The COVID-19 pandemic has exposed vulnerabilities faced by many populations, including the Two-Spirit, lesbian, gay, bisexual, transgender, queer, non-binary, and sexual minority (2SLGBTQ+) communities. Although social and material wealth varies in 2SLGBTQ+ communities as it does among cisgender heterosexuals, 2SLGBTQ+ people have experienced inequitable effects of the pandemic compared with other people in Canada. This may be due to greater health disparities (such as cardiovascular conditions, poorer mental health, and/or greater substance use) and socioeconomic inequities, including a higher representation among low-income and housing-insecure people. Health inequities experienced by 2SLGBTQ+ communities must be understood as intersectional across axes of oppression and privilege.
Evidence presented by CITF-funded researchers Drs. Daniel Grace (University of Toronto) and Nathan Lachowsky (University of Victoria) focuses on a subset of 2SLGBTQ2+ communities in Canada, made up of gay, bisexual, queer, and other men who have sex with men. Because of the importance of socioeconomic diversity and the scarcity of research with the broader 2SLGBTQ+ community, our research synthesis includes studies by other Canadian and international researchers to show the effects of the COVID-19 pandemic on the lives and well-being of members of these communities.
Our synthesis aims to address the following questions:
1 – What are the main risk factors driving the social and economic vulnerabilities of people within 2SLGBTQ+ communities in Canada?
A report presented by Statistics Canada in December 2020, based on a 2018 Survey of Safety in Public and Private Spaces (SSPPS), outlines some of the economic vulnerabilities faced by 2SLGBTQ+ communities (1).
- The average personal income of 2SLGBTQ+ earners was notably lower ($39,000) than those of non-2SLGBTQ+ individuals ($60,000).
- 33% of 2SLGBTQ+ people in Canada reported difficulties meeting their basic needs for housing, transportation, food, and other essential expenses, compared with 27% of non-2SLGBTQ+ people in Canada.
- 2SLGBTQ+ people in Canada were more than twice as likely (27%) to have experienced some form of housing insecurity or homelessness, compared with their non-2SLGBTQ+ counterparts (13%).
Recent studies have documented a wide range of health disparities faced by some individuals in 2SLGBTQ+ communities:
- According to the Ontario HIV Treatment Network, LGBTQ+ populations have unique health needs that may not be met by existing healthcare services in Canada (2)(2).
- Some chronic conditions disproportionately affect 2SLGBTQ+ people in Canada, including, but not limited to, asthma, arthritis, and heart disease (3, 4).
- 2SLGBTQ+ individuals face higher risks of some cancers, such as cervical cancers in women or anal cancers in men, with human papillomavirus (HPV) infections also being particularly common among 2SLGBTQ+ individuals (2, 3). Gay, bisexual, and other men who have sex with men have an estimated 20 times higher rate of anal cancer compared with those in the general male population (about 45 versus 1.5-2 per 100,000 people) (3). According to the Canadian Cancer Society, HPV infection is related to 90% of anal cancers, and high-risk HPV infections are the cause of 70% of cervical cancers (5).
- Gender and sexual minorities are also more likely to acquire a sexually transmitted infection (STI), such as syphilis or human immunodeficiency virus (HIV). In 2016, gay, bisexual, and other men who have sex with men accounted for almost 50% of new HIV cases in Canada while making up only 3-5% of the adult male population (3).
- Mental health disorders, particularly depression and anxiety, as well as substance use, are also of significant concern within 2SLGBTQ+ communities, particularly among young and racialized individuals (4).
- LGBTQ+ individuals are more likely than their cisgender heterosexual peers to consult mental health service providers, suggestive of higher mental health burden and/or increased care-seeking behaviour (6).
- 2SLGBTQ+ youth are estimated to be 2-3 times more likely to attempt suicide than their cisgender heterosexual counterparts (7).
- Among the barriers to accessing healthcare services is the potential lack of knowledge by healthcare professionals about the specific needs of 2SLGBTQ+ individuals (2)(2).
- Experiences of past discrimination or perceived homophobia also play a role, resulting in challenges for some 2SLGBTQ+ people to safely disclose their sexual orientation to health care providers (2) (2, 8).
