Suicide in Trans Individuals During the COVID-19 Pandemic.

The COVID-19 pandemic has affected the physical health of individuals as well as their emotional and mental health. Strict lockdowns, quarantine policies, closure of international borders, and transitioning of in-person work at schools and universities to working online from home have limited social interactions and instilled anxiety, fear, stress, panic, and trauma. Preexisting psychiatric illnesses, isolation, unemployment, barriers to health care, and serious medical illness are all risk factors for suicide and suicidal behavior during COVID times.

Wide-ranging factors such as social conventions, decreased availability of resources, and economic burden, along with an individual’s specific psychosocial fragility in such circumstances, might contribute to a suicide attempt. The COVID-19 pandemic has been suggested to have a noteworthy effect on suicide rates because of its social and psychological consequences (e.g., depressive symptoms, anxiety, and posttraumatic stress) on people’s lives.

The Center of Disease and Control and Prevention (CDC) has identified several populations as particularly vulnerable to this pandemic. These encompass individuals aged over 65 years and people with preexisting diseases such as cardiac abnormalities, asthma, or renal disorder. In addition, those in an immune- deficient state, such as diabetes or HIV infection, are further at risk of acquiring COVID-19. Moreover, according to the CDC, people who were financially unstable, socially isolated, and homeless even before the pandemic appear to be at a higher risk and powerless against this pandemic. The impact of quarantine is likely to be more severe in already disadvantaged communities such as transgender people, especially with lockdown protocols, social distancing, economic burden, isolation, and limited access to community and religious activities, which can further deteriorate their mental well-being. Transgender people are those individuals whose gender identity differs from the sex they were designated at birth. According to the World Professional Association for Transgender (WPATH) Standard of Care, trans people are a diverse group who cross or transcend culturally recognized gender categories. As per the 2011 census, a minimum of 488,000 individuals belong to the trans community in India. Moreover, 31% of the transgender population in India have committed suicide, and amongst them, 50% attempted it before the age of 20.

Mental Health and Suicide Risk in Transgender People

Trans people experience discrimination and exclusion due to their gender identity. COVID-19 restrictions have now amplified their challenges and can have extreme consequences such as suicide, as we will further discuss in our paper. Even before the pandemic, these groups were a particular target of bullying, violence, substance abuse, and suicidal ideation. Their fear of being mistreated on the grounds of gender distinction causes stress, anxiety, and self-destructive behaviors. The transgender community is at a fourfold higher risk of suicide. This article highlights the possible contributing factors towards the increase in suicide rate in trans people in the light of the COVID-19 pandemic, as they are more vulnerable and sensitized to stress, resulting in a higher risk of poor psychosocial outcomes. Following is a list of all risk factors for suicide among the transgender population during the COVID-19 pandemic (summarized in Table 1):

Table 1.

Risk Factors for Suicide Among the Transgender Population During Covid-19 Pandemic

Risk Factor	Authors
Social isolation	DeMulder et al., 2020; Zwickl et al., 2021
Family rejection	DeMulder et al., 2020; Sachdeva et al., 2021
Lack of attention and health care insurance/health care disparity	Herman et al., 2019; Sachdeva et al., 2021; Salerno et al., 2020
Inability to seek androgen deprivation therapy	DeMulder et al., 2020; Sachdeva et al., 2021
Community rejection/social inequality	DeMulder et al., 2020; Sachdeva et al., 2021
Financial insecurity/unemployment	Herman et al., 2019; Sachdeva et al., 2021; Zwickl et al., 2021
Depression	Zwickl et al., 2021
Gender discrimination	DeMulder et al., 2020; Herman et al., 2019
Mental health burden	Salerno et al., 2020
Co-morbidities	Herman et al., 2019
Homelessness	Herman et al., 2019

Health-related Factors

Transgender people are more vulnerable to COVID-19 as many already have underlying health issues, increasing their chances of contracting this virus. This group may be at a higher risk for severe illness. Many transgender adults suffer from underlying health conditions, including asthma, diabetes, heart disease, and HIV infection. Similarly, transgender adults, along with other members of the transgender community, are more likely to smoke, and smoking itself is an additional risk factor for COVID-19. Their poor health, coupled with the fact that many of them lack access to basic health care facilities, makes it difficult for them to recover from the virus, potentially leading to more frustration and thus increasing the risk of them attempting suicide.

According to the past literature, the rate of sexually transmitted diseases and HIV in the transgender population is significantly high in India. HIV prevalence in the trans community is nearly 68% in Mumbai, 18.1% in South India, and 17.5 % in Chennai. In the United States, there are currently one million transgender people, and over 2% of adult transgender people have recently been diagnosed with HIV. Approximately 483,000 transgender adults in the United States fear the retaliation and hatred that can occur on verbalizing and proclaiming their gender identity. They believe that society’s bitterness might deprive them of good health care facilities, and 77,000 feel discontented with care received in the past. It is estimated that 450,400 transgender adults did not visit the doctor in the previous year because of high cost and unaffordability.

