With the COVID-19 pandemic evolving rapidly across the globe, scarce medical resources
have become centered around care for those who are infected with COVID-19, and so-called
non-essential medical care has been set on hold. While there is general consensus
about the prioritizing of COVID-19 care, a growing number of health care providers
and patient representatives have expressed their concerns with the (long-term) consequences
of deferring other medical care (Wang & Zhang, 2020). As this global outbreak continues
to spread, inducing fear and anxiety without a clear perspective, this pandemic will
especially impact those who depend on proper medical and mental health care. It is
largely unknown what the (mental) health status is of the groups that remain out of
scope during this COVID-19 crisis, especially those in vulnerable positions and with
prior health problems. In this Guest Editorial, we express our concerns over the deferral
of most gender-affirming (medical) treatments and the direct and indirect effects
this might have on the public (mental) health of transgender and gender non-conforming
(TGNC) people, and the health system that serves these individuals. We highlight the
increased vulnerability of this group, underline the cumulative burden (e.g., physical,
mental, socioeconomic) for many TGNC individuals, and argue why gender-affirming medical
and mental health care should be prioritized when re-introducing non-essential medical
care (see also Bowleg, 2020; Wang et al., 2020)
Access to Transgender Care
TGNC individuals concern a sizable group in society, among children, adolescents,
and adults (Goodman et al., 2020; Zucker, 2017). The incongruence between gender identity
and physical characteristics results in experienced dysphoria and severe mental health
problems in a considerable share of this group (e.g., Dhejne, van Vlerken, Heylens,
& Arcelus, 2016; van der Miesen, Nabbijohn, Santarossa, & VanderLaan, 2018). Gender-affirming
treatments have repeatedly been shown to improve physical and mental health of TGNC
adults (van de Grift, Elaut, Cerwenka, Cohen-Kettenis, & Kreukels, 2018; White Hughto
& Reisner, 2016), as well as in youth (van der Miesen, Steensma, de Vries, Bos, &
Popma, 2020). For TGNC individuals, gender-affirming treatments may consist of mental
health care, including psychological support and/or medical treatments. Due to the
diverse needs of care-seekers, both aspects of care are important in providing adequate
gender-affirming care. Yet, access to this essential care has been challenging, whether
it is due to waiting lists, strict treatment protocols, or practical barriers such
as travel distance or lack of insurance (Puckett, Cleary, Rossman, Newcomb, & Mustanski,
2018). Baseline access to gender-affirming medical care is already a serious issue
in many countries around the world; a recent survey in The Netherlands found, for
example, that 67% of the adult TGNC care-seekers waited more than 18 months for an
initial intake and hormone treatment, and another median of 6 months before surgical
intake (Ministry of Health, Welfare, and Sports, 2019). In many regions, TGNC individuals
have no access to gender-affirming care at all (Puckett et al., 2018). Deprivation
of adequate care in the short term might result in an increase in self-medication
of gender-affirming hormones, including potential physical risks without proper monitoring.
In the long term, deprivation of adequate care might also increase allostatic load
(i.e., stress), depression, non-suicidal self-injury, and suicidal ideation and behavior,
which ultimately results in a decreased life expectancy (White Hughto, Reisner, &
Pachankis, 2015). In this respect, not only the start of treatment is important, but
also the continuation of ongoing treatment and support, as a recent study found that
increased risk for suicidality might also be present during the course of gender-affirmative
treatments (Wiepjes et al., 2020).
Physical Health Effects: Risk of Severe COVID-19 Infections and Limited Follow-Up
Care
Early evidence on characteristics of individuals at risk of developing more severe
COVID-19 infections and less favorable outcomes include male sex, obesity, and coexisting
physical health issues, such as hypertension (Hu et al., 2020; Pozzilli & Lenzi, 2020;
Zhou et al., 2020). Although evidence on the course of COVID-19 infections is largely
unknown for all individuals, it is specifically uncertain how findings on sex differences,
as opposed to gender differences, relate to TGNC individuals. Who are at risk? Those
who currently identify with a male gender (and receiving testosterone treatment) and/or
those with a male sex assigned at birth with a non-male gender identity? While some
hypothesize the possible role of testosterone in influencing the course of COVID-19
infections (Pozzilli & Lenzi, 2020), conclusive evidence is lacking. In addition,
lower body awareness and barriers toward sports engagement result in higher incidences
of overweight in TGNC individuals (VanKim et al., 2014), making them more at risk
of developing severe COVID-19 infections. Also, forthcoming cardiovascular diseases
as well as chronic stress may impact the functioning of the immune system, putting
TGNC individuals further at risk. Fortunately, gender-affirming medical treatments
can result in better physical health and lowered stress (White Hughto et al., 2015),
and therefore might protect TGNC individuals from more severe COVID-19 infections.
