By Lorin Cartwright, MS, ATC, CAA, and Mitchell Anderson, AT, ATC
To commemorate Pride Month throughout June, the NATA Now blog will share a variety of topics to support our members’ efforts to provide compassionate and culturally competent patient care to all.
Since the start of the pandemic, 80.4 million people have contracted COVID-19, with more than 985,523 dying.1 Millions of people have been impacted by contracting COVID-19, knowing someone who has had COVID-19 or lost a loved one. Every community, no matter how big or small, has been affected. For the athletic training profession, lives and jobs have changed and we are still figuring out what the new normal will be.
Health care disparities among minority populations is well-known and researched. Concerns regarding LGBTQIA+ patients and athletic trainers who treat them, or are part of this minority, will be addressed in this blog. The challenges within the LGBTQIA+ community are unique and awareness of their needs during the COVID-19 pandemic are critical to providing care.
Most at Risk for COVID-19
Individuals with chronic illnesses are most at risk of complications from COVID-19.2 The LGBTQIA+ community is statistically more likely to have a chronic illness than the general population. Chronic illnesses most often associated with the LGBTQIA+ community include asthma,2,3,4 chronic obstructive pulmonary disease (COPD),3 cancer,3 kidney disease,3 liver disease,3 hypertension,3 diabetes,2,5,6 obesity,4,7,8 heart disease3,9,10 and HIV.2,4,11 LGBTQIA+ people are 10% more likely to smoke2 and have an increased use of alcohol,4,12 placing them in a higher risk category if they contract COVID-19.
Sexual minorities, as well as racial and ethnic minorities, within the LGBTQIA+ population are more prone to chronic diseases and COVID-19. Non-Hispanic African American individuals have a higher prevalence of asthma, COPD and smoking than their heterosexual counterparts.3 Hispanic individuals who are among the sexual minority population have a higher prevalence of asthma, cancer, COPD, smoking (currently) and stroke than their heterosexual counterparts.3 Sexual minorities are more likely to have more severe complications from COVID-19.3 These demographics are important to be aware of when providing patient-centered care.
Challenges Faced by LGBTQIA+ Patients During Pandemic
Mental health has been greatly impacted by the COVID-19 pandemic. More specifically, LGBTQIA+ individuals have suffered from isolation from their community due to their identity and, even more so, because of COVID-19. Gender and sexual minority populations are already at increased risk for depression, anxiety and suicidal ideation. Even though COVID-19 is gradually subsiding, social isolation is still a risk and can seriously impact a community that already faces systemic vulnerabilities.
As LGBTQIA+ individuals shifted physical locations during the pandemic (e.g., moving back home after universities closed or to care for sick family members), their connections to their existing therapists may have been severed. Although life is slowing getting back to normal, policy stakeholders are still urged to lift state-based licensure requirements to increase access to affirming online therapy.14 With this restriction, it can be difficult for LGBTQIA+ individuals to obtain gender and identity affirming care.
Accessing Medical Health Care
Before the pandemic, LGBTQIA+ individuals found access to health care difficult because of previous issues related to stigmatization.15,16 Thirteen percent of LGBTQIA+ households have lost health care insurance, while 8% of non-LGBTQIA+ households lost health care insurance since the beginning of the pandemic.17 LGBTQIA+ adults of color and transgender adults are even less likely to have medical insurance.18
Nineteen percent of non-LGBTQIA+ households reported the inability to get medical care or having to delay care for a significant issue.17 LGBTQIA+ households reported 38% having to delay medical care for a significant issue.17 Similarly, 8% of non-LGBTQIA+ households reported having difficulty obtaining prescription medications as opposed to 25% of LGBTQIA+ households.17
Those who use pre-exposure prophylaxis (PrEP) to reduce the risk of HIV have reported the pandemic prevented them from obtaining their prescriptions.19 Approximately 9% had a hard time getting their prescriptions for PrEP and 33% had a difficult time getting tested for HIV and sexually transmitted infections.19
Transgender patients are still at an increased risk of exposure to COVID-19 and its adverse outcomes. Transgender patients have experienced delays in access to gender-affirming care and diminished access to social support; all appropriate to keep in mind when treating transgender patients.20
Gender-affirming care is vital to successful outcomes for transgender patients. More specifically, transgender patients may have experienced repercussions from a legal standpoint during the COVID-19 pandemic. More specifically, delays in gender-affirming care were also exacerbated by court closures for non-essential business. Transgender individuals rely on the courts to legally change their given name and gender markers to match their gender identity.20 While court systems have made access to a legal name change more attainable, transgender patients continue to suffer without appropriate documentation of legal name change when presenting documentation to an employer. This puts the individual at risk for discrimination in the workplace and could lead to denial of benefits, such as adequate and appropriate health insurance.
