Center for Health Policy and Inequalities Research, Duke University, 310 Trent Avenue, Durham, NC 27708, USAUnited States
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Introduction Lesbian, gay, bisexual, transgender, queer, and questioning+ (LGBTQ+) people have historically faced disproportionate economic and health-related challenges, which have likely been further exacerbated by coronavirus disease-2019 (COVID-19). To provide support and equitable resources for this community, it is critical to identify resource needs and challenges and understand the experiences of this community during the COVID-19 pandemic. Materials and Methods We administered an online survey to examine the experiences and needs of minority LGBTQ+ people, ages 18-35, who resided in an Ending the Human Immunodeficiency Virus (HIV) Epidemic (EHE) metropolitan jurisdiction in the Southeastern United States (U.S.). Results Since the onset of COVID-19, the majority of survey respondents reported increases in mental health symptomology and substance use, and decreases in economic stability, food security, and medical care access. Conclusion The findings support the need for extended reach of substance use and mental health-related services, linkage to medical/sexual healthcare, and financial assistance.
Keywords: LGBTQ; COVID-19; Sexual and gender minority; Substance use; Mental health
Lesbian, gay, bisexual, transgender, queer, and questioning+ (LGBTQ+) people have historically faced disproportionate economic and health-related challenges, which have likely been further exacerbated by coronavirus disease-2019 (COVID-19). To provide support and equitable resources for this community, it is critical to identify resource needs and challenges and understand the experiences of this community during the COVID-19 pandemic.
We administered an online survey to examine the experiences and an Ending the Human Immunodeficiency Virus (HIV) Epidemic (EHE) metropolitan jurisdiction in the Southeastern United States (U.S.).
Since the onset of COVID-19, the majority of survey respondents use, and decreases in economic stability, food security, and medical care access.
The findings support the need for extended reach of substance use and mental health-related services, linkage to medical/sexual healthcare, and financial assistance.
LGBTQ; COVID-19; Sexual and gender minority; Substance use; Mental health.
oronavirus disease-2019 (COVID-19) continues to pose health- and economic-related challenges for communities, with C certain communities being especially vulnerable to these disparities. The lesbian, gay, bisexual, transgender, queer, and questioning+ (LGBTQ+) community has historically experienced greater disparities and inequities related to the social determinants of health including economic stability such as high rates of poverty and unemployment; healthcare access and quality including limited access to health insurance and culturally affirming providers; and social and community factors such as societal stigma and discrimination as 1,2 well as anti-LGBTQ+ policies.1,2 LGBTQ+ people also experience
cc Copyright 2022 by Cooper H. This is an open-access article distributed under Creative Commons Attribution 4.0 International License (CC BY 4.0), which needs of minority LGBTQ+ people, ages 18-35, who resided in
reported increases in mental health symptomology and substance
high rates of mental health disorders and substance use.3 Each of these factors contribute to a greater risk of COVID-19 and related 4-6 adversities in the LGBTQ+ community.4-6
In the United States (U.S.) South, LGBTQ+ populations may be at an even greater risk for COVID-19 and related negative outcomes, compared to other U.S. regions, due to pervasive culturally conservative views that contribute to high-levels of stigma; a history of systemic racism, which has been associated with inadequate health care and mistrust of healthcare systems; a high prevalence of violence against LGBTQ+ people; and high-levels 7-11 of poverty and other financial challenges.7-11 Further, COVID-19 vaccination rates in the South are some of the lowest in the nation.