Social Factors (Homelessness, Financial, Unemployment, and Social Support)

Many transgender individuals face homelessness. According to the CDC, 96,400 transgender adults reported experiencing homelessness before the coronavirus pandemic. An online cross-sectional study conducted in the United States during 2018 found that youth belonging to the Lesbian, Gay, Bisexual, Transgender, and Queer (or sometimes Questioning) community who suffered from homelessness or housing instability had twice the rate of suicidal ideation and thrice the rate of suicidal attempts versus transgender individuals without housing instability. There are reports of tragic consequences in this population. For example, a 38-year-old HIV-positive, transgender person in India committed suicide by hanging herself, seemingly because of the loss of income and inaccessibility of medicines because of lockdown. Another example is of a 33-year-old transgender person in India who was a beggar and who died by suicide because of the inability to earn amidst the COVID-19 restrictions.

The CDC also identifies financial worry and unemployment as risk factors for a high suicide rate. According to the Trans Pop survey (2016–2018), the unemployment rate for transgender adults was higher (12.8%) than the overall unemployment rate for the US population (3.9%–4.9%). COVID-19 led to a drastic increase in unemployment, thus leading to more economic disparities for transgender people and further deteriorating their mental health.

Lack of parental closeness or acceptance negatively affects health in cis- and transgender children. Sexual minorities, overall, experience a lower level of parental affection. Compared to their cisgender peers, transgender youth are also subject to a higher level of child abuse. In a study conducted in Thailand, family rejection was predictive of the severity of depression, suicidal ideation, and sexual risk behaviors among cis- and transgender adolescents.

With the current pandemic, the instructions to “practice social distancing” and “stay at home” can increase the risk of frustration, depression, and self-destructive thoughts in these individuals. This has created an adverse impact, as the home is not a safe place for many of them, and they may face increased hostility. Based on data from the 2015 US Transgender Survey (USTS), it is estimated that 755,900 transgender adults have been victims of domestic violence in their lifetimes. In India, many of them go through physical abuse, money extortion, defamation, and some have been raped by police officers. A 2007 study revealed that 46% of transgender people report having been raped, while 44% and 56%, respectively, reported physical and verbal abuse. This hostile treatment magnifies the risk of both depression and thoughts of self-harm or suicide.

To address the high rates of depression, suicidal ideation, and suicide attempts, access to mental health services and support needs to be provided to this group. In this pandemic, where physical interaction is limited, such services can be provided remotely, being mindful of the distinctive challenges and problems faced by transgender adults. Timely and effective health care needs to be made accessible to them, and health insurance need to be provided to them to treat the COVID-19 complications. Moreover, they need to be included in the efforts made to provide them with essential health care services and make them feel safe in society. Understanding these issues and better transgender cultural competency among health professionals can support a more inclusive health care environment for them.

Strict legislation needs to be implemented to prevent violence towards transgender persons and address the social and economic disparities they face. A plan of action is required to ensure the safety of transgender individuals to live peacefully without any abuse, fear, sexism, and inequity, especially during the social restriction amidst COVID-19.

Awareness needs to be raised in public about the transgender community to address the stigma, their mental and physical barriers during this pandemic, and the discrimination towards them. Mental health professionals can discuss with directors, teachers, and faculty counsellors to supply resources and trainings on anti-trans prejudice and to develop safer school environments for transgender students. Peer support from other trans individuals can buffer the negative effect of stigma on mental health. All this can be done online to make them realize that they are not alone in this pandemic.

The government should highlight the accurate statistics of the trans individuals’ sufferings during the pandemic and emphasize the data in the public arena. This will further encourage policymakers to strengthen and stipulate the policies for transgender persons and to address their basic requirements amidst COVID-19.

A multisector approach can limit the disparities faced by the transgender communities. A cohesive plan needs to be developed by all stakeholders of the society as it can play a major role in reducing the challenges and sufferings faced by transgender people. This can only be achieved if all the departments, including teachers, health care facilitators, and parents, can serve as a single unit as this can mold the trajectory of the pandemic and its repercussion on the unguarded population. Social media campaigns, proper policy pertaining to the rights of minorities, and thorough discussion and awareness regarding the inequality and ineffective health facility should be implemented through media platforms by using culturally appropriate messages.

Physicians ought to be culturally sensitive to satisfy the requirements of the transgender people and learn to deal with the transgender community with compassion, empathy, and care. Appropriate training is required to provide nurturing, open, and nonjudgmental communication and care to that population in a respectful and unbiased fashion.

Parental affection and emotional support are effective in preventing depression among transgender youth, and this results in a higher quality of life.[22, 24] There is a need for further studies to determine the basic requirements of transgender youth together with physical and mental well-being, financial aid, and employment opportunities, specifically during the era.

All national health frameworks and strategies should consider the benefits of health promotion strategies and service accreditation standards for providing culturally appropriate services for transgender communities, with their advantages to the transgender communities taken into account.

Recommendations

To conclude, COVID-19-pandemic-related stressors seem to have further aggravated the ongoing challenges faced by transgender people. This community is highly vulnerable to suicidal behavior as this pandemic has likely compounded the impacts of preexisting comorbidities, social downgrading, discernment, and mistreatment. Furthermore, it is difficult for them to follow the safety protocol as they mostly live in dense areas with poor sanitation facilities. Therefore, it is a global challenge to understand the cultural background and formulate the management plan using a culture- specified, tactful, and transgender- inclusive approach. They need to be considered as an endangered group of individuals with urgent conciliation. Therefore, it is crucial to create a more directed public health response accompanied by a separate set of regulations towards trans individuals to address their difficulties, and thoughts of self-harm, and suicide during the pandemic.