Transgender individuals do not always have support from their families of origin and consequently, many rely on peer networks and transgender-affirming organizations for social support (e.g., university-affiliated LGBTQIA+ centers, community LGBTQIA+ centers, meetup groups).20 The COVID-19 pandemic made it difficult to develop these connections, even at a social distance or virtual view. As the world closed its doors to the public, adults and youth trans men and women didn’t have the ability to seek out emotional support from their community. For example, transgender youth were likely to live at home with family members struggling to accept and understand them.20
From a physical well-being perspective, there are many needs health care providers must be aware of when providing health care for transgender patients:
- Binding the chest: COVID-19 is a respiratory illness. Chest binding, which gives the appearance of a flat chest and is often vital for the self-image of transgender male patients, could exacerbate breathing difficulties associated with COVID-19. Chest binding should be avoided if they experience symptoms of COVID-19.21
- Compromised Immune System: Transgender patients may be at an increased risk for contracting an acute severe case of COVID-19, which impacts the respiratory system. If the individual has HIV or is immunosuppressed (for example undergoing chemotherapy, or a recent organ transplant patient), taking special care to avoid close social interaction is crucial at this time.
In light of these effects, some ways athletic trainers can support their LGBTQIA+ patients during the COVID-19 pandemic includes:
- Provide resources to online and in-person mental health experts
- Encourage continuity of care for chronic illness
- Connect persons with community members through social media and social networks that are safe and easily accessible to “gather,” such as Gay Straight Alliance
- Support persons who are in their coming out process – listen, validate and support
- Provide online pharmacy resources
- Ensure access to team physician, endocrinologist and behavioral health team
- Provide a list of LGBTQIA+ resources in their local community
- Provide information for 24-hour hotlines, such as Trevor’s Project
- Connect individuals with organization that can affect change such as Athlete Ally, the World Professional Association for Transgender Health or the Human Rights Campaign
- Help the athlete set up a food delivery service
- Encourage learning new things to remain active
Self-care recommendations for the LGBTQIA+ community include:
- Maintaining social connections with friends with virtual meetings
- Using telemedicine
- Keeping a supply of prescription medications
- Wearing a protective mask
- Knowing where to get a COVID-19 test
- Preparing to be quarantined in the event of testing positive for COVID-19
- Knowing how to get food and medication delivery
- Getting at least eight hours of sleep
- Reducing stress
- Cleaning and disinfect surfaces
- Exercising to maintain health
- Getting an approved vaccine if not contraindicated for health
- Covering coughs and sneezes with a tissue and disposing of tissues properly
- Providing resources for housing, food and financial insecurity
- Having LGBTQIA+ friendly resources for mental health
ATs, as health care providers, should understand the disparities that exist among minorities, including in the LGBTQIA+ population. Understanding the needs of the LGBTQIA+ community can improve health care and create a greater connection between them and their patients. When there is an improved connection between patient and provider, the outcomes are better.
1. CDC. (2021). COVID data tracker. https://covid.cdc.gov/covid-data-tracker/#datatracker-home.
2. Human Rights Campaign Foundation. (2020). The lives & livelihoods of many in the LGBTQ community are at risk amidst COVID-19 crisis. https://www.hrc.org/resources/the-lives-and-livelihoods-of-many-in-the-lgbtq-community-are-at-risk-amidst-covid-19-crisis.
3. Heslin, KC, and Hall, JE. Sexual orientation disparities in risk factors for adverse COVID-19-related outcomes, by race/ethnicity – behavioral risk factor surveillance system, United States, 2017-2019. Weekly. February 5, 2021/70(5); 149-154.