Of the 15 states with the lowest percentage of their population fully vaccinated, 60% (n=9) are located in the South.12 Additionally, the Southern region also experiences a disproportionate burden of human immunodeficiency virus (HIV) due to the aforementioned 7,9,10,13-17 inequities and disparities. Research has shown that HIV and COVID-19 prevalence intersect, especially in the South. Of 75 U.S. counties identified as HIV/COVID-19 co-existing hotspots, 99% (n=74) were located in the South.18
LGBTQ+ young adults may be particularly vulnerable to the negative consequences from the COVID-19 pandemic and may face additional challenges compared to older LGBTQ+ people and cisgender, heterosexual people. Researchers evaluated health disparities of sexual minorities, 18-65, and found that young sexual minorities experienced higher rates of mental health burden, increased tobacco use, and increased rates of alcohol and drug use.6 LBGTQ+ young adults may also experience lasting effects of stigma related to “coming out”, family rejection, and 6,19 school-victimization.6,19 In addition, Macapagal and colleagues described that LGBTQ+ young adults, 18-29, have lower rates of healthcare use compared to other age groups, and unmet health needs compared to cisgender, heterosexual people. LGBTQ+ people of color (POC) are at an even greater risk for COVID-19 and related disparities compared to White LGBTQ+ and cisgender, heterosexual people.5 A series of online surveys disseminated in the U.S. during the pandemic found indications of greater economic impact of COVID-19 among POC.5
This study sought to examine, more thoroughly, the impact of COVID-19 on the health and well-being of LGBTQ+ POC, with a focus on the particularly vulnerable population aged 18-35, in an Ending the HIV Epidemic (EHE) designated metropolitan jurisdiction in the U.S. Southeast. Current research that explores resource needs and behavioral- and wellness-related concerns in the LGBTQ+ community during COVID-19, and strategies to address these needs are limited. In addition, this study examined whether increased mental health burden, defined by selfreported increases in feelings of anxiety, depression, and stress during the pandemic compared to before the pandemic, was associated with increased alcohol and drug use. Previous research has identified a greater burden of substance use and psychiatric symptoms in the LGBTQ+ population,11 thus identifying additional risk for these concerns during COVID-19 will be particularly beneficial in developing and targeting strategies to address behavioral health needs for LGBTQ+ POC.
An online survey was launched and available for completion from July to September 2020 by people ages 18-35 who identified as LGBTQ+ and Black/African American and/or Latinx and resided in a large metropolitan area in the Southeastern U.S., a designated EHE metropolitan jurisdiction. Young adults, 18-35, were the only age group surveyed due to findings from previous studies that indicate young LGBTQ+ people are particularly vulnerable to the negative consequences of COVID-19.20 A local program providing free services for LGBTQ+ people promoted the survey via the program’s peer specialist’s social network and through the program’s network of partner organizations including medical clinics and community-based organizations providing services for LG- BTQ+ people as well as the program’s Facebook and Instagram pages. A waiver of informed consent was obtained; details of the study were presented to potential participants and the individual could decide whether they wanted to participate by clicking the link and completing the survey. Only email addresses were collected for incentive distribution; once the participant received compensation, emails were removed.
Participants were asked questions concerning their economic- and health-related experiences during COVID-19 (defined 5,6,19 th as beginning March 19 , 2020, when social distancing orders were established in the area). Specific areas explored included day-to-day conditions and basic needs; COVID-19-related experiences; and changes in social support, loneliness, access to medical care, sexual behaviors, mental health indicators (feelings of anxiety, depression, and stress), and substance use from before the COVID-19 pandemic to the time of survey. For substance use, participants were asked to self-report how frequently they had used alcohol and drugs (response categories on a Likert scale included “Daily”, “A few times a week”, “Once a week”, “A few times a month”, “Less than monthly”, and “Never”). Participants were also asked if their use of alcohol and drugs had “increased”, “decreased”, or “stayed the same” during COVID-19. To measure anxiety and depression, participants were asked to self-report if they had experienced depression and anxiety in the last month and if their depression and anxiety had “decreased”, “increased”, or “stayed the same” during COVID-19. Participants were eligible to receive a $10 gift card upon completion of the survey.
Descriptive statistics were used to provide information about participant characteristics and experiences, and bivariate analyses, using Chi Square tests, were performed to examine the associations between increased depression, anxiety, and stress during COVID-19 and increased alcohol and drug use. A thematic framework approach was used to analyze the open-ended question – “What would you say has been the most challenging aspect of this time during COVID-19?”. The thematic analysis process involves identifying responses that are linked by a common theme and then categorizing the responses by the identified common themes.21 All study procedures were approved through the Duke Medicine Institutional Review Board (IRB).
