Queers in quarantine: Young LGBTQ+ people's experiences during the COVID-19 pandemic in Sweden.

The COVID-19 pandemic led to major restrictions of everyday life activities. This worsened the social situation of many people, and marginalized groups have been especially affected. This article explores how LGBTQ+ young adults in Sweden have been affected by the COVID-19 pandemic and the subsequent recommendations and restrictions. Fifteen participants between 20-29 years, who self-identified as lesbian, gay, bisexual, transgender, and queer (LGBTQ+), were interviewed about their experiences. A thematic analysis of the data showed that the participants perceived their psychological wellbeing to have been greatly affected by the pandemic. Several reported symptoms of clinical depression, as well as anxiety, worry, rumination, and a heightened sensitivity to stress. Stressors included fear of the disease itself, and fear of spreading the virus, as well as the negative consequences of adhering to the recommendations of social distancing, which constantly interplayed with the marginalized position of being a young LGBTQ+ person. Most participants experienced a decrease in minority stress in face-to-face interaction with social distancing measures in place, but an increase in minority stress online. Those who faced minority stress at home experienced the isolation as particularly stressful. Limited access to the LGBTQ+ community was a common stressor. For transgender participants, the effects on transgender healthcare, such as prolonged waiting times for gender dysphoria assessment and hormone treatment, were a major challenge. Our results have added valuable knowledge to research indicating how vulnerable young adults were highly affected by the COVID-19 pandemic restrictions.

INTRODUCTION

Worldwide, people have been faced with the struggles of living through the COVID‐19 pandemic. There have been widespread concerns over the negative mental health effect that the pandemic, and its accompanying social distance, has caused globally (Holmes, O'Connor, Perry et al., 2020). Lesbian, gay, bisexual, transgender, and queer (LGBTQ+) people, and in particular youths and young adults, on average suffer from increased mental illness (McDonald, 2018; Public Health Agency of Sweden [PHAS], 2014, 2015). This in turn has raised concerns about the pandemic's effect on this already vulnerable group. For the present study, 15 young adult LGBTQ+ people in Sweden were interviewed about their experiences of the pandemic and the associated restrictions.

The COVID‐19 pandemic and subsequent restrictions in Sweden

COVID‐19, short for Coronavirus Disease 2019, has tormented the world since the end of 2019. On December 31, 2019, the Chinese government informed the World Health Organization (WHO) about a type of pneumonia with an unidentified cause in Wuhan City, China (WHO, 2020a). Thereafter, the spread of the virus went fast, and by the end of March 2020 COVID‐19 had appeared in over 200 countries and territories around the world, amongst them Sweden (WHO, 2020a). The World Health Organization classified COVID‐19 as a pandemic on March 11, 2020 (WHO, 2020b) and by the end of January 2021, when the present study was conducted, there were 93 m reported cases worldwide, including a reported death toll of 2 m people (WHO, 2021a).

The disease COVID‐19 is caused by the virus SARS‐CoV‐2 (PHAS, 2021a), which exists in different variations caused by virus mutations (PHAS, 2021b). The most common symptoms of COVID‐19 are a dry cough, fever, and tiredness. Severe symptoms include breathing difficulties, shortness of breath, and loss of speech or movement (WHO, 2021b). If treatment is unsuccessful, the condition may require hospital care and may even result in death (PHAS, 2021a). In addition, old age, being immunocompromised, obesity, and other health conditions are risk factors that can worsen the experience and symptoms of COVID‐19 (The Swedish Civil Contingencies Agency, 2021).

Nations worldwide have responded to the threats of the pandemic in different ways. Several countries perceived various degrees of lockdown to be necessary to limit the spread of the virus (Han, Tan, Turk et al., 2020). This included a state of quarantine for the citizens, often excluding for instance people classified as essential workers (Han et al., 2020).

Sweden's response to the pandemic differed from many other similar countries around the world (Ludvigsson, 2020). The goal of the Public Health Agency of Sweden (PHAS) has been to prevent large numbers of the population contracting the virus at the same time, to enable the Swedish healthcare system to sustain capacity. Emphasis has also been placed on protecting high risk groups from severe COVID‐19 while maintaining important societal health services and many of the measures to limit the spread have been voluntary. During the spring of 2020 the Swedish strategy included a restriction of public gatherings to 50 people, recommendations to avoid all unnecessary domestic travel, and requirement for universities to close their campuses and initiate distance learning. Moreover, employers were strongly encouraged to let their employees work from home if possible. With a well‐developed internet infrastructure, many office workers and students were able to continue their work from home.

During the summer and early autumn of 2020, several of these restrictions and recommendations were lifted, but during the last months of 2020, when an increase of COVID‐19 cases occurred, stricter recommendations and regulations were reinstated (PHAS, 2020a). The Public Health Agency of Sweden strongly urged people to limit their social contacts to include only a few people, to avoid visiting shops, gyms, and other public places, and to wear face masks on public transport during rush hour (PHAS, 2020a). The implementations enforced in Sweden, although varying in strictness and severity, have impacted the everyday life of Swedish citizens (PHAS, 2020b) and most restrictions were still active when the data collection for the current study took place in early 2021.

