116
views
0
recommends
+1 Recommend
2 collections
    0
    shares
      • Record: found
      • Abstract: found
      • Article: not found

      “You Have to Wait a Little Longer”: Transgender (Mental) Health at Risk as a Consequence of Deferring Gender-Affirming Treatments During COVID-19

      letter

      Read this article at

      ScienceOpenPublisherPMC
      Bookmark
          There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.

          Abstract

          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.

          Related collections

          Most cited references28

          • Record: found
          • Abstract: found
          • Article: not found

          Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study

          Summary Background Since December, 2019, Wuhan, China, has experienced an outbreak of coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Epidemiological and clinical characteristics of patients with COVID-19 have been reported but risk factors for mortality and a detailed clinical course of illness, including viral shedding, have not been well described. Methods In this retrospective, multicentre cohort study, we included all adult inpatients (≥18 years old) with laboratory-confirmed COVID-19 from Jinyintan Hospital and Wuhan Pulmonary Hospital (Wuhan, China) who had been discharged or had died by Jan 31, 2020. Demographic, clinical, treatment, and laboratory data, including serial samples for viral RNA detection, were extracted from electronic medical records and compared between survivors and non-survivors. We used univariable and multivariable logistic regression methods to explore the risk factors associated with in-hospital death. Findings 191 patients (135 from Jinyintan Hospital and 56 from Wuhan Pulmonary Hospital) were included in this study, of whom 137 were discharged and 54 died in hospital. 91 (48%) patients had a comorbidity, with hypertension being the most common (58 [30%] patients), followed by diabetes (36 [19%] patients) and coronary heart disease (15 [8%] patients). Multivariable regression showed increasing odds of in-hospital death associated with older age (odds ratio 1·10, 95% CI 1·03–1·17, per year increase; p=0·0043), higher Sequential Organ Failure Assessment (SOFA) score (5·65, 2·61–12·23; p<0·0001), and d-dimer greater than 1 μg/mL (18·42, 2·64–128·55; p=0·0033) on admission. Median duration of viral shedding was 20·0 days (IQR 17·0–24·0) in survivors, but SARS-CoV-2 was detectable until death in non-survivors. The longest observed duration of viral shedding in survivors was 37 days. Interpretation The potential risk factors of older age, high SOFA score, and d-dimer greater than 1 μg/mL could help clinicians to identify patients with poor prognosis at an early stage. Prolonged viral shedding provides the rationale for a strategy of isolation of infected patients and optimal antiviral interventions in the future. Funding Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences; National Science Grant for Distinguished Young Scholars; National Key Research and Development Program of China; The Beijing Science and Technology Project; and Major Projects of National Science and Technology on New Drug Creation and Development.
            Bookmark
            • Record: found
            • Abstract: found
            • Article: found
            Is Open Access

            The consequences of the COVID-19 pandemic on mental health and implications for clinical practice