4. Human Rights Campaign Foundation. (2015). Health disparities among bisexual people. https://assets2.hrc.org/files/assets/resources/HRC-BiHealthBrief.pdf?_ga...
5. Gay and Lesbian Medical Association. (2006). Guidelines for care of lesbian, gay, bisexual, and transgender patients. http://glma.org/_data/n_0001/resources/live/GLMA%20guidelines%202006%20FINAL.pdf.
6. UCSF. (2020b). Overview of feminizing hormone therapy. https://transcare.ucsf.edu/article/information-estrogen-hormone-therapy.
7. Bowen DJ, and Boehmer, U. The lack of cancer surveillance data on sexual minorities and strategies for change. Cancer Causes Control. 2007 May;18(4):343-9.
8. Hafeez, H., Zeshan, M., Tahir, M.A., Jahan, N., and Naveed, S. Health care disparities among lesbian, gay, bisexual, and transgender youth: A literature review 2017; 9(4).
9. Hatzenbuehler, M.L., Bellatorre, A., Lee, Y., Finch, B.K., Muennig, P., and Fiscella, K. Structural stigma and all-cause mortality in sexual minority populations. Soc Sci Med. 2014 Feb;103:33-41.
10. Substance Abuse and Mental Health Services Administration. (2012). Top health issues for LGBT populations information and resource kit. https://store.samhsa.gov/sites/default/files/d7/priv/sma12-4684.pdf.
11. Centers for Disease Control and Prevention. (2019). Lesbian, gay, bisexual, and transgender persons, and tobacco use. https://www.cdc.gov/tobacco/disparities/lgbt/index.htm.
12. Pollock, JA, Halkitis, PN, Moeller, RW, et al. Alcohol use among young men who have sex with men. Subst Use Misuse. January 2012/ 47(1):12-21. https://doi.org/10.1146/annurev-clinpsy-021815-093153.
13. For LGBTQ patients, the coronavirus brings new challenges. Johns Hopkins Medicine. https://www.hopkinsmedicine.org/health/conditions-and-diseases/coronavir.... Accessed August 31, 2021.
14. Salerno JP, Williams ND, Gattamorta KA. LGBTQ populations: Psychologically vulnerable communities in the COVID-19 pandemic. Psychological Trauma: Theory, Research, Practice, and Policy. 2020;12(S1). doi:10.1037/tra0000837
15. Martos, AJ, Wilson, PA, Gordon, AR, Lightfoot, M, and Meyer, IH. Like finding a unicorn: healthcare preferences among lesbian, gay, and bisexual people in the United States. Soc Sci Med. 2018;208:126-133.
16. Ng, BE, Moore, D, Michelow, W, et al. Relationship between disclosure of same-sex sexual activity to providers, HIV diagnosis and sexual health services for men who have sex with men in Vancouver, Canada. Can J Public Health. 2014; 105(3):186-191.
17. Movement Advancement Project. (2020) The disproportionate impacts of COVID-19 on LGBTQ households in the U.S. Results from a July/August 2020 National Poll. https://www.lgbtmap.org/file/2020-covid-lgbtq-households-report.pdf.
18. Human Rights Campaign. The lives and livelihoods of many in the LGBTQ community are at risk amidst COVID-19 crisis. Washington, DC: Human Rights Campaign; 2020.
19. Stephenson R, Chavanduka TMD, Rosso MT, et al. Sex in the Time of COVID-19: Results of an Online Survey of Gay, Bisexual and Other Men Who Have Sex with Men's Experience of Sex and HIV Prevention During the US COVID-19 Epidemic. AIDS Behav. 2021;25(1):40-48. doi:10.1007/s10461-020-03024-8
20. The impact of the COVID-19 pandemic on the transgender and non-binary community. Columbia University Department of Psychiatry. https://www.columbiapsychiatry.org/news/impact-covid-19-pandemic-transge.... Published October 9, 2020. Accessed August 31, 2021.
21. Navigating the trans experience during coronavirus/COVID-19. Legacy Community Health. https://www.legacycommunityhealth.org/newsblog-navigating-the-trans-expe.... Published July 16, 2020. Accessed August 31, 2021.