The pandemic's impact on mental health

At the onset of the pandemic, many raised concerns about the impact of the pandemic and accompanying restrictions on mental health around the world (Gavin, Lyne & McNicholas, 2020; Holmes et al., 2020; WHO, 2020c), including on the Swedish population (PHAS, 2020b). In addition, there was particular concern for those with a pre‐existing vulnerability to mental health problems (Gavin et al., 2020). Specific concerns were raised about the vulnerabilities of young LGBTQ+ people (see for example Salerno, Williams & Gattamorta, 2020). Thus, exploring the lived experiences of LGBTQ+ adults under 30 years old became the focus of our current investigation.

Social distancing has been a term used to describe the reduction of interactions between individuals, by requiring them to keep physical distance from others (De Vos, 2020). Social distancing and quarantine are presumed to have a negative impact on the mental health of the population (Brooks, Webster, Smith et al., 2020; Saltzman, Hansel & Bordnick, 2020). Effects on mental health during quarantine have been linked to factors such as the duration of the quarantine, fear of the virus, feelings of frustration and boredom, stigma, financial difficulties, and insufficient information (Brooks et al., 2020; Prati & Mancini, 2021).

The full impact of the pandemic on the well‐being of the Swedish population, including its eventual long‐term consequences, is still unclear due to the ongoing status of the pandemic. Surveys conducted on the Swedish general population at the beginning of the pandemic demonstrated varied effects on well‐being: one survey indicated only minimal effect on mental health (PHAS, 2020c) while another indicated a marked increase in rates of mental health problems such as depression, anxiety, and insomnia (McCracken, Badinlou, Buhrman, & Brocki, 2020). Among Swedish youth there seems to have been a general increase of mental health problems (including loneliness, anxiety, and stress) with a notable rise in problem rates when distance learning was imposed (Kapetanovic, Gurdal, Ander & Sorbring., 2021).

Many Swedish youths and young adults became more dependent on their families of origin during the pandemic (Kapetanovic et al., 2021). This may have a negative or positive impact on mental health depending on the quality of the family relationships. However, family relationships with parents and sometimes siblings are often reported as stressful for young LGBTQ+ people (Gato, Leal & Seabra, 2020). Pandemic restrictions have led youths and young adults to spend less time with their friends and more time with their family and for some young people this time has been filled with higher levels of conflict and less fun than in the pre‐pandemic period (Kapetanovic et al., 2021).

LGBTQ+ young adults: Mental health and minority stress

It is well established that LGBTQ+ people, and especially young individuals, struggle more with mental health problems and in particular are at higher risk of suicidal behaviors and depression and anxiety disorders than are their non‐LGBTQ+ peers (Marshal, Dietz, Friedman et al., 2011; McDonald, 2018; Russell & Fish, 2016; PHAS 2014, 2015). In Sweden a national survey indicated that LGBTQ+ youth were less satisfied with their lives and experienced more symptoms of mental illness (including stress and sleeping problems) than did their non‐LGBTQ+ peers (SAYCS, 2019). Within the LGBTQ+ group, bisexual women and transgender people were at particular risk of mental health problems, including experiencing suicidal thoughts and making suicide attempts (Forte, 2018).

One plausible factor linking gender and sexual minority status and mental illness has been the high rates of minority stress experienced by LGBTQ+ people (Bränström, 2017; Meyer, 2003). Minority stress theory provides a conceptual framework to explain the unique stress that people in a minority group experience in addition to general life stressors (Meyer, 2003; Testa, Habarth, Peta, Balsam & Bockting, 2015). Exposure to discrimination, abuse, and violence in relation to prejudice can burden LGBTQ+ person and cause chronic increased stress. Microaggressions are an additional type of minority stress in the form of subtle forms of prejudice, such as comments and glances (Nadal, Rivera & Corpus, 2010). In Sweden, LGBTQ+ youth and young adults experience worse living conditions than heterosexual cisgender people of the same age (PHAS, 2014, 2015; SAYCS, 2019). Compared to other youth, sexual and gender minority youth are more likely to be exposed to stigma‐related discrimination, bullying, threats, sexual violence, and abuse, and more commonly feel unfairly treated by others, or unsafe in public places.

The LGBTQ+ community is important for many LGBTQ+ people, as it buffers against the impact of homo/transphobic minority stressors by providing additional social support (Garcia, Vargas, Clark, Magaña Álvarez, Nelons & Parker, 2020; Meyer, 2003). The LGBTQ+ community also plays an important role in advocating for rights for gender and sexual minority people and can provide members with an increased feeling of happiness (Frost & Meyer, 2012).

Young trans people have reported an especially high rate of exposure to minority stress and experience of mental illness (PHAS, 2015). Transgender people in Sweden often feel invisible and invalidated by the Swedish society (Swedish Government Official Reports [SOU], 2017), and nonbinary individuals in particular report not being able to live in accordance with their gender identity. Feeling invalidated has been a common complaint voiced by transgender people in relation to experiences with healthcare provision (Forte, 2018).

