key: cord-0072010-jnlj1qqm
authors: Banerjee, Debanjan; Nair, Vasundharaa S.
title: “The Untold Side of COVID-19”: Struggle and Perspectives of the Sexual Minorities
date: 2020-07-24
journal: nan
DOI: 10.1177/2631831820939017
sha: 5557756de0408415dcaea1e90a192ceb4aab7cb7
doc_id: 72010
cord_uid: jnlj1qqm

The coronavirus disease 2019 (COVID-19) pandemic has threatened global public health. Travel has been restricted, economies slashed, borders sealed, and billions quarantined at their residences, in an attempt to contain the outbreak. Social distancing and lockdown measures have disrupted human lives in terms of social relationships and emotional bonds. Every individual is facing unique challenges to cope with these unprecedented times. However, certain sections of the population, like the Lesbian, Gay, Bisexual, Transgender and Queer (LGBTQ) community, are particularly vulnerable to not only the infective risks of the virus, but also the psycho-social offshoots of the global lockdown and the pandemic aftermath. The various factors range from the immunocompromised state, increased comorbidities of sexually transmitted diseases, other chronic medical disorders and substance abuse, as well as reduced access to health care, to stigma and social discrimination, administrative apathy, economic constraints, and uncertainty of social rituals like the Pride Celebrations. These can lead to the underdetection of the viral load, increased physiological risks to COVID-19, decreased help-seeking, and inequality in health and legal care. Their emotional and psychosexual well-being also gets impaired, with increased risks for psychiatric disorders and suicidality. Keeping these factors in the background, this article glances at the disproportionate risk related to the COVID-19 pandemic in the sexual minorities, explores the psycho-social factors behind the same, and highlights specific ways to mitigate these risks for better care. Adopting a rights-based perspective for the LGBTQ community through public health measures during such crises can help reduce stigma and promote their social inclusion.

The coronavirus crisis has threatened the world, as the World Health Organization (WHO) declared it to be a global pandemic. With closed borders, controlled travels, economic crisis, uninhabited migrants, and millions isolated in their own homes, it would be right to state that the current pandemic has extended beyond just the traditional pill provision methodology. As the world's focus has shifted toward the development of vaccines and other biological cures, the underlying psycho-social concerns are often neglected. 1 Certain vulnerable sections are at increased risk for both the physiological and emotional offshoots of the virus. They are usually the minorities, be it related to age, sex, sexuality, race, or ethnicity. One such minority populations are the Lesbian, Gay, Bisexual, Trans, and Queer (LGBTQ) people, who live within a socially compromised condition and are said to be more vulnerable during the pandemic. The association between LGBTQ and comorbid psycho-social stress factors is well established, with the concerns ranging from mood disorders, generalized anxiety and distress, chronic stress, adjustment disorders, and complex trauma. 2 With the general population being prone to the pandemic threat and fear, persons living under social restraints and stigma, like the LGBTQ, have unique concerns that are largely neglected and unspoken about. The studies related to this community have been complicated by the ambiguity of homosexuality as a "mental disorder" in the early 1970s. 3 The prolonged debate was initiated between the "same-sex affirmatives" and conservative approaches, which ended in 1973 with the elimination of homosexuality from the second edition of the Diagnostic and Statistical Manual of Mental Disorders. 4 Ironically, the "claim" that the LGBTQ community has a higher prevalence of mental disorders, which is indeed true due to various other reasons, has been the reason for substantiating homosexuality as a psychiatric disorder. 5 Even though it is no longer scientifically proposed as a "disease," the public understanding is yet to come to terms with it. Widespread misinformation, myths, and beliefs about samesex orientation and transgender people thus lead to sexual stigma, a form of social stigma held against "nonheterosexual" individuals, considered to have a "deviant" identity. 6 This has led to gender-based discrimination, stereotyping, labeling of the "third gender," and inequality related to the LGBTQ. During COVID-19, when the world is facing an unprecedented crisis, there have already been reports of political and personal "othering" and prejudice based on socio-economic class, gender, and race. 7 Sexual stigma also gets exacerbated by such outbreaks that can lead to special considerations for the psycho-social well-being of such susceptible populations. There have been reports of similar incidents against this community from various parts of the world. 8 This article relates to the processes of marginalization of the LGBTQ community during the pandemic, highlights their unique physical and psycho-social risks, and specific ways to mitigate them. Goffman, in 2003, 9 while defining stigma documented it as a barrier to help-seeking behavior, engagement in the care provision, and the adherence to treatment across various health conditions. This eventually enables different forms of discrimination, thereby denying an individual or groups' social acceptance, reducing opportunities and increasing social inequality. The Health Stigma and Discrimination Framework enunciates stigmatization as a process including the facilitators, barriers, stigma markers, their manifestations, and the subsequent outcomes. 10 It differs from other models in not differentiating the "stigmatized" from the "stigmatizer" and hence discards the "we versus they" dichotomy as a cause of stigma. It thus proposes that every affected group would anticipate, perceive, internalize, and propagate stigma based on specific markers that lead to certain outcomes. It is, therefore, useful to understand the prevalent self-stigma in the LGBTQ population, which reflects on the society and vice versa, thereby maintaining the vicious circle of marginalization. These factors eventually reflect on the health and social conditions, especially during biological disasters like COVID-19.

