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. Author manuscript; available in PMC: 2021 May 4.
Published in final edited form as: Psychol Trauma. 2020 Jun 18;12(Suppl 1):S239–S242. doi: 10.1037/tra0000837

LGBTQ Populations: Psychologically Vulnerable Communities in the COVID-19 Pandemic

John P Salerno 1, Natasha D Williams 2, Karina A Gattamorta 3
PMCID: PMC8093609  NIHMSID: NIHMS1693834  PMID: 32551761

Abstract

In the wake of the 2019 novel coronavirus (COVID-19) pandemic and the psychological consequences that will follow, it is critical to acknowledge and understand the unique vulnerabilities of lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ) populations in order to provide equitable mental health intervention that reaches these highly at-risk groups. It is well established that LGBTQ persons face social disadvantages and mental health disparities, which may be exacerbated as a result of COVID-19 pandemic trauma and social isolation measures. This commentary highlights structural, social, and individual-level challenges among LGBTQ populations in the context of COVID-19 and proposes prevention recommendations to mitigate the psychological ramifications of COVID-19 pandemic-related trauma among LGBTQ persons.

Keywords: COVID-19, LGBTQ, mental health, social distancing, healthcare policy

Editor’s Note.

This commentary received rapid review due to the time-sensitive nature of the content. It was reviewed by the Journal Editor.—KKT

As of April 29, 2020, there were 1,005,147 cases and 57,505 deaths due to the 2019 novel coronavirus (COVID-19) in the United States (Centers for Disease Control and Prevention [CDC], 2020). As the incidence of COVID-19 cases and deaths begins to decline, it is of utmost importance to act fast in responding to the psychological impact of COVID-19 pandemic trauma. Despite well-documented vulnerability to several social, health, and psychological risks, lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ) populations have received minimal attention during the COVID-19 pandemic. This commentary discusses the status of U.S. healthcare systems and COVID-19 crisis response, outlines LGBTQ-specific risks for COVID-19 psychological burden, and proposes recommendations for mitigating the negative mental health impact of COVID-19 among LGBTQ persons.

U.S. Healthcare Systems During COVID-19

Thus far, millions of Americans have been laid off as a result of COVID-19. Recent data indicate that over 30 million Americans filed initial unemployment claims between March and April 2020 (U.S. Department of Labor, 2020), skyrocketing national unemployment rates to peak levels greater than those seen in the Great Recession of 2009 (Amadeo & Anderson, 2020). Unfortunately, LGBTQ persons may be overrepresented in these figures. For instance, 40% of all LGBTQ persons in the United States work in service-industry jobs (compared with 22% of non-LGBTQ persons), which suggests that LGBTQ persons are particularly vulnerable (especially LGBTQ persons of color) to financial, employment, and health-insurance-status ramifications as a result of COVID-19 (Whittington, Hadfield, & Calderon, 2020). To mitigate financial burden, the Coronavirus Aid, Relief, and Economic Security Act has provided one-time financial support to millions of eligible individuals, couples, and families in the United States during the pandemic (Snell, 2020).

For those with employer-sponsored health insurance, the loss of their jobs likely signifies the loss of health insurance coverage. These individuals may purchase private insurance under the Affordable Care Act (ACA) if granted a special enrollment period (Centers for Medicare and Medicaid Services [CMS], n.d.-b), sign up for Medicaid if they meet the “low-income” eligibility requirement (Garfield, Orgera, & Damico, 2020), or sign up for Medicare if they meet the “elderly age or disability” eligibility requirements (Social Security Administration, 2019). However, in states that have not expanded Medicaid (14 as of April 27, 2020; Kaiser Family Foundation, 2020), low-income workers who lose their jobs may fall into a coverage gap (Garfield et al., 2020), in which they make too much money to qualify for Medicaid but too little to afford ACA health insurance, significantly reducing their access to health care.

For currently insured persons, the Families First Coronavirus Response Act eliminated cost-sharing for COVID-19 testing under employer-sponsored and public health insurance plans (Cubanski & Freed, 2020; Moss et al., 2020; Rudowitz, 2020), and most private health insurers have waived cost-sharing for COVID-19 testing (America’s Health Insurance Plans [AHIP], 2020), benefitting many currently insured persons in the United States.

