The Impact of COVID-19 on Healthcare Access for Gender-Diverse Adults: A Qualitative Study

Abstract

Background

Transgender and gender-diverse (TGD) individuals, whose well-being relies on gender-affirming care, faced heightened barriers during the COVID-19 pandemic. Structural inequities intensified as non-emergent services were deprioritized.

Objective

In this paper we examined changes and delays in healthcare access by TGD populations across the United States during the COVID-19 pandemic.

Methods & Design

From September 2022 through March 2023, we administered an online survey to TGD adults in the United States. Participants responded to the question, “How did COVID-19 impact your experience accessing healthcare?” We used inductive coding and thematic analysis techniques to analyze the 87 responses.

Results

Response themes were: (1) shift to telehealth, (2) availability and access and why those were limited, (3) affordability, (4) delays in gender-affirming care, and (5) delays in healthcare overall. Participants frequently discussed telehealth shifts and access limitations.

Conclusion

TGD individuals face significant, structurally rooted healthcare barriers that COVID-19 intensified. Integrating gender-affirming care into comprehensive healthcare systems is essential for ensuring accessible care for TGD populations. Additionally, creating and reforming relevant policies with input from TGD individuals can help reduce healthcare access disparities going forward and in future crises.

Introduction

In April 2020, the Centers for Medicare and Medicaid Services (CMS) recommended postponing non-emergent, non-urgent, and elective in-person services. ¹ The decision forced many healthcare organizations to delay in-person services, triage operative resources, and rapidly shift to telehealth.^2-6 “Elective” surgeries and “non-essential” surgical, medical, and dental procedures were cancelled, including gender-affirming care (GAC) procedures.^1,7 GAC is a holistic approach to speciality and general healthcare that addresses the physical, mental, and social needs of gender-diverse individuals while affirming their gender identity. ⁸ GAC can include correct use of names and pronouns, dignity in screenings, hormone therapies, surgeries, and various forms of specialty care including dermatology, otolaryngology, speech therapy, etc.^9,10 GAC can alleviate dysphoria ¹¹ and promote gender euphoria.^12,13 GAC has been associated with improved well-being, psychosocial functioning, and body satisfaction, as well as reduced depression, anxiety, and suicidality, making GAC not only necessary for some, but lifesaving.^9,10,14,15

Despite this, many GAC procedures were deemed “routine priority,” “elective,” and “non-emergent” based on guidance from local and state governments and relevant surgical speciality societies, leading to their deprioritization during the COVID-19 pandemic.^6,7,16-21

Trans and gender-diverse (TGD) adults, comprising ∼1.3% of the U.S. population, already experienced disparities in accessing healthcare, including GAC, prior to the pandemic.^22-24 Such barriers include geographic isolation, inadequate insurance, unknowledgeable providers, referral requirements, stigmatization, and legislative attacks on GAC.^23-27 Beyond GAC, primary and general care serve not only as the foundation for preventive health and chronic condition management, but also as a critical access point for GAC, including hormone therapy and specialist referrals. ¹⁰ Affirming and accessible primary care has also been associated with reduced health disparities and improved mental health outcomes for TGD people. ²⁸

During the pandemic, access to GAC, especially services that are necessarily in-person (e.g., surgical procedures and hormone-related bloodwork), was further reduced.^2,29-32 TGD individuals were also more likely to experience healthcare interruptions during the pandemic than their cisgender (i.e., non-TGD) counterparts.^3,4 These issues were related to the postponement of non-urgent care, provider shortages, and clinic closures, further contributing to pre-existing barriers to care for TGD people.^1,2,23,24 The centralized lockdown and reopening response, which was not co-related to the local disease burden and hospital capacities, ³³ exacerbated healthcare access challenges and unintentionally disproportionately allocated burdens to the TGD population.^1,29,34-36

Primary, preventive and gender-affirming care are all critical for TGD populations; however, existing research on the impact of COVID-19 on TGD populations has primarily focused on GAC, with limited attention paid to disruptions in primary, preventative and other essential healthcare services.^2,6,7 To address this gap, we examined how the COVID-19 pandemic affected access and utilization of primary care, mental health services, and GAC for TGD individuals in the U.S. We hypothesized that the pandemic exacerbated existing structural barriers, leading to delays in care.

