'The volume has been turned up on everything': Pandemic places alarming pressure on transgender mental health

The Washington Post

By Alyssa Fowers

August 18, 2020

The surgery was supposed to be a turning point.

Brenda Emery spent a year preparing for the vaginoplasty. To save up for it, she took jobs in food service straight out of college and moved in with her mother. She talked at length to therapists and medical experts to make sure the procedure to modify her lower body was what she really wanted as a transgender woman.

After the surgery, Emery hoped, she would be fully comfortable in her own body. Finally, she could pursue dreams of working in local theaters that had been put on hold to save money. So this March, she quit her restaurant job and prepared to travel from her home in the Maryland suburbs to New York for the procedure.

Then came the novel coronavirus, halting all non-emergency surgeries.

“I just felt numb. I didn’t know how to process it,” Emery, 26, said. Her surgery got rescheduled for May, only to be canceled again. Unemployed and unsure whether the procedure would still happen, Emery spent her days in bed, grappling with anxiety, sadness and frustration. “It felt like I put my whole life on hold.”

Even as the coronavirus has upended lives throughout the country, it has taken a deep toll on the transgender community, a population that has long struggled with higher rates of mental illness and poor medical care because of discrimination and abuse.

Since the pandemic began, crisis calls to Trans Lifeline — a crisis telephone line staffed by transgender people — have risen 40 percent and continue to climb. At Whitman-Walker, an LGBTQ-focused community health center in Washington, mental health providers are seeing 25 percent more patients than they did before the pandemic, and they are no longer able to accept new referrals. Transgender peer support groups at Whitman-Walker have also reached capacity since the start of the pandemic.

Meanwhile, advocates say some are experiencing more abuse than usual, especially as some are forced to move back home or stay closer to people who don’t support them. Homicides of transgender people, for example, have skyrocketed. In 2019, the Human Rights Campaign tracked at least 27 deaths nationally from violence against transgender and gender nonconforming people. In the first half of this year, the homicide total has already reached 26, according to the Human Rights Campaign.

In recent months, the cratering economy has alarmed many in the transgender population, which experiences a substantially higher rate of unemployment and workplace discrimination.

Advocates for transgender rights say unemployment has a domino effect: lack of jobs means lack of insurance and medical care. Such struggles combined with isolation have placed increasing psychological pressure on a population already beset with high rates of suicide and mental health crises.

“We’re survivors as a community,” said Elena Rose Vera, executive director of Trans Lifeline. “But all these problems reinforce each other and exacerbate everything we’re already facing. … It’s like the volume has been turned up on everything.”

While studies have shown the coronavirus has disproportionately infected and killed African Americans and Hispanics, the extent of the coronavirus’s effect on the transgender community is unclear because most states do not collect data on the LGBTQ community. In recent weeks — five months into the pandemic — California became one of the few to begin doing so.

Experts are particularly worried about an alarming increase in mental health problems. The pandemic has increased anxiety and depression across the country. Even before the pandemic, the U.S. Transgender Survey conducted in 2015 found that transgender people attempted suicide at 9 times the rate of the general population. That suggests the population is enduring the additional stresses of this pandemic with an already elevated risk for mental crises.

In the past, what has driven much of that mental health burden is gender dysphoria — the psychological pain caused by living in a body that does not match one’s gender identity. “But that’s powerfully alleviated by getting the care that we need,” Vera said. “The further struggles we have are due to people treating us poorly.”

Transgender mental health counselors say they have seen signs those struggles have increased in intensity during the pandemic.

In many of the calls fielded by Trans Lifeline, counselors say, people have talked of being forced to quarantine with families or partners who were unsupportive or abusive. Other people, like Emery, have struggled with rescheduled surgery or obtaining other transition-related care.

Britt Walsh, director of gender-affirming care at Whitman-Walker, said mental health problems early in the pandemic were often attributable to delays in care.

“There’s very real devastation and day-to-day upheaval. Access for surgery requires jumping through hoops and gate-keeping to prove to your insurance that this is medically necessary,” Walsh said.

Some in the transgender community have struggled during the pandemic to maintain hormone therapy.

In the early days of the pandemic, Coral Mercy Cruse was turned away when she tried to pick up a refill of her estrogen prescription. The pharmacy technicians insisted not enough time had passed between prescriptions even after she explained they were mistaken. And as she turned to leave, she said, she heard them laughing at her.