            There is a wide consensus that the COVID-19 pandemic not only affects physical health, but also mental health and well-being [1,2]. The current pandemic is changing priorities for the general population, but it is also challenging the agenda of health professionals, including that of psychiatrists and other mental health professionals [3]. Everywhere in the world, psychiatric clinics are modifying their practice in order to guarantee care and support to persons with mental health problems, but also to those who are not mentally ill and are suffering from the psychosocial consequences of the pandemic. The number of those who will need psychiatric help is going to increase in the next weeks or months, requiring a reconsideration of our current practices. From a psychopathological viewpoint, the current pandemic is a relatively new form of stressor or trauma for mental health professionals [4]. It has been compared with natural disasters, such as earthquakes or tsunamis [5]. But in those cases, the emergencies are usually localized, limited to a specific area and to a given time; people know that they can escape, if they want to or if they have the possibility to do so [6]. It has also been compared with wars and international mass conflicts. But in those circumstances, the enemy is easily recognizable, while in pandemic the “threat” can be everywhere and it can be carried by the person next to us [7]. We consider that the mental health and psychosocial consequences of the COVID-19 pandemic may be particularly serious for at least four groups of people: (a) those who have been directly or indirectly in contact with the virus; (b) those who are already vulnerable to biological or psychosocial stressors (including people affected by mental health problems); (c) health professionals (because of higher level of exposure); and (d) even people who are following the news through numerous media channels. The pandemic and the related containment measures—namely quarantine, social distancing, and self-isolation—can have a detrimental impact on mental health. In particular, the increased loneliness and reduced social interactions are well-known risk factors for several mental disorders, including schizophrenia and major depression. Concerns about one’s own health and that of their beloved ones (particularly elderly or suffering from any physical illness), as well as uncertainty about the future, can generate or exacerbate fear, depression, and anxiety. If these concerns are prolonged, they may increase the risk of serious and disabling mental health conditions among adult males and females, including anxious disorders including panic, obsessive–compulsive, stress, and trauma-related disorders. A group at a particularly high risk is represented by infected people, physicians, and nurses working in emergency units and resuscitation departments. It is likely that in the next months—when the pandemic is over—we may have a shortage of health professionals due to burnout and mental exhaustion [8]. Another aspect which should be considered is related to stigma and discrimination toward infected people and their family members. Fighting social stigma toward those treating and caring for people with COVID-19 should be another priority for mental health professionals in the next months. Finally, Internet is spreading very rapidly a large amount of uncontrolled news. This information overload has been defined “infodemic,” with the risk of fake news running faster than the virus itself, and creating uncertainties and worries. This should be regulated by a continuous interaction with media and also by national regulations. Another consequence of the pandemic on mental health practice may be that psychiatric problems will be considered less important than physical ones. We should continue to advocate for our patients and their caregivers; our patients often need long-term treatment, continuous support and advices, personal meetings with their physicians or therapists. Their rights to be treated, also in a period of social distancing, should be preserved even though mental health services may be overloaded by a considerable number of requests for psychiatric consultations. Many of these psychosocial and mental health consequences of the pandemic will have to be addressed by psychiatrists and mental health professionals in the months to come. Most probably we will face an increase of mental health problems, behavioral disturbances, and substance-use disorders, as extreme stressors may exacerbate or induce psychiatric problems. In order to reduce the risk of developing mental health problems, simple advices may be provided to the general population: 1. Limit the sources of stress: to rely on a limited amount of official information sources only and to limit the time of the day devoted to this activity, disregarding those which come from unofficial channels and uncontrolled sources. 2. Break the isolation: to increase the communication with friends, family members, and loved ones, even if at a distance. Video-chat or group calls with family members may help to reduce loneliness and precariousness. In case of insufficient social network, professional helplines are particularly useful, if managed by qualified trained professionals. 3. Maintain your usual rhythm: keep a regular routine, by having regular sleep–wake rhythms and diet patterns. Addictive behaviors might be particularly at risk of rebound or relapses, therefore intellectual, physical, and social (even if virtual) activities will be useful. 4. Focus on the benefit of the isolation: we should indeed be conscious that this is a transient period and that this isolated time is needed as we are not only saving our health, but also protecting all others by stopping the epidemic, and therefore shaping our own future. 5. Ask for professional help: getting a psychiatric help or consultation, if the effects of stress is becoming too invasive, is always possible, even if with different modalities. Almost all psychiatric clinics are now equipped for providing support, emotional defusing, problem-solving strategies, and psychiatric consultations—also at a distance. The pandemic will be over, but its effects on mental health and well-being of the general population, health professionals, and vulnerable people will remain for a long time. We hope that all of the mental health community will have very quickly the opportunity to take care of patients in more conventional and personalized ways. Crises also reveal resilience skills and quality of links, the solidarity observed between European countries for severe cases (exchanging patients, material, and competencies) is a nice example to follow.
              Bookmark
              • Record: found
              • Abstract: found
              • Article: not found

              Transgender stigma and health: A critical review of stigma determinants, mechanisms, and interventions.

              Transgender people in the United States experience widespread prejudice, discrimination, violence, and other forms of stigma.
                Bookmark

                Author and article information

                Contributors
                t.vandegrift@amsterdamumc.nl
                Journal
                Arch Sex Behav
                Arch Sex Behav
                Archives of Sexual Behavior
                Springer US (New York )
                0004-0002
                1573-2800
                9 June 2020
                : 1-5
                Affiliations
                [1 ]GRID grid.16872.3a, ISNI 0000 0004 0435 165X, Department of Child and Adolescent Psychiatry, , Amsterdam UMC, VU University Medical Center, ; Amsterdam, The Netherlands
                [2 ]GRID grid.16872.3a, ISNI 0000 0004 0435 165X, Amsterdam UMC, VU University Medical Center, Center of Expertise on Gender Dysphoria, ; Amsterdam, The Netherlands
                [3 ]GRID grid.16872.3a, ISNI 0000 0004 0435 165X, Department of Plastic, Reconstructive, and Hand Surgery, Center of Expertise on Gender Dysphoria, , Amsterdam UMC, VU University Medical Center, Amsterdam Public Health Research Institute Amsterdam, ; PO Box 7057 (ZH 4D120), 1007 MB Amsterdam, The Netherlands
                [4 ]Rotterdam, The Netherlands
                [5 ]GRID grid.16872.3a, ISNI 0000 0004 0435 165X, Department of Plastic, Reconstructive, and Hand Surgery, , Amsterdam UMC, VU University Medical Center, ; Amsterdam, The Netherlands
                Author information
                http://orcid.org/0000-0003-4382-7000
                Article
                1754
                10.1007/s10508-020-01754-3
                7282831
                32519279
                77732af0-ed8c-45a7-ba1c-ce21c161ba32
                © Springer Science+Business Media, LLC, part of Springer Nature 2020

                This article is made available via the PMC Open Access Subset for unrestricted research re-use and secondary analysis in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the World Health Organization (WHO) declaration of COVID-19 as a global pandemic.

                History
                : 7 May 2020
                : 21 May 2020
                : 22 May 2020
                Categories
                Guest Editorial

                Sexual medicine
                Sexual medicine

                Comments

                Comment on this article

                scite_
                0
                0
                0
                0
                Smart Citations
                0
                0
                0
                0
                Citing PublicationsSupportingMentioningContrasting
                View Citations

                See how this article has been cited at scite.ai

                scite shows how a scientific paper has been cited by providing the context of the citation, a classification describing whether it supports, mentions, or contrasts the cited claim, and a label indicating in which section the citation was made.

                Similar content92

                Cited by42

                Most referenced authors422