A Systematic Review

1 Sexual and Gender Minorities Facing the Coronavirus Pandemic: A Systematic Review Bleckmann, Clara1, Leyendecker, Birgit1 & Busch, Julian1 1 Child and Family Research, Faculty for Psychology, Ruhr-University Bochum, Germany Correspondence to Julian Busch, Email: [email protected] 2 Abstract Sexual and gender minorities (SGM) constitute vulnerable groups in many countries. Thus, they might be affected to a different extent than heterosexual and cisgender individuals by the Coronavirus pandemic. The aim of this systematic review is to summarize the current state of international research on the effects of the Coronavirus pandemic on SGM individuals. Following the PRISMA protocol, we synthesized 35 publications including different article formats. Key findings yield that SGM individuals overall suffer to a larger extent from combinations of both minority- and pandemic- specific stressors. Some evidence was contradicting across studies, for example changes in the extent of risk behavior, and minority stress experiences during the pandemic. Although our review distinctively spots on the impact of the pandemic on SGM individuals’ lives, its pathways still remain to be better understood. Moreover, future research should also examine the yet unforeseeable long- term consequences of the pandemic for SGM populations. 3 Since the beginning of the Coronavirus pandemic in December 2019, people all over the world face unprecedented challenges that have coerced to adapt their ways of living. For sexual and gender minorities, the pandemic could implicate extraordinary challenges that might add to disparities they are confronted with in their everyday lives (Egede & Walker, 2020; Gibb et al., 2020; Kantamneni, 2020; Turner-Musa et al., 2020). In this review, we refer to diverse populations that contrast cisgender and heterosexual populations with the term sexual and gender minorities (SGM). Those include individuals who identify as lesbian, gay, bisexual, transsexual, or queer and feel affiliated (LGBTQ). Further related groups addressed in previous research are men who have sex with men (MSM), transgender and/or nonbinary (TGNB) and sexual minority women (i.e., lesbian, bisexual, queer women, SMW). During previous health-related crises, SGM were found to be affected to a greater extent than other populations (Bowleg, 2020). Apart from higher health-related vulnerabilities (Kline, 2020), such disparities also reflected structural disregard of LGBTQ populations in responses to crises. Previous studies that have examined the psychosocial situation of SGM, both in times of crisis and generally, found a higher prevalence for several mental health problems when compared to cis-hetero and heterosexual groups (Borgogna et al., 2019; Plöderl & Tremblay, 2015; Russell & Fish, 2016). The severity of such disparities was greater among particular SGM subgroups, for example transgender males (Price-Feeney et al., 2020). Regarding age, younger individuals from SGM are more likely to be exposed to sexual, psychological, and also physical abuse compared to cisgender youth (Baams et al., 2018; Friedman et al., 2011). Several studies highlight an increased risk and prevalence of SGM for a series of physical and chronic conditions including asthma, diabetes, heart diseases, cardiovascular disease or cancer (see (Dispenza et al., 2017). Their increased risk for developing physical and mental health problems is also linked to socio-economic living constellations. A survey-based report of the Movement Advancement Project (2020) found that SGM households (broadly compared to non-SGM households) are more likely to experience financial problems, job losses or wage reduction, poorer internet access, and more challenges of accessing health care services. Again, certain subgroups of SGM were found to be affected more severely, including transgender individuals and transgender people of color. According to pre-pandemic data 4 by the Williams Institute (2019), 22% of LGBTQ adults in the US live in poverty, compared to 16% of cisgender and heterosexual adults. Of all LGBTQ individuals, transgender individuals (29%) are most vulnerable to poverty. In the light of their distinctive living situations, research needs to clarify whether SGM populations are disproportionately affected by the Coronavirus pandemic which reflects a complex and multidimensional stressor that poses socio-economic and health-related challenges. One approach to explain mechanisms of vulnerability to mental and physical ill-health of SGM postulates the “minority stress theory” (Meyer, 2003). Minority stress describes such distress that individuals experience due to their belonging to stigmatized social categories. SGM-specific minority stress may reach from gender-based or sexuality-based