Besides the direct health effects of more severe COVID-19 infections, limited access
to follow-up of gender-affirming medical care can put TGNC individuals at risk for
multiple physical health conditions or complications. Long-term suboptimal gender-affirming
hormone doses can increase the chance of developing osteoporosis or cardiovascular
disease (Defreyne, Van de Bruaene, Rietzschel, Van Schuylenbergh, & T'Sjoen, 2019).
Limited access to postoperative follow-up care can result in developing, for example,
voiding issues (e.g., urinary tract hesitancy) or increased chance of requiring reoperations
at a later point. This is of particular importance for TGNC individuals as it has
been reported that this population already feels hesitant to access medical care due
to fear of stigma and misunderstanding (Kosenko, Rintamaki, Raney, & Maness, 2013).
Mental Health Effects: COVID-Stress, Increase in Dysphoria, and Suicidality
Next to physical vulnerabilities, TGNC individuals are at increased risk for developing
mental health problems, regardless of the COVID-19 crisis (Dhejne et al., 2016). Social
isolation, fear for the health of oneself and others, and the loss of routine impact
the mental well-being of many individuals during the COVID-19 pandemic (Fiorillo &
Gorwood, 2020). However, for many TGNC individuals, these effects are superimposed
on existing mental health problems and decreased resilience due to longer existing
stress. For TGNC individuals experiencing severe bodily distress or social stigma
due to physical incongruence, gender-affirming medical care is essential to decrease
these feelings of (social) anxiety, depression, hopelessness, and subsequent suicidal
thoughts (White Hughto & Reisner, 2016; Wiepjes et al., 2020). Conversely, insufficient
access to this care puts a significant mental health burden on this population.
The current COVID-19 crisis not only defers gender-affirming medical treatments of
people who already had clinical intakes or surgeries scheduled, the limited total
capacity of the health system makes it likely that access to care will be substantially
delayed for all TGNC individuals seeking gender-affirming care in the coming years.
This causes many TGNC individuals to live in the difficult twilight zone between assigned
sex and experienced gender identity for an extended period. While the effects of deferring
initial care remain largely out of scope of health care professionals (since individuals
are on waiting lists), TGNC support groups have already expressed their concerns signaling
an increase in suicidal ideation among their members (e.g., The Trevor Project, 2020).
Additionally, for those who are already enrolled in mental health clinical services,
the frequency and effectiveness of mental health counseling might be decreased for
many because of the lack of good-quality telehealth. Moreover, the decreased opportunities
to have social and peer support likely affect (mental) health as well (de Vries et
al., 2015). For TGNC youth, the closing of schools can be distressing due to the absent
availability of peer support. As TGNC individuals already experience more loneliness
and are less often in a relationship (Kuyper, 2017), social isolation and social distancing
will further impact these intersections with mental health (Brennan, Card, Collict,
Jollimore, & Lachowsky, 2020). Taking all those different aspects of mental health,
the deferral of gender-affirming medical treatments, and all the potential impacts
into consideration, TGNC individuals will likely be suffering from a cumulative mental
health burden during this global pandemic.
Socioeconomic Factors: Intersections Between Health, Human Rights, and Socioeconomic
Stress
In general, socioeconomic factors can impact (mental) health significantly. Parallel
to the physical and mental health challenges TGNC individuals face, socioeconomic
stress (e.g., lower job security and income) also intersects with their overall well-being
(White Hughto et al., 2015). Recognizing this relationship, TGNC individuals are thus
likely to be disproportionally affected by both the COVID-19 pandemic, as well as
the deferral of gender-affirming medical and mental health care. With the possible
loss of jobs and income, financial access to gender-affirming care can be threatened,
especially when being uninsured or being insured through employers. On top of this,
attending TGNC-safe spaces is temporarily impossible due to social distancing restrictions,
which may be more important when living in households threatened by violence or transphobic
stigma. On a larger scale, advocacy and stakeholder groups may experience additional
barriers in getting organized. TGNC advocacy and stakeholder groups will likely have
less possibilities for providing general public health education at schools and through
mainstream media. With the current global restrictions on organizing meetings and
protests, it will be more difficult to attend to the need for equal human rights for
TGNC individuals. TGNC legislation was already at risk in certain countries, but the
current COVID-19 pandemic may push this topic even further down the political agenda.
Some governments even use the state of emergency to file legislation that reduces
TGNC rights (e.g., legal gender recognition is being banned in Hungary; see Walker,
2020), and increased discrimination has already been reported (Perez-Brumer & Silva-Santisteban,
2020), while multiple pro-TGNC legislations have been put on hold given the COVID-19
initiatives. Ultimately, this will further delay or endanger the possibilities to
access proper gender-affirming care and gender recognition, putting TGNC individuals
at risk of negative health outcomes, considering the intersections among socioeconomic,
human rights, mental, and physical health.
