Impacts of the COVID-19 Pandemic on Gender-Affirming Healthcare Access Among Transgender and Gender Diverse Persons in Toronto, Canada: A Convergent Parallel Mixed Methods Study

Background and Purpose: It is widely recognized that access to timely, affirming healthcare for transgender and gender diverse people (TGD) is life-saving and improves mental health and quality of life. TGD populations encounter significant barriers in accessing gender-affirming healthcare (GAH), in particular, gender-affirming hormone therapy (GAHT) and gender-affirming surgery (GAS). Scant research has explored the experiences of TGD people during the COVID-19 pandemic, with even less known about the experiences of racialized TGD people, particularly regarding GAH. This study sought to understand TGD people's experiences, as well as barriers and facilitators, in accessing GAH during the COVID-19 pandemic.

Methods: Utilizing a convergent parallel mixed methods study design, we examined baseline data collected from TGD persons (n=39) participating in an eHealth intervention (Oct. 2020–Dec. 2021) for promoting COVID-19 knowledge and protective behaviors and reducing pandemic-related distress (#SafeHandsSafeHearts) in Toronto, Canada. Measures included sociodemographics, access to GAH and GAHT during the pandemic, depression (PHQ-2), anxiety (GAD-2), and resilience (RSES-4). After the intervention, participants (n=13) were purposively recruited from among the full sample of TGD participants—based on age, race/ethnicity, mental health, and reported COVID-19-related access barriers—to take part in a semi-structured interview. Quantitative data from the cross-sectional baseline survey were analyzed descriptively and integrated with qualitative data from post-intervention interviews analyzed using reflexive thematic analysis.

Results: The full sample had a mean age of 31 years (standard deviation [SD], 12); 33% (13/39) identified as Black, 23% (9/39) Asian, 23% (9/39) White, 5% (2/39) Latinx, and 15% (6/39) multiethnic/other ethnicity. Overall, 15.4% (n=6/39) reported decreased access to GAHT because of COVID-19. Qualitative interview participant demographics matched the full sample by age and race/ethnicity. Participants reported a de-prioritization of TGD health during the pandemic; of utmost concern was the cessation of GAS, which was deemed ‘nonessential’. De-prioritization was also reported as contributing to complications in securing GAHT, longer wait-times for GAH and transphobic and racial discrimination by healthcare providers. Overall, TGD participants' mental health suffered, with nearly three-quarters (n=28/39, 72%) screening in for clinically-significant anxiety symptoms and two-thirds (n=26/39, 67%) for clinically-significant depression symptoms during the pandemic. Participants discussed negative mental health impacts of increased barriers to accessing GAH, compounded by fear that pre-pandemic progress in access to GAH was being unraveled. Participants had a mean individual resilience score of 14 (SD, 4; Range 4–20). Qualitative findings showed community resilience: TGD participants highlighted the importance of their seeking community support, connection, and developing TGD communities of care to compensate for the lack of systemic support. Despite these struggles, participants embodied trans joy, an act of resistance, protest and defiance, refusing to be erased by a system that marginalizes and devalues their healthcare needs.

Conclusions: These findings demonstrate gaps in timely access to life-saving GAH during the COVID-19 pandemic amidst the broader devaluation of TGD healthcare. Despite these challenges, racially/ethnically diverse TGD people demonstrated perseverance, strength, and initiative through communities of care. Findings inform tangible recommendations for TGD healthcare services and improvements that re-center the needs of TGD communities.