Methods

Study Design and Participants

This study was approved by the Dartmouth College Committee for Protection of Human Subjects Review Board on July 1, 2022. Senior author collected data from transgender, non-binary, and gender-diverse adults aged 18 and older across the United States between September 2022 and March 2023. The online survey, delivered via a Qualtrics-based questionnaire, included both open-ended and closed-ended questions. A waiver of signed consent was granted because the study involved minimal risk and did not collect any personally identifying information, thereby protecting participants’ anonymity in accordance with IRB regulations for electronic consent processes. An electronic consent was obtained from the participants. All participants were presented with an IRB-approved digital consent text before beginning the Qualtrics survey. Only participants who consented were able to proceed to the survey questions and submit their answers. Those who did not consent were exited from the survey and their responses were not recorded.

Participants were recruited using purposive social network sampling and snowball sampling. Recruitment was carried out through the personal social media accounts of the study team, some which identified as being TGD and/or people of color, leveraging existing social networks to access the target population, especially in the local communities. The study team reached out to the TGD community organizers, many of whom were people of color, to share the study within their networks. Additionally, the study was shared on TGD focused social media forums and TGD exclusive app like TRACE, a transition recording and community engagement mobile application for Transgender and Non-Binary individuals, and their allies. A team member who identifies as a TGD individual posted about the study through their personal account. Eligibility criteria were as follows: (a) self-identified as transgender, non-binary, gender nonconforming, or gender diverse, (b) were 18 years of age or older, (c) lived in the United States at the time of the survey, (d) reported accessing gender-affirming care during their lifetime and (e) consented to participate in the study.

The study team made efforts to include TGD respondents from diverse backgrounds, particularly focusing on variations in race/ethnicity, socioeconomic status, sexual orientation, and geographic location, and reached out to individuals at organizations that work with transgender people of color.

Data Collection and Review

The study team developed and pretested a survey with seven TGD American community members representing diverse social, racial, and gender identities, as well as varying educational and occupational backgrounds. Pretesting ensured questions were affirming, culturally appropriate, and meaningful. The survey, was designed to understand the experiences that transgender, nonbinary, and gender non-conforming individuals have when accessing health care, included 35 closed- and 15 open-ended items on (i) demographics, (ii) access to gender-affirming sociolegal services (e.g., name changes on identification), (iii) physical health care access, and (iv) experiences with gender-affirming care (e.g., hormone therapy, surgeries). Participants received a $5 gift card for completing the screener and a $15 gift card upon survey completion.

To ensure data quality, the team implemented CAPTCHA, screened for duplicate IP addresses, and manually reviewed responses. Of 2,283 initial submissions, 2,167 were identified as bot-generated through manual review and were excluded. Manual review assessed completeness, and coherence to ensure that included response were not bot-generated. Given the number of suspected bot responses, the study implemented additional verification processes, beginning with requiring each interested participant to complete a screener. Eligible participants were then assigned unique participant ID numbers. Any survey responses lacking a corresponding ID number were rejected. Each response was also manually and proactively reviewed by a study team member, and responses containing repeated segments were rejected. Same/similar responses entered at the same date/time were considered as an indicator of a bot. The team closely reviewed responses for inconsistencies and cross-checked consistency across survey and screener responses. The team specifically tracked whether certain items, such as income, were missing or skipped. ³⁷ Additionally, a sensitivity analysis was conducted comparing the survey completion duration between human responses and suspected bot responses. The difference in duration was statistically significant (p < 0.001), with human mean duration being substantially lower than that of bots, and a completion threshold of 70-80% was applied. There was a total of 116 verified human responses. All personal identifying information was removed to protect the privacy of study participants. The final analytic sample consisted of 87 participants, following the exclusion of 29 respondents who did not respond to the relevant measure of analysis: “How did COVID-19 impact your experience accessing health care?”

The survey included multiple questions, of which only one related to COVID-19 and participants’ experiences accessing healthcare, including but not limited to gender-affirming care, during the pandemic. The responses to this open-ended question provided rich and detailed explanations that fulfilled content saturation. Additionally, the study team identified a pattern of triangulation across the responses and was able to successfully conduct inductive thematic analysis. Given these findings, the authors decided to proceed with the paper despite its focus on a single question.