2 – What has been the impact of the COVID-19 pandemic on the health and well-being of 2SLGBTQ+ communities in Canada?
Our knowledge of the health burden that SARS-CoV-2 infections and COVID-19 deaths have had among people within 2SLGBTQ+ communities in Canada is incomplete.
However, there is evidence that the COVID-19 pandemic has substantially altered the general well-being of 2SLGBTQ+ people. According to the CITF-funded Engage COVID-19 study led by Dr. Grace:
- Depressive symptoms over the year following the onset of the pandemic increased among gay, bisexual, queer, and other men who have sex with men. Most participants (52.2%) reported worsening mental health. A majority (60.7%) also reported receiving regular emotional support from loved ones. Younger men reported more loneliness and less emotional support (9).
- Some participants also expressed feelings of guilt following in-person sexual encounters. Others experienced disappointment toward those who did not respect isolation or lockdown guidelines and judged them or felt judged by others when they themselves did not respect guidelines (10).
- The COVID-19 pandemic reinforced existing racial disparities and stigma. Some gay, bisexual, queer, and men who have sex with men of color described experiences of discrimination in daily life because of their race and sexual orientation. East Asian and Black individuals were among the most affected. (10, 11).
In August 2020, Egale Canada released findings from their second national report, in partnership with the African Canadian Civic Engagement Council and INNOVATIVE Research Group. It revealed the larger impact of the pandemic on 2SLGBTQ+ communities than on the general population in Canada. The impact was even larger among Black, Indigenous and people of color (BIPOC) members of 2SLBGTQ+ communities (12):
- In comparison with the national population, BIPOC 2SLGBTQ+ people were more likely to report that the pandemic has had a significant negative impact on their overall quality of life (42% vs. 29%).
- 2SLGBTQ+ people and members of their households were more affected (52%) by layoffs and/or reduced work hours than other national respondents (43%).
- Compared with the total population, members of BIPOC 2SLGBTQ+ communities were more than twice as likely to report that the pandemic had a significant impact on their mental health (47% vs. 26%).
- BIPOC 2SLGBTQ+ were less likely (60%) to report feeling confident and secure in their household’s current financial situation, compared with all 2SLGBTQ+ people (67%) and national respondents (72%).
- However, financial confidence grew among surveyed 2SLGBTQ+ individuals, from 45% in March 2020 to 67% in June 2020.
A research brief commissioned by the Human Rights Campaign (HRC) Foundation suggested that the LGBTQ+ community in the United States has been more vulnerable to COVID-19 disease. Additionally, its evidence highlights that LGBTQ+ adults faced disproportionate economic effects during the first year of the pandemic.
- In July 2021, 21% of LGBTQ+ adults reported having tested positive for SARS-CoV-2 or being “pretty sure” they had COVID-19 disease (compared with 14% in the general population) (13).
- 30% of LGBTQ+ respondents had their work hours reduced in 2020 (versus 22% of the general population) (14).
- 20% of LGBTQ+ respondents reported worse personal finances than before the pandemic (versus 11% of the general population) (14).
- Even with the gradual reopening of the economy after the lockdown, these trends continued to be more salient for LGBTQ+ community members compared with the general population. In addition to reduced work hours, LGBTQ+ respondents were more likely to agree to have their wages reduced in order to return to work (15).
3 – How have the lives of 2SLGBTQ+ communities been affected by public health measures implemented during the COVID-19 pandemic?
The CITF-funded study by Dr. Grace showed that most study participants from the communities of gay, bisexual, queer, and other men who have sex with men in Montreal, Toronto, and Vancouver adjusted their social and sexual behaviours to protect themselves and others from contracting SARS-CoV-2, following public health measures during the onset of the pandemic.
- Early in the pandemic, about a quarter of participants reported temporarily abstaining from social activities and contacts including sexual activities, and one third described engaging in “temporary monogamy” while being in an open relationship (16).
- During the first wave, 68% reported fewer in-person sexual activities with new casual partners, 70% reported engaging less in group sexual activities and 73% reported having fewer sexual activities outside their household, than pre-pandemic (16, 17).