Human behavior is fraught with irrational, illogical, aggressive, and impulsive decisions during a crisis, as shown by behavioral research during disasters. 11 Such responses can further foster hate and polarization against already stigmatized groups like the LGBTQ. Hence, understanding their psycho-social distress and integrating them in the public health care system might be essential for their overall well-being. Research has shown that during the human immunodeficiency virus (HIV) pandemic, there has been widespread discrimination against the homosexuals and transgender people, so much so that earlier HIV was labeled as the "Gay Plague," the connotation of which still exists in the legislation of some countries, where people of same-sex orientation are prohibited from donating blood or organs. 12 "Stigma-based stress," as research in these sexual minority groups can amplify their cognitive, behavioral and affective reactions to stress. Cognitive biases are common among them in stressful situations, where the social stigma is misattributed to personal failure, identity, and guilt, which can eventually lead to the increased prevalence of depression, anxiety, grief, and suicides. 13 It has also led to a rise in substance abuse, sexual compulsivity, and high-risk sexual behaviors. The various facets of this model 10 are depicted in Figure 1 .

The following are the ways how they are relevant to the LGBTI community.

The fear of infection due to their marginalized condition and restrained social identities is increased by the factors of authoritarianism, social judgment, blame, prejudice, and the associated economic ramifications in the background of socio-cultural norms and the environmental−legal policies. The way society views them adds to their self-worth and sexualityessential components of emotional well-being. Preston et al 14 reported that social facilitators of stigma, wrong ideas about homosexuality, and mistreatment of the LGBTQ community in young age could foster aggression, self-stigma, and risky sexual behaviors, with the increased prevalence of HIV and other STDs. Stereotyping and genderbased discrimination are essential facilitators of stigma against this population. Social stereotypes assert that gay men are more feminine, and lesbians are more masculine in their body language, speech, and physical appearances. 15 Gender versus sex misunderstanding has been proposed to be one of the main reasons for this, and "transvestites" are frequently misconstrued as homosexual individuals. "Same-sex" orientation is also labeled that contributes to negative attitudes and ambiguity toward homosexuality. Research has shown that interaction and visualization of "gay men" have brought about emotional discomfort in heterosexual males. 16 The term "acting gay" is frequently used as ridicule for males with close bonding, which is again a marker of stereotyped gender roles and understanding.

The associated health-related sexual stigma has been found to intersect with the race, gender, orientation, and class. This stigma can have several manifestations: Enacted sexual stigma or courtesy stigma: (Discrimination or violence against the sexual minorities and those related to them.) Example: Stigma against the friends or relatives of the LGBTI community. 17 Perceived sexual stigma: (Anxiety and apprehension that one might be prejudiced on the basis of behavioral or attitudinal stereotypes that society holds about the sexual minorities.) Example: Someone might conceal his/her transgender status or leave home or pretend to have "prototype" sexual orientation due to a fear of being labeled. The same holds for males with feminine traits or vice versa, as they are often ridiculed for behaving like the opposite gender. 18 Sexual self-stigma: (Internalized views about sex, gender, and sexuality that become ingrained in a person on the basis of his/her negative and biased social interactions, which eventually affects their mental state, sexual practices, and attitudes.) Example: Self-hate and hatred toward others of the same community when someone who has same-sex orientation starts believing that "homosexuality" is a crime, illness, or punishment inflicted upon them. This type of stigma is responsible for many transgender people to leave their respective residences and is also the reason for psychiatric disorders and suicides. 17 