Data Analysis

The data analysis process involved an inductive thematic analysis approach to explore the experiences of TGD individuals.^38,39 The thematic analysis was guided by the Structural Stigma Framework as a sensitizing framework, informing interpretation while remaining open to emergent themes. The Structural Stigma Framework describes how societal-level conditions, cultural norms, and institutional policies systematically disadvantage and constrain opportunities, resources, and well-being for stigmatized groups, including transgender and gender-diverse individuals. ⁴⁰

This study used a fixed sample of 87 responses, precluding the iterative data collection and analysis. Accordingly, the study used a thematic analysis approach that focused on identifying and describing key patterns and trends related to healthcare access for the TGD population during the pandemic.^38,39 The process began with researchers familiarizing themselves with the data and discussing patterns of data saturation, followed by inductive coding. Two researchers independently coded a subset of the data to develop an initial codebook. They then met to discuss their findings, refine the codebook, and create initial themes. Next, the researchers organized the codes into broader themes. These themes were further validated through an iterative process of coding and refinement, during which the researchers revisited the data to ensure that the themes and their titles accurately reflected the evidence.

Research Team

Our research team brings diverse professional expertise and social identities, informing our perspective on structural barriers to healthcare access for marginalized populations. The senior author is a health services researcher specializing in structural and institutional inequalities at the intersections of race, ethnicity, sexual orientation, and gender identity. One of the authors is a physician and public health researcher focused on health systems strengthening and equitable healthcare policy. Another author is a student researcher with a background in psychology and experience studying healthcare experiences of sexual and gender minority young adults. Study team members represent diverse social identities across race, gender, sexual orientation, and lived experience. These diverse identities and professional experiences informed the survey’s development and interpretation of findings, particularly in the context of healthcare access during COVID-19.

Participant Sample

The final sample in this qualitative study consisted of 87 TGD adults residing in the United States, detailed in Exhibit 1 (Table 1). Individuals were between the ages of 19 and 55 years old at time of response, with an average age of 29.25 and a standard deviation of 6.61. The majority identified as transmasculine, followed by non-binary, transfeminine, and then questioning. Of the sample, 78.2% were of White/European descent, 14.9% identified as mixed race, 2.3% as of African descent, and the rest identified as Asian, Hispanic/Latine, Indigenous, or Middle Eastern/North African at 1.1% each. Most respondents were from the West Census region, followed by the Northeast, then the South, and the least from the Midwest.

Table 1.

Descriptive Characteristics of the Study Sample

​	%	Count
Gender Identity
Non-binary	26.6	24
Transmasculine	59.8	52
Transfeminine	11.5	10
Questioning	1.1	1
Sexual Orientation Identity
Gay	2.3	2
Lesbian	3.4	3
Bisexual	8	7
Straight/Heterosexual	3.4	3
Queer	29.9	26
Everyone else	3.4	3
Multiple SOI	49.4	43
Age Categories
19-26	35.6	31
27-39	59.8	52
40-55	4.6	4
Ethnoracial Groups
Indigenous	1.1	1
Asian	1.1	1
African Decent	2.3	2
Hispanic/Latine	1.1	1
Middle Eastern/North African	1.1	1
White/European Decent	78.2	68
Mixed Race	14.9	13
Employment Status
Full-time	60.9	53
Part-time	19.5	17
Self-employed	3.4	3
Unemployed	1.1	1
Student	11.5	10
Not in workforce	3.4	3
Not able to work due to disability
No	97.7	85
Yes	2.3	2
Education
High school graduate or equivalent (e.g., GED)	5.7	5
Trade/Technical/Vocational training	1.1	1
Some college	28.7	25
2-year college degree	5.7	5
4-year college degree	26.4	23
Some post-baccalaureate education, no degree	4.6	4
Master’s degree	18.4	16
Doctoral degree	3.4	3
Professional degree (e.g., MD, JD, MBA)	5.7	5
Census Region
West	40.2	35
Midwest	12.6	11
South	14.9	13
Northeast	32.2	28

% means percent of the study population; SOI means sexual orientation identity, M = mean; SD = standard deviation.

Findings

Five main themes emerged from the analysis of 87 responses to the question, “How did COVID-19 impact your experience accessing health care?”: (1) delays in gender-affirming care, (2) shift to telehealth, (3) delays in healthcare overall, (4) availability and access and why those were limited, and (5) affordability. The number of responses by the participants of the survey by theme is illustrated in Exhibit 2 (Table 2). Participants are referred to with respondent IDs (R###s) generated by the study team for the purposes of differentiation.