The number of people seeking treatment for gender dysphoria in Sweden has increased in recent years (SOU, 2017). Gender affirming healthcare is a preventive measure to improve the mental health of transgender people with gender dysphoria (Bränström & Pachankis, 2020). Due to the long waiting lists, some transgender people feel compelled to resort to self‐medicating options (SOU, 2017). The act of self‐medicating is deemed by researchers as highly problematic due to the risk of unwanted side‐effects and incorrect medication (The National Board of Health and Welfare [NBHW], 2015).

Mental health of LGBTQ+ people during the pandemic

Currently, we have only limited knowledge about how LGBTQ+ people have been affected by the pandemic and associated restrictions. One study has indicated that LGBTQ+ people have had higher levels of depression and anxiety symptoms during the pandemic as well as an increased risk for developing clinical mental illness compared to the general population (Moore, Wierenga, Prince, Gillani & Mintz, 2021). The rise of mental illness revealed the need for adequate mental health support, especially among the most vulnerable within the LGBTQ+ community, for example, among young people with those living in unsupportive homes being particularly affected (Fish, McInroy, Paceley et al., 2020; Gato et al., 2020). Another study found that young transgender people who felt highly affected by the pandemic also experienced increased mental health problems (Jones, Bowe, McNamara, Guerin & Carter, 2021).

There has been particular concern about how LGBTQ+ people have been affected by being socially isolated during the pandemic (Brennan, Card, Collict, Jollimore & Lachowsky, 2020; Jones et al., 2021). For many young LGBTQ+ individuals, social distancing has caused them to live in close contact with non‐supportive family members in unsafe households (Barrientos, Guzmán‐González, Urzúa & Ulloa, 2021; Fish et al., 2020; Gato et al., 2020; Gato, Barrientos, Tasker et al., 2021). Furthermore, the pandemic has hindered LGBTQ+ people's contact with their supportive networks and limited their ability to express their own identity freely (Barrientos et al., 2021). Generally, many LGBTQ+ youth have felt the loss of safe spaces during the pandemic (Fish et al., 2020) with LGBTQ+ community venues affected by the requirements of social distancing (Grant, Gorman‐Murray & Briohny Walker, 2021). This has led many LGBTQ+ youth to lose their connection to the local community, and, as a consequence, limited their visibility in society.

When isolated in the home, LGBTQ+ youth have reported feelings of loneliness and boredom (Grant et al., 2021), as well as experiencing the loss of routines and increasing sleeping difficulties (Fish et al., 2020). Aside from these general effects of social isolation on psychological well‐being, social isolation has led some gender and sexual minority youth to ruminate more and question their LGBTQ+ identity (Fish et al., 2020).

The political climate has changed during the pandemic, which has affected the amount of anti‐LGBTQ+ propaganda around the world (ILGA‐Europe, 2020, 2021) and also within Sweden (RFSL, 2020). This has further been complicated by the fact that LGBTQ+ members and activists have not been able to meet and advocate for their rights due to the pandemic, as many Pride events have been cancelled or rescheduled online (RFSL, 2020). Simultaneously, the need for LGBTQ+ venues has increased, due to rising mental illness and an increasing need for support during the pandemic (SAYCS, 2021).

In ILGA‐Europe's (2020) annual review of the human rights situation it was clear that the LGBTQ+ population suffered from inadequate healthcare during 2020. Waiting times to get a first appointment for a gender dysphoria assessment have been prolonged. Furthermore, there has been an increase in the amount of negative information about transgender issues and gender affirming treatments to the detriment of some transgender people's well‐being (ILGA‐Europe, 2020).

RESEARCH AIM

The aim of the present study was to explore young Swedish LGBTQ+ people's experiences of the COVID‐19 pandemic and psychological well‐being. A focus on Sweden is important because the Swedish response to the pandemic was substantially different to that seen in other European countries with fewer social restrictions being imposed on the Swedish population during the first phase of the pandemic. Our investigation therefore sought to explore whether LGBTQ+ young adults living in Sweden during the first phase of the pandemic experienced mental health effects similar to those noted in other investigations or whether the relative freedom of movement in Sweden had mitigated some of the more detrimental associations of pandemic and LGBTQ+ minority stress on well‐being.

METHOD

Fifteen interviews were conducted with LGBTQ+ young adults concerning their experience of living through the first phase of the COVID‐19 pandemic in Sweden. The study is a part of a larger international project, Project Global Queerantine, where data from seven European and Latin American countries have been collected researching the social support networks and psychological health of LGBTQ+ individuals during the COVID‐19 pandemic (Gato et al., 2021). The study was approved by the Swedish Ethical Review Authority in 2020 (Dnr 2020–03187).

Data collection: Interviews

The data consisted of audio‐recorded semi‐structured interviews. The interviews were conducted by Bredenberg and Melin (2021), for their joint master thesis in psychology. A semi‐structured interview guide was constructed by Malmquist in collaboration with Wurm, Gato and Tasker. The interview guide included questions about the participants' experiences of the COVID‐19 pandemic, including how the disease had affected them personally and how the governmental restrictions had impacted their everyday lives, their mental health, and their experiences of minority stress. The interview guide was pretested in two pilot interviews with psychology students who self‐identified as LGBTQ+, which were not included in the main sample, but did not result in any changes to the original interview guide.

