When COVID-19 changed our lives in 2020, it became apparent early on that the burden would fall disproportionately on marginalized communities. While often described as “unprecedented times,” COVID-19 impacted the country on similar lines as pandemics throughout history, placing some individuals at higher risk of exposure, death, and deleterious impacts of infection and isolation. Similar to COVID-19, gender-based violence (GBV), including sexual and domestic violence, may be a result of imbalanced power dynamics and oppression, disproportionately affecting marginalized communities. At the intersection of these issues, an invisible epidemic of GBV sprung from isolation and inequitable social dynamics, leaving many at home without adequate resources for care. For transgender people, these barriers often meant worsening physical and mental health outcomes when compared to cisgender populations.
Pandemic Effects on LGBTQI+ Communities
People in the LGBTQI+ community, who disproportionately held jobs in highly affected industries during the onset of the pandemic, were more likely than cisgender and heterosexual people to be exposed to the virus and/or experience layoffs, resulting in the discontinuation of health insurance. While prevalence or outcome data collected at the onset of COVID-19 did not routinely include sexual orientation or gender identity, research has shown that the LGBTQI+ community experiences significantly higher prevalence rates for chronic diseases such as cancer and diabetes, which have been found to increase the risk for severe COVID-related illnesses and death. These impacts, which have a direct link to widespread homophobia and transphobia, are also compounded by racial and socioeconomic marginalization, often further impacting access to adequate care.
Pandemic Effects on Gender-based Violence
Generally, the prevalence of domestic violence rose at least 10% during the onset of the pandemic, likely influenced by stay-at-home orders, economic stressors, and maladaptive coping strategies. Transgender individuals are exposed to unique stressors that may impact their risks for victimization, and transphobia may enable abusers to exploit insecurities related to societal stigma. While disaggregated data on this statistic is unavailable, a study published in the American Journal of Public Health found that out of any identity group, transgender individuals experience the highest rate of domestic violence of any gender identity. The prevalence of non-partner sexual violence was more difficult to track during the onset of COVID-19, in part due to surveillance priorities and barriers to in-person care. However, an increased prevalence may be inferred based on existing evidence that states of emergency increase the incidence of sexual violence. In the United States, this was reflected in an increased demand for services at nearly 40% of rape crisis centers at the height of COVID-19. The transgender community is more likely to experience sexual violence victimization than cisgender people, and nearly half of transgender individuals will experience sexual violence in their lifetime.
Health Equity and Transgender Communities
COVID-19 and gender-based violence (GBV) are health equity issues that pose significant risks for the transgender community. Exposure to GBV during COVID-19 may have been particularly difficult for transgender individuals who have low levels of support in the home due to transphobic family members or have limited access to supportive community support resources, further compounding risks for isolation and disconnection from help-seeking resources. While a necessary public health measure, stay-at-home orders may have created greater vulnerability for transgender and LGBTQI+ individuals confined to living arrangements with abusive partners or unsupportive, violent families. During the onset of the pandemic, transgender and gender-diverse individuals were over two times more likely to experience housing instability than their cisgender peers and nearly three times more likely to experience disruptions in medical care. For transgender individuals experiencing these disparate impacts, pandemic conditions created even greater challenges for finding resources to leave abusive situations. Coupled with reductions in access to gender affirming care, the risk for mental health conditions, including suicide, PTSD, anxiety, and depression may have been exacerbated at this time.
At the U.S. Department of Health and Human Services (HHS), our agency is responsible for protecting the health and wellbeing of the American people. In the Office of the Assistant Secretary for Health, we oversee key public health offices and programs, a number of Presidential and Secretarial advisory committees, 10 regional health offices across the nation, and the Office of the Surgeon General, all of which have a role in COVID-19 response. Across our work, we made a concerted effort to center the communities at highest risk.