Table 2.

Number of Responses by the Participants of the Survey by Theme

Theme	Number
Shift to telehealth	30
Availability and access and why those were limited	29
Affordability	6
Delays in gender-affirming care	9
Delays in healthcare overall	15
Others	6
N/A	29

Note. There are 87 total participants but 124 data points, as some participant responses were sufficiently long to provide evidence for multiple themes.

Delays in Gender-Affirming Care

Nine participants described delays in accessing gender-affirming care (GAC) during the COVID-19, and its associated healthcare disruptions exacerbated existing structural barriers to accessing gender-affirming care (GAC). Detailed in Exhibit 3 (Table 3). For example, respondent R026 reported a “postponed top surgery…” - surgical procedures commonly sought by TGD individuals, including breast reductions, double mastectomies, and breast augmentations - and R069 noted “I waited a lot longer to go to the doctor for my regular check-ups, and it stalled me getting top surgery and going on HRT [hormone replacement therapy].” While only nine participants specifically mentioned delays in GAC, others alluded to similar challenges in their broader discussions of healthcare access, suggesting that this issue was more widespread than the numbers alone reflect.

Table 3.

Illustrative Responses by the Participants of the Survey by Subthemes for the Theme ‘Gender-Affirming Care Delays,’ ‘Delays in Other Healthcare,’ and ‘Affordability Challenges

Theme	Gender-affirming care delays (N=9)
Subthemes (n=number of responses addressing the subtheme)	Few examples of survey responses illustrating the subtheme
Gender Affirming Surgeries (4)	“Postponed top surgery…” (R026)
	“I waited a lot longer to go to the doctor for my regular check ups and it stalled me getting top surgery and going on HRT.” (R069)
	“i got top surgery during covid, was incredibly stressful” (R077)
Routine HRT bloodwork required in-person visits (1)	“I go to the Dr less frequently, mostly just for routine bloodwork for HRT” (R052)
Challenges accessing HRT (3)	“…I would have to cross state lines to attend virtual meetings in my home state in order to continue care with my gender center…” (R034).
	“…I also had to stop T [testosterone] because my provider was overwhelmed” (R035)
	“i just got testosterone from my boyfriend and only went to the doctor when absolutely necessary” (R059)

Note. Participants are referred to using respondent IDs (R###s) generated by the study team independent of identifiable information for the purposes of differentiation. Any grammatical or spelling errors in quotes originate with participants and have been kept for accuracy.

Shift to Telehealth

Thirty participants discussed the shift to telehealth, detailed in Exhibit 4 (Table 4), with four respondents specifically noting a complete transition to telehealth services and 13 respondents noting an increase in telehealth services. A few patients believed that telehealth was lower quality care than face-to-face consultations and preferred in-person visits, with respondent R016 stating “It [telehealth] created stress because I prefer in person [visits].”

Table 4.

Illustrative Responses by the Participants of the Survey by Subthemes for the Theme ‘Shift to Telehealth’

Theme	Shift to telehealth (N=30) sample quotes
Subthemes (n=number of responses addressing the subtheme)	Few examples of survey responses illustrating the subtheme
Complete transition to telehealth for healthcare needs (4)	“All care went Telehealth” (R082)
	“It [COVID-19] made everything virtual for a while.” (R074).
Increase in telehealth adoption since the pandemic (13)	“Most appointments went from in person to telehealth” (R078)
	“… COVID-19 has changed nothing about my experience accessing health care, except that telehealth is more available (where applicable; tests cannot be performed remotely).” (R018)
	“More virtual visits” (R054)
Improved accessibility to healthcare (9)	“Made it easier with telehealth” (R023)
	“Healthcare became more accessible via telehealth.” (R093)
	“Telehealth is dope, honestly. It’s been really helpful to receive care in my own home.” (R098)
	“Telehealth became more widely available and I feel I have more access to care that way” (R116)
Expanded access to previously unavailable providers (3)	“Made it easier, able to access virtually as opposed to in-person. This allowed me to pick and choose my care providers better than what is actually available in area” (R053)
	“Increased access to providers via telehealth” (R073)
Access to mental healthcare services (8)	“Actually improved as I was able to do therapy remotely which made it more accessible for me” (R051)
	“It was easier because of tele-health appointments, otherwise I would have expected it to take longer to get to see a MH provider.” (R088)
	“More prevalent telehealth, especially for mental healthcare, was very helpful” (R092).
Challenges (6)	“…I would have to cross state lines to attend virtual meetings in my home state in order to continue care with my gender center…” (R034)
	“It created stress because I prefer in person [visits].” (R016)

Note. Participants are referred to using respondent IDs (R###s) generated by the study team independent of identifiable information for the purposes of differentiation. Any grammatical or spelling errors in quotes originate with participants and have been kept for accuracy.

