Health care and mental health challenges for transgender individuals during the COVID-19 pandemic

As a medical and socially vulnerable group, transgender individuals face numerous health disparities and mental health problems.¹ The coronavirus disease 2019 (COVID-19) pandemic brings international health concerns and devastating psychological distress on a global scale to many populations. Transgender individuals are now facing unprecedented difficulties with mental, physical, and social wellbeing, as well as difficulties accessing health care. Before the pandemic, there already existed many barriers to transgender individuals accessing health care, such as a shortage of specialised health-care professionals; as a result, very few transgender individuals receive gender-affirming surgeries and hormone interventions, especially in low-income and middle-income countries.² As a marginalised group, inequalities faced by transgender individuals in policies and social aspects, such as legislated policies based on binary gender norms, could increase the risk of illness and mortality during the COVID-19 pandemic.³ In addition, to prevent the potential overload of health-care systems by COVID-19 cases, most hospitals have cancelled or postponed elective procedures to save resources. Thus, it is even more difficult for transgender individuals to access hormone interventions and gender-affirming surgeries.

Besides access to health care, it is also important to highlight mental health issues of transgender individuals. Previous studies showed that gender-affirming surgery was associated with reduced mental health problems.⁴ Because of the difficulties caused by COVID-19 discussed above, it is likely that transgender individuals are also facing challenging situations with regards to their mental health. In our transgender clinic, in Beijing, China, we found that difficulty in accessing hormone interventions was associated with high levels of anxiety and depression due to uncertainty about the availability of future treatments and struggles with maintaining unwanted gender identities during the COVID-19 pandemic.

We call for an inclusive assessment of the mental and physical health of transgender individuals that includes quality of life, physical functions, surgical complications, and hormone-related health problems. These assessments could identify transgender individuals at a high risk of developing severe psychological or physical health problems. Early screening could help to provide timely interventions for symptoms that occur during the COVID-19 pandemic. Furthermore, we suggest that it is important to note that there are subgroup differences in transgender individuals' physical and mental health needs. After gender-affirming surgery, groups such as transgender women tend to have adverse outcomes of vaginoplasty, such as visceral injury, fistulas, vaginal prolapse, and pelvic floor disorders, which occur because of the complex nature of the gender reassignment and require long-term care after surgery.⁵ During the COVID-19 pandemic, transgender women might therefore face additional difficulties compared with transgender men.

To prevent detrimental consequences caused by barriers to health care when resources are scarce, governments should implement urgent solutions to ensure both prescription supply, such as hormones, and provide remote online physician counselling for transgender individuals. Hormone intervention requires lifelong medical support as the concentration of hormones and adverse events need to be carefully monitored.² In response to the ongoing COVID-19 pandemic, we suggest that governments, policy makers, and the private sector should actively consider the unprecedent difficulties and situation faced by transgender people when planning to address the health-care crisis, and implement suitable strategies to help this minority group. Finally, it is important for health-care systems to establish assessment screening and provide a monitoring service to ensure psychological wellbeing of this vulnerable population.