A stock image shows a person flying a transgender flag. GETTY

March 31 was International Transgender Day of Visibility. Minus a few posts online by media outlets, little was said about it this year. As a public health student, I have been wondering how marginalized communities will be negatively affected by COVID-19 and how some communities’ needs will be overshadowed as healthcare systems become overwhelmed and medical resources are focused on treating coronavirus patients.

Ryan Sutherland

One of the communities that will undoubtedly face increased pressure is the transgender and non-binary community as a result of restrictive coronavirus lockdowns, disrupted access to social services, barriers to prescribing and managing hormone therapy medications, and hospital decisions to halt gender-affirming surgeries.

And in some ways, “stay-at-home” orders and enforced social distancing policies, while they effectively reduce opportunities for viral transmission, also contribute to trans erasure and create more opportunities for the existence of members of the trans and non-binary communities to be ignored, denied or minimized. What isn’t seen isn’t heard, and only through increased visibility comes equal rights.

Recently, Gov. Brad Little of Idaho signed into law House Bill 500, the Fairness in Women’s Sports Act, and House Bill 509, the Idaho Vital Statistics Act. H.B. 500 states that “athletic teams or sports designated for females, women, or girls shall not be open to students of the male sex” and that disputes can be resolved by inspecting “the student’s reproductive anatomy, genetic makeup, or normal endogenously 19 produced testosterone levels,” effectively banning female-identifying transgender athletes from performing on teams aligned with their chosen gender identity.

H.B. 509 prohibits transgender individuals from changing their gender on their birth certificates. These bills originated from complaints strikingly similar to those articulated in a recent lawsuit filed against the Connecticut Association of Schools, Connecticut Interscholastic Athletic Conference and the boards of education in Bloomfield, Cromwell, Glastonbury, Canton and Danbury aimed to block transgender athletes from participating in girls sports.

With more than 40 states that have introduced similar legislation this year, statewide “stay-at-home” orders and social distancing policies limit the ability for transgender activists to protest and overturn discriminatory legislation such as these bills. And the media focus on COVID-19 developments might allow this type of legislation to fall through the cracks.

Additionally, trans and non-binary workers are three times more likely to be unemployed compared to the general population, and a lack of employer-based insurance results in a disproportionate insurance coverage gap. The pandemic has only exacerbated existing disparities. The International Foundation for Employee Benefit Plans reported that transgender inclusive healthcare benefits are offered to less than one-third of U.S. employees. With widespread furloughing and unemployment in response to the pandemic, even those with insurance benefits that cover hormone replacement therapy (HRT), counseling, or gender-affirming surgery are at risk of losing coverage.

While over 3 million Americans filed for unemployment as a direct result of layoffs caused by COVID-19, applying for unemployment might create unique challenges for trans individuals who might be required to use their “deadname,” a name assigned at birth that has electively been changed to match their gender identity, to prove their identity on government forms — this can undoubtedly be traumatizing. Furthermore, trans and non-binary individuals might be wary to seek unemployment help as waiting in long lines outside unemployment offices might put them at an increased risk of discriminatory violence.

And it is no secret that, as a result of social stigma and discrimination, the transgender population has a higher rate of unstable housing and homelessness. According to the Williams Institute, over 30% of individuals served by drop-in centers, street outreach workers, and housing programs identified as LGBT. Unfortunately, those who are transgender and homeless are at increased risk of exploitation, violence, and abuse, and may be turned away from shelters as a result of their gender identities. As some homeless shelters close or limit occupancy to stop the spread of COVID-19, this further limits available housing options for unhoused transgender individuals.

Past negative experiences of being misgendered or refused service when seeking care or out of fears of contracting COVID-19 in healthcare settings may cause trans people to forego care. And trans individuals may be reluctant to go to hospitals and clinics to request hormone replacement therapy (HRT) treatment during the pandemic – already overburdened hospitals might not have the capacity to provide sufficient social services or hormone treatments.