While respondent R091 noted the convenience of telehealth “Move to telehealth appointments, no need to go into the office for gender-affirming care.”, R034 had to cross state lines to attend virtual meetings “I was… living in another state, I would have to cross state lines to attend virtual meetings… to continue care with my gender center…”, highlighting the policy implementation resulting structural limitations of telehealth. This demonstrates how systemic barriers, such as lack of access to TGD-affirming providers in some geographic regions, can be both overcome and exacerbated by expanded telehealth policies.

While nine respondents mentioned that telehealth improved access to healthcare, six highlighted challenges and limitations, indicating that the shift was not universally beneficial. The shift to telehealth, while intended to improve access, inadvertently exposed and amplified existing structural barriers for GAC for some TGD individuals.

Delays in Healthcare Overall

Fifteen participants described delays in accessing a range of healthcare services beyond gender-affirming care, including preventive care screenings and regular primary care visits, due to the pandemic. Further illustrated in Exhibit 3 (Table 3).

Several participants noted that they had decided to delay check-ups and avoid seeking various forms of healthcare during the pandemic. For instance, R015 stated that they “… put off getting all usual check-ups during covid…” and R024 wrote that they “…did not see a doctor for two years.” While these were seemingly personal choices, these decisions occurred within a context of the pandemic, systemic barriers to care, and healthcare rationing, which likely influenced their choices. Additionally, some individuals who delayed seeking care felt that the decision to not seek care was more imposed on them, like respondent R017, who stated “[I] Might not have ended up having to have a tooth pulled if I’d not had to skip out on regular cleanings and checkups for a while because of covid, for instance.” Finally, the long wait times and difficulties in scheduling appointments contributed to delays in care for others, such as respondent R064, who wrote “Made it much harder - longer wait times, unable to meet in person for needed things.”

Availability and Access and why Those Were Limited

Twenty-nine respondents described issues related to the limited availability of and access to healthcare during the pandemic, listed in Exhibit 5 (Table 5). This theme illustrates how structural stigma can manifest through policies and practices that limit access to care for marginalized groups.

Table 5.

Examples of Responses by the Participants of the Survey by Subthemes for the Theme ‘Availability and Access to Care’

Theme	Availability and access to care (N=29)
Subthemes (n=number of responses addressing the subtheme)	Few examples of survey responses illustrating the subtheme
Increased need for mental health services due to COVID-19 pandemic and social isolation (2)	“…Covid led to increased loneliness and isolation, so I think it contributed to me getting re-established with therapy, which I had stopped a while before covid.” (R001)
	“Increased social anxiety.” (R033)
Restrictions for preventing the spread of COVID-19 and their effect (4)	“I have had to test for covid before many procedures and have had longer wait times for scheduling procedures and appointments. My mother almost couldn’t visit me in the hospital after a major surgery…” (R028)
	“The walk in clinic that I usually go to was closed and turned into a Covid testing only facility.” (R075)
	“Made it more difficult to see doctors in person and more time consuming when you do because of all of the surveys and screenings you have to do” (R089)
Challenges faced by respondents due to COVID-19 exposure (2)	“[I] Missed appts when sick” (R031)
	“made it harder to show up because it [COVID-19] gave me long-haul fatigue” (R110)
Impact of pre-existing conditions on accessing care during COVID-19 (2)	“Preexisting health condition makes COVID a concern for me, so I can’t go to appointments in person as easily as I’d like” (R011)
	“I am immunocompromised, so prioritized getting urgent needs met to prevent exposure to Covid 19” (R079)
Transportation restrictions and related challenges (1)	“Could no longer use ride-sharing. Had to get rides from family members until I was able to get a personal vehicle.” (R056)
Providers issues (4)	“My psychiatrist at the time had to close her practice and I was forced to find a new psychiatric office.” (R099)
	“Most offices around me stopped accepting new patients so I went without any healthcare for about 2 years.” (R114)

Note. Participants are referred to using respondent IDs (R###s) generated by the study team independent of identifiable information for the purposes of differentiation. Any grammatical or spelling errors in quotes originate with participants and have been kept for accuracy.

