Instability in Housing and Medical Care Access: The Inequitable Impacts of the COVID-19 Pandemic on U.S. Transgender Populations

"Being Queer, It Was Really Isolating": Stigma and Mental Health Among Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ+) Young People During COVID-19

Lesbian, Gay, Bisexual, Transgender, Queer, and other sexual and gender minority (LGBTQ+) youth and young adults (YYAs) have poorer mental health outcomes than their cisgender, heterosexual peers in large part due to multilevel stigmatization and minority stress. This was exacerbated by psychological stressors stemming from the COVID-19 pandemic; these experiences intersected with YYA unique developmental stage. Here we explored LGBTQ+ YYA's pandemic-related experiences, focusing on intersections between stigma and belonging, developmental processes, and their relationship to mental health. We conducted qualitative interviews from August to November 2021 with 34 LGBTQ+ YYA ages 14 to 24; interviews were nested within a quantitative study on YYA experiences during COVID-19. Interviews were transcribed and coded using thematic analysis. YYA described how pandemic impacts like quarantine and isolation directly impacted their mental health; these coalesced around four types of thematic shifts: shifts in (1) time, (2) living situations, (3) community supports, and (4) social and political climate. Multilevel stigmatization also created new mechanisms of norm enforcement for LGBTQ+ YYA. Interviews demonstrated how the pandemic also impacted key developmental processes including identity formation and autonomy seeking. The potential consequences of these pandemic-related shifts largely depended on YYA's experiences of stigma and/or belonging throughout the pandemic. Findings suggested that isolation from the COVID-19 pandemic intersected with existing socio-ecological structures in LGBTQ+ young people's lives. Efforts to investigate longitudinal impacts of the pandemic, as well as to intervene to reduce the stigmatization experienced by LGBTQ+ YYA, remain urgent.

Participant attrition from statewide, population-based Survey of the Health of Wisconsin into the longitudinal SHOW COVID-19 cohort

PURPOSE

Longitudinal studies are essential for examining how social and institutional determinants of health, historical and contemporary, affect disparities in COVID-19 related outcomes. The unequal impacts of COVID-19 likely exacerbated selected attrition in longitudinal research. This study examines attrition and survey mode effects in the SHOW COVID-19 study which recruited from a statewide, representative cohort.

MATERIALS & METHODS

Participants were recruited from the Survey of the Health of Wisconsin (SHOW) cohort. Online surveys, or phone interviews, were administered at three timepoints during 2020-2021. The surveys captured social, behavioral, and structural determinants of health and the lived experience. Univariate and multivariate logistic regression was used to examine predictors of participation and survey mode effects.

RESULTS

A total of 2304 adults completed at least one COVID-19 online survey. Participants were more educated, older, and more likely to be female, married, non-Hispanic, and White compared to non-participants. Phone participants were older, less educated, and more likely be non-White, food insecure, and have co-morbidities compared to online participants. Mode effects were seen with reporting COVID-19 beliefs, loneliness, and anxiety.

CONCLUSION

The SHOW COVID-19 cohort offers unique longitudinal data but suffered from selected attrition. Phone interview is an important mode for retention and representation.

COVID-19, lockdowns, and the mental wellbeing of LGBTQ people in Australia

LGBTQ communities around the world entered the COVID-19 pandemic with generally high rates of poor mental health and faced additional challenges including stigma, discrimination, and barriers to care. This study sample was drawn from a survey of 3135 LGBTQ adults residing in Australia during the pandemic. Regression analysis was used to explore individual differences in psychological distress and perceived change in mental wellbeing since the onset of the pandemic as well as the impact of lockdowns, by taking advantage of a natural experiment comparing the states that experienced more extensive lockdowns (Victoria and New South Wales) to the rest of Australia. The burden of mental health was found to vary across gender, sexual orientation, age, and area of residence. While no impact of lockdowns on psychological distress was observed, participants living in the states of Victoria (β = -0.15; 95% CI = -0.23, -0.07) and New South Wales (β = -0.13; 95% CI = -0.21, -0.05) self-reported a more negative impact of the pandemic on their mental wellbeing compared to the rest of the country. The findings suggest that the COVID-19 pandemic had a negative impact on the mental wellbeing of LGBTQ populations, particularly among those who experienced extensive lockdowns and highlight the need for increased efforts to enable access to mental health supports during times of crisis.

