With COVID-19 receding, though not quite in the rearview mirror, an assessment of the mental health toll from the 18-plus month pandemic is just beginning. It’s been a hard slog, from challenging to downright terrifying, for many Americans—and for many in the LGBTQ community, the impact has been compounded by some unique issues.
A big caveat: National numbers on depression and suicide are hard to come by, at least for the LGBTQ population. For one, the federal government doesn’t break out LGBTQ people in their reporting. Overall, according to a March analysis, the number of deaths from suicide dropped by 5% in 2020, the second year in a row the number has fallen. Another caveat: Suicides are a lagging indicator of psychosocial crises.
There are very limited data on how the LGBTQ community has been impacted by COVID-19, partly due to lack of sexual orientation and gender identity (SOGI) information in hospital intake forms and testing-center questionnaires. One large, national study, however, seeks to provide some useful data on LGBTQ people in the era of COVID-19. The national coalition We Count Collaborative is teaming with the ongoing PRIDE study (the first long-term, national health study of LGBTQ people) to get a fuller picture of the COVID-19 experiences of more than 45,000 LGBTQ people across five federally qualified health centers (FQHCs). If all goes according to plan, the data will be released next year, according to Annesa Flentje, Ph.D., director of the University of California, San Francisco Center for Sexual and Gender Minority Health and associate director of the PRIDE study.
“We will find out what medical records can tell us about diagnoses, visits, COVID tests, about health trends, and the depths of physical and mental problems [brought on by the pandemic], as well as economic impacts,” said Flentje.
An initial look at the data gathered so far suggests the pandemic hit the LGBTQ community particularly hard. “We saw that just after COVID started, depression and anxiety got worse, especially among people who didn’t have anxiety and depression before,” said Flentje. Part of that upheaval was due to job disruption, even though unemployment benefits have softened the blow for many. “We do know that LGBTQ people are more likely to work in industries directly impacted by COVID, like health care and the service industry,” added Flentje.
Unprecedented Demand for Mental Health Services
The pandemic has had a marked impact on the availability of mental health providers and services, as well. “The wait list [for new patients] is 10 times longer than before COVID-19,” said Sean Boileau, Ph.D., Behavioral Health Services director at APLA Health in Los Angeles. “There are 160 people on the wait list [here], and it’s probably the shortest in town.”
The increased demand, he said, is all due to the pandemic. “People who had anxiety and depression before—it’s worse now.” In addition to difficulties brought directly by the pandemic, the lack of activities for many has turned up the heat on long-simmering problems, said Boileau.
“You take away people’s jobs and social life and keep them at home, and suddenly they have all this time to think,” he said. “And for some, domestic abuse goes up, and that’s an even bigger problem if you can’t afford to leave your partner.” Boileau added that LGBTQ people are more likely to have rifts with their biological families, and not being able to see their families of choice for more than a year can magnify the sense of being adrift and alone. Like many, Boileau is interested to see whether reopenings and looser restrictions on social activities and gatherings will alleviate, at least in part, the pandemic’s hefty toll on mental health.
Telehealth May Be Here to Stay, but Payment May Not
Telehealth has helped APLA Health and other clinics manage the increased demand for counseling. For one thing, it helps with cutting down on no-shows. If someone texts at 9:55 a.m. saying the 10:00 a.m. session won’t happen due to traffic, with online sessions, counselors can text the next person on the wait list without missing a beat.
“Video sessions have gone better than many expected,” Boileau said. “We were grumbling for a month, when we started, but now a majority are begging us to keep it up.”
There is, however, a big question about how long state Medicaid agencies will pay for private sessions if done by video conference. At least in California, the state’s version of Medicaid, MediCal, made no accommodations for such sessions conducted outside the four walls of a participating clinic. That changed last year when the government issued stay-at-home orders, and the coverage has been extended several times. A bill in the state legislature, if passed into law, would make remote counseling sessions in California payable permanently.
