The coronavirus pandemic is affecting everybody, but as with other public health crises, its impact could be especially severe in marginalized communities. LGBTQ people are more likely to live in poverty than the general population, according to a recent study from UCLA’s Williams Institute, meaning members of our community experience disparities in health care access and resources.
With this reality in mind, The Fenway Institute of Fenway Health, a leading Boston-based research and medical center that focuses on underserved populations, including the LGBTQ community, recently published a policy brief outlining the ways in which LGBTQ people and those living with HIV could be uniquely affected by COVID-19. Other groups across the country, including the National Center for Transgender Equality, have made similar arguments.
One of the authors of Fenway’s policy brief, Sean Cahill, PhD., the Director of Health Policy Research at The Fenway Institute, spoke this week with Outsports about the potential impact of COVID-19 on the LGBTQ community. The conversation has been edited for clarity.
In the policy brief, you say everyone is at risk of infection, but especially those who are marginalized. What does that mean for the LGBTQ community?
LGBT people are not at greater risk of getting the coronavirus, but we may find it more difficult to access the tests. As a population, we are less likely to be connected to regular health care and routine and preventative health care. That is especially true for lesbian and bisexual women and transgender people. Gay and bisexual men, I think, because of the focus on HIV, and the disproportionate effect of HIV on our community, are more connected to the health care system, because we’ve been getting tested for HIV for decades — depending on how old we are. But a lot of sexual minority women and transgender women are less likely to have access to quality care, so that may make it harder for them.
Another reason why marginalized people are more at risk to contract the virus, in addition to access to care, is they are the ones who are still going out and working — they are the essential workers.
Yeah, I think that’s true. A lot of the people who work in grocery stores, which is an incredibly important thing nowadays, because food security is so important, a lot of them are lower income. We do have data from the Williams Institute that on average the LGBTQ community, prior to the economic shock we’re going into now, are more likely to be low income. We are more likely to live in poverty than the general population, and that is especially true for sexual minority women and transgender people.
Another thing we know, and this is kind of anecdotal, but we know a lot of members of our community work in the restaurant and entertainment industries. They work on Broadway and in the film industry, and a lot of the arts and restaurants, obviously, have shut down. Suddenly, a lot of LGBT people who worked in those industries are out of work, filing for unemployment, suddenly worrying how they’re going to pay the rent, pay the mortgage, put food on the table. That causes a lot of stress, and as a population, we already have a lot of stress related to disclosure and navigating an often hostile world, and now to add to that ongoing minority stress that a lot of us experience is the economic stress that could be disproportionally affecting our community
How about people who have HIV? What are some things to look out for there?
It’s very important in any time for people with HIV to adhere to their medications and try to stay as healthy as they can — eat well, get enough sleep, exercise on a regular basis, meditation, whatever you do to minimize the stress you’re experiencing. If you do that, you will be better prepared if you’re exposed to the disease. That’s true for people without HIV as well, but especially people with HIV.
What we’re particularly concerned about is people who are not treatment adherent and who are not virally suppressed. The other thing is, this is a new virus. It’s the novel coronavirus. There’s a lot of stuff we don’t know. Another concern we have is, we want to see people have a very low viral load. But there’s also the CD4 count, and you want to have a robust CD4 count. That will come about with adherence and taking care of your health. But we’re concerned with people who may have had a very low nadir with CD4 at a certain point. For example, when a lot of people got diagnosed with HIV, they got diagnosed with AIDS as well, so they have a very low CD4 count. I think even if you’re virally suppressed and healthy now, if at one point you had a low CD4 count, that could make you more susceptible to complications if you develop COVID-19.
How about smoking? This is a respiratory illness, and a lot of people in our community smoke.
We see very high rates of tobacco use in our community, so that’s a risk factor as well for complications.
Are there are other chronic conditions that are especially important for our community to look out for?
We see people who are obese and people that have diabetes at elevated rates in our community. Some research over the years has shown higher rates of obesity among lesbian and bisexual women. And it’s also important to think about the intersection with race and ethnicity, too. We see higher rates of obesity among black women — most of whom are heterosexual — and among Latino women. If you look at people of color, a lot of those risk factors are found at even greater rates.
Another interesting thing I found was that older LGBT people are more likely to be socially isolated. How does social isolation contribute to this? I guess that’s more of the mental health component.
I think more and more, as a society, we have a holistic understanding of health. Mental health can affect your physical health, it can affect your body’s ability to stave off a cold or influenza. We do know, prior to the COVID-19 pandemic, LGBT older adults are more likely to be socially isolated. That could be for a number of reasons: we are less likely to have partners, we are definitely less likely to have children and grandchildren, and they are the built-in caregivers in our society. So we are often in need of more formal caregiving per capita compared to the rest of the population. That’s problematic now, because older people are more at risk for complications if they get COVID-19.
A lot of older gay and bisexual men and transgender women lost their friendship networks to the HIV epidemic in the 80s and 90s, for example. Those are all reasons why as a population older LGBT adults are more isolated to begin with, and now older adults in general are being severely socially isolated.
I think that loss of a physical social network is especially tough for members of our community, that’s such a part of the culture in a lot of aspects.
Absolutely, and on that note, we just put out some guidance on safe sex in the age of COVID-19.
Is it possible?
I think you need to be really weigh the risks and benefits. If you have a partner, this is a time to spend time with your partner. Hopefully you can stay in as much as possible. If you both haven’t been exposed to the disease, then obviously that wouldn’t be an unsafe thing. But if you’re meeting somebody through a social media site and wanting to get together with someone whom you don’t know, that’s probably not a good idea right now. I would put that off for the next few weeks or next few months.
On that note, and I know it’s not as serious, but it’s coming up a lot with my friends: if you’re not engaging in sexual activity due to social distancing, is it still important to take PrEP daily?
If you plan on being sexually active in the near future, I would say continue to take PrEP or Truvada.
Is there anything else you would like to add?
This is an unprecedented situation we are in as a human race. It’s a very challenging and scary time, so we have to be able to take care of one another. We have to be kind and gentle to one another to the extent we can be. That might mean virtually checking in on each other — calling people you know. This is a terrible situation we’re in, but there are silver linings. One of them is, I’ve had friends from way in the past reach out to me, I’ve reached out to friends who I haven’t spoken with in a long time. I think especially if you have a friend who you know is living alone and isolated, check in on them, and let them know they can reach out to you if they want to talk. I think for a lot of people this is very stressful time. But we can get through it together if we follow the advice of the public health professionals. And don’t think about what it’s going to be like six months or a year from now, because that can be overwhelming. Just think about it day by day and week by week.
There are promising signs coming out of Washington and California. There is evidence that the social distancing people are doing, which many people are taking very seriously, is having a positive effect.