“I felt dehumanized,” Cruse said. “My hormones were being dangled in front of me, and I wasn’t even being talked to like a human being. I felt a lot of hopelessness about being treated this way forever.”

That night, she struggled with suicidal thoughts and called Trans Lifeline for help. “If they hadn’t been there,” Cruse said, “I don’t know what would have happened that night.”

Amid a pandemic in which health care has become especially urgent, transgender people also face barriers to medical care because of discrimination — clinicians who dismiss medical injuries as minor or somehow related to being transgender because they are uncomfortable with treating them.

Advocates describe the phenomenon as “trans broken arm syndrome” — being turned away from medical care when clinicians treat issues such as broken arms as a symptom of being transgender.

That discrimination has in turn caused some transgender people to distrust medical establishments or made them less likely to seek medical help.

“The president of the United States told doctors they will be protected if they treat me unfairly. That doesn’t increase my confidence in my chances if I catch covid-19,” said Vera, who leads Trans Lifeline.

This summer, the Trump administration rolled back nondiscrimination protections for transgender people in health care, which was seen as a significant setback in the movement for LGBTQ rights. The rollback has since been challenged in court.

Advocates say transgender people are also more vulnerable during the pandemic because of how closely America has tied access to health care to employment.

Transgender people experience rates of unemployment three times as high as the general population and often face losing their jobs if they come out or start to transition, according to the U.S. Transgender Survey. About half of employed transgender people keep their gender identity a secret or delay their transition to avoid discrimination at work.

The pandemic has made jobs — and the employer-based insurance it offers — a lifeline that transgender people cannot afford to lose, which for some has meant hiding who they are during this time of crisis, crisis counselors say.

Monica, an engineer in Upstate New York, said she feels drained every day by the effort of staying in the closet. “What I show out in the field is Charlie. I have to translate from Charlie to Monica, and Monica to Charlie, and that’s exhausting.”

Speaking on the condition only her first name be used for of fear of workplace discrimination, she said she decided to stay in the closet after watching a transgender colleague experience so much harassment she was forced to leave their company and work as an outside contractor. Another friend lost her job after coming out at work. “If you get ridiculed all the time, it’s really tough to take,” she said. “I fear I could lose my job and insurance at 60 years old. This is what has ruled my world for the last 35 years.”

Nearly 1 in 6 transgender people who have been employed say they lost a job because of their gender identity or expression. Those job losses can be devastating. More than half of those who have lost employment because of anti-transgender discrimination have attempted suicide at some point in their lives, according to the U.S. Transgender Survey.

Beyond loss of insurance, unemployment puts food, rent and other necessities out of reach, increasing anxiety and chances of mental health crises, counselors say. “There is a joke in the community that we’re always passing the same $15 around to each others’ fundraisers,” Vera said. “That’s been true for as long as I’ve been part of the community. But now more than ever, I’m seeing fundraisers for rent, for food. The need is enormous.”

As transgender people lose jobs, many have also lost housing. Some younger transgender people were forced to move back in with family members who don’t always support them and have in some cases tried to force them back into the closet, according to peer facilitators for transgender support groups at the DC Center for the LGBT Community.

Since the pandemic started, virtual support groups held by the center have attracted almost twice as many people as their in-person sessions before the crisis.

The counseling team at Whitman-Walker has received messages from those trapped in unsafe living situations. “We sometimes get messages from Instagram or Facebook Messenger where someone says: ‘You can’t call me, I can’t email you. It’s not safe where I am. But please, can you help me access services?’” Walsh said.

As the pandemic stretches on, transgender people have continued a tradition of turning to one another for support.

Even amid a pandemic, police brutality, nationwide protests and rollback of transgender rights, “we’re still finding ways to see each other and meet our community’s needs,” said Jessica Austin, a peer support facilitator at the DC Center. “Community allows us to move through all this unrest.”

“We do this because it’s necessary,” said Vivian Topping, another peer support facilitator. “There’s a world where we say, we’re exhausted, we can’t do it, and the group doesn’t continue. But that doesn’t happen because trans folks push really hard to support our people and be resilient. There’s still beauty. There’s still joy. There’s still a life to keep looking forward to.”