- Participants also reported increased engagement in physically distanced sexual activities, including texting, virtual sex and self-stimulation (17).
Social activities eventually rebounded in the communities of gay, bisexual, queer, and other men who have sex with men in all three cities, much as they did in the cisgender heterosexual community, as SARS-CoV-2 infections declined and public health restrictions eased (16).
- The majority of gay, bisexual, queer, and other men who have sex with men interviewed continued following public health measures while engaging in social activities, including sex. Research suggests they continued preventing the transmission of SARS-CoV-2 and other infections.
- Partner screening based on vaccination status appears to have been fairly common since COVID-19 vaccine roll-out. Some men also reported keeping track of local COVID-19 cases and variants of concern, wearing masks, or participating in more outdoor sexual activities.
International evidence also indicates that:
- Early in the pandemic, people in the LGBTQ+ community were more likely than the general population to take steps to actively learn about COVID-19, while paying more attention to news and avoiding gatherings (14).
- During the first wave of the pandemic, decreased social and sexual activities were reported across all sexual orientations within the LGBTQ+ community in the United States (18).
Drs. Grace and Lachowsky also looked at access to HIV and STI testing, treatment, and prevention during the COVID-19 pandemic. Their preliminary findings reveal that (17):
- Nearly 30% of gay, bisexual, queer, and other men who have sex with men reported experiencing impacts of COVID-19 on their access to and use of STI testing or treatment (9).
- Among those who were taking HIV pre-exposure prophylaxis (PrEP) before the pandemic, half did not change their use following the start of the pandemic. Indeed, barriers to PrEP access within the GBM community (such as challenges reaching a primary care provider, a lack of insurance coverage, and the high cost of medication) existed before the pandemic and persisted.
- However, 21% stopped using PrEP completely and 18% switched from continuous to on-demand use. The main drivers for change were the perceived lower perceived risk of HIV resulting from decreased sexual activity.
- Overall, access to HIV care for gay, bisexual, queer, and other men who have sex with men does not appear to have been affected by the pandemic, as 88% of participants living with HIV reported no impact on their ability to take their HIV medication regularly (9).
- Still, one-third of the gay, bisexual, queer, and other men who have sex with men who were surveyed avoided using health services, most notably visits to dentists and family physicians, because of fear of COVID-19 exposure. This was more marked among men who were not living with HIV (9).
Most members of 2SLGBTQ+ communities in Canada prioritized their health and complied with public health measures implemented during the COVID-19 pandemic. A survey conducted by Statistics Canada in March 2021 (19) highlighted that:
- 2SLGBTQ+ people in Canada are more likely to get the COVID-19 vaccine than non-2SLGBTQ+ people in Canada.
- Among 2SLGBTQ+ people in Canada aged 15 and older, 83.3% reported that they were somewhat or very willing to get the vaccine in fall 2020 (before vaccines were readily available), compared with 76.9% of non-2SLGBTQ+ people in Canada.
Similarly, in the United States (US):
- 60% of the LGBTQ+ community surveyed in July 2021 reported confidence in the COVID-19 vaccine research and development process, as opposed to 33% of the general adult population (13).
- Another US survey from February 2022 revealed that a great majority of the vaccinated people in 2SLGBTQ+ communities (79%) had received a booster dose, with an additional 17% planning to receive one, which was substantially higher than the 48% of US adults with a booster dose at the time (20).
Furthermore, survey results from Dr. Grace’s Engage-COVID-19 study indicate that:
- Some public health instructions unintentionally reinforced gendered inequalities. Participants explained how “cis-heteronormativity” was common in COVID-19 public health messaging, often reinforcing heterosexual forms of family and relationships and restricting access to queer spaces. Others explained that stay-at-home orders failed to account for the diversity of queer people’s experiences of homelessness, unsafe housing, and structural racism.
- Participants further reported that they adhered to prevention measures implemented during the pandemic, feeling this would avoid further stigmatization, as well as rejection by their peers.
Despite feelings of marginalization and stigmatization, 2SLGBTQ+ communities were more accepting of public health measures and adopted vaccines at a higher rate than did cisgender heterosexual individuals. People in 2SLGBTQ+ communities exhibited significant behaviour change to cope with the pandemic and to protect both their own health and wellbeing and the health of others.