Manifestations are often the experiences and the associated practices of an individual from the LGBTQ community. These could be the stigma experienced by the person (internalized, perceived, or in anticipated forms) and the associated attitudes and behavior that the society promotes. This might get reflected in the lifestyle, dressing sense, ways of interactions, speech, and occupational patterns. Classically known as "Hijras" in the Indian context, the transgender people often take to begging, dancing at baby showers (Badhai), etc. Sometimes they just conform to the social pattern as an obligation, rather than a choice. 19 Certain reported crimes against the LGBTI communities are a result of group involvement due to a "coerced role" rather than voluntary involvement. On similar lines, people of same-sex orientation often conceal their sexual identities and end up confirming to the family's expectation of a "social heterosexual relationship or marriage," which eventually becomes catastrophic for both the person and his/her partner. It can also foster self-hate, guilt, and a biased belief system that can be psychologically damaging. At times, forceful medical or surgical procedures can bring upon additional physiological harm, as some of these are also irreversible.

The triangulation of the LGBTQ community and the respective organizations and institutions can be understood in terms of their access to justice, adherence to the treatment, resilience, accessibility, and availability of quality health care. Till the recent landmark judgment of the Supreme Court of India on "Section 377," the law was ambiguous and relatively silent on the gender roles, same-sex marriage, as well as mental health and human rights of the LGBTQ community in the country. 20 Due to various barriers for access to health and legal care, this group tends to be more polarized, especially at times of crisis. This stress of "social segregation" is one of the primary outcomes that gets them caught in the middle of "nowhere" between their families who refuse to accept them and the rest of the society who ridicule them. Joining their community thus forms an essential part of their self-esteem and social identity.

In the current conditions, limited research states that LGBTQ individuals with their emotional and social vulnerabilities might be at increased risk for the uncertainty, fear, and discrimination during the pandemic. 21 Xenophobia and racism have already been on the rise during the COVID-19 situation. This might further affect the Asian LGBTQ community, and agism might affect the seniors in an enhanced way. 22 Several issues increase the risk of this community for contracting COVID-19. Subsequently, social inequalities lead to poor health outcomes. Sadly, the LGBTQ community is vulnerable both to the direct infective effects of the virus and the measures like social distancing and lockdown to contain it. Though there are no studies so far, linking a directly increased risk of COVID-19 in them, the factors that can complicate their care and health during the pandemic crisis, are highlighted as follows.

In the current overloaded public healthcare system, when providing care to the regular population has been difficult, the focus on the treatment and care of the LGBTQ individuals gets interrupted or deprioritized, which might affect the individuals on the hormonal and gender-affirming treatments, thereby creating a disadvantage. Stigma against them also makes access to healthcare facilities difficult. This can decrease the viral testing, promote concealment of symptoms, noncompliance to the precautionary measures, and increase the rates of asymptomatic carrier status in the LGBTI community. 23 Awareness and understanding of the illness might also be an issue in specific segregated populations of transgender and intersex people, who live in impoverishment and poverty. Gender inequality, stereotyping, and discrimination add to their "othering" in health care.

South Korea was in the news for the increased threats and outcaste toward the LGBTI community through the unfair accusation of them spreading COVID-19, thereby creating conditions of discrimination, harassment, and hostility. 24 Section 377, though legalized in India, has not gained public acceptance. In the current scenario, where one spends more time with their family due to the lockdown, the number of questions raised and the level of discrimination with the hate speeches might be high, thereby making the person more vulnerable to violence, abuse, and associated mental health conditions.

Inequality and discrimination, as mentioned above, lead to a poor support structure as they are often not supervised or adequately taken care of. The high comorbidity of STDs and mental disorders in them can relapse due to the lack of follow-up with health care, nonavailability of medications, and travel restrictions. Substance abuse further compounds the situation. The knowledge, attitude, and practice (KAP) gap is also high in them related to diseases, which contributes to infection spread and susceptibility.

