Although there is no evidence to suggest that LGBT people are inherently more likely to contract COVID-19 than other groups, a number of factors exist which may result in people from LGBT communities being more at risk of infection than the general population. These include the following factors:
LGBT communities are disproportionately impacted by HIV(i). Without the right treatment, a compromised immune system is more susceptible to the effects of COVID-19(ii). BHIVA advises that people living with HIV with a CD4 count of under 50 or people who have been diagnosed with an opportunistic infection in the last 6 months should stay at home at all times and avoid face to face contact for 12 weeks(ii). Those people living with HIV who do not know their status or are not accessing treatment of particular concern.
LGBT people are more likely to smoke(iii) than the general population. Smoking has been linked as a factor that is ‘highly likely’ to increase the risk of coronavirus pneumonia(iv).
LGBT communities may be more reluctant to access healthcare due to fears of encountering LGBTphobia(v). This may result in people with COVID-19 symptoms avoiding advice or care once these develop.
LGBT people are less likely to be active enough to benefit from the protective factors of exercise - resulting in a higher prevalence of long term conditions. Both of these have been linked as risk factors leading to people getting more seriously ill from COVID-19(vi). Exercise has also been listed as a factor in making people less likely to be admitted to intensive care should they develop symptoms associated with COVID-19(vii).
LGBT people are more likely to be homeless (viii, ix) meaning that many may be unable to self-isolate effectively & may not have what they need if they do fall ill.
These factors mean that LGBT communities run the risk of being disproportionally vulnerable to COVID-19 infection.
What impact might the safety measures related to COVID -19 have on LGBT communities?
Aside from the risk of contracting COVID-19, the health and wellbeing of LGBT people may be affected by the safety measures which have been implemented.
Strategies such as social isolation can have a greater impact on some LGBT people due to their circumstances, experiences, or conditions.
One of the most significant strategies for supporting outcomes in LGBT healthcare is to be aware of these experiences, and what community assets or supports are available.
Trans and Non-Binary Health
LGBT Foundation has received numerous reports from trans and non-binary people who have been denied access to prescribed and scheduled hormone injections, with some being told that these are ‘non-essential’. World Health Organisation & European Commission guidelines on essential services include the provision of ongoing medications for the trans community. LGBT Foundation reached out to a number of GP’s for additional advice. This included:
RCGP guidelines say that practices should aim to continue essential injections (such as testosterone) regardless of the scale of the virus outbreak. Where appropriate, consider teaching patients to self-administer.
Other options include the changing to longer acting injections if possible. For example, Nebido testosterone injections can be given in 3 month form. If the risk of coming in for testosterone injection is considered too great, then Testogel could be substituted.
Routine blood monitoring can wait but should not delay the administration of hormone therapy.
Gender Identity Clinics have frozen their waiting lists and other services, such as gender affirming surgeries have been cancelled. This is likely to add to the anxiety and other associated mental health conditions which are already more prevalent. The common practice of chest binding can also increase the risk of being severely affected by COVID-19 symptoms.
LGBT people, in particular older LGBT people, are more likely to be socially isolated (x). Coupled with the fact LGBT people are less likely to have children or wider family social networks this means that if someone falls ill they may have less of a support network upon which to rely. While it is recommended that healthcare professionals are familiar with local provisions for organisations which can deliver food to isolated individuals, we also recommend being aware of services such as the LGBT Foundation Befriending Service which can provide contact as support remotely.
Social isolation means that many are trapped inside with abusive partners or family members. Reports of domestic abuse have risen since safety measures were implemented. As LGBT people are more likely to experience domestic abuse this rise is likely to be disproportionately affecting LGBT people. Since the new safety measures came into effect, LGBT Foundation has seen a 30% increase in domestic abuse/violence calls to our helpline. Social isolation and lack of employment, income or savings may mean that many people have little option but to move back in with parents or family who are LGBTphobic or otherwise unaccepting of their identity. This is particularly true of younger LGBT people. Difficult living situations can make it more difficult to access confidential support and can result in poorer mental health or could rise to the level of domestic abuse in some cases.
Mental Health & Substance Misuse
It is widely acknowledged that LGBT people are more likely to have poor mental health(ix). As well as higher rates of anxiety and depression, poor mental health has been linked other behaviours detrimental to overall health including extended use of substances, self-harm, eating disorders and suicide ideation(xii). The LGBT community has higher rates of smoking, and alcohol and drug use and dependency. Many of these issues may be worsened by having normal routines disrupted and lack of access to face-to-face support.