In total, 13 interviews were conducted over the Zoom online platform for video and audio conferencing and two interviews were conducted by telephone. Only audio recordings were stored and analyzed. The interviews were conducted during January and February 2021 and each lasted between 40 and 70 min. Oral informed consent to participate in the study was given by all participants. Thirteen of the interviews were conducted in Swedish, one in English, and one in a combination of Swedish and Norwegian.

Participants

The interviewees were recruited from a Swedish online survey included in Project Global Queerantine via a question requesting that survey respondents indicate their interest in participating in an interview study. Purposive sampling was applied and all respondents under 30 years old who had expressed an interest to participate in the interview study were sent an email providing further information about the purpose and procedure of the interview study. A total of 15 people responded to the email and upon individual agreement with each all contributed an interview to the study.

Out of the 15 participants, aged between 20–29 years old (mean age 23 years), seven identified as lesbian, three as bisexual and one as pansexual, two as gay, one as asexual and one as heterosexual. One participant additionally identified as polyamorous. Regarding gender identity, nine identified as transgender. Three identified as transgender women, one as a transgender man, four as non‐binary and one as questioning. Furthermore, one participant identified as a cisgender male and five as cisgender female. One of the cisgender females additionally identified as queer. Out of the 15 participants, eight were in at least one romantic relationship, while seven were not in a relationship at the time of the study. In addition, one of the participants was a parent. Seven participants co‐habited with their partner, five had single households, one shared a household with a friend, one lived in a dorm, and one lived in their parental home. In addition, two had been living in their parental home during parts of the pandemic. Seven of the participants were university students whilst the remaining eight were employed. Four participants had an upper secondary education, 11 had completed post‐secondary exams or were in ongoing studies, six were aiming to complete a Bachelor's degree and five a Master's degree.

All participants lived in Sweden. Eleven resided in larger city areas and four lived in smaller towns. Thirteen participants were Swedish citizens, one participant was British, and one participant was Norwegian. Twelve participants described themselves as white, and three as multiracial.

Data analysis

The data was analyzed by and large following Braun and Clarke's (2006) six step thematic analysis. The data was approached exploratively as prompted by the research aim to explore the unprecedented context of experiences of the COVID‐19 pandemic among young LGBTQ+ people living in Sweden.

The interviews were transcribed verbatim by a researcher who had not conducted the interview. Across the research team a good understanding of Swedish, English and Norwegian for interviewing, transcription and analyses meant that interview transcripts were initially analyzed in their original language to retain as much as possible of the original linguistic nuance. All participants were given pseudonyms that matched their gender identity.

Four interviews were coded by Bredenberg and Melin separately. This procedure is a sidestep from the procedure outlined by Braun and Clarke (2006) but gave the researchers an opportunity to compare and discuss their codes before deciding how to proceed with the coding in this study. The remaining interviews were coded only once. To enable comparison of open codes across all interviews, those from the Norwegian and English transcripts were then translated to Swedish. As a next step, all codes were collected and categorized into themes. This procedure resulted in four major themes (detailed in the results section).

In the result section transcript excerpts are presented with these pseudonyms, and each participant's nominated gender pronoun (she, he, or they). Ellipses within the brackets, […], mark parts of the transcript omitted from the excerpt to remove repetition and facilitate the reading of spoken material.

RESULTS

By the time of the interviews almost one year into the World Health Organization's declared pandemic, most participants had not contracted COVID‐19 themselves, and those who reported experiencing covid symptoms had experienced only mild infections. However, one participant had lost her grandmother to the disease, and a few participants had friends or family members who suffered from long‐term COVID. Besides these direct effects of the disease, all participants had been mentally and socially affected in some way by the pandemic and/or the associated restrictions. Using thematic analyses we identified four distinct themes within the interview data: Mental health effects – Covered in a pandemic fog; Catching up with LGBTQ+ network – Everyone has gone indoors and online; Minority stress experiences – Abuse has gone online too! and Difficulties accessing gender affirmative healthcare needs – Hopelessness and activating self‐care.

Mental health effects: Covered in a pandemic fog

While two participants reported good mental health during the pandemic, 13 struggled with various degrees of ill health. Several reported symptoms of clinical depression, such as diminished interest, low mood, and cognitive difficulties. Several also experienced anxiety, worry and rumination, and a heightened sensitivity to stress. A few participants had other psychiatric problems, such as dissociation, compulsive thoughts and behaviors, and symptoms of eating disorders. Some participants experienced an onset of mental illness during the pandemic, which they saw as a consequence of lost support or routine and an increased sense of uncertainty. Several had, however, a history of previous mental illness – problems that in many cases worsened during the pandemic. Josephine described her experiences:

My mental health is worse than usual. It's covered in a pandemic fog somehow. Josephine, 29, lesbian, queer, and cisgender woman.

Josephine's mental health issues had been manageable prior to the pandemic but became intolerable due to the circumstances of the pandemic. Therefore, she had sought support at her local healthcare center.

