Early in the COVID-19 pandemic, it was common to hear, “the virus is the great equalizer.” However, this crisis quickly illuminated the deep inequities in obtaining access to the necessary building blocks of health. This is especially true for the Transgender and Non-Binary (TGNB) community, who have been uniquely affected by the pandemic in several ways, including the risk of exposure to the virus and its adverse outcomes, delays in access to gender-affirming care, and diminished access to social support, which is crucial to protecting against the effects of stigma and discrimination. Notably, these challenges are occurring alongside numerous legal and interpersonal challenges and attacks on transgender rights.
Legacy of Economic Instability and Health Outcomes Related to COVID-19
Emerging evidence demonstrates that social determinants of health, defined as the day-to-day factors affecting stress levels, access to health care, and the ability to protect oneself against negative health outcomes, impact rates of exposure to and adverse outcomes of the virus. There is evidence that economic status (e.g., poverty, living in overcrowded conditions, homelessness) shapes one’s risk for infection and poor outcomes. Due to a legacy of education discrimination, employment discrimination, and family rejection, many TGNB individuals experience economic instability. The 2015 National Transgender Discrimination Survey found that TGNB people were unemployed at three times the rate of the general population, and TGNB people of color were unemployed at up to four times the rate general population. Respondents reported significantly lower household incomes than the population as a whole, with 12% of the sample making less than $10,000 a year. TGNB people of color reported higher rates of poverty than their white counterparts. Strikingly, almost a fifth of the sample reported experiencing homelessness at some point in their life because they were TGNB. The pandemic has contributed to an economic crisis that disproportionately affects working-poor Americans. Given the relative economic disadvantage of TGNB people, one would expect that the damage to the economy will seriously impact working poor TGNB people – making it easier for members of this vulnerable group to fall further into poverty and experience its corresponding health risks. Moreover, TGNB people are uninsured at higher rates than their cis-gender counterparts, which affects access to care for COVID-19 infection. As a whole, TGNB communities, and particularly low-income and TNGB people of color, may be especially vulnerable to developing severe short- and long-term health risks associated with COVID-19.
Increased Barriers to Gender-Affirming Medical Care and Legal Rights
The postponement of non-emergency medical care represents another way in which the COVID-19 pandemic has impacted the TGNB community, especially in the first few months of the pandemic. Individuals with gender dysphoria need to plan and prepare in advance to access medically necessary gender-affirming interventions, such as top surgery. Procedures may not be covered by insurance companies or require appeals for coverage. Thus, postponement of these medically necessary procedures can prolong suffering and hardship in what can be an already challenging and circuitous process. Additionally, puberty suppression in early adolescence is especially time-sensitive because of an optimal window to effectively prevent the onset and progression of pubertal changes; thus, postponement of care due to the pandemic especially impacts young TGNB people. Fortunately, the availability of in-person appointments for accessing hormone therapy and surgeries has resumed. Nevertheless, the impact of COVID-19 remains. For example, the complications of travel during COVID-19, such as travel restrictions, quarantines across states, and risk of infection, may limit people’s options to obtain gender-affirming surgeries in another state or country or impact their post-operative care plans (e.g., if they planned on having a family member come from another state to help care for them or if they planned to go home during their post-operative care time). Additionally, international students who needed to re-locate home or who are unable to return to the US due to border restrictions may no longer have access to gender-affirming care.
Delays in gender-affirming care were also exacerbated by court closures for non-essential business. TGNB individuals rely on the courts to legally change their given names and gender markers to match their gender identity. While progress has been made in many states to make these processes less cumbersome, there remain barriers to TGNB people wanting to attain these services, such as lack of cultural competency and training of professionals involved in the process. Further delays in legally changing one’s name or gender marker are not only frustrating but can be highly dysphoric for individuals who are dependent on the legal system to facilitate living in their affirmed identity. Implications can be longstanding, for example, in the case of an individual who is applying for a new job and would like to use their correct name. Delays in obtaining correct legal documents may also lead to having to disclose one’s transgender identity to potential employers, given the requirement to provide legal identification during the application process.
The Impact of Social Isolation
The COVID-19 pandemic has diminished TGNB individuals’ access to the critical emotional and instrumental social support networks that are vital to their well-being. TGNB people do not always have support from their families of origin and consequently, many rely on peer networks and TGNB-affirming organizations for social support (e.g., university-affiliated LGBT centers, Community LGBTQ centers, Meetup groups). Peer and community support are essential to one’s sense of wellness and especially critical to TGNB people as they work to navigate identity development, stigma, and discrimination. With school and university closures, TGNB youth may be living at home with family members who are struggling to accept and understand, or who do not accept their identities. TGNB adults also have diminished access to supportive communities given the limited number of online and virtual resources for TGNB people.
Anti-TGNB Violence and Legislation
Social isolation during COVID-19 is also occurring in the context of violence against and systemic disenfranchisement of this population. At least 28 TGNB people have been murdered in the first eight months of 2020 (26 murders were reported in 2019) (National Center for Transgender Equality). The impact of TGNB deaths (both from COVID-19 infection and from violence) during this time of social isolation is particularly challenging given restrictions to gather and mourn with others. Moreover, the interpersonal violence against TGNB people is occurring during a time that a number of anti-transgender bills and policy changes are being proposed across both state and federal legislatures. The recent proposed US Department of Housing and Urban Development policy change denying TGNB peoples’ access to single-gender homeless or domestic violence shelters aligned with their gender identity is likely to impact the TGNB community, given their increased risk of domestic violence due to stay-at-home orders and the unemployment crisis. Moreover, there is well-documented research demonstrating the link between TGNB peoples’ mental health and laws and protections available for this community. Thus, these proposals, even if they are not ultimately passed, have consequences for the health of the community. These attacks are particularly insidious during a global pandemic that has disproportionately affected marginalized individuals.
TGNB Resilience and Resistance
The TGNB community is tremendously resilient. There have been significant gains by the TGNB community in securing civil rights and gaining more visibility in political and cultural spaces – even while navigating the impact of the COVID-19 pandemic. The Supreme Court ruling that LGBT individuals cannot be discriminated against based on their sexual orientation or gender identity in the workplace provides critical economic protection for TGNB people as well as access to workplace-based health insurance. The pandemic has also presented many TGNB people with the opportunity to focus on themselves by experimenting with gender expression or beginning hormone therapy in the privacy of their own homes without having to worry about how others may respond to their gender expression or physical transition. The TGNB community has moved “online” in many ways to continue to provide support to each other in the form of Zoom social support groups and social activities. Moreover, in New York City, the community has organized and worked to preserve the dignity and rights of its most vulnerable members by hosting the Black Trans Lives Matter marches this past June. Many TGNB people are feeling more confident in their ability to come out and seek acceptance from their friends and families during this time than ever before.