key: cord-1055230-9hzp0ceq
authors: Sachdeva, Ishaan; Aithal, Sathya; Yu, Wenhui; Toor, Parm; Tan, Josephine C.H.
title: The disparities faced by the LGBTQ+ community in times of COVID-19
date: 2021-01-14
journal: Psychiatry Res
DOI: 10.1016/j.psychres.2021.113725
sha: 20a5fe6d391684d6b9722c6b7a01d9b820a5c55e
doc_id: 1055230
cord_uid: 9hzp0ceq

nan

Dear editor,

The COVID-19 pandemic has highlighted various healthcare disparities faced by the marginalized members of society. Most of the attention has been placed on visible groups, such as ethnic minorities and Indigenous peoples, who have borne a disproportionate burden of the illness (Hall et al 2020) . However, the LGBTQ+ community which is a less visible segment of the marginalized population, has received relatively less attention.

The rates of smoking are higher among the LGBTQ+ community than their straight and cisgender counterparts and are partially attributed to the unique stresses faced by the sexual minority populations (Hoffman et al., 2018) . Smoking is associated with respiratory and tobaccorelated health conditions such as chronic obstructive pulmonary disease as well as cancer and cardiovascular disease (Hafeez et al., 2017) , all of which are linked to an increased risk of serious COVID-19 outcomes (Zheng et al., 2020) .

Many transgender individuals in the LGBTQ+ community seek hormone therapy with androgens as a part of the gender transition process. This might be particularly risky during the pandemic because androgen receptor activity has been considered to regulate the transcription of transmembrane protease serine 2, an enzyme needed for COVID-19 viral entry in the lungs of infected hosts, which may further increase COVID-19 viral load and severity (Barnes et al, 2020) . Androgen-deprivation therapy (ADT) has been found to relate to a significantly lower risk of SARS-CoV-2 (OR 4.05; 95% CI 1.55-10.59) among prostate cancer patients (Montopoli et al., 2020) . Additionally, androgenetic alopecia was found to be present in a significant percentage of COVID-19 patients (42% female, 79% male) who had to be hospitalized due to the severity of the disease (Wambier et al., 2020) . These results provide support for the androgendriven worsening of COVID-19 severity, leading to increased hospitalizations. As a result, transgender individuals of the LGBTQ+ community using androgen hormone therapy may have increased susceptibility to COVID-19 infection and more severe outcomes.

The COVID-19 pandemic and the containment policies that have been put in place have exacerbated mental health issues among the general population (Holmes et al., 2020) . The psychological consequences of these social isolation measures and stay-at-home orders may be more severe for LGBTQ+ individuals who experience identity concealment and parental rejection at home. One third of LGBTQ+ youth experience parental rejection, and another third do not disclose their gender or sexual identity until they are adults (Katz-Wise et al, 2016) . Family rejection is associated with a sixfold increased likelihood of developing depression, and an eightfold increased likelihood of suicide attempts (Ryan et al., 2009) . Additionally, the lack of access to school or university services that may provide a gateway to mental health programs can further compound the mental health burden in LGBTQ+ individuals, who may already be struggling with identity development, coming out, and family rejection. Intersectionally marginalized LGBTQ+ individuals who also identify as a racial or ethnic minority or who come from low socioeconomic backgrounds, might be particularly affected as they are more likely to rely on school-based mental health services that act as a buffer against mental health struggles resulting from social isolation (Salerno et al., 2020) . These issues have significant relevance for the LGBTQ+ community due to its greater vulnerability to depression, anxiety, and suicidality (Hafeez et al., 2017) .

Similar to other minority groups, the LGBTQ+ community have reported experiencing discrimination, prejudice, financial insecurity, and lack of healthcare insurance (Durso and Meyer, 2013) . These problems pose challenges to obtaining healthcare information, diagnosis, and treatment, all of which are more critical during the pandemic. However, LGBTQ+ individuals also report encountering a lack of healthcare provider knowledge of LGBTQ+ needs that may lead to avoidance or delay in seeking healthcare (Quinn et al., 2015) . The delay among those who have the coronavirus can lead to adverse outcomes such as acute respiratory distress syndrome (ARDS), septic shock, multiple organ failure and possibly death. Furthermore, a higher proportion of LGBTQ+ individuals (22%) than their non-LGBTQ+ peers (16%) face poverty (Salerno et al., 2020) which makes the acquisition of personal protective items, such as masks and hand sanitizers, less affordable at a time when such items are essential to reduce the risk of personal exposure to the coronavirus. These have implications for COVID-19 containment measures in the community that require early detection and isolation of positive cases, contact tracing, and sustained efforts in preventative care.

There is a need for the healthcare system to be more aware of the unique challenges that members of the LGBTQ+ community encounter in accessing healthcare, and the increased risk of severe COVID-19 complications that they face. Sensitivity to these issues coupled with increased LGBTQ+ cultural competency among health professionals can help to provide a more inclusive and comfortable healthcare environment for them (Quinn et al., 2015) . It is important that the less visible minority groups in our population are included in our efforts to provide healthcare and address disparities during the pandemic.

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