As well as being disproportionately impacted by HIV*, we know that 96% of those on the PrEP trial are men who have sex with men (MSM)(xiii). There has been a significant amount of misinformation shared about PrEP and the coronavirus, with some people stopping taking PrEP, and others unable to access PEP, or their usual PrEP source or prescription. We know that syphilis and gonorrhoea are rising in MSM communities, and that women who have sex with women (WSW) are 21% more likely to receive a positive diagnosis at a GUM clinic than heterosexual women(xv).
COVID-19 safety measures often mean that sexual health drop-ins are unavailable. We know that many members of the LGBT community will avoid healthcare settings they feel unsafe in, and are more likely to access LGBT-specific services for issues like mental health or sexual health(x).
Additionally, sex workers – a group where LGBT people are overrepresented - are more likely to experience social exclusion, such as low income, unemployment, health problems, housing problems, or lack of social support - all of which may contribute to higher risk of contracting COVID-19, and to poorer outcomes when unwell.
*Having HIV in itself does NOT put people at greater risk. If someone's CD4 count is less than 200 additional protective measures should be followed in line with BHIVA advice. However, people with a CD4 count of more than 200 should follow general population social distancing advice. ‘Wherever the question is asked, LGBT people experience poorer outcomes in healthcare.’ – Dr. Michael Brady, National Advisor for LGBT Health
WE’RE STILL HERE IF YOU NEED US
While LGBT people experience poorer outcomes in a wide range of areas, we know that mental health, sexual health and trans health are key areas in which impact is likely to be acutely felt. LGBT people are also more likely to be disabled, or living with a long-term conditions, and may be ‘ multiply marginalised’
It is key that in times of stress we continue to provide equitable care to all of the communities we serve, particularly those who might be vulnerable or at higher-risk of poor outcomes. LGBT Foundation exists to support these communities and the professionals who work with them.
As ever, we’re here if you need us. LGBT Foundation’s national helpline continues to be open on 0345 3 30 30 30 Monday to Friday between 9am and 9pm, and weekends from 10am-6pm. Details of our other remote service provisions can be found on the LGBT Foundation website. Please email firstname.lastname@example.org to access our detailed health inequalities briefings, ask about our online training, resources, or other forms of support for services and professionals, such as policy consultations or Equality Impact Assessments.
REFERENCES, RECOMMENDATIONS, & FURTHER READING:
British HIV Association – COVID-19 Guidance Public Health England- Clinical Outcomes for Trans people accessing HIV Care in England Prepster – COVID19 Tips & Tricks NHS Advice on mental health issues if you're gay, lesbian, bisexual or trans i Public Health England (2018) ‘Progress towards ending the HIV epidemic in the United Kingdom’, p.40. ii https://www.tht.org.uk/news/coronavirus-COVID-19 iii ONS. 2018. The Odds of Smoking by Sexual Orientation in England, 2016. iv https://www.independent.co.uk/life-style/health-an... v https://www.stonewall.org.uk/system/files/lgbt_in_... vi https://www.nhs.uk/conditions/coronavirus-COVID-19... vii https://www.bbc.co.uk/news/uk-52076856 viii Albert Kennedy Trust. 2017. LGBT Youth Homelessness: A UK National Scoping of Cause, Prevalence, Response & Outcome. Available at:https://www.akt.org.uk ix Bachmann, C. and Gooch, B. 2018. LGBT in Britain. Home and Communities. Stonewall and YouGov x LGBT Foundation, The State of the City for Manchester’s Lesbian, Gay and Bisexual Communities, 2015 xi Guasp, 2011. Lesbian, Gay & Bisexual People in Later Life, London: Stonewall. Heaphy, B., Yip, A.K.T. and Thompson, D., 2003. Lesbian, gay and bisexual lives over 50: report on the project: 'The social and policy implications of non- heterosexual ageing', Nottingham: York House Publications. Alden, S. and Wigfield, A. (2018) Reducing social isolation amongst older LGBT people: A case study of the Sage project (PDF, 513 KB) xii LGBT Foundation. Hidden Figures, 2020 xiii PrEP IMPACT Trial updates, NHSE Commissioning, 2020 xv Beyond Babies & breast Cancer: Table 6: Number of STI Diagnoses & Services in England 2009-2012, Public Health England, UK, 2013 (data available at http://www.hpa.org.uk/stiannualdatatables)