In the past year, the COVID-19 pandemic has uniquely threatened the LGBTQ community, especially transgender people, due to existing disparities in income, housing and health care. But with historically rooted hesitancy toward the vaccine, some experts and community members worry that transgender people won’t receive vaccinations as quickly — or access them as easily — as their cisgender peers.
Vaccine hesitancy certainly exists among transgender people, especially among trans people of color, who tend to have more mistrust of the medical system. Although more than half of transgender adults said they’d get vaccinated as of January 2021, a higher rate than the general adult population, the percentages varied by race and decreased among non-white respondents. LGBT people of color and trans people overall were also most concerned about factors like affordability, effectiveness and side effects.
That mistrust — which is based on historical neglect and abuse of marginalized populations — compounds concerns over the vaccine’s potential interaction with Hormone Replacement Therapy (HRT). And researchers haven’t provided data to assuage these fears.
Research has indicated that women are slightly more likely than men to experience side effects from COVID-19 vaccines. But Kathryn Stephenson, an infectious disease doctor and vaccine researcher at Harvard Medical School, says that she hasn’t heard of studies looking into discrepancies in COVID-19 vaccine response between transgender and cisgender people.
“To date there is no evidence that hormone therapy has any effect, but we are not aware of any investigator who has specifically looked at this question,” Stephenson says. “All the vaccine trials do record what medications participants are taking, so in theory such an analysis could be performed.”
Clinical Trials Lack Trans Participants
One reason why trans people may mistrust the vaccine: Clinical trials, like those that evaluated COVID-19 jabs, don’t always include or account for gender diversity in their data. At Beth Israel Deaconess Medical Center in Boston, the vaccine research team aims to include people of all gender identities. Research Assistant Rachel Hemond says that they track gender identity, preferred pronouns and sex assigned at birth for participants in their clinical trials. However, that still isn’t the norm in medical studies.
Trial design may also present challenges for trans people. “In terms of vaccine research, another barrier is that it can sometimes be upsetting for transgender individuals to participate in rigid research protocols,” Hemond says. “For example, it can be traumatic to go through things like urine pregnancy tests if you fully identify as male.”
Hemond added that transgender individuals may have details within their medical history that could prevent them from participating in clinical trials. For example, transgender youth are statistically more likely to have a history of substance abuse and are at higher risk for HIV, which can prevent them from joining a study. Without sufficient inclusion of trans people in clinical trials, there’s limited data on how vaccines or treatments impact transgender people.
Kristen Witte, an exhibit developer at the Museum of Science and Industry in Chicago, says that they feel there’s not enough medical research on trans and non-binary people to begin with. “I take a low dose of testosterone. There’s no research on what a low dose of testosterone does over a long period of time,” Witte says. “We’re having to self-medicate because there's not enough medical knowledge.”
In their work as a scientist, Witte provides education around vaccine hesitancy and COVID-19 via social media and museum exhibits. They got their first shot recently, and have their second dose scheduled.
Broader Health Care Barriers
In Witte’s eyes, the biggest issue isn’t hesitancy, but a lack of affordable and gender-affirming healthcare. Witte’s medical provider — Howard Brown Health Center — specializes in providing care to queer people in Chicago, but Witte says that the organization was “underwater” with COVID. Witte couldn’t get an appointment, and ran out of their testosterone for a few weeks. The inability to access HRT was terrifying: They were preparing to deal with dysphoria and serious mental health issues.
Meanwhile, one of Witte’s friends struggled to get testing for COVID-19 because all of her identifying documents include her deadname and list her gender as male. Witte believes that many queer and trans people want the vaccine — and see it as a service to their community — but don’t always have positive experiences with the health care system.
With traumatic experiences so commonplace, hesitancy surrounding the vaccine must be contextualized in a history of transgender people’s experience with the medical system. Transgender people have good reason to be mistrustful of healthcare, especially in areas where state policies put restrictions on transgender health care and accommodations.
Any protections for transgender people are still relatively new, Hemond says. “Older generations also still remember the discrimination experienced in their young adult lives, when diverse gender expression was considered a psychiatric illness,” they say.
Despite past alienation within the health care system, LGBT people may be more likely to view COVID-19 vaccines as a duty to others. A Kaiser Family Foundation phone poll published in March 2021 found that 75 percent of LGBT-identifying respondents saw vaccination as part of everyone’s responsibility to protect the health of others, as compared to 48 percent of non-LGBT people.
This research also concluded that LGBT people were more likely to bear the brunt of the pandemic: They have higher rates of comorbidities, often work in highly affected industries such as health care and restaurants, live on lower average incomes, and experience stigma and discrimination (including during medical visits).
Transgender people are also less likely to have health insurance than the broader population. Though the vaccine is free, perceived costs could be a deterrent, says Lindsey Dawson, associate director of HIV policy at the Kaiser Family Foundation. Given frequent employment discrimination and lower-than-average salaries, it’s likely more difficult for trans people to take time off for a vaccine appointment.
Eva Padilla, a transgender woman who teaches in Chicago, says that her school didn’t provide her a substitute when she got her second dose. She had to give her class remote work, run down the street to get her shot, and hurry back to make the next class session. Padilla considers herself lucky that she was close to a clinic and could head out for an hour. “You start weighing your options of ‘Well, there's a chance I could get sick, or there's a 100 percent chance of missing a day of work,’” Padilla says.
Padilla is on HRT and has been fully vaccinated for six weeks with no side effects. When the vaccine rollout started, she heard skepticism from other trans people about how the vaccine would interact with HRT. Now, as the benefits of vaccination become clearer, she has observed that skepticism die down.
Ultimately, COVID-19 infection poses a much greater risk to transgender people than the vaccine, says Adrian Dobs, an endocrinologist with the Center for Transgender Health at Johns Hopkins Medicine.
The biggest sides effect from hormones include getting blood clots, and immobilization and hospitalization — which could happen as a result of severe COVID-19 infection — makes that risk much worse. “Because of these risk factors, and because COVID makes them worse, trans people should be getting the vaccine,” Dobs says.