Eighty-seven participants were included in the analysis after the removal of duplicates, incomplete responses, and participants who were not living in the designated metropolitan area. Almost half (46%; n=40) of the participants identified as male, 30% (n=26) as transgender female, 9% (n=8) as gender queer, 7% (n=6) as gender non-conforming, and 7% (n=6) as transgender male. A little over half (52%; n=45) of the participants were between the ages of 27-29, and 55% (n=48) identified as Black/African American. Almost half of the participants (47%; n=41) identified as Hispanic/ Latino. Ninety-four percent (n=82) of participants had completed
some college or had received a college diploma (Table 1).
Almost half (48%) of participants received most of their information about COVID-19 through social media, with the remaining participants receiving most of their information through online news media (29%), a television (TV) news station (22%), and through friends (1%). The majority (71%) completely or somewhat trusted the information they had received about COVID-19 and 98% felt moderately or very concerned about the pandemic. Thir-
Table 1. Participant Characteristics (n=87)
Male 40 46% Female 1 1% Gender non-conforming, non-binary, neither male nor female 6 7% Genderqueer 8 9% Trans female, trans woman, transfeminine 26 30% Trans male, trans man, or transmasculine 6 7%
33-35 3 3% 30-32 10 11% 27-29 45 52% 24-26 25 29% 21-23 4 5%
Black/African American 48 55% White 37 43% Multiple races/Mixed race 2 2%
Yes 41 47% No 46 53%
College diploma 41 47% Some college 41 47% High school diploma/equivalent 5 6%
Bisexual 7 8% Gay 43 49% Homosexual 7 8% Lesbian 16 18% Queer 10 11% Same gender loving 4 5% Straight/Heterosexual 3 3% ty-six people (41%) had been tested for COVID-19, with only one individual disclosing a positive test.
The majority (64%) of respondents lived in their own apartment or house the month before COVID-19 measures began, and since the start of COVID-19, 93% continued living in the same place for at least part of the time since the start of COVID-19. Before COVID-19, 86% of participants were working full-time, 11% were working part-time, and 2% were unemployed. Following social dis-
Table 2. Day-to-Day & Basic Needs (n=87)
Hotel 3 3% Relative’s or friend’s apartment or house 26 30% My apartment or house 56 64% Shelter 2 2%
Hotel 2 2% Relative s or friend s apartment or house 11 13% ’ ’ My apartment or house 1 1% Shelter 3 3% Streets/outdoors, tent, car 2 2% Same place as before 81 93%
Unemployed, looking for a job 2 2% Working full-time from home 0 0% Working full-time outside of home 75 86% Working part-time outside of home 10 11%
Laid off 9 10% Unemployed, looking for a job 25 29% Unemployed, not looking for a job 9 10% Working full-time from home 2 2% Working full-time outside of home 8 9% Working part-time from home 21 24% Working part-time outside of home 13 15%
Have not attempted 13 38% No 6 18% Yes 15 44%
Lost my job or had hours reduced 76 87% Childcare 0 0% Paying for food 58 67% Getting hand sanitizer, toiletries, and/or cleaning supplies 24 28% Transportation 23 26% Paying rent 25 29% Paying utilities 5 6% Paying other bills 31 36% Getting my medications 3 3% Other 0 0%
tancing mandates, 11% were working full-time, 39% were working part-time, and 39% were unemployed. Of the 34 individuals who were unemployed, 44% (n=15) had received unemployment benefits. The majority (87%) of participants reported losing their job or having hours reduced and two-thirds (67%) reported trouble paying for food (Table 2).
More than half of the participants had decreased/less access to medical care (64%) and pre-exposure prophylaxis (PrEP) (61%) than before COVID-19. Of the 30 participants (34%) taking gender affirming hormones, 37% had somewhat decreased access to their hormone therapy during the pandemic. Over three-quarters of participants reported decreased/less sexual activity (79%) and decreased number of sexual partners (80%) during the pandemic compared to the time before COVID-19. The majority (84%) of participants reported increased use of dating/hook-up apps to connect virtually; 61% reported a decrease in in-person dating. During the pandemic, access to condoms decreased for 60% of participants. The majority (87%) of participants had not been interested in HIV testing since the start of COVID-19, and of those 76 participants not interested in testing, 45% (n=34) did not know where to access an HIV test if they became interested.