- Vulnerabilities related to COVID-19 among LGBTQ2+ Canadians [press release]. www150.statcan.gc.ca: Statistics Canada; 2022.
- Mitra S, Globerman J. Facilitators and barriers to health care for lesbian, gay and bisexual (LGB) people. www.ohtn.on.ca: Ontario HIV Treatment Network; 2014.
- THE HEALTH OF LGBTQIA2 COMMUNITIES IN CANADA. www.ourcommons.ca: House of Commons; 2019.
- Higgins R, Hansen B, Jackson BE, Shaw A, Lachowsky NJ. Programs and interventions promoting health equity in LGBTQ2+ populations in Canada through action on social determinants of health. Health Promot Chronic Dis Prev Can. 2021;41(12):431-5.
- Human papillomavirus. https://cancer.ca: Canadian Cancer Society.
- Tjepkema M. Health care use among gay, lesbian and bisexual Canadians. Health Rep. 2008;19(1):53-64.
- Health Equity Impact Assessment: LGBT2SQ Populations Supplement. www.health.gov.on.ca: Ontario’s Ministry of Health and Long-Term Care (MOHLTC).
- Gahagan J, Subirana-Malaret M. Improving pathways to primary health care among LGBTQ populations and health care providers: key findings from Nova Scotia, Canada. International Journal for Equity in Health. 2018;17(1):76.
- Hanes D, Grace D. How did the first wave of COVID-19 impact gay, bi, and queer men? Insights from the Engage COVID-19 Study. www.engage-men.ca; 2022.
- Grey C, Skakoon-Sparling S, Brennan D, Burchell A, Ferlatte O, Gaspar M, et al. Sexual Health, Public Health Responses, and Risks: A Qualitative Exploration of Gay, Bisexual and Queer Men’s Negotiation of Safety during the COVID-19 Pandemic. Canadian Association for HIV Research (CAHR); 2021.
- Grey C, Tian IL, Grace D. Will you take on the challenge? Combatting racism in our communities will require all our efforts. www.engage-men.ca; 2022.
- Egale Canada, African Canadian Civic Engagement Council (ACCEC), INNOVATIVE. Impact of COVID-19 on the LGBTQI2S Community: Second National Report. https://egale.ca: Egale Canada; 2020.
- LGBTQ+ Health Equity & COVID19: Building Trust and Confidence for the Health of our Communities” Human Rights Campaign Foundation; 2021.
- The Economic Impact of COVID-19 on the LGBTQ+ Community. Human Rights Campaign Foundation; 2022.
- COVID-19 Continues To Adversely Impact LGBTQ+ People While Initial Phases Of Reopening Create New Economic Problems. Human Rights Campaign Foundation; 2020.
- Daroya E, Grey C, Lessard D, Klassen B, Skakoon-Sparling S, Gaspar M, et al. ‘I did not have sex outside of our bubble’: changes in sexual practices and risk reduction strategies among sexual minority men in Canada during the COVID-19 pandemic. Culture, Health & Sexuality. 2022:1-17.
- Grace D, Skakoon-Sparling S, Lachowsky N, Moore D, Jollimore J, Grey C, et al. The impact of COVID-19 on sexual behaviours, PrEP use, and healthcare access among gay, bisexual and other men who have sex with men : Preliminary Findings from Engage-COVID-19. Canadian Association for HIV Research (CAHR);2021.
- Griffin M, Jaiswal J, Martino RJ, LoSchiavo C, Comer-Carruthers C, Krause KD, et al. Sex in the Time of COVID-19: Patterns of Sexual Behavior Among LGBTQ+ Individuals in the U.S. Archives of Sexual Behavior. 2022;51(1):287-301.
- Study: COVID-19 vaccine willingness among Canadian population groups [press release]. www150.statcan.gc.ca: Statistics Canada; 2021.
- LGBTQ+ Health Equity & Covid-19: Vaccines, Boosters and Pathways to Positive Long-term Health. Human Rights Campaign Foundation 2022.