The prevalence of HIV and other STDs being higher in the LGBTQ population, 25 the inherent risk of morbidity due to COVID-19 rises. The infection is found to be prolonged and more fatal in those with poor immunity, 1 and hence the theoretically raised risk of this group. Additional comorbidities such as diabetes, hypertension, asthma, and substance abuse are reportedly higher in them, which can influence the course of the infection. According to the Behavioral Risk Factor Surveillance System data (2016), 26 LGB and transgender adults are at 49% and 42% increased risk of smoking than non-LGB and cisgender adults, respectively. 27 Self as well as social neglect and impaired access to care can add to it.

The Human Rights Campaign for the LGBTQ community released a research brief on April 2020 to mention that they are at heightened risk for the socio-economic aspects of COVID-19. 27 People of this community are more likely to work in profoundly affected industries, which has more exposure to the infection as well as financial sensitivity to the pandemic crisis. Also, insurance coverage tends to be less for them. Unemployment and salary cuts have been massive during COVID-19, which affects their livelihood and pushes them further toward the social downhill. Data from the PSB (PEOPLE × SCIENCE × BUSINESS) Research Group in the United States show that 30% of the LGBTQ community had their work hours reduced and salary decreased, compared with 22% of the general population. 28 Personal finances, access to food and health care, difficulties in transportation, and trust toward public health agencies like the WHO and the Center for Disease Control and Prevention have also decreased in the LGBTQ Americans. Studies show that LGBTQ youth are much more at risk to experience homelessness and lack of family support, with the lack of administrative accountability. 29 In low-and middle-income countries of Asia and Africa, where racism and xenophobia add to the stigma against sexual minorities, living conditions can be worse for many of them who do not have a salaried job or are homeless. Social distancing tends to be impossible in temporary shelters and detention facilities, further increasing the risk of infection. Lack of data and societal apathy add to their poverty and impoverishment. Many reports in media mention hunger, overcrowding, and lack of sanitary facilities as broader concerns in them than the threat of the virus itself. 21 

The Pride Movement emerged after the Stone Wall Riots in 1969 as a tradition of protest and connectedness among the sexual minorities. 30 Typically, Pride Events give a chance to the LGBTQ community to come together, celebrating their concerns and sharing the achieved social changes. In this year, due to the COVID-19 crisis, more than 220 Pride celebrations were postponed or canceled globally, which is an emotional setback for this group, who look forward to these events of the year. 31 To prevent their isolation, InterPride and the European Pride Organizers Association had recently organized a digital "Global Pride" on 27th June 2020. Though a reasonable substitute, digital meeting fails to replace a personal gathering of a minority group, who look at these events for sources of social support from their communities and resilience against the crisis.

The factors mentioned above have a complex interplay leading to discrimination, social inequality, and stereotyping in a sexual minority like the LGBTQ community (Minority Stress), which gets amplified during biological disasters like COVID-19 ( Figure 2 ). 

When a population is vulnerable, it needs special care. This applies to even age-related susceptible groups like the elderly and children. Public health measures incorporating the medical and psycho-social needs of the LGBTQ community are to be tailored based on their risk understanding and estimation. Health disparities need to be eliminated, and the barriers to healthcare access need to be addressed. Certain Acts passed by the US Congress in response to the pandemics such as the Coronavirus Preparedness and Response Supplemental Appropriations Act, Families First Coronavirus Response Act, and the Coronavirus Aid, Relief, and Economic Security (CARES) Act are useful for the socio-economic and health benefits of the affected LGBTQ communities. 32 Flexibilities in the homelessness, custodial, and immigrationrelated policies have also been suggested for helping them. Many countries like India need an overhaul of the Pandemic Act of 1897, and the Disaster Management Act 2005 does not have a specific mention of this at-risk population. 33 COVID-19 and postpandemic aftermath might be a good time to incorporate their needs into the administrative system.