Due to pandemic restrictions, the participants described spending most of their time in their home, isolated from society. Social distance was experienced as difficult for all participants, and several claimed that the isolation itself was the leading cause of their overall mental suffering. Some stated that they became restless while being alone, and some ruminated more. While some participants felt that the shift to communicating with others online worked well, others found it strenuous and difficult. Jessika described the isolation as strenuous:

It was terrible, it was really difficult, like to not even be able to go outside, and like, I live with my girlfriend so when I ended up in quarantine and got symptoms, she had to be quarantined as well, and just us in a one‐bedroom student apartment. Jessika, 24, lesbian transgender woman.

All participants except for one, had been working or studying remotely during most of the pandemic. Many complained that this resulted in loneliness, but a few participants also mentioned positive aspects, such as gaining more flexibility in working hours and having to spend less time on commuting. However, a common experience was that keeping up good routines was difficult during the isolation. Sandra explained:

[It is] really hard right now to separate work and life, because I'm like working in a very special job and I, plus that I'm doing everything at home right now. It's really hard to separate it [work and free time]. It gets, several times I've thought of something I should do, at 9 pm, and then I've started working again. Sandra, 20, bisexual transgender woman.

Worry about catching COVID‐19 was a source of mental stress for some participants, albeit most worried more about infecting others than their own vulnerabilities. In particular participants were concerned about their older relatives. One participant, with a previous obsessive–compulsive disorder, had experienced more severe compulsive behaviors due to a fear of spreading the virus. These fears resulted in almost no social contacts outside home. In contrast, some other participants had continued to meet a couple of carefully chosen people. These participants ensured that their social needs were partially met while maintaining physical distance.

Uncertainty about the future and the continuation of the pandemic was a source of distress for several participants. While many had experienced a relief during the summer of 2020, when infection rates were low, most had felt more isolated and resigned during the autumn, when infection rates increased and the climate obstructed options to socialize outdoors. Liam, who managed most of the pandemic with good mental health, reflected on the strenuous autumn of 2020. According to Liam, November had been particularly difficult. During this time the heaviest restrictions so far and high infection rates coincided with a period of little daylight in the Nordic region:

November I felt was eh then I felt that it was heavier than most months. Eh because there was a lot [to do] at work, there were new [pandemic] restrictions, it was a very long time left until the light was coming, beginning to come back and you hadn't heard anything about vaccines like eh, so it felt like it was dark on all fronts. Liam, 26, gay cisgender man.

Catching up with LGBTQ+ networks: Everyone has gone indoors and online

Access to the LGBTQ+ community also had diminished due to pandemic restrictions limiting physical contact and thus forcing more online‐based communication and service delivery. This in turn had generally negatively affected the participants and created a feeling of lack of community and support. In fact almost all LGBTQ+ activities had been moved online, such as socialization within the community, support groups, Pride festivals and other events. Several participants were dissatisfied with only having access to online‐based resources, which did not feel equivalent to physical meeting places. Jessika missed her support group during the pandemic. Clearly, the online‐based resources were insufficient for Jessika. The lack of physical meeting options had led her to reject the support group altogether:

I felt that I really needed that, what can I say, the physical contact, it does not feel the same way online, it is not the same connection, you do not get the same support, it feels like, everyone feels so far away like, when it is just through voice and video […] *sigh* I really miss life before Corona. Jessika, 24, lesbian transgender woman.

Larger events for LGBTQ+ people, such as Pride festivals and parades around the country, and physical activities in connection to the Transgender Day of Remembrance, had transferred to digital platforms. Participants emphasized the importance of this type of events for them explaining how these arenas could provide a safe haven for LGBTQ+ people to gather and gain a sense of alliance. Several participants described how cancellations of these events created a void in the community that could not satisfactorily be filled by online‐alternatives:

The possibility for LGBTQ specific contexts has maybe been limited and, ’cause I think that a lot of the LGBTQ culture has evolved around like partying, and so gatherings and so crowds of people and yeah, but both like LGBTQ clubs but also Pride events and things where you physically have met up in order to, in some sort of safe‐space, be an LGBTQ person like, and that they have disappeared when you haven't been able to gather in larger groups. Liam, 26, gay cisgender man.

Liam emphasized the importance for LGBTQ+ people to be able to meet up in a physical place where they can be themselves without the threat of criticism from others. For some participants meeting others physically played a vital part in creating feelings of community togetherness and safety, but this was prohibited by the pandemic. In addition, the role of physical meetings within the LGBTQ+ community emphasized how LGBTQ+ people mostly felt unable to experience similar feelings of togetherness or safety within cisheteronormative culture – an alternative venue or cultural space to be with other LGBTQ+ people was needed.

While many participants highlighted negative aspects of a digitalized community, others saw online expansion as a (partly) positive development. For example, those living in rural areas relished the expanded opportunities created through increased online provision. Some participants further stated that they had received good support online, such as in online chat groups with other LGBTQ+ people that had helped them to cope with stress during the pandemic. Sam described their experiences of setting up and receiving support through a messenger group. Unlike many of the other participants, who suffered from the lack of physical meeting, Sam had been able to transfer their need for a supportive LGBTQ+ network to an online forum:

So we started a small messenger group [with LGBTQ+ people] where we write to each other, help each other, and discuss like how invisible for example wheelchair users are in queer environments or if someone has anything difficult they’re going through so there's been a support group on a media [platform] it's been very helpful and I think it's helped me to cope better with […] all that's going on. Sam, 29, gay and non‐binary.

