COVID-19 pandemic-related changes in psychological distress, as measured by the BSI-18 Global Severity Index (GSI) score. (a) Overall trend in GSI between pre-pandemic and COVID-19 assessments, across the full cohort of TGNB individuals (N=208). Points represent individual observations, boxplots and half-violin plots show the shift in the full distribution. Color shows the proportion of participants with GSI scores classified as “clinically significant.” (b) Differential trends in pandemic-related GSI based on reduction of LGBTQ/TGNB-specific support (left) and disrupted gender-affirming healthcare (right). Colored points, boxplots, and half-violin plots show subgroup-specific changes in GSI.