Participants frequently mentioned that access to non-urgent healthcare services was delayed for long periods. As respondent R114 wrote, “Most offices around me stopped accepting new patients so I went without any healthcare for about 2 years…” and respondent R075 noted, “The walk-in clinic that I usually go to was closed and turned into a Covid testing only facility,” highlighting how existing provider shortages and referral challenges worsened due to various COVID-19-centered healthcare requirements during the pandemic.

As the pandemic spread across the U.S., various restrictions were implemented. Respondents described how these restrictions, like COVID-19 testing and limits on family and support network visiting patients in the hospital, affected their access to and availability of care. Respondent R028 noted “My mother almost couldn’t visit me in the hospital after a major surgery…” Some respondents had pre-existing care that made it difficult and stressful for them to access required healthcare during COVID-19, respondent R079 mentioned “I am immunocompromised, so prioritized getting urgent needs met to prevent exposure to Covid 19”.

Affordability

Six participants described challenges related to the affordability of healthcare during the pandemic, as noted in Exhibit 3 (Table 3). Many participants mentioned financial hardship that contributed to difficulties affording care. Concerns about affordability were not isolated to the pandemic but instead reflect broader issues of economic inequality and inadequate insurance coverage for TGD individuals that worsened during the pandemic.

R081 wrote “Covid-19 cost me my job and my health insurance for nearly a year so I was unable to seek affordable care,” and R100 noted “COVID-19 resulted in me losing my job and health insurance… I have not been able to find another job and still do not have health insurance or the medicine that makes my life a lot easier to live.” illuminating the intersection of economic vulnerability and systemic barriers to healthcare.

Participants lost their health insurance coverage when they lost their jobs due to COVID-19-related measures and struggled to find a new job during the same period. This finding, along with the fact that Medicaid policy in at least 11 states explicitly doesn’t cover GAC, ⁴¹ points to the ways in which inadequate insurance coverage for GAC can exacerbate financial hardships especially during pandemics like COVID-19.

Discussion and Recommendations

This study examined the impact of the COVID-19 pandemic on healthcare access for 87 TGD adults in the United States, revealing significant challenges related to telehealth, access, and affordability, as well as delays in accessing GAC and other healthcare. While the qualitative data collected does not allow for comparative insights between TGD and non-TGD populations, the findings and recommendations remain transferable to broader contexts. This study focuses specifically on how COVID-19 shaped healthcare access experiences for TGD adults, and the themes that emerged from the personal narratives offer meaningful implications beyond the COVID-19 time period. These findings support our hypothesis that the pandemic compounded existing structural barriers, leading to significant delays in accessing GAC, preventive, and other non-GAC healthcare services.

The findings align with the Structural Stigma Framework, wherein societal-level norms, and policies constrain the opportunities, resources, and well-being of stigmatized people.^40,42 This framework highlights how societal-level forces continued to limit access to timely healthcare for TGD people during the pandemic.^40,42 Thematic analysis facilitated an understanding of the multiple manifestations of structural stigma during the pandemic and how these contributed to barriers in accessing healthcare.^38,39 It also revealed where, during situations like the pandemic, the healthcare system is not adequately equipped or incentivized to address the needs of marginalized individuals.

Experiences described by participants are consistent with previous studies on structural barriers to accessing GAC in the U.S., as well as TGD experiences related to healthcare access, economic stability, and mental health during COVID-19 globally.^23,24,29 The affordability challenges experienced by TGD participants reflect broader pandemic-exacerbated economic inequalities, such as loss of or difficulty securing employment, which combined with already inadequate insurance coverage to further hinder access to GAC. Barriers to GAC include discrimination, geographic isolation, inadequate insurance, referral requirements, unknowledgeable providers, and legislative attacks on GAC.^23,24