Persons who were uninsured before the pandemic are likely unable to enroll in a health insurance plan under the ACA because they are currently outside of the open-enrollment period or because they are ineligible (e.g., undocumented immigrants). Luckily, nine states and the District of Columbia are currently offering special open-enrollment periods during COVID-19 (Nania, 2020). Eligible persons in other states will have to wait until November 1, 2020, to be able to enroll in ACA health insurance (CMS, n.d.-a). Thus, many will remain unable to access health insurance during and after the pandemic and will be left with little to no alternatives for receiving health care and mental health care.

Structural Vulnerability Among LGBTQ Populations During COVID-19

Research consistently elucidates mental health disparities among LGBTQ persons relative to their heterosexual, cisgender counterparts (Plöderl & Tremblay, 2015; Price-Feeney, Green, & Dorison, 2020; Russell & Fish, 2016). These disparities are related to social inequalities that disproportionately affect LGBTQ persons. For instance, greater proportions of LGBTQ persons lack access to health insurance (17% vs. 12%) and face poverty (22% vs. 16%) compared with their non-LGBTQ counterparts (Whittington et al., 2020). Poverty figures extend to same-sex parents and single LGBTQ parents and their families, who are at least twice as likely to be living near the poverty line compared with their non-LGBTQ counterparts (Whittington et al., 2020). LGBTQ persons of color face even greater risk for social inequality (Baams, Wilson, & Russell, 2019; Conron & Wilson, 2019; Movement Advancement Project & SAGE, 2017; Morton et al., 2018; Whittington et al., 2020). Ultimately, mental health burden among LGBTQ persons (e.g., PTSD, anxiety, depression, suicidality) may be exacerbated by the psychological impact of COVID-19 pandemic trauma and its intersection with dimensions of social inequality (Galea, Merchant, & Lurie, 2020; Green, Price-Feeney, & Dorison, 2020; Reger, Stanley, & Joiner, 2020; Whittington et al., 2020).

U.S. Social and Physical Distancing Response to the COVID-19 Pandemic

On March 26, 2020, the president issued the “30 days to slow the spread” national social distancing and stay-at-home guidelines (White House, 2020). Between March 15 and April 7, 2020, 42 states, three counties, 10 cities, Puerto Rico, and the District of Columbia issued “curfew,” “stay-at-home,” or “shelter-in-place” executive orders (i.e., social and physical distancing mandates) to reduce the spread of COVID-19 (Mervosh, Lu, & Swales, 2020). As of April 29, 2020, 25 states were partially reopened or had begun to lift their mandates, and 25 states and the District of Columbia remained shut down or restricted (Mervosh & Lee, 2020).

Although these orders are designed to keep individuals and communities safe, they present unique challenges for many LGBTQ youth. The closing of K–12 and higher education institutions may confine LGBTQ young persons to traumatic and possibly abusive environments (Green et al., 2020; Whittington et al., 2020). Many LGBTQ youth cannot be their authentic selves at home because they have not disclosed their sexual and gender identities or because they were not met with support or acceptance from their parents and families (Green et al., 2020; Human Rights Campaign, 2018). Additionally, many college students who were living on or near university campuses have been forced to return to homes that may not be welcoming and safe (Green et al., 2020; Whittington et al., 2020). Indeed, research suggests that one third of LGBTQ youth experience parental rejection, and another third do not come out until they are adults (Rosario & Schrimshaw, 2013), and suicide (8 times more likely) and depression (6 times more likely) are significantly more likely among LGBTQ youth who are rejected by their parents (Ryan, Huebner, Diaz, & Sanchez, 2009), emphasizing the severity of this potentially co-occurring psychological trauma.

Schools and universities are a common gateway to mental health services for LGBTQ young persons (Dunbar, Sontag-Padilla, Ramchand, Seelam, & Stein, 2017; Pitcher, Camacho, Renn, & Woodford, 2018; Zhang, Finan, Bersamin, & Fisher, 2020). Among LGBTQ youth, even larger proportions of school-based mental health services are likely used by intersectionally marginalized LGBTQ youth, such as racial and ethnic minorities, the homeless, undocumented immigrants, and those from backgrounds of low socioeconomic status (Ali et al., 2019; Golberstein, Wen, & Miller, 2020). For LGBTQ youth relying on schools for mental health supports around identity development, coming out, and family rejection, the closing of schools is particularly grave (Green et al., 2020). Stay-at-home orders further reduce access to social and community support resources in schools, such as gender and sexualities alliances; other affirming student organizations; and supportive teachers, professors, coaches, counselors, and peers, all of which serve as buffers that protect LGBTQ youth against mental health burden due to social isolation and psychological trauma (Kaniuka et al., 2019; Parra, Bell, Benibgui, Helm, & Hastings, 2018; Poteat, Sinclair, DiGiovanni, Koenig, & Russell, 2013; Reger et al., 2020; Van Orden et al., 2010).