Opportunities for Nurses to Decrease the Stigma Associated with Housing Instability and Homelessness

The number of people experiencing homelessness (PEH) in the United States has increased in the past 5 years. PEH have a higher disease burden and early mortality compared to people who are housed. Stigma adds to the burden of disease and disease management for PEH. In this article the authors review stigma, define housing and homelessness, describe the health and health care disparities PEH experience, and using the socio-ecological model as a framework, offer opportunities for nurses to intervene in efforts to decrease the stigma that PEH and housing instability encounter to improve health outcomes.

HIV pre-exposure prophylaxis programme preferences among sexually active HIV-negative transgender and gender diverse adults in the United States: a conjoint analysis

INTRODUCTION

Current implementation efforts have failed to achieve equitable HIV pre-exposure prophylaxis (PrEP) provision for transgender and gender-diverse (trans) populations. We conducted a choice-based conjoint analysis to measure preferences for key attributes of hypothetical PrEP delivery programmes among a diverse online sample predominantly comprised of transmasculine and nonbinary individuals in the United States.

METHODS

Between April 2022 and June 2022, a national online survey with an embedded conjoint analysis experiment was conducted among 304 trans individuals aged ≥18 years in the United States to assess five PrEP programme attributes: out-of-pocket cost; dispensing venue; frequency of visits for PrEP-related care; travel time to PrEP provider; and ability to bundle PrEP-related care with gender-affirming hormone therapy services. Participants responded to five questions, each of which presented two PrEP programme scenarios and one opt-out option per question and selected their preferred programme in each question. We used hierarchical Bayes estimation and multinomial logistic regression to measure part-worth utility scores for the total sample and by respondents' PrEP status.

RESULTS

The median age was 24 years (range 18-56); 75% were assigned female sex at birth; 54% identified as transmasculine; 32% as nonbinary; 14% as transfeminine. Out-of-pocket cost had the highest attribute importance score (44.3%), followed by the ability to bundle with gender-affirming hormone therapy services (18.7%). Minimal cost-sharing ($0 out-of-pocket cost) most positively influenced the attribute importance of cost (average conjoint part-worth utility coefficient of 2.5 [95% CI 2.4-2.6]). PrEP-experienced respondents preferred PrEP delivery in primary care settings (relative utility score 4.7); however, PrEP-naïve respondents preferred pharmacies (relative utility score 5.1).

CONCLUSIONS

Participants preferred programmes that offered PrEP services without cost-sharing and bundled with gender-affirming hormone therapy services. Bolstering federal regulations to cover PrEP services and prioritizing programmes to expand low-barrier PrEP provision are critical to achieving equitable PrEP provision. Community-engaged implementation research conducted by and in close collaboration with trans community stakeholders and researchers are needed to streamline the design of patient-centred PrEP programmes and develop implementation strategies that are salient to the diverse sexual health needs of trans patients.

The intersectional social patterning of early-COVID-era digital intimacies among transgender and gender-diverse young adults: effects on peri-pandemic sexual decision-making

Interactive communications technologies facilitate identity formation and socio-sexual connection among transgender and gender-diverse young people. However, within their communities, variations in technology use along ethno-racial, sexual and gendered lines, and as facilitators of sexual resilience during the early COVID-19 pandemic, remain under-studied. Among N = 230 transgender and gender-diverse young adults, surveyed between October 2020 and September 2021, latent class analyses characterised participants by preferred functional affordances, such as finding dates, sex and friends (Model 1), and by simultaneous account-keeping across social, dating and 'hookup' apps (Model 2). Werron and Ringel's typology of pandemic practices characterised qualitative descriptions of sexual decision-making attributed to COVID-19. Both fit indices favoured two-class solutions. Model 1 detected an n = 89, 43% 'high interactive communications technologies-enabled intimacy' (versus 'low technology-enabled intimacy') class, in which digitally mediated friendships, dates, sexual encounters and gay/lesbian sexualities, predominated. An n = 38, 17% 'high socio-sexual polymedia' (versus 'low polymedia') class in Model 2 was characterised by simultaneous social media, 'hookup' and dating app usage. 'High' subgroups saw statistically significant reductions in sexual partners, with the high polymedia class also associated with reductions in HIV testing. Qualitative results contextualised these reductions as, predominantly, 'responsive' pandemic practices: reactions to stay-at-home orders.

Are Cisgender Women and Transgender and Nonbinary People Drinking More During the COVID-19 Pandemic? It Depends

PURPOSE

This narrative review of research conducted during the first 2 years of the COVID-19 pandemic examines whether alcohol use among cisgender women and transgender and nonbinary people increased during the pandemic. The overarching goal of the review is to inform intervention and prevention efforts to halt the narrowing of gender-related differences in alcohol use.

