, mobile outreach, and food and clothing distribution. We spoke with Nicole Wells, a case manager for BSH, who said that throughout the pandemic her organization never closed its doors. When asked about the impact of COVID-19 on the trans community, Wells told us that it has been unlike anything she has seen before: “We had a line all the way down the street of people wanting food. It was, in a way, overwhelming.” Some of these clients were seeking help accessing health care as well.
Inadequate access to health care in transgender communities is a well-documented contributor to health disparities, and results both from transphobia in healthcare settings and from scarcity of clinicians trained to provide gender-affirming care (GAC), among other factors. COVID-19 has exacerbated this problem. Early in the pandemic, policies were put in place to minimize the spread of COVID-19, such as limiting the enrollment of new patients. This made it difficult for many trans people to connect with providers to initiate hormone replacement therapy (HRT). With limited guidance from health societies, some clinicians have decided to forgo in-person physical examinations, while others have insisted they are necessary for HRT prescriptions. Inconsistency across health-care institutions, with some requiring and others forgoing in-person visits, made it difficult for patients to navigate an already complex and often overwhelming system. With widespread reductions of in-person visits, the pandemic has also interrupted follow-up care for those prescribed HRT, which may lead to suboptimal dosing and adverse side effects. Pandemic-related shortages of syringes and other safe injections supplies could increase the risk of dangerous HRT injection practices.
The transgender community has been disproportionately impacted by COVID-19 due to disrupted access to gender-affirming care that stems from disruptions in all health care, restrictions on certain surgeries, and increased economic disparities.
Another policy put in place to limit the spread of COVID-19 was the pause of some surgical procedures, including many transition-related surgeries. This has led to delays that have further exacerbated excessive wait times, which were already on the order of years for some gender-affirming procedures. Effects of these delays will be felt for years to come. The pandemic also disrupted post-surgical follow up care, which is essential for proper healing and reducing complication rates. Inability to access GAC can be detrimental to physical and mental health for transgender people.
The COVID-19 pandemic has also exacerbated pre-existing disparities in social determinants of health. For example, economic disparities faced by transgender people reinforce barriers to care and disproportionately impact trans people with additional marginalized identities. Due to COVID-19, 19 percent of transgender people and 26 percent of transgender people of color became unemployed, as compared to 12 percent of the general population. Unemployment impacts housing, food security, insurance status, and ability to access care, all vital components of health.
These circumstances have increased demand for Baltimore Safe Haven’s services during the pandemic. As Wells shared, many trans people had to turn to sex work after losing their jobs. She explained that having to interact with different people every day at the height of the pandemic put her clients at risk and described how survival sex work negatively impacts physical and mental health, for example by increasing exposure to violence and discrimination.
Mental health disparities also have been worsened by social isolation. Trans Lifeline, a trans-led crisis line, reported that from the start of the pandemic to June 2020 there was an 81 percent increase in calls that mentioned lack of trans community. There are well-documented protective health effects of social support, particularly within the transgender community. However, the pandemic caused many LGBTQ+ youth to become isolated from support systems, social connections, and identity-based resources and to move in with unsupportive families. In addition to reducing trans community connections, shelter in place orders early on in the pandemic may have heightened the danger of domestic violence, which is twice as likely among trans people.
As the leaders of BSH have shown time and again, when the trans community is under attack, trans people take action. “I just have to be strong for the community,” Wells told us. But it should not just be trans community-organizers working to address these inequities. As health professionals, it is our responsibility to acknowledge and combat health inequity whenever we encounter it. So, what can we do?
First, we should educate ourselves. As Wells informed us, many trans people struggle to find competent providers and instead seek HRT outside of healthcare settings. She suggests that provider education about gender affirming care would be a great help. Any physician or nurse practitioner in a primary care setting can prescribe and manage HRT, increasing accessibility to this lifesaving care and reducing the amount of unregulated HRT use. Furthermore, learning about gender-related health disparities and the manifestations of discrimination in healthcare will better equip us to recognize and address barriers to care in our own practices and communities. This means making sure all members of our care teams understand what respectful communication with transgender patients looks like and that we consult trans-led educational organizations when needed. And of course, including transgender people and GAC in research is vital to address disparities in health knowledge. More research must be conducted exploring the impact of the COVID-19 pandemic on the transgender community so these disparities can be understood and addressed.
[W]e as medical professionals must advocate for transgender people. Across the United States in the first three months of 2022 alone, 238 bills attacking the rights of LGBTQ+ people were proposed, a majority of which target transgender people. We should all advocate to reduce systemic barriers and improve access to GAC...
Second, we as medical professionals must advocate for transgender people. Across the United States in the first three months of 2022 alone, 238 bills attacking the rights of LGBTQ+ people were proposed, a majority of which target transgender people. We should all advocate to reduce systemic barriers and improve access to GAC, for example by testifying at local legislative meetings and spreading awareness of new bills. Advocacy related to insurance expansion, housing, and legal protections against discrimination, in particular, could have powerful downstream effects on the health of the transgender community.
Finally, we can support and collaborate with trans-led advocacy groups in our own communities. Local groups like BSH are already working to address these disparities every day, and they understand the unique needs of their community. By volunteering with, donating to, and supporting the initiatives of these organizations, we can support the members of our community who are best equipped to address these issues directly. Learning about local organizations also better enables us to make resource referrals to trans community-building spaces for those struggling with social isolation.
The COVID-19 pandemic has increased health disparities for many marginalized communities, including the transgender community. The impact of these unfortunately will be felt for the foreseeable future. However, there are ways we can begin to close these gaps. Through education, advocacy work, and partnership with local trans-led organizations, we can build a more equitable and accessible healthcare landscape for our transgender neighbors, colleagues, family, and friends.
Calvin Schuster is a medical student at Johns Hopkins University School of Medicine, the Director of Health and Wellness of the nonprofit Trans Maryland, and a co-founder of the education and advocacy group The Transgender Connection; his commitment to transgender health equity and to gender-affirming care research is what originally inspired his interest in medicine. Claudia Taccheri is a medical student at the Johns Hopkins University School of Medicine where they have worked on transgender and nonbinary advocacy and education through the LGBTQ+ student group, the student diversity counsel, the sexual and gender diversity taskforce, and partnerships with local community-based organizations.
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