Minority stress experiences: Abuse has gone online too!

All participants had experienced some level of minority stress prior to the pandemic, but many of them described how such experiences had lessened during the pandemic, due to the limited social interactions. Many mentioned the relief of not having to socialize to the same extent with relatives, work colleagues, or strangers, thereby avoiding many of the microaggressions and other hostile comments that they would otherwise normally be exposed to. Notwithstanding, one arena where most participants had experienced an increase in minority stress during the pandemic was in their interactions online. Some of the participants claimed that this was a result of them spending more time online due to social distancing. However, some participants also claimed that intolerance against the LGBTQ+ community had boomed on social media during the pandemic, making participants feel mistreated and misunderstood. Fredrik expressed his frustration about how people online seem to express themselves freely without regard for those who are affected. Clearly, online discussions can be hurtful. Fredrik reflected on his experiences:

I do not know if it has increased, or if it is because you are there more [in social media], but it feels like there is, it feels like there is some kind of discussion about transgender people, like whether “they exist or not” and like […] by other people who are not transgender […] I do not know if exposed is the right word, but like I feel like someone is discussing my life in a way that is not, yeah as if it is a concern, or as if it is something that, something that you can discuss like if it is “okay or not”. Fredrik, 28, heterosexual transgender man.

Dealing with discrimination online had also been complicated by the fact that, during social distancing, support from others was not available to the same extent. During the pandemic some participants described how the requirement to be more active online for work and studies, became problematic when dealing with minority stress situations. Situations that participants had previously experienced in‐person such as how to cope with being unwillingly outed or being misgendered, had felt more uncomfortable or been more difficult to address online.

Besides encountering increased online stressors, a few participants experienced recurrent minority stress situations in their homes. Sandra, a twenty‐year‐old transgender woman, had moved back in with her parents during the pandemic. She described this as a difficult time, due to her father's invalidating attitude about her gender identity, which meant that Sandra had not felt comfortable expressing herself at her parents' home. This resulted in her feeling hurt and stressed about the situation. She said:

If it [her gender identity] comes up in a conversation one day then he [dad] may not want to look me in the eye, [he] will like, just shut down.

Mm mm, and how do you handle this?

I think it is very sad, but, I do not know, I do not do much about it. […] [It's] stressful when I'm living there and try to convert my dad to understand. Sandra, 20, bisexual transgender woman.

It was obvious that the social distance recommendation led to different consequences in terms of face‐to‐face exposure to minority stress for the participants. While some participants experienced less minority stress because they avoided the arenas where they usually were exposed, others experienced more stress either because they were online more than previously or because the pandemic had led them to move into a more stressful home environment.

One participant also reflected on the long‐term consequences and risks of social isolation leading to an increased invisibility of the LGBTQ+ community. Standing on the barricades, or simply being visible in the society as a non‐normative person, has its challenges in terms of exposure to minority stress. Therefore, the social isolation can be seen as a welcome break from this exposure. However, Eli highlights the long‐term benefits of being part of a visible community, as increased visibility may lead to increased acceptance. Eli claimed:

The more visible we get, the more we become accepted. But also the more visible we get, the more we risk ourselves, eh? So then it's very understandable if you do not want to be seen, or you do not want to stand on the barricades. Eh, but at the same time, like, how are we supposed to do it otherwise? Eli, 24, bisexual, polyamorous and non‐binary.

Difficulties accessing gender affirmative healthcare needs: Hopelessness and self‐care

Of the 15 participants, nine identified as transgender. Among those, five had ongoing gender affirmative treatment, or were on the waiting list to receive a gender dysphoria assessment. For them, deficiencies in transgender healthcare had been their main issue during the pandemic. Participants on waiting lists suffered from prolonged waiting times for assessment, while those in ongoing treatment expressed their frustration with lack of information and uncertainty about further contact with transgender healthcare.

Some participants stated that assessment and treatment within transgender healthcare had prolonged waiting times even prior to COVID‐19 and acknowledged that these waiting times had lengthened due to the pandemic. Delayed transition plans resulted in participants feeling frustrated and powerless. One of the participants, Lo, had already received their diagnosis, but felt frustrated about cancelled follow‐up sessions and their limited access to further treatment options during the pandemic:

The problem is that during the beginning of the pandemic it happened that many nurses were summoned, just summoned to [University Hospital] […] they pretty much had to drop all follow‐ups. Lo, 22, lesbian non‐binary person.