SEARCH METHODS

Eight databases (PubMed, APA PsycInfo, CINAHL, Embase, Scopus, Gender Studies Database, GenderWatch, and Web of Science) were searched for peer-reviewed literature, published between March 2020 and July 2022, that reported gender differences or findings specific to women, transgender or nonbinary people, and alcohol use during the pandemic. The search focused on studies conducted in the United States and excluded qualitative research.

SEARCH RESULTS

A total 4,132 records were identified, including 400 duplicates. Of the remaining 3,732 unique records for consideration in the review, 51 were ultimately included. Overall, most studies found increases in alcohol use as well as gender differences in alcohol use, with cisgender women experiencing the most serious consequences. The findings for transgender and nonbinary people were equivocal due to the dearth of research and because many studies aggregated across gender.

DISCUSSION AND CONCLUSIONS

Alcohol use by cisgender women seems to have increased during the pandemic; however, sizable limitations need to be considered, particularly the low number of studies on alcohol use during the pandemic that analyzed gender differences. This is of concern as gender differences in alcohol use had been narrowing before the pandemic; and this review suggests the gap has narrowed even further. Cisgender women and transgender and nonbinary people have experienced sizable stressors during the pandemic; thus, understanding the health and health behavior impacts of these stressors is critical to preventing the worsening of problematic alcohol use.

Racial-ethnic, gender identity, and sexual orientation disparities in COVID-19-related social and health outcomes: A decomposition analysis

Despite the growing literature on racial-ethnic disparities during the pandemic, less is known about the explanatory mechanisms of these disparities and inequalities across other axes, such as gender and sexual identities. We studied the levels and sources of racial-ethnic, gender identity, and sexual minority disparities in social (i.e., unmet resource needs) and health (i.e., hospitalization) outcomes among individuals diagnosed with COVID-19, hypothesizing differential age structure, underlying health, and work and living arrangements as contributors to inequalities. Using large-scale administrative data from Chicago and adjusting for covariates, we found substantial racial-ethnic and gender identity disparities in both outcomes, and weak evidence of sexual minority disparities in unmet needs. Subsequent decomposition analyses revealed that living in larger households, having a higher share of non-adult cases, and facing higher burdens of chronic illness, obesity, and unemployment each statistically significantly drove racial-ethnic disparities in unmet needs, but these together explained less than 15% of the disparities. Similarly, about 20% of the Black-White gap in hospitalization resulted from disparities in underlying health and unemployment, whereas a higher proportion of non-adult cases or higher unemployment rates respectively proved the only significant pathways to partially explain transgender individuals' disadvantages in unmet needs (12%) or hospitalization (6%). These findings highlight the importance of considering multiple dimensions of social differences in studying health disparities, the vulnerabilities of transgender and non-adult communities during the pandemic, and the valid yet quite limited roles of previously suggested sociodemographic factors in accounting for COVID-19-related categorical inequalities.

A Single Center Review of COVID-19 Testing and Vaccination in the Transgender and Nonbinary Population

Purpose: The coronavirus disease 2019 (COVID-19) pandemic has disproportionately affected transgender and nonbinary (TGNB) persons. We evaluated COVID-19 testing and vaccination rates among TGNB patients at our institution. Methods: We compared COVID-19 testing and vaccination rates between TGNB patients and a cisgender population matched by age, race, and ethnicity. Data were collected through September 22, 2021. Demographic variables, testing rates, and vaccination rates were collected. Descriptive statistics were calculated, and regression was performed on outcomes of interest: any vaccination dose, at least one test, and at least one positive test. Gender modality was the exposure of interest. Results: There were 5050 patients: 1683 cisgender men, 1682 cisgender women, and 1685 TGNB individuals. TGNB patients were more likely to be on Medicaid/Medicare and more likely to be single. The number of patients with at least one test was similar between TGNB (n = 894, 53.1%) and cisgender (n = 1853, 55.1%) groups. The number of patients who had at least one positive test was higher among cisgender patients (n = 238, 7.1%) compared with TGNB patients (n = 73, 4.3%). Vaccination rates were significantly greater among TGNB patients. Compared with cisgender patients, TGNB patients had greater odds of vaccination (adjusted odds ratio [aOR] = 1.25 [95% confidence interval; CI 1.06-1.48]). Compared with cisgender patients, TGNB patients had lower odds of having at least one positive COVID-19 test (aOR = 0.51 [95% CI 0.36-0.72]). Conclusion: Our institutional experience found that vaccination rates for TGNB patients were higher and COVID-19 positivity lower than for cisgender patients.