Table 3. Mental Health, Substance Use and Resource Needs (n=87)
All of the time Most of the time Some of the time None of the time
Greatly decreased Somewhat decreased No change Somewhat increased Greatly increased
No Yes
No Yes
Has decreased/less because of COVID-19 Has not changed or changed for reasons other than COVID-19 5 6% Has increased/more because of COVID-19 Does not apply
Has decreased/less because of COVID-19 Has not changed or changed for reasons other than COVID-19 5 6%
Before COVID-19, 83% of participants reported drinking alcohol a few times a week and 60% reported using recreational drugs a few times a week. A quarter (25%) of respondents reported increased use of recreational drugs and 86% reported increased alcohol use during the pandemic.
All participants reported being able to find social support at least some of the time when they needed it before social distancing began. After the start of social distancing mandates, 60% reported that their level of social support had greatly or somewhat decreased. Increased feelings of loneliness were reported by 90% of participants. In the last month before social distancing began, 24% had experienced anxiety and 36% had experienced depression. The majority of respondents reported increased feelings of anxiety (89%), depression (90%), and stress (92%) because of the pandemic. Associations of feelings of anxiety (p<0.001), depression (p<0.001), and stress (p<0.003) with increased alcohol use during the pandemic were found. No associations were found between feelings of anxiety, depression, and stress with drug use (Table 3).
3 3% 34 39% 50 57% 0 0%
3 3% 50 57% 12 14% 15 17% 7 8%
66 76% 21 24%
56 64% 31 36%
2 2%
77 89% 3 3%
2 2%
Has increased/more because of COVID-19 Does not apply Compared to the time before COVID-19, please tell us if COVID-19 and the plans used to
Has decreased/less because of COVID-19 Has not changed or changed for reasons other than COVID-19 5 6% Has increased/more because of COVID-19 Does not apply Compared to the time before COVID-19, please tell us if COVID-19 and the plans used to
Has decreased/less because of COVID-19 Has not changed or changed for reasons other than COVID-19 4 5% Has increased/more because of COVID-19 Does not apply
Has decreased/less because of COVID-19 Has not changed or changed for reasons other than COVID-19 49 56% Has increased/more because of COVID-19 Does not apply Compared to the time before COVID-19, please tell us if COVID-19 and the plans used to
Has decreased/less because of COVID-19 Has not changed or changed for reasons other than COVID-19 6 7% Has increased/more because of COVID-19 Does not apply
Daily A few times a week Once a week A few times a month Less than monthly Never Decline to answer
Daily A few times a week Once a week A few times a month Less than monthly Never
Connection to general medical care Connection to sexual health care (HIV/STI testing, PrEP, condoms) 63 72% Connection to substance use resources Connection to resources to help with feelings of depression, anxiety, and/or stress 6 7% Connection to financial assistance (rent, utilities, medical care, etc.) 32 37% Job resources Support groups Housing Food Other Does not apply 78 90% 2 2%
3 3%
78 90% 1 1%
2 2%
80 92% 1 1%
13 15%
22 25% 3 3%
2 2%
75 86% 4 5%
1 1% 52 60% 23 26% 5 6% 1 1% 4 5% 1 1%
3 3% 72 83% 3 3% 4 5% 1 1% 4 5%
46 53%
60 69%
5 6% 9 10% 9 10% 7 8% 0 0% 1 1%
The most commonly reported resource needs were linkages to sexual health care (HIV/sexually transmitted infections (STIs) testing, PrEP, condoms; 72%), substance use resources (69%), general medical care (53%), and financial assistance (rent, utilities, medical care, etc.; 37%). Seven percent of participants reported a need for connection to mental health care. Major themes identified in the open-ended question regarding the most difficult aspects of the pandemic included economic/financial hardship, food insecurity, and mental health concerns. For example, one participant said the most difficult aspect of the pandemic was “anxiety triggered by the new Coronavirus”.