LGBTQ elders also face significant psychological threats as a result of stay-at-home orders during COVID-19. Indeed, LGBTQ elders are twice as likely to be single and living alone, 4 times less likely to have children, and more likely to be estranged from their biological families compared with their heterosexual, cisgender counterparts (de Vries et al., 2019; Whittington et al., 2020). This is highly concerning because social isolation, loneliness, and existing health and mental health concerns may be exacerbated among already-vulnerable LGBTQ elders as a result of COVID-19 pandemic trauma (Steinman, Perry, & Perissinotto, 2020; Yarns, Abrams, Meeks, & Sewell, 2016; Zelle & Arms, 2015).

Supporting Mental Health Among LGBTQ Persons During the COVID-19 Aftermath

Clearly, social isolation is a great challenge faced by LGBTQ populations as a result of the COVID-19 pandemic. It is critical for mental health therapists, social services providers, employers, community-based organizations, schools, and higher education institutions serving LGBTQ persons to move toward online delivery of services and modes of work and education to mitigate the mental health ramifications of COVID-19 psychological trauma and social isolation (Galea et al., 2020; Green et al., 2020). Strong efforts are needed from leadership stakeholders in these institutions to incorporate LGBTQ-affirming virtual extracurricular activities that strengthen and maintain social support and community connectedness (Green et al., 2020). These institutions should further leverage social media to connect LGBTQ individuals to trusted, accessible, and affirming mental health resources, such as the Trevor Project (Galea et al., 2020; Green et al., 2020). Even more critical is ensuring human connections among intersectionally marginalized LGBTQ groups, such as low-income persons of color in unstable housing, who may lack equitable access to the digital technologies required to receive online services (Galea et al., 2020; Golberstein et al., 2020). Given the potential confining of LGBTQ young persons to abusive and traumatic environments, it is critical to provide attention to surveillance, reporting, and intervention of child abuse and domestic violence during and after the pandemic (Galea et al., 2020; Green et al., 2020).

Fortunately, many insurance companies are allowing therapists to bill for online therapy during the pandemic (AHIP, 2020). However, although many states have loosened credentialing requirements for doctors, the same is not true for therapists. Some states are granting extensions on licensure expiration dates and/or requesting that therapists with expired licenses return to the field, but state laws still require therapists to hold a license in the state where their client is physically located during teletherapy (American Association for Marriage and Family Therapy, 2020; American Psychological Association, 2020; National Association of Social Workers, 2020). Therefore, as LGBTQ persons shift physical locations during the pandemic (e.g., moving back home after universities closed or moving homes to care for sick family members), their connections to their existing therapists may be severed. Policy stakeholders are urged to lift state-based licensure requirements to increase access to affirming online therapy. Lastly, to help mitigate the psychological ramifications of COVID-19 pandemic trauma, policy stakeholders are urged to open ACA health plan enrollment and close the Medicaid coverage gap so that all uninsured persons are able to obtain health insurance and access affirming health and mental health care (Politz, 2020).

Acknowledgments

This work was supported by the National Institute of Mental Health (Award 1R36MH123043) and the National Institute on Minority Health and Health Disparities (Award U54MD002266) of the National Institutes of Health (NIH) and by the University of Maryland Prevention Research Center Cooperative Agreement U48DP006382 from the Centers for Disease Control and Prevention (CDC). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or the CDC. We are grateful to student members of LGBTQ+ Students and Allies in Public Health at the University of Maryland for their commitment to LGBTQ communities and their mental health in the midst of the COVID-19 pandemic crisis; our work together inspired the idea for this commentary. Additionally, Williams gratefully acknowledges support from the Southern Regional Educational Board.

Contributor Information

John P. Salerno, Department of Behavioral and Community Health, School of Public Health, University of Maryland, College Park;.

Natasha D. Williams, Department of Family Science, School of Public Health, University of Maryland, College Park;.

Karina A. Gattamorta, School of Nursing and Health Studies, University of Miami..

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