Improving the inclusion of transgender and nonbinary individuals in the planning, completion, and mobilization of cardiovascular research

Cardiovascular disease is the leading cause of morbidity and mortality globally. Transgender and nonbinary (TNB) individuals face unclear but potentially significant cardiovascular health inequities, yet no TNB-specific evidence-based interventions for cardiovascular risk reduction currently exist. To address this gap, we propose a road map to improve the inclusion of TNB individuals in the planning, completion, and mobilization of cardiovascular research. In doing so, the adoption of inclusive practices would optimize cardiovascular health surveillance and care for TNB communities.

Disparities in HIV Testing, Condom Use, and HIV Education Between Transgender and Not Transgender High School-Aged Youth: Findings From the 2019 Youth Risk Behavior Survey

Transgender individuals are disproportionately affected by HIV in the United States. Given increased risk of HIV among youth, there is a need to understand HIV risk and protective factors among transgender individuals who are 18 years and younger. Patterns of HIV testing, HIV education, and condom use have known associations with HIV outcomes among youth in general, but are understudied among transgender youth. This study assessed these outcomes by developing a series of sex-stratified multivariable logistic regression models using pooled Youth Risk Behavior Survey data. Results indicate female and male transgender youth as well as males who were not sure they were transgender were more likely have tested for HIV compared with their not transgender peers. Male transgender youth were significantly less likely to have received HIV education compared with not transgender males. Females not sure if they were transgender and male transgender youth were significantly less likely to have used condoms compared with, respectively, not transgender female and not transgender male counterparts. In sum, condom use and HIV education both remain lower among transgender individuals relative to their not-transgender peers. This highlights the need for the promotion of culturally appropriate HIV education and HIV prevention supports among transgender youth.

Impacts of COVID-19 on trans and non-binary people in Canada: a qualitative analysis of responses to a national survey

Background

Emerging international evidence indicates the COVID-19 pandemic has exacerbated socioeconomic and health challenges faced by transgender (trans) and non-binary populations globally. This qualitative study is among the first to characterize impacts of the pandemic on these groups in Canada.

Methods

Drawing on data from the Trans PULSE Canada survey (N = 820), we used thematic analysis to examine the free-form responses of 697 participants to one open-ended question on impacts of the pandemic. We first organized responses into descriptive themes, and then used this preliminary analytical process to construct more refined, higher order themes that provided a rich account of the pandemic’s impacts.

Results

Our results are organized into five themes that highlight the pandemic’s impacts on trans and non-binary populations in Canada. These include: (1) reduced access to both gender-affirming and other healthcare, (2) heightened financial, employment, and housing precarity, (3) strained social networks in an era of physical distancing and virtual communication, (4) an intensification of safety concerns, and (5) changes in experiences of gender affirmation.

Conclusion

Our findings highlight the pandemic’s systemic impacts on the lives of trans and non-binary people in domains such as healthcare, employment, and housing, and on the social networks of these groups, many of which reflect an exacerbation of pre-existing inequities. Based on our analysis, we recommend that public health researchers, policymakers, and practitioners attend to the structural impacts of the pandemic on these groups as primary sites of inquiry and intervention.

Telehealth in Trans and Gender Diverse Communities: the Impact of COVID-19

Purpose of Review

This paper synthesizes current knowledge regarding telehealth and the impact of the SARS-COV2 pandemic on transgender and gender diverse (TGD) patients. We discuss the benefits and challenges of telehealth for patients, providers, and trainees.

Recent Findings

Mental health of TGD populations has been disproportionately challenged in the context of SARS-COV2, and telehealth interventions focused on gender affirmation and mental health are desired and acceptable by TGD populations.

Summary

Telehealth in the era of SARS-COV-2 has a mixed impact on TGD patients and families, increasing access, decreasing travel time, and allowing for comfort and safety during care while also leaving gaps in care for patients without web/phone access and/or without a confidential place to participate in appointments, or to manage health concerns that require in-person evaluation. Providers have benefitted from the ability to reach TGD patients that are far from practice sites and to provide remote consultation for procedures and other interventions. Trainees have challenges as a result of telehealth practice which can impair the ability to learn in-person care, but have benefitted from remote training opportunities, including surgical training. Alterations in compensation structures have allowed sustainable telehealth practice to be an option for providers and health systems. As telehealth evolves, quality improvement and research efforts aimed at resolving known challenges and expanding beneficial uses of telehealth should consistently include and consider not only the beneficiaries of telehealth but also those who may struggle with access.