By Caroline McKenna
While COVID-19 has fractured the world’s health care systems and economies, more than anything it has highlighted and exacerbated the pre-existing health inequities in vulnerable populations. Among the most vulnerable is the trans community, and even more so, the Black trans and Two Spirit communities.
First, a brief note on definitions. While “cisgender” refers to people who identify as the sex they were assigned at birth, the term “trans” refers to people who do not identify as the sex they were assigned at birth, including transgender and non-binary individuals. Not all trans people want or need medical interventions to live comfortably in their gender. Two-Spirit, a translation of the Anishinaabemowin term niizh manidoowag, two spirits, refers to “Indigenous people who adopt roles, attributes, dress or attitudes with various gender identities for personal, spiritual, cultural or social reasons”. The term therefore encompasses sexuality, gender, and spirituality, and can have different connotations depending on the individual.
Trans health is affected by a complex variety of factors. Transphobia contributes to health inequities, which are exacerbated by other determinants of health including ethnicity, income, and access to healthcare. Trans people in Canada experience high rates of violence and harassment. In the 2019 Trans PULSE study – which collected data from 2,873 trans and non-binary people in Canada – the majority of participants had experienced verbal harassment related to being trans; 16% and 26% had experienced physical and sexual assault, respectively; and 64% reported avoiding at least 20% of public spaces for fear of being harassed or outed. Income and employment are also an issue, as a 2015 study reported that 13% of trans Ontarians have been fired for being trans and 18% were turned down for a job due to their trans identity. Furthermore, 50% of the trans people surveyed live in low-income neighbourhoods, compared with 37% of the general population. Furthermore, stigma and discrimination contribute to reluctance to seek healthcare services. An Ontario study found that 50% of transgender patients with family physicians experienced discomfort when discussing transgender health issues. Even more concerning, 21% reported avoiding emergency department care due to fear of mistreatment as a result of their trans status, with 52% reporting at least one trans-specific negative experience while receiving emergency department care.
These factors contribute to poor health outcomes in the trans population. More than 1 in 5 transgender adults have at least one chronic disease, such as diabetes, arthritis, or asthma. Trans individuals are also disproportionately affected by mental health issues. The 2009-2010 Trans PULSE study found that 60% of trans people reported having depression; 36% said they had suicidal thoughts in the past 12 months and 10% indicated that they had attempted suicide . For those trans individuals that require gender affirming surgery, lack of providers, intensive medical gatekeeping, and long wait times contribute to limited access to surgeries, which increases the risk of depression and suicidal ideation.
The detrimental effect of transphobia on health is even more pronounced in Black trans and Two-Spirit communities, as the intersections of racism, sexism, homophobia, and transphobia come together and interact to create barriers that further their vulnerability. Transgender people of color and transgender women are disproportionately affected by violence, with nearly 3 out of 4 lethal anti-LGBT hate crimes in the US committed against trans women and girls. Black transgender people reported much higher rates of biased harassment and assault by police officers than the general trans population (38% and 15%, respectively). A Trans PULSE study of Indigenous gender-diverse Ontarians, 44% of which were Two-Spirit, identified high levels of poverty (47%), homelessness or underhousing (34%), having to move due to being trans (67%), unmet health care needs (61%), violence due to being trans (73%), suicidal thoughts (76%), and incarceration while presenting in their felt gender (20%). In another Trans PULSE study on the effect of transphobia and racism on HIV risk among trans persons of colour in Ontario, researchers found that increases in one type of discrimination had the strongest effects on HIV risk when coupled with high levels of the other.
COVID-19 worsens longstanding health vulnerabilities in the trans community, making trans individuals disproportionately affected by the pandemic. While the virus doesn’t care about gender identity, vulnerabilities like a high-risk job, no paid leave, lack of safe housing, and use of public transportation all increase one’s risk, and trans people are more likely to experience these risk factors. Trans people are more likely to have part-time or informal employment, and low income, making them disproportionately affected by COVID-related work closures, and/or less able to practice social distancing. Higher rates of cancer, chronic disease, and HIV in trans people make this population more likely to be immunosuppressed and vulnerable to COVID. In addition, chest binding, while a vital practice to improve self-esteem for many trans and non-binary people, may exasperate respiratory symptoms in people that contract the virus. Furthermore, access to trans health services including hormone interventions and gender-affirming surgeries, which was already insufficient prior to COVID, is incredibly limited in light of hospitals postponing or cancelling non-emergent surgeries. It should be recognized that individuals have fought long and hard to access medically necessary gender-affirming surgeries, and that postponing surgeries has a significant impact on mental health for many trans individuals. As well, hormone therapy, used by 43% of trans people in Ontario, requires monitoring every 3 months until stable, then every 6 months, which is a challenge during COVID. Additionally, there is a lack of appointments for new patients. A transgender clinic in Beijing, China, found that low access to hormone interventions during the pandemic was associated with increased depression and anxiety due to uncertainty about the availability of future treatments and struggles with maintaining unwanted gender identities.
In terms of recommendations, it cannot be understated that members of these communities know best how to improve their health and that they should be included in all related decision-making. Recommendations include providing increased support to transgender-led organizations that support the trans community. For example, Trans Lifeline is a grassroots hotline and microgrants organization that handles 75,000 calls annually and offers direct emotional and financial support via transgender operators. Elena Rose Vera, the hotline’s executive director, reported that since the pandemic, “We’ve seen four to five times as many calls about unemployment and about workplace discrimination,” and “Calls about domestic violence and health care increased 300 percent, because of lockdown-related hurdles to accessing treatments and medications”. Secondly, it is more important than ever for health care providers to evaluate their privilege and work towards a healthcare system that doesn’t discriminate against trans people. Thirdly, governments should implement measures to ensure the availability of both prescription hormones and online telemedicine counselling for transgender individuals, as hormone intervention requires lifelong medical support and monitoring. Lastly, it is imperative to include sexual orientation and gender identification in pandemic statistics, and general health statistics. The lack of LGBTQ+ data even before COVID makes it impossible to fully understand health outcomes in order to address them. The world has a long way to go in terms of addressing gaps and inequities in trans healthcare, and further inaction during this pandemic places an already vulnerable community at great risk of negative health outcomes.
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