victimization, rejection, or discrimination up to internalized trans-, bi- or homophobia. These SGM-specific experiences disproportionately influence mental health outcomes. Which role the individual vulnerability resulting from minority stress plays for coping potential consequences of the Coronavirus pandemic is unclear. Intersectionality - the complex overlap and concurrence of (discrimination) experiences by individuals who can be assigned to multiple social (disadvantaged) identities (Crenshaw, 1989) - must be considered in the exploration of the impact of the Coronavirus pandemic as SGM individuals are not only facing discrimination due to their gender and sexuality but also discrimination due to social class or race. The Coronavirus pandemic has the potential to multiply discrimination experiences for SGM individuals. Preliminary evidence suggests that an infection with this virus can be associated with shame and stigmatization (Perry, 2021), and similar to Asian populations, SGM groups were occasionally also blamed for the Coronavirus outbreak (Greenhalgh, 2020). Taken together, both theories on minority stress and intersectionality suggest that the pandemic has the potential to increase the distress of the SGM populations. The objective of this systematic review is to contribute to our understanding of the impact of the Coronavirus pandemic on psychosocial consequences on different domains of life for SGM populations worldwide. 5 Methods Eligibility Criteria and Search Strategy For this literature search, several databases were chosen to be relevant to this review including EBSCO Information Services (including PsycARTICLES and PsycINFO), PubMed (including MEDLINE and Ovid), and Scopus. The literature search for German data was conducted through Web of Science. The search strategy aimed to identify literature on the multidimensional effects of the Coronavirus pandemic on SGM populations, including (1) psychological distress and isolation (PDI), (2) health care and disease (HCD), and (3) economic disadvantages and poverty (EDP). For the initial search we used variations of a pre-defined set of English keywords linked by Boolean operators (see Figure 1). The keywords had to be mentioned in the title of the publication, ensuring the focus was set on SGM in connection with the Coronavirus pandemic. The search string was developed and piloted in EBSCO and was adapted to the requirements of the other databases. However, this search strategy appeared to be too inconclusive, as many previously exploratory- researched important papers were not found. Thus, two other search strategies were additionally applied. The literature search was carried out between the 20th of February and the 1st of March 2021. Secondly, we conducted a manual backward citation search for potentially relevant studies in the reference lists of the previously identified articles (yielding n=5 further publications). With a third, more explorative search strategy we aimed to especially identify grey literature and those literature published in German language (n=12). Different types of scientific publications beyond research articles (i.e., commentaries, reports, letters to the editor, or editorials) were included for the purpose of summarizing the current state of empirical literature as comprehensively as possible. For the inclusion in this review, publications had to meet four criteria. First, the publication date of the studies had to be in 2020 or 2021, as the worldwide Coronavirus outbreak started in November 2019. The clear focus of the literature had to be on the impact of the pandemic on youth and adult SGM populations. Finally, literature including data collection had to consist of a sample size of at least ten subjects. Studies reporting results from less than ten subjects were excluded. All publications were evaluated in a three-stage selection process according to the criteria mentioned above. In the first stage, solely the title of the publication was analyzed, during the second stage, 6 abstracts of the publications were screened for eligibility criteria. The publications that passed the first two stages were then fully screened. In cases where the relevance and fit of a publication was unclear, the text was kept for the next screening stage. Overall, 44 records were identified through the database search. Following the initial database search, the manual literature search resulted in 17 additional records. After duplicate removal 15 records were excluded, resulting in 46 publications to preliminary meet the inclusion requirements. We give a detailed overview of our search stages in the PRISMA Flow Diagram (see Figure 2). Data Management and Extraction We used Citavi 6 (Swiss Academic Software, Schweiz) for the management

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