Gender-affirming care, mental health, and economic stability in the time of COVID-19: A multi-national, cross-sectional study of transgender and nonbinary people

  1. Brooke A. Jarrett
  2. Sarah M. Peitzmeier
  3. Arjee Restar
  4. Tyler Adamson
  5. Sean Howell
  6. Stefan Baral
  7. S. Wilson Beckham

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Abstract

Transgender and nonbinary people are disproportionately affected by structural barriers to quality healthcare, mental health challenges, and economic hardship. This study examined the impact of the novel coronavirus disease (COVID-19) crisis and subsequent control measures on gender-affirming care, mental health, and economic stability among transgender and nonbinary people in multiple countries.

Methods

We collected multi-national, cross-sectional data from 964 transgender and nonbinary adult users of the Hornet and Her apps from April to August 2020 to characterize changes in gender-affirming care, mental health, and economic stability as a result of COVID-19. We conducted Poisson regression models to assess if access to gender-affirming care and ability to live according to one’s gender were related to depressive symptoms, anxiety, and changes in suicidal ideation.

Results

Individuals resided in 76 countries, including Turkey (27.4%, n = 264) and Thailand (20.6%, n = 205). A majority were nonbinary (66.8%, n = 644) or transfeminine (29.4%, n = 283). Due to COVID-19, 55.0% (n = 320/582) reported reduced access to gender-affirming resources, and 38.0% (n = 327/860) reported reduced time lived according to their gender. About half screened positive for depression (50.4%,442/877) and anxiety (45.8%, n = 392/856). One in six (17.0%, n = 112/659) expected losses of health insurance, and 77.0% (n = 724/940) expected income reductions. The prevalence of depressive symptoms, anxiety, and increased suicidal ideation were 1.63 (95% CI: 1.36–1.97), 1.61 (95% CI: 1.31–1.97), and 1.74 (95% CI: 1.07–2.82) times higher for individuals whose access to gender-affirming resources was reduced versus not.

Discussion

The COVID-19 crisis is associated with reduced access to gender-affirming resources and the ability of transgender and nonbinary people to live according to their gender worldwide. These reductions may drive the increased depressive symptoms, anxiety, and suicidal ideation reported in this sample. To improve health of transgender and nonbinary communities, increased access to gender-affirming resources should be prioritized through policies (e.g., digital prescriptions), flexible interventions (e.g., telehealth), and support for existing transgender health initiatives.

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  3. Version published to 10.1371/journal.pone.0254215
  4. ScreenIT

    SciScore for 10.1101/2020.11.02.20224709: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Institutional Review Board StatementConsent: To take the survey, individuals had to report being 18 years or older, view a consent form, and indicate their informed consent by clicking a button to begin.
    IRB: The Johns Hopkins School of Public Health Institutional Review Board provided a Category 4 exemption to the larger survey prior to distribution.
    RandomizationTo ensure the quality of our study population, we screened for duplicate survey responses based on IP address, and again by searching for identical responses to twenty randomly selected variables but found none.
    Blindingnot detected.
    Power Analysisnot detected.
    Sex as a biological variableWe excluded all women assigned female or intersex at birth (n=161), all men assigned male or intersex at birth (n=12,740), individuals who did not report a gender (n=9,751), individuals who only reported not knowing, not wishing to disclose, or being unable to disclose their gender (n=654), and non-transgender identifying men and women who did not report an assigned sex at birth (n=27).

    Table 2: Resources

    No key resources detected.

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    These results, however, may reflect a limitation of our measurement tool. For example, the former group likely had a low baseline ability to live according to their gender pre-pandemic and hence could only increase the amount of time lived according to their gender. The worse mental health in this group may be linked to low pre- pandemic levels of living according to their gender, rather than the recent increase in their ability to do so. Because we did not measure pre-pandemic and current ability to live according to one’s gender separately, we could not control for baseline levels in the model. It is also possible that people who recently began living in their gender more may be subjected to elevated levels of anticipated and experienced stigma that could be driving increased suicidality; prior research has shown discrimination due to gender expression, rather than gender identity itself, to be associated with mental distress.45–47 Positive screens for depression and anxiety were correlated with decreases in access to gender-affirming care and decreased time lived according to one’s gender, and were present in nearly half the sample. These data align with results from transgender and non-binary youth from the Trevor Project poll and another sample of 201 young adults (19-25 years) attending college, both from the U.S.44,48 Findings in a small study of 15 Latinx trans women in the United States suggest that these poor mental health indicators represent declines as a result o...

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

    About SciScore

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  5. Version published to 10.1101/2020.11.02.20224709v1 on medRxiv
  6. Version published to 10.1101/2020.11.02.20224709v2 on medRxiv