Nationally, the Centers for Medicare and Medicaid Services (CMS) now includes some telehealth services, including group psychotherapy, cognitive assessment, and psychological and neuropsychological testing, but not individual therapy sessions. Having CMS cover telehealth sessions—either video or audio-only—permanently, would benefit patients and be a boon to clinics like APLA Health, where most patients rely on Medicare or MediCal. “If only private practices get to work from home, there will be a mass exodus [of staff] from clinics,” said Boileau. “It is a big ask for clinics to say, ‘You’ll make $20,000 less working here and have to commute five days a week.’” He added that the clinic would continue to offer in-person services if it works better for the patient.
LGBTQ Youth Face Higher Rates of Depression and Family Struggles
Even before the pandemic, LGBTQ youth faced much higher rates of depression and anxiety than their non-LGBTQ peers—as well as increased odds of unemployment and homelessness. And more than 18 months of COVID life has amplified those disproportionate risks.
“Our numbers doubled since March of last year,” said Cynthia Ruffin, community relations and outreach director of COLORS LGBTQ Youth Counseling Services in Southern California. “Young people are looking for people to talk to. If they struggle with sexual identity, they can talk to friends at school.” But such interaction hasn’t been an option for many over the past year and a half. Nor has teachers’ mandatory reporting of instances when suicidal ideation, sexual abuse, or assault of students is suspected or confirmed.
“There is a lot of trauma we don’t even hear about,” said Ruffin. The issues leading the bulk of young people to seek free counseling at COLORS now are generalized depression, anxiety, and loneliness. Bad enough, but left unaddressed, these woes can morph into even bigger problems. “Without someone trusted to talk to, you see more risky behavior, drinking, and unsafe sex,” she said.
Much of those issues were either made worse—or were sparked—by the COVID-19 stay-at-home orders. While it may come as a surprise to people who graduated some time ago, schools these days can actually be a safe environment to discuss or explore sexual or gender identity. On the other hand, family, for many young people, does not provide the safety for them to be themselves. And since March 2020, most youth have been trapped in some of the least affirming places.
In a survey released in October 2020 by The Trevor Project, one-third of LGBTQ youth said they were unable to be themselves at home, and a third of transgender and nonbinary youth said they actually felt unsafe in their living situation since the beginning of the pandemic.
In another national survey on the impact of the pandemic on the mental health of LGBTQ youth, released in May, more than 80% said COVID-19 made their living situation more stressful, while only one out of three found their home to be LGBTQ-affirming. Nearly three-quarters of LGBTQ youth surveyed said their mental health was poor most of the time or always during COVID-19. Even more troubling: 42% said they seriously considered suicide, including more than half of transgender and nonbinary youth. The survey also showed stark racial disparities; while 12% of white LGBTQ youth said they had attempted suicide, numbers for other races were much higher: 31% for Native/Indigenous, 21% for Black, and 18% for Latinx youth.
Amy Green, Ph.D., vice president of research for The Trevor Project, said the data also showed that gender nonbinary LGBTQ youth, in every measure, are disproportionately impacted by the pandemic, and that for all groups, food insecurity made life disruption from COVID-19 worse. “Thirty percent said they went hungry at some time in the past month,” said Green. And food insecurity may increase depression and helplessness among those already feeling depressed and helpless. “Our data showed that suicide was considered by 11% who did not experience food insecurity, versus 32% who did [experience food insecurity].”
Ruffin, however, finds some hope amid these concerning statistics. “More people are talking about mental health, and that de-stigmatizes it,” she said. And de-stigmatizing mental health is likely to lead more people who need counseling to seek it.
Beyond individual counseling, said Ruffin, schools opening their doors need to prepare for an influx of youth with PTSD and make efforts to recognize it and handle it. Students could ease their transition to “normality” by seeking like-minded groups and understanding through school counselors, teachers, or other potential allies. For everyone, building or rebuilding support networks and learning to use dormant socializing skills will be crucial in a time when the virus is not quite gone and definitely not forgotten.