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Investigating COVID-19’s impact on LGBTQ+ health

More data on LGBTQ+ health is key — not only for understanding the effects of COVID-19, but also to improve overall health, says a Stanford researcher.

Some of the biggest health care issues for LGBTQ+ people are also risk factors for COVID-19.

Sexual and gender minorities have higher rates of smoking and substance abuse, as well as a higher prevalence of chronic illnesses, including asthma, diabetes, eating disorders, anxiety and depression (largely from societal stigma and discrimination), and HIV.

However, it's hard to quantify the impact of COVID-19 on LGBTQ+ people because until recently, health care providers and labs weren't required by state officials to collect information on gender identity and sexual orientation for reports on COVID-19 test results.

Gathering more data on these vulnerable populations is key -- not only for understanding the effects of the coronavirus, but also to improve overall public health, said Mitchell Lunn, MD, a Stanford Medicine nephrologist and co-director of The PRIDE Study, a national prospective, longitudinal cohort of sexual and gender minority people.

The mental health toll of the pandemic

Lunn and his team conducted one of the first studies to examine LGBTQ+ mental health in the context of the COVID-19 pandemic. They measured self-reported levels of anxiety and depression among 2,288 sexual and gender minority people by comparing responses from the 2019 PRIDE Study questionnaire, with responses obtained during the pandemic in the spring.

In the study, participants ranked their levels of depression and anxiety from 0 to 27 using the Patient Health Questionnaire-9 scale for scoring depression, and from 0 to 21 using the General Anxiety Disorder-7 scale for scoring anxiety.

Overall, survey participants reported increases in depression and anxiety between the pre-pandemic and pandemic time points. Most of this increase was due to people who didn't report feeling anxious and depressed in 2019, feeling this way after the coronavirus pandemic began.

The results were more nuanced for people who reported feeling depressed and anxious before the pandemic. LGBTQ+ people who felt high levels of depression in 2019, reported feeling better -- though still depressed -- in spring 2020. For participants who reported feeling anxious in 2019, there was no significant change in anxiety scores between the pre-pandemic and pandemic time points.

According to Lunn, this study underscores the importance of checking in with LGBTQ+ patients. The authors recommend health care providers ask sexual and gender minority patients about their stress level and screen them for mood and anxiety disorders, even if the patient has no prior history of anxiety or depression.

The importance of representation

Lunn told me that more LGBTQ+ representation in COVID-19 studies is needed not only because LGBTQ+ communities are at risk, but also because LGBTQ+ is an umbrella term for several different groups.

Studies often combine different sexual and gender minorities into a single group when there aren't enough data points to yield statistically significant results -- as Lunn and his team did for the mental health study. But, "a lesbian woman is very different from me, a gay man, who is very different from a bisexual person," Lunn told me.

When studies include large numbers of LGBTQ+ people, Lunn explained, "we can suss out differences among the categories." For example, he said, if a study finds that bisexual men are most likely to smoke, then clinicians can tailor interventions to that group of people.

However, some sexual and gender minority people are apprehensive about participating in research, Lunn said.

"With every minority population ever, there's been a really high-profile transgression at some point in history," he told me. "We think of the Tuskegee syphilis study for African American people. For us, it was the lack of recognition of HIV in the '80s. And in the late '90s, it was the hunt for 'the gene' to find out why people are gay."

Involving the community

As a gay man and a scientist familiar with these issues, Lunn understands why the thought of participating in research gives many minorities pause.

That's why The PRIDE Study directly involves LGBTQ+ people through a community advisory board. The board reviews applications from researchers who wish to use data from The PRIDE Study, and they can reject studies they find problematic, Lunn said: "If they think it's bad, it doesn't happen."

Participants have given their approach positive reviews, Lunn said: "We have gotten feedback along the lines of, 'Thank you so much for doing this. It was the first time that I've ever really felt heard and appreciated, or like a survey was designed for me.'"

Image of SARS-CoV-2 virus via Wikimedia.

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