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How the COVID-19 pandemic affects transgender health care in upper-middle-income and high-income countries – A worldwide, cross-sectional survey

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Abstract
Background Since the beginning of the COVID-19 pandemic, access to medical care was restricted for nearly all non-acute medical conditions. Due to their status as a vulnerable social group and the inherent need for transition-related treatments (e.g., hormone treatment), transgender people are assumed to be affected particularly severely by the restrictions caused by the COVID-19 pandemic. This study aims to assess the impact of the COVID-19 pandemic on the health and health care of transgender people. Methods and findings As an ad hoc collaboration between researchers, clinicians, and 23 community organizations, we developed a web-based survey. The survey was translated into 26 languages, and participants were recruited via various social media and LGBTIQ-community sources. Recruitment started in May 2020. We assessed demographical data, physical and mental health problems (e.g., chronic physical conditions), risk factors (e.g., smoking), COVID-19 data (symptoms, contact history, knowledge and concerns about COVID-19), and the influence of the COVID-19 pandemic on access to transgender health care and health-related supplies. To identify factors associated with the experience of restrictions to transgender health care, we conducted multivariate logistic regression analysis. 5267 transgender people from 63 higher-middle income and high-income countries participated in the study. Over 50% of the participants had risk factors for a severe course of a COVID-19 infection and were at a high risk of avoiding testing or treatment of a COVID-19 infection due to the fear of mistreatment or discrimination. Access to transgender health care services was restricted due to the COVID-19 pandemic for 50% of the participants. Male sex assigned at birth and a lower monthly income were significant predictors for the experience of restrictions to health care. 35.0% of the participants reported at least one mental health conditions. Every third participant had suicidal thoughts, and 3.2% have attempted suicide since the beginning of the COVID-19 pandemic. A limitation of the study is that we did not analyze data from low-income countries and access to the internet was necessary to participate. Conclusions Transgender people are assumed to suffer under the severity of the pandemic even more than the general population due to the intersections between their status as a vulnerable social group, their high amount of medical risk factors, and their need for ongoing medical treatment. The COVID-19 pandemic can potentiate these vulnerabilities, add new challenges for transgender individuals, and, therefore, can lead to devastating consequences, like severe physical or mental health issues, self-harming behaviour, and suicidality.

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MLA
Koehler, Andreas, et al. “How the COVID-19 Pandemic Affects Transgender Health Care in Upper-Middle-Income and High-Income Countries – A Worldwide, Cross-Sectional Survey.” MedRxiv, 2020, doi:10.1101/2020.12.23.20248794.
APA
Koehler, A., Motmans, J., Alvarez, L. M., Azul, D., Badalyan, K., Basar, K., … Nieder, T. O. (2020). How the COVID-19 pandemic affects transgender health care in upper-middle-income and high-income countries – A worldwide, cross-sectional survey. medRxiv. https://doi.org/10.1101/2020.12.23.20248794
Chicago author-date
Koehler, Andreas, Joz Motmans, Leo Mulió Alvarez, David Azul, Karen Badalyan, Koray Basar, Cecilia Dhejne, et al. 2020. “How the COVID-19 Pandemic Affects Transgender Health Care in Upper-Middle-Income and High-Income Countries – A Worldwide, Cross-Sectional Survey.” MedRxiv. https://doi.org/10.1101/2020.12.23.20248794.
Chicago author-date (all authors)
Koehler, Andreas, Joz Motmans, Leo Mulió Alvarez, David Azul, Karen Badalyan, Koray Basar, Cecilia Dhejne, Dragana Duišin, Bartosz Grabski, Aurore Dufrasne, Natasa Jokic-Begic, Antonio Prunas, Christina Richards, Kirill Sabir, Jaimie Vaele, and Timo Ole Nieder. 2020. “How the COVID-19 Pandemic Affects Transgender Health Care in Upper-Middle-Income and High-Income Countries – A Worldwide, Cross-Sectional Survey.” MedRxiv. doi:10.1101/2020.12.23.20248794.
Vancouver
1.
Koehler A, Motmans J, Alvarez LM, Azul D, Badalyan K, Basar K, et al. How the COVID-19 pandemic affects transgender health care in upper-middle-income and high-income countries – A worldwide, cross-sectional survey. medRxiv. 2020.
IEEE
[1]
A. Koehler et al., “How the COVID-19 pandemic affects transgender health care in upper-middle-income and high-income countries – A worldwide, cross-sectional survey,” medRxiv. 2020.
@misc{8686387,
  abstract     = {{Background
Since the beginning of the COVID-19 pandemic, access to medical care was restricted for nearly all non-acute medical conditions. Due to their status as a vulnerable social group and the inherent need for transition-related treatments (e.g., hormone treatment), transgender people are assumed to be affected particularly severely by the restrictions caused by the COVID-19 pandemic. This study aims to assess the impact of the COVID-19 pandemic on the health and health care of transgender people.
Methods and findings
As an ad hoc collaboration between researchers, clinicians, and 23 community organizations, we developed a web-based survey. The survey was translated into 26 languages, and participants were recruited via various social media and LGBTIQ-community sources. Recruitment started in May 2020. We assessed demographical data, physical and mental health problems (e.g., chronic physical conditions), risk factors (e.g., smoking), COVID-19 data (symptoms, contact history, knowledge and concerns about COVID-19), and the influence of the COVID-19 pandemic on access to transgender health care and health-related supplies. To identify factors associated with the experience of restrictions to transgender health care, we conducted multivariate logistic regression analysis.
5267 transgender people from 63 higher-middle income and high-income countries participated in the study. Over 50% of the participants had risk factors for a severe course of a COVID-19 infection and were at a high risk of avoiding testing or treatment of a COVID-19 infection due to the fear of mistreatment or discrimination. Access to transgender health care services was restricted due to the COVID-19 pandemic for 50% of the participants. Male sex assigned at birth and a lower monthly income were significant predictors for the experience of restrictions to health care. 35.0% of the participants reported at least one mental health conditions. Every third participant had suicidal thoughts, and 3.2% have attempted suicide since the beginning of the COVID-19 pandemic. A limitation of the study is that we did not analyze data from low-income countries and access to the internet was necessary to participate.
Conclusions
Transgender people are assumed to suffer under the severity of the pandemic even more than the general population due to the intersections between their status as a vulnerable social group, their high amount of medical risk factors, and their need for ongoing medical treatment. The COVID-19 pandemic can potentiate these vulnerabilities, add new challenges for transgender individuals, and, therefore, can lead to devastating consequences, like severe physical or mental health issues, self-harming behaviour, and suicidality.}},
  author       = {{Koehler, Andreas and Motmans, Joz and Alvarez, Leo Mulió and Azul, David and Badalyan, Karen and Basar, Koray and Dhejne, Cecilia and Duišin, Dragana and Grabski, Bartosz and Dufrasne, Aurore and Jokic-Begic, Natasa and Prunas, Antonio and Richards, Christina and Sabir, Kirill and Vaele, Jaimie and Nieder, Timo Ole}},
  language     = {{eng}},
  pages        = {{29}},
  series       = {{medRxiv}},
  title        = {{How the COVID-19 pandemic affects transgender health care in upper-middle-income and high-income countries – A worldwide, cross-sectional survey}},
  url          = {{http://dx.doi.org/10.1101/2020.12.23.20248794}},
  year         = {{2020}},
}

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