At times of social distancing, technology can aid care. Teleconsultations help this population, especially as they often restrict in-person access due to stigma and concealment. In the past, telemedicine has shown to benefit LGBTQ people affected with HIV by improving their CD4+ counts, decreasing viral loads, promoting medication compliance, and reducing hospitalization rates. Harm reduction has also been achieved in injectable opioid and alcohol users of the community. 34 Rogers et al 35 have discussed a telemedicine infrastructure for HIV prevention and care in the LGBTQ community, in response to the COVID-19 pandemic.

Similarly, the use of social media for information, education, and communication for community awareness related to their social needs and helplines for their mental health care and abuse notification can help. This needs to be implemented at all levels of health care, especially at the primary level that involves general physicians, nurses, and lay counsellors, who form the first contact of majority at the grass-root levels. Banerjee and Nair had recently proposed a community-based psycho-social toolkit for the COVID-19 pandemic, on the basis of the earlier Zika outbreak. 36 It involves a stepped approach, with crisis management through various modules, adequate psychosocial health communication, and implementation at the individual, community, and organization levels. A similar model can be used for the LGBTQ community, tailored to their needs, monitoring their stressors, improving their social support, and coping strategies at times of crisis. The attribution-value model suggests that improving their gender-based identity and assigning social roles can prevent negative attitudes toward themselves and hence help selfstigma. 37 Also, socialization and occupational involvement targeted for the LGBT community help social inclusion and reduces perceived stigma. Stigma interventions are vital during a pandemic crisis to prevent blaming, othering, homophobia, and hate crimes, which can put an additional burden on public health during pandemics. The various possible interventions in different areas of vulnerability are summarized in Table 1 . 

Economic and financial needs ·• Government allowances and loans for temporary jobholders, manual workers, and unemployed ·• Emergency leave protection and health insurance ·• Promoting worker and labor rights ·• Liaison with nongovernmental organizations and private facilities for the rehabilitation of those infringe and at-risk groups ·• Regulation of salary cuts and job loss Mental illness and substance abuse ·• Promotion of mental health and health communication (educate on distress and panic during pandemics) ·• Train primary care health workers to screen for common mental disorders ·• Telemedicine services structured for the needs of the community ·• Mental health helplines sensitized for their needs (integrated with women, elderly, and child helplines) ·• Harm-reduction approach for substance abuse Social rituals ·• Liaison with the various Pride communities ·• Online and local meets (when feasible)

Special groups within the LGBTQ community ·• Homeless (housing and shelter placements, quarantine facilities, basic living amenities, and hygiene) ·• Immigrants (flexible legal policies, upholding of rights, and preventing immigrant detention) ·• Elderly (prevent agism, stigma and abuse, housing in old age homes, and looking after those with sensory and cognitive deficits)

Having an immunocompromised condition during the current situation of the COVID-19 distress with the amplification of the pre-existing stigma and discrimination can significantly increase the minority stress of the LGBTQ community, making it overwhelming and challenging for them. As the numbers affected rise globally due to this highly contagious infection and the world faces an unprecedented crisis, it is essential to remember that the virus does not discriminate based on sex, race, ethnicity, or class. If the sexual minorities are not included in a social framework, it can create ripples of the detrimental effect on the overall public health, due to increased community spread and inadequate control measures. The inequality and polarization experienced by the LGBTQ group disproportionately increase their risk to COVID-19 and also the effects of the lockdown. It can affect them at the social, sexual, financial and emotional levels, thereby increasing additional morbidities of STDs, HIV, drug abuse, psychiatric disorders, and suicidality. 27 Upholding their social and sexual rights are essential, just like for any minority groups, and it is high time that their welfare becomes a priority rather than an option. All levels of stakeholders, from an individual to the governments need to be sensitive to their needs and move beyond the taboo of stigma and stereotyping. The pandemic is still in its early stages in many countries. Mixed method and longitudinal studies to understand their risks, comorbidities, unmet needs, and lived experiences at a broader level can help shape policies. The LGBTQ community has been trying for ages to make their voices heard for social inclusion, civil rights, legal protection, and psychological well-being. The COVID-19 pandemic might be yet another global eye-opener to include them in the public health system, protect them from the viral crisis, and improve their quality of life, before it is too late.

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The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The authors received no financial support for the research, authorship, and/or publication of this article.

Debanjan Banerjee https://0000-0001-8152-9798Vasundharaa S. Nair https://0000-0002-5632-1108