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

Background and Purpose: The onset of the COVID-19 pandemic immeasurably altered the human experience, particularly contributing to social isolation and negative mental health impacts in the wake of necessary restrictions (e.g., lockdowns). Transgender (trans) and gender diverse (TGD) populations experience a disproportionate prevalence of negative mental health outcomes due to pervasive anti-trans and intersecting forms of stigma. Yet, less is known about experiences of social isolation and mental health challenges faced by TGD persons during the pandemic, particularly in settings with lengthy COVID-19 restrictions. Thus, our study sought to describe mental health impacts and coping among TGD persons in Toronto, Canada, during the pandemic.

Methods: This convergent parallel mixed methods study drew on quantitative (n=39) and qualitative (n=13) data collected from 2021 to 2022 among TGD persons in Toronto, Ontario, Canada. All participants were enrolled in an eHealth intervention for promoting COVID-19 knowledge and protective behaviors and reducing pandemic-related distress (#SafeHandsSafeHearts). Qualitative participants were purposively sampled from the quantitative participant pool based on age, race/ethnicity, and depression score. Quantitative cross-sectional survey data (demographics, PHQ-2 [depression], GAD-2 [anxiety], UCLA Loneliness Scale) were analyzed descriptively (means, standard deviations [SD]; proportions) and integrated with qualitative semi-structured interview findings, analyzed using reflexive thematic analysis.

Results: Participants in the total sample (n=39) had a mean age of 31 years (SD=12); one-third (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), with parallel demographics among those who completed interviews. Mental health challenges were pervasive: 72% of participants (n=28/39) reported clinically-significant anxiety symptoms, 67% (n=26/39) clinically-significant depression symptoms, and 74% (n=29/39) high levels of loneliness. Qualitative findings contextualized quantitative findings by elucidating participants’ immense grief from deaths of loved ones, inability to engage in critical life events (e.g., graduations, funerals, etc.), and cut-offs of friends/family due to differing vaccination beliefs and practices. Financial barriers, compounded by job loss and cost-of-living increases, were common drivers of anxiety and depression. Of note, a few participants described a reduction in social anxiety due to mask wearing and less pressure to attend social functions. Mental health challenges were exacerbated by intersecting sexual and anti-trans stigma, racism, ableism, and other forms of oppression. Overall, participants described lack of access to timely, accessible, affirming mental health care. In the absence of accessible formal mental health care, participants coped individually in a variety of ways (e.g., substance use, eating, gaming), aligned with each individual’s unique challenges and circumstances. Social connection, particularly with LGBTQ+ community members, was deemed vital for participants’ coping, while challenges were noted related to computer-mediated social interaction (e.g., Zoom) fatigue and the need to balance social interaction with protective measures.

Conclusions: Findings highlight the myriad of ways in which TGD persons living in Toronto, a city with lengthy COVID-19 restrictions, experienced mental health and coping during the height of the pandemic. Findings should inform future supports—particularly the development of accessible gender affirmative mental health care—needed during future waves of the COVID-19 pandemic and in the event future emergency situations.