Participants described delays in access to GAC in general, and gender affirming surgeries (GAS) specifically, similar to prior literature.^2,7,35 The policies that categorised GAC as “elective” resulted in deprioritization of GAC procedures early in the pandemic and disrupted access to GAC.^6,19 There was a significant reduction in the volume of GAS in the initial part of the COVID-19 pandemic, especially for non-white TGD individuals in 2020.^7,35 The initial reduction in the volume of was comparable to the decrease observed in other non-emergent and elective surgical procedures.^7,43 Access to some GAS began to improve only in July 2020, with surgical volumes returning to pre-pandemic levels by Fall and Winter 2020.^7,43 A surge in GAS in 2021 suggests that, although recovery reached pre-pandemic levels in fall and winter 2020, it did not fully account for the increasing need during the timeline of the pandemic.^7,44

Additionally, frameworks such as the Medically Necessary, Time-Sensitive (MeNTS) procedures guidance developed during the pandemic fell short by not considering the impact of surgical procedures on health outcomes past six weeks post-operation. ¹⁸ GAS is associated with improved mental health outcomes for TGD persons long-term, while delays are associated with poor mental and physical health outcomes.^{10,17,19,45,46} As such, the shorter MeNTS timeline could not accurately account for how postponing GAS can undermine the health and well-being of TGD individuals. ¹⁸ This reflects a lack of societal understanding of the importance of, value of, and increasing need for timely GAC for the well-being of TGD individuals. ⁴⁴

Beyond surgical interventions, participants also noted losing access to hormone replacement therapy and care that must take place in-person, such as diagnostic tests and bloodwork. Reduced access to these services led to delays in both surgical care and routine hormone monitoring. ⁶ As GAC is often sequentially planned, disrupted access to TGD-affirming primary care providers, specialists, ambulatory services, and therapists delayed the initiation and continuation of GAC.^9,10 Furthermore, the economic impact of the pandemic, including loss of employment, coupled with existing insurance barriers to GAC, made GAC and other forms of healthcare less affordable for TGD individuals in this study, limiting access to several forms of care. Finally, systemic barriers, fear of discrimination, and a lack of TGD-affirming providers contributed to delays in seeking care for non-GAC needs by creating a climate of distrust. ²

The pandemic also saw an increase in the use of telehealth to bridge care gaps, with claims rising from 0.1% in 2019 to 5% in 2021, according to data from FAIRHealth. ⁴⁷ While the initial shift to telehealth was slow, it gained momentum after the Coronavirus Aid, Relief, and Economic Security (CARES) Act and CMS 1135 waiver expanded its use for non-emergent care.^47-49 Other literature has suggested that telehealth improved access to transgender-inclusive care by reducing geographic and structural barriers to care, which some participant responses in this study corroborated. ² However, some respondents indicated that telehealth came with its own challenges, with one individual still needing to cross state lines to attend online appointments. As such, telehealth, while intended to improve access to care, also inadvertently exposed existing inequalities, including disparities in access to technology, the limited availability of TGD-competent care providers, and variability in the adoption and legality of telehealth, particularly across state lines, which continued to force individuals to travel between states to access care, even during the COVID-19 pandemic.^23,50,51

These findings have important implications for policy and practice. First, to improve TGD health and care access, GAC should be integrated into broader healthcare systems rather than treated in isolation. This requires educating healthcare providers about the importance of GAC, which is currently limited in formal training settings. ⁵² Supplemental trainings, evidence-based clinical trainings, and continuing education programs, such as the Sexual and Gender Diversity Learning Community (SGDLC) developed by the University of Maryland, can support healthcare providers in improving their competency in LGBTQ+- and gender-affirming care. ⁵³ Informed healthcare providers with strong communication skills, who understand the historical context, distinct health risks, challenges, and needs of the TGD population, can deliver compassionate and affirming care to TGD people. ⁵⁴ Expanded access to such providers is necessary to improve TGD health, particularly in underserved areas; targeted recruitment efforts and incentives may encourage providers to practice in these areas.^52,53