Participants who needed transgender healthcare described a sense of uncertainty due to the lack of information from healthcare providers about when and how they could get help. This left participants unsure whether they would receive any support at all during the pandemic. All the participants who were on the waiting list for assessment of their gender dysphoria, or who were undergoing gender affirming treatment, reported that the waiting, uncertainty, and lack of information was a strain on their mental health. Participants commonly reported anxiety and uncertainty about how to cope with the situation with a few of them mentioning suicidal thoughts because of their suffering. In addition, some participants worried that friends on the waiting list would commit suicide before being offered treatment. Participants were also pessimistic and worried about the future: some expressed a feeling of hopelessness as to whether transgender healthcare services would even improve after the pandemic. Sandra linked her anxiety to being on the waiting list for a long time, and not knowing how to deal with the situation. Sandra described how she struggled to find ways to cope with this sense of waiting list distress:

How do you cope with this waiting?

I do not know really, I'm not doing it very well, I'm not doing it at all really.

No, you do not know how to cope with it, right?

No, I actually have no idea how you should cope with it.

Mm.

That's probably also like a contributing factor to why I have a lot of anxiety. Sandra, 20, bisexual transgender woman.

Two transgender participants felt compelled to find alternative ways to access hormonal treatments, when they realized waiting times for receiving a diagnosis were being prolonged by the pandemic. Both of these participants would clearly have preferred an official route to hormonal treatment in Sweden but could not see a way to doing this during the pandemic. As a result, one of them sought care at a private clinic abroad, and the other began to self‐medicate. Jessika decided to seek care abroad after finding that the waiting list time in Sweden was unacceptably long (as seen in Jessika's transcript extract below through her repetition of at least two years). Jessika's decision to seek care abroad had led to a huge financial burden:

When I realized that, it will take like at least two years, at least, at least, to even get the diagnosis, then I felt, I cannot, I cannot like wait anymore, I need to do something about it myself. Jessika, 24, lesbian transgender woman.

The participant who was self‐medicating also described how this required a lot of time and effort, due to seeking out information about necessary blood tests, reading up on how to interpret them, and assessing what medicines to order. Accessing self‐medication was further complicated as clients stocked up on medication as a precaution with concern that dwindling supplies might cause further shortages. Thus, the participant who decided to self‐medicate waited a further six months after applying for her medication to arrive, during which time her anxiety worsened significantly.

DISCUSSION

According to previous research, the COVID‐19 pandemic together with the accompanying restrictions and recommendations, have led to an increase in mental health problems among Swedish youth in general (Kapetanovic et al., 20210), as well as among young LGBTQ+ people abroad (Drabble & Eliason, 2021). In line with these reports, the present study showed how all participants – fifteen LGBTQ+ individuals in their twenties, living in Sweden – experienced negative effects on their mental health during the pandemic. Several participants reported symptoms of depression, anxiety, and stress, and some reported symptoms of OCD, eating disorders, and dissociation. Despite the relatively mild Swedish government's response to the pandemic by imposing social restrictions (Ludvigsson, 2020), most participants were substantially affected.

Many of the participants in our study reported a history of mental illness prior to the pandemic, and most of them explained how their symptoms had increased during the pandemic. Similar findings have been reported in previous studies on social isolation and mental health during the COVID‐19 pandemic, where factors like the length of quarantine, lack of information, and fear of infection, have been linked to more prevalent mental health problems (Brooks et al., 2020; Prati & Mancini, 2021). Under normal circumstances, LGBTQ+ young adults have an increased risk of developing mental illnesses in comparison to young adults in the general population (e.g. McDonald, 2018), and in particular show increased risk of developing depression and anxiety disorders (Russell & Fish, 2016). Vulnerability to mental health difficulties has been further exacerbated by the circumstances of the pandemic, where social isolation has put increased stress on the population (Wang et al., 2020) and the effects of this could clearly be seen in detail in the reports of many of the LGBTQ+ young adults interviewed in our study. Participants in the present study described how the longevity of the pandemic, uncertainty about the future, and their adherence to social distancing had all affected their mental health.

Participants in our study reported adhering to recommendations of social distancing (see PHAS, 2020a), reducing contact with their social networks and remaining relatively isolated at home. Some mentioned beneficial aspects of working or studying from home, such as increased flexibility. However, most participants primarily experienced this isolation as a strain and described how it had led to several negative effects on their well‐being. Many of the participants reported difficulties in adjusting to pandemic related changes and upholding new routines while being isolated at home. This is unfortunate, since the American Psychological Association (APA) (2020) lists creating and following a daily routine as an important coping strategy during the pandemic.

For the participants, physical distancing resulted in varying degrees of limitation in relation to their usual social network interactions. Many participants described their social isolation and loneliness as being the primary source of their mental suffering during the pandemic. Other studies have pointed out that young people are particularly vulnerable to experiencing loneliness (Beam & Kim, 2020), which is problematic, as loneliness is associated with serious mental health impacts (Killgore, Cloonan, Taylor & Dailey, 2020).

Being less able to meet other people had for many participants also resulted in a lack of social support. Social support is a vital coping mechanism for people going through crises (Saltzman et al., 2020). Already prior to the pandemic, young LGBTQ+ people in Sweden reported experiencing lower levels of social support than did their peers (SAYCS, 2019), and participants in the present study reported that the pandemic had reduced their support levels further. Many participants noted the considerable reduction in LGBTQ+ community activities during the pandemic, which potentially is harmful to their sense of belonging and self‐identity (Grant et al., 2021). To many, LGBTQ+ community venues function as a safe space where they can express themselves freely and seek support for experienced minority stress (Garcia et al., 2020). It is therefore worrying that these arenas to a large extent have been inaccessible during the pandemic. Although many LGBTQ+ community services have been offered through online‐based resources, several participants in the current study noted that such options did not offer them the same level of emotional support.