Furthermore, gender-confirmation surgeries, deemed non-essential and elective, have been delayed or cancelled at many U.S. hospitals due to coronavirus. Interruptions in HRT provision or postponing long-awaited gender-affirming surgeries could augment feelings of isolation and gender dysphoria and amplify psychological distress. The Trevor Project’s 2019 survey reported that more than half of transgender and non-binary young people have contemplated suicide and one-third have attempted it.

The minority stress model, a social psychology theory widely adopted in public health, describes how extreme minority stress causes adverse health outcomes among stigmatized minority groups. Consistent stress, discrimination and internalized stigma faced by transgender people increases their risk of suicidality. And as health systems react to treat coronavirus patients and critical services previously available to transgender patients are interrupted or deprioritized, feelings of isolation and marginalization might further increase rates of suicide or affect transgender mental and physical health and wellbeing.

School closures might also pose unique challenges to transgender youth. With campus LGBTQ resource centers and peer support unavailable and the suspension of all school-based social activities, transgender students might feel unsupported. Furthermore, self-quarantining with abusive family members who do not affirm their trans identity can be extremely traumatizing to trans youth.

As one trans commenter pointed out on a recent Buzzfeed article, “I have to make a decision about whether to stay in the UK where I study or fly back to the States to be with my parents, one of whom doesn’t use my name or pronouns and has refused to do so.” With campuses and dormitories closed to suppress viral transmission, some transgender students must return home to unsafe emotionally and physically abusive homes because they are left with nowhere else to go. And once there, due to enforced lockdowns, they potentially cannot leave.

Quarantine and lockdowns may also increase rates of domestic and intimate partner violence perpetuated against transgender individuals. According to conservative estimates, the National Coalition Against Sexual Violence reports that one in three women and one in nine men will experience sexual violence during their lifetime, and these estimates do not accurately capture the increased risk of sexual violence within the LGBTQ community. Lockdowns and social distancing policies, budget cuts to IPV-related social services and mental health counseling, and financial instability due to unemployment all create opportunities for abusers to perpetrate sexual violence and make it more difficult for transgender victims to leave abusive relationships or report abuse.

Lastly, conservative graphs from the Imperial College COVID-19 Response Team and others by the Centers for Disease Control and Prevention (CDC) show frightening estimates that up to 2.2 million Americans — mainly older adults, those who are immunocompromised, or those who have other pre-existing health conditions such as diabetes or lung disease — might die as a result of contracting COVID-19. Elderly trans individuals at higher risk of contracting COVID-19 might refuse help from aging providers such as meal delivery programs, senior centers, or other social programs because they are afraid of harassment or discrimination.

Furthermore, statistics show the LGBTQ community is 50% more likely to smoke than the general population, potentially resulting in increased susceptibility to respiratory failure brought on by COVID-19, a respiratory illness. Moreover, trans individuals are more likely than the general population to be diagnosed with cancer and HIV, and reduced immune function could put them at a higher risk to contract coronavirus and face harsher symptoms.

Overall, the coronavirus has not just affected the trans and non-binary communities by restricting access to gender-affirming surgeries or HRT, but has effectively reduced their visibility. Fears of being misgendered or mistreated when seeking unemployment benefits or care in healthcare settings may cause trans and non-binary people to forego seeking assistance during this crisis.

Disruptions in hormone replacement therapy (HRT), counseling, or gender-affirming surgeries and self-quarantining with abusive family members may increase psychological distress and can augment rates of suicidality. Widespread unemployment might result in a loss of employer-based insurance coverage of hormone therapy and gender-affirming surgeries and cause an increase in homelessness among this population. And transphobic legislation may pass in the absence of assembled protestors who remain sequestered at home due to public health efforts to stop the spread of the coronavirus.

While COVID-19 has had a pronounced effect on everyone, those most vulnerable, such as those in the trans community, are poised to receive the most collateral damage.

Ryan Sutherland is a Master of Public Health candidate at the Yale School of Public Health in the Social and Behavioral Science Department with a concentration in global health.  

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