Transgender Research: Possible Consequences and Considerations
Next to the emerging risks for TGNC individuals, the COVID-19 pandemic is likely to
delay ongoing and future transgender research initiatives. As the pandemic has not
only shut down non-essential care but also universities and research institutes as
a whole, some ongoing and follow-up studies have been put on immediate hold. While
there has been a consistent increase in publications related to transgender research
over the past decades (Wanta & Unger, 2017), the current pandemic might have long-term
consequences for this field that already has many understudied topics and populations
(e.g., transgender elderly, non-binary individuals, new surgical techniques). For
ongoing studies, the data collected during the COVID-19 pandemic might be subject
to bias, as questionnaires regarding mental health, for example, will be strongly
dependent on the current global situation. As no standardized measures have yet been
developed to assess the (mental health) effects on life during a pandemic, it remains
uncertain how generalizable data collected at present will be.
For researchers, this pandemic might also come with an increased uncertainty with
regard to financial resources to perform research. While some universities might have
more flexible policies regarding, for example, grant applications, other researchers
might not experience this leniency, thereby putting future projects on hold. In addition,
although some scientific societies transfer research conferences to online-only, others
are canceled. This might reduce network building, research dissemination, and future
career possibilities.
Lastly, the travel restrictions and conference cancellations could be a threat for
stakeholder involvement in research. TGNC stakeholder involvement is increasingly
on the global scientific agenda, in both TGNC adult (Bouman, 2018) and youth research
(Strang et al., 2019). Since human contact facilitates listening, learning, and the
exchange of views, the COVID-19 pandemic might challenge these developments. On the
other hand, novel ad hoc collaborations develop online, including a global scientific
study on the effects of COVID-19 on TGNC health and health care (Trans Care COVID-19:
https://www.transcarecovid-19.com/).
Summary and Opportunities
The COVID-19 pandemic is a global crisis taking place on an unprecedented scale, and
the full effects have yet to unfold. Almost every individual, household, industry,
and country is affected in some way or might be in the future. TGNC individuals and
their supporting health care systems are no exception. While gender-affirming care
was already facing substantial challenges, the pressure the COVID-19 pandemic puts
on the health care system adds a sizable burden to effectively support the (mental)
health of many TGNC individuals. At the moment, the main obstacles are the deferral
of gender-affirming treatments and limited access to (mental) health care, jeopardizing
the physical and mental health of a large number of TGNC individuals. Additionally,
socioeconomic hardship and less attention for the improvements of TGNC rights will
put an increased strain on the community.
TGNC advocates, supporting health care providers, governments, and policy makers are
collaboratively responsible to address the physical and emotional consequences of
the COVID-19 pandemic and to address not only these present obstacles, but also structural
obstacles to gender-affirming health care. Before this pandemic, already increasing
attention has been given to the implementation of blended care (i.e., combining face-to-face
consultations with online appointments and therapy; Wentzel, van der Vaart, Bohlmeijer,
& van Gemert-Pijnen, 2016) but widespread use in transgender care was lacking. As
it is unlikely that TGNC health care facilities will operate as usual soon, professionalizing
telehealth and online peer support becomes a necessity now. The current situation
might therefore provide opportunities to critically review aspects of health care
systems’ barriers, increasing the systems’ capacity, and implementing blended care
to optimally benefit of the advantages of this type of care. This could lead to a
decreased number of standard face-to-face intake contacts prior to transition by,
for example, providing psychoeducation online. By substituting physical contacts with
telemedicine, travel cost will be reduced and by developing teleconferencing between
health care disciplines interdisciplinary and speedy clinical decision-making will
be facilitated. In this regard, given the scarce resources, collaboration between
institutions to implement this blended care is highly recommended to arrange effective
regional networks and interdisciplinary care, whereas expanding telemedicine would
also further increase the strength of (worldwide) clinical collaboration.
In addition, the current situation, in which many are getting accustomed to teleconferencing,
can provide opportunities for scientific collaborations. This can include online conferences,
educational initiatives, and disseminating new research findings with TGNC communities.
Similar to clinical opportunities, researchers can experiment with digital substitutes
for study participation, such as online interviews and questionnaires, in order to
reduce barriers to engage and improve the generalizability of their findings (e.g.,
by reaching traditionally underserved populations).
In conclusion, the COVID-19 pandemic is obviously causing numerous societal challenges.
During this crisis, many TGNC individuals may be subject to severe (mental) health
threats, resulting from both the pandemic itself and the subsequent deferral of gender-affirming
care. We argue that non-essential gender-affirming care, both medical and psychological,
is actually essential to ensure the health of this population, which should be prioritized
when re-introducing care. At the same time, the present crisis provides opportunities
in critically reviewing existing barriers to care, introducing telemedicine, and implementing
novel methods of education and research. Attaining these outcomes, however, is strongly
dependent on how effectively all relevant stakeholders will be able to collaborate
together.