The impact of the COVID-19 health alert on psychosexual and health care for transsexuals and for people with diverse gender identities during social confinement

Psychosexual, endocrinological and surgical support for transsexual people and people with gender incongruence (ICD-11) was implemented in Spain relatively recently. It is currently in an expansion and consolidation phase, thanks to the development of various regional laws intended to provide these people with comprehensive care.¹

The transsexual population often faces stigmatisation, discrimination and minority stress. Members of this population also have very high rates of depression, anxiety and post-traumatic stress, and a high prevalence of self-injurious behaviours has been reported.^2–4

Lockdowns put in place to prevent the spread of COVID-19 have given rise to very special healthcare-related and social circumstances.

Although the definition of “natural disaster” varies widely and the term is usually used to refer to acute natural circumstances, the current COVID-19 pandemic, given the speed of its propagation and the sudden establishment of said social distancing measures, could well qualify as a natural disaster in light of its economic, healthcare-related, psychological and social consequences.⁵

Negative effects on domestic violence and gender-based violence, deterioration of social relationships, increased mental health problems and increased suicide rates have been previously reported in cases of natural disasters.^6–8

There is a lack of data on whether the current health alert situation and special lockdown measures, as well as the social and economic consequences thereof, may lead to a situation similar to that described above in natural catastrophes, with increased rates of depression, anxiety and even suicide.

These “social dysfunction” phenomena would be added to those that some at-risk transsexual people already experience and suffer through.

Given the extraordinary situation created by the measures adopted to manage the spread of COVID-19, which rendered in-person care with these individuals impossible, special measures had to be formulated in order to safeguard the rights of this particularly vulnerable population and ensure suitable support for its members.

The telephone healthcare support that had to be implemented quickly almost certainly amounts to a prototype of more standardised telemedicine.

Apart from clinical management (reviewing laboratory values, making dose adjustments, detecting undesirable effects and renewing prescriptions), management of people with gender incongruence presents special difficulties and requires attention to additional, much more complex considerations. The absence of information gleaned from non-verbal cues may be among them. Similarly, family support, which is almost always necessary, should also be taken into account.

Suitable legislation must be developed with particular consideration for data confidentiality, signing of informed consent forms (especially in minors) and accurate identification of patients and their family members.

The main problems that are being detected on our unit are as follows:

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  Access on the part of new users to the care pathway.

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  Supply of certain drugs as well as administration thereof in primary care (parenteral preparations).

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  Disruption of processes of changing one's name and gender due to saturation of courts and civil registration offices.

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  Loss to follow-up of people with associated cardiometabolic risk factors.

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  Disruption of surgical activities and lengthening of waiting lists.

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  Signing of informed consent forms, especially in individuals under 18 years of age.

On the Gender Identity Unit at Hospital Universitario Doctor Peset de Valencia, a reference hospital for the Valencian Community, we initiated a personalised care protocol that includes remote visits (directed according to a standardised survey) with special attention to the following risk groups:

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  People who are more vulnerable and lack social and financial resources.

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  People with serious associated psychiatric disease.

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  People with a history of self-injury.

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  Minors.

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  Elderly people.

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  Cases of hormone treatment and cumulative cardiovascular risk factors (obesity, diabetes, hypertension, dyslipidaemia and smoking), sleep apnoea/hypopnoea syndrome and polyglobulia/polycythaemia, which is increasingly common and could lead to thromboembolic phenomena and cardiovascular events.

The healthcare landscape in the post-COVID era will demand that new healthcare models be proposed for people with gender incongruence and gender diversity. These models should be developed according to a personalised strategy in which each case is stratified by risk level and always handled by a multidisciplinary team made up of professionals with expertise in identity. It is also important to involve and work jointly with primary care.

Telemedicine could be proposed for cases at low social, psychological and clinical risk, and in-person care could be reserved for cases considered to be at higher risk. Only thus can high-quality mental health care with guarantees and rights equal to those of all other public health system users be provided.

Funding

No funding was received for the research reported in this article.

Conflicts of interest

The authors received no funding to conduct this study. They also did not sign any agreement by which they would receive benefits or fees from any commercial organisation. Furthermore, no commercial organisation has made or will make payments to any foundations, educational institutions or other non-profit organisations with which the authors are affiliated.