The findings from this survey provided insight into the experiences and needs of young LGBTQ+ minority adults in a large urban county in the Southeastern U.S. during the COVID-19 pandemic. Economic consequences were frequently reported as most participants (87%) reported losing their jobs or having work hours reduced and difficulties paying for food (67%). Less access to medical care and PrEP during COVID-19 were reported by a majority of participants, as was a lack of knowledge of where to access HIV testing.
Furthermore, a majority of participants indicated increased mental health symptomology and substance use since the beginning of the pandemic and reported mental health as one of the most difficult aspects of the pandemic. However, only 7% of respondents indicated mental health support as a needed/helpful resource. The significant stigma associated with mental health and mental health treatment may have contributed to this finding. These findings are consistent with other research that has documented increases in anxiety and depression in the LGBTQ+ community related to the COVID-19 pandemic.3 Centers for Disease Control and Prevention (CDC) researchers have asserted that people may use substances to cope with the stress and anxiety of the COVID-19 pandemic,22 which may have been a contributor to the increased alcohol and drug use found in this study along with the significant relationships identified between increased depression, anxiety, and stress with alcohol use among study participants.
Although these findings documented experiences near the beginning of the pandemic, they have likely continued as pandemic restrictions and repercussions have remained at various levels. In addition, long-term impacts of the pandemic and related hardships and needs are likely to occur and have been documented in other studies. Findings from a Pew Research Center survey indicated that among non-retired adults who say their financial situation was worsened due to COVID-19, 44% think it will take three-years or more to get their finances back to where they were pre-COVID-19 and 10% do not think their finances will ever recover.23 In addition, researchers have identified how people with ongoing trauma, which is prevalent in the LGBTQ+ community,24 may experience increased social detachment; increased harmful, self-injurious, or suicidal behaviors; and/or an exacerbation of post-traumatic stress disorder symptoms in the long-term due to the pandemic.25 Additionally, an analysis estimated as many as 75,000 people may die from drug or alcohol misuse and suicide by 2029 due to the ongoing effects of the COVID-19 pandemic, especially those related to economic concerns, social isolation, and uncertainty of the virus.26 More research on the longer-term effects of the pandemic on the LGBTQ+ community is needed as well as interventions to address the ongoing resource, behavioral health, and medical care needs.
The survey findings should be considered in the context of the research limitations. The survey was disseminated through an online link, which may have resulted in spam responses. The research team made efforts to prevent spam by asking open-ended questions, using a completely automated public turing test to tell computers and humans apart (CAPTCHA) system, and triangulating locations of respondents. Further, since the survey was disseminated online, the responses may not be representative of members of the LGBTQ+ community who are harder to reach including those experiencing unstable housing and lacking internet access. Due to the small sample size and location of data collection, the study findings may lack generalizability to other areas of the country; however, participants’ experiences may be similar to other southern urban areas where stigma and racial inequities are pervasive, and resources are often limited. Lastly, measures of mental health and substance use were obtained cross sectionally so causality between these variables cannot be conclusively determined.
The findings from this research support the critical need for an extended reach of both telehealth and in-person behavioral, sexual, mental health, and general health care services; financial assistance and economic mobility programs; as well as used to strategize effective mechanisms to address the barriers and needed resources during and post-COVID-19, as the identified disparities are likely to pose long-term repercussions including increased risk for HIV transmission. Though the preliminary findings demonstrated challenges of the LGBTQ+ community during CO- VID-19, further research is needed to examine the ongoing and longer-term effects of the pandemic on harder to reach members of the LGBTQ+ community and to develop effective strategies to address related needs and challenges to improve the well-being of the minority LGBTQ+ population and to continue to progress toward goals for ending the HIV epidemic.
This work was supported by the Substance Abuse and Mental Health Services Administration under grant number 1H79TI081999.
The authors have no conflicts of interest to declare that are relevant to the content of this article.