Proximal support provided within the household becomes more important when physical distancing limits access to distal support networks (Barrientos et al., 2021). Unfortunately, experiencing increased conflict among people in a household also lessens the feeling of support and correspondingly increases stress (Kapetanovic et al., 2021). A few participants mentioned living a socially isolated life in non‐supportive households during the pandemic. As seen in this and other studies, such isolation and confinement within a negative household climate can be very damaging to a young LGBTQ+ person's mental health (Brennan et al., 2020; Gato et al., 2020, 2021).

While generally experiencing the social isolation as difficult, some participants highlighted that staying at home was associated with a decrease in some types of minority stress as exposure to minority stress usually experienced outside the home had lessened. While this had been a relief to the participants, this finding also pinpoints that LGBTQ+ people have become used to facing and coping with discrimination, verbal abuse, and physical violence in public arenas, which is a major problem.

Even though exposure to minority stress outside the home lessened, the amount of minority stress experienced online increased. Participants described an increase in the amount of online hatred and discrimination during the course of the pandemic. Furthermore, some participants explained that they felt less prepared and able to stand up for themselves when exposed to minority stress online, as their coping strategies in face‐to‐face interactions could not always be transferred. Online‐based resources were therefore perceived as potentially stressful. Other research has found that people have a tendency to become morally disengaged online leading them to be more likely to make aggressive statements than they would in face‐to‐face interactions (Runions & Bak, 2015).

In terms of receiving social support during the pandemic, many participants relied upon online resources. Many participants described this reliance as stressful and unsatisfactory. A link between frequent social media use and poorer mental health and loneliness among adults during the pandemic has been identified (Geirdal, Ruffolo, Leung et al., 2021), which could explain the increased use of online resources reported by participants in our study. Furthermore, the majority of participants in the current study identified as transgender. In their international yearly report ILGA‐Europe especially mentions a rise in anti‐trans discussions in media during the pandemic, which also has been evident in Sweden (ILGA‐Europe, 2021). Nevertheless, some participants reported positive experiences of online support and staying virtually connected during the pandemic has been highlighted generally as an important coping strategy for maintaining good mental health (APA, 2020).

Transgender participants in the present study expressed frustration over the state of transgender healthcare during the pandemic. Prior to the pandemic waiting lists for gender affirming treatment had been long and were a documented cause of suffering for transgender groups (SOU, 2017). The pandemic has prolonged gender affirming clinic waiting lists even further (ILGA‐Europe, 2020; Jones et al., 2021), and according to several of our participants this has increased suffering. Transgender people on average have reported higher rates of mental illness than those recorded by the general public, and gender affirming treatment is an important route for improving mental health outcomes for many transgender (Bränström & Pachankis, 2020). It is therefore understandable that the state of transgender healthcare was one of the stressors causing the greatest strain among the transgender participants in the present study.

Self‐medication with gender affirming hormones has been common among transgender people in Sweden even prior to the pandemic, due to the long official waiting lists for the assessment and treatment of gender dysphoria (Swedish Government Official Reports, 2017). Prolonged waiting times during the pandemic may have increased the usage of self‐medication even more, certainly this was a route taken by at least one participant in the present study. Self‐medication, without monitoring, has inherent risks such as unwanted side‐effects, incorrect dosage, and the risk of applying medication that is unsafe (Metastasio, Negri, Martinotti & Corazza, 2018; NBHW, 2015). Self‐medication is therefore highly problematic. Furthermore, worry about the pandemic's effect on supply, and the behavior of stocking medication, has resulted in shortages, and caused additional stress about the ability to access medication or continuous supplies.

LIMITATIONS OF THE STUDY

The present study reports findings from a small‐scale interview study of 15 LGBTQ+ identified young adults living in Sweden during the first year of the pandemic (2020–21). While providing insight into LGBTQ+ people's struggles during the pandemic, it is important to highlight that the sample was self‐selected and may not be representative for young LGBTQ+ people in general. Given that the Swedish authorities and government responded differently to many other countries with respect to the pandemic, conclusions from the present study remain to investigated in other countries.

CONCLUSION

The COVID‐19 pandemic, and associated restrictions in everyday activities, have been a difficult time for many people. In the current qualitative study we found that LGBTQ+ young adults living in Sweden experienced a marked deterioration in their psychological wellbeing in various ways. Young people identifying as LGBTQ+ generally experienced less minority stress from face‐to‐face interactions but experienced more from online contexts. Waiting times to access gender affirming healthcare increased for transgender people during the pandemic and this reduction in accessibility negatively influenced transgender participant's psychological wellbeing. The current study has highlighted the importance of ensuring young LGBTQ+ people's continued access to support groups and appropriate healthcare facilities to prevent the deterioration of health in an already marginalized group.

The present work has been funded by the Swedish Royal Academy of Science, grant no AM2021‐0005.