Additionally, policymakers must recognize that TGD people are vulnerable due to stigma, negative past experiences, and providers’ lack of knowledge. These challenges are further compounded during crises and should be considered when drafting policy. The financial barriers that were exacerbated during the pandemic highlight the need for policymakers to improve insurance coverage for GAC, ensuring that TGD individuals have access to the care they need. As of March 2026, two states (Arkansas and Mississippi) permit insurers to exclude GAC coverage, and only 24 states and Washington, D.C. have laws prohibiting health insurance discrimination based on gender identity, limiting access to care for TGD people. ²⁶ Policies that impact non-clinical determinants of health that disproportionately affect TGD individuals, like employment discrimination and limited access to safe and affordable housing, are also essential. ⁵⁵ Furthermore, in emergencies like COVID-19, it is essential to adopt a decentralized approach that prioritizes restoring access to care at the local level. Such an approach could have facilitated a quicker shift to telehealth and reduced delays in rescheduling cancelled surgeries.^6,7,56,57 Finally, relevant medical and surgical societies and advisory bodies should expand their procedure prioritization matrices and frameworks to include “elective and non-urgent,” “elective and urgent,” and “emergent” categories to ensure the medical necessity of timely gender affirming procedures is more accurately accounted for.^17,19,58

Limitations

This study had several limitations. First, the use of snowball and purposive sampling, primarily through social media and TGD community organizations, may have introduced selection bias and limited generalizability. Despite efforts to recruit a diverse sample population, the sample was predominantly White and from the West and Northeast Census regions, with limited representation across racial, ethnic, and South and Midwest geographic groups. Second, less than five percent of the sample population was in the age group of 40–55 and none was above the age of 55. Therefore, the results of this study are not representative of the TGD elder population. Future research should employ more diverse sampling strategies to improve sample representativeness. Third, data were collected via an online survey, with a single open-ended question as the basis for analysis, which may have limited the depth of responses. The absence of follow-up questions and the written format may have discouraged the disclosure of sensitive information. Future studies utilizing in-depth interviews or focus groups may yield richer, more contextualized data while also strengthening participant authenticity. In this study, a proportion of survey responses were identified as bot-generated and subsequently reviewed manually for completeness, response time, and coherence, a necessary and rigorous step given the rapidly advancing capabilities of generative Artificial Intelligence applications. Despite this, the manual review process ensured the integrity of the data retained in the final analysis. Finally, reliance on self-reported data introduces the potential for recall and social desirability bias. ⁵⁹ While data quality safeguards were implemented, these biases cannot be fully ruled out.

Conclusion

This study provides evidence that the COVID-19 pandemic exacerbated existing structural barriers to healthcare access for TGD individuals in the U.S., including financial and insurance barriers, low provider availability, and limited access to gender-affirming care. In linking these barriers to the Structural Stigma Framework, our findings highlight the systemic nature of these challenges and underscore the urgent need for policy and practice changes. To address these health inequities and structural barriers, policymakers must prioritize the integration of GAC into broader healthcare systems, address systemic barriers to telehealth, expand access to TGD-affirming providers, and improve insurance coverage for GAC through policy interventions like Medicaid expansion for GAC.^25,41

Implementing anti-discrimination policies, like the proposed federal law Equality Act (2021), and addressing economic disparities and other social determinants of health inequities that disproportionately affect TGD individuals, are also essential for improving TGD health. Ensuring TGD voices are included in policy decisions through advisory boards, stakeholder consultations, and feedback mechanisms is critical for creating inclusive healthcare policies. ⁵⁷ Only through comprehensive and coordinated efforts that studies gaps and stigmas in the healthcare policies and health services can we ensure that TGD individuals have equitable access to the healthcare they need to thrive.

Appendix.

Abbreviations

GAC

Gender-affirming care

GAS

Gender-affirming surgeries

TGD

Transgender and gender-diverse

CMS

Centers for Medicare and Medicaid Services

ED

Emergency Department

CARES Act

Coronavirus Aid, Relief, and Economic Security Act

SGDLC

Sexual and Gender Diversity Learning Community

ORCID iDs

Saniya Sahasrabudhe https://orcid.org/0009-0000-7021-4141

Jaylin Snyder https://orcid.org/0009-0003-7666-5076

Ellesse-Roselee Akré https://orcid.org/0000-0002-2380-6344

Ethical Considerations

Our study was approved by the Dartmouth College Committee for Protection of Human Subjects (approval number STUDY00032506) on July 1, 2022.

Consent to Participate

A waiver of signed consent was granted because the study involved minimal risk and did not collect any personally identifying information, thereby protecting participants’ anonymity in accordance with IRB regulations for electronic consent processes. An electronic consent was obtained from the participants. All participants were presented with an IRB-approved digital consent text before beginning the Qualtrics survey. Only participants who consented were able to proceed to the survey questions and submit their answers. Those who did not consent were exited from the survey and their responses were not recorded.