During the state of emergency, federal programs offering free or low-cost vaccines helped ensure that vaccines were distributed equitably, providing much needed relief to uninsured Americans and front-line workers. The Health Resources and Services Administration’s COVID-19 Coverage Assistance Fund helped provide individuals in need with access to diagnostic care during the first few years of the pandemic, with explicit protections for the uninsured and underinsured, children, and Americans living in rural areas. The Administration for Community Living’s National Institute on Disability funded several projects focused on increasing support for people with long COVID, which disproportionately impacts transgender and bisexual individuals. Efforts to ensure precision in our public health response were reflected in HHS’ adoption of a Sexual Orientation and Gender Identity (SOGI) Data Action Plan. By including SOGI elements in our data instruments we can better measure health disparities and health outcomes.
Similarly, the Biden-Harris administration’s unprecedented commitment to eradicating gender-based violence has sparked systematic change throughout the government, much of which has centered on communities at highest risk. At HHS, the Administration for Children and Families awarded funds to culturally specific organizations to facilitate the provision of trauma-informed, developmentally sensitive, and culturally relevant services for individuals from underserved communities who are affected by sexual assault and domestic violence. At the Centers for Disease Control and Prevention, updates to the National Intimate Partner and Sexual Violence Survey included improved questions about gender identity and sensitivity for transgender respondents. Similarly, the National Institute of Health published a Request for Information to the field to identify scientific directions in research to better capture violence against transgender populations. Throughout our work, we have centered health equity, knowing that wins for some are not wins for all.
As our fight for health equity continues to evolve, new challenges will emerge. These transitions cannot harden us, and we must continue to fight for the most vulnerable among us. This requires actively practicing reflexivity, collaboration, and empathy. COVID-19 will very likely not be the only pandemic in many of our lifetimes. If we face this again, we can draw from what LGBTQI+ communities have experienced to improve the response for everyone. Considering the implications of how pandemics impact marginalized communities is not only necessary for stopping the spread of disease but for protecting the overall wellness of the American people.
This blog was published in The Resource 2025 online magazine special issue Sexual Violence and Sexual Health Outside the Gender Binary.
About the Authors:
Admiral Rachel L. Levine serves as the 17th Assistant Secretary for Health for the U.S. Department of Health and Human Services (HHS), after being nominated by President Joe Biden and confirmed by the U.S. Senate in 2021. As Assistant Secretary for Health, ADM Rachel Levine fights every day to improve the health and well-being of all Americans. She's working to help our nation overcome the COVID-19 pandemic and build a stronger foundation for a healthier future - one in which every American can attain their full health potential. ADM Levine also is the head of the U.S. Public Health Service Commissioned Corps, one of the eight uniformed services.
After graduating from Harvard College and Tulane University School of Medicine, ADM Levine completed her training in Pediatrics and Adolescent Medicine at the Mt. Sinai Medical Center in New York City. As a physician, she focused on the intersection between mental and physical health, treating children, adolescents, and young adults. ADM Levine was a Professor of Pediatrics and Psychiatry at the Penn State College of Medicine. Her previous posts included: Vice-Chair for Clinical Affairs for the Department of Pediatrics, and Chief of the Division of Adolescent Medicine and Eating Disorders at the Penn State Hershey Medical Center.
In 2015, Pennsylvania Governor Tom Wolf nominated ADM Levine to be Pennsylvania's Physician General and she was subsequently unanimously confirmed by Pennsylvania's state Senate. In March of 2018, ADM Levine was named Pennsylvania's Secretary of Health. During her time in state government, ADM Levine worked to address Pennsylvania's opioid crisis, focus attention on maternal health and improve immunization rates among children. Her decision to issue a standing order for the anti-overdose drug, Naloxone, saved thousands of lives by allowing law enforcement to carry the drug and Pennsylvanians to purchase it without a prescription from their doctor.
ADM Levine is a member of the National Academy of Medicine and a Fellow of the American Academy of Pediatrics, the Society for Adolescent Health and Medicine, and the Academy for Eating Disorders. She was also the President of the Association of State and Territorial Health Officials. In addition to her recent posts in medicine and government, ADM Levine is an accomplished speaker and author of numerous publications on the opioid crisis, adolescent medicine, eating disorders, and LGBT medicine.
Madeline Anscombe serves as the Special Advisor on Gender-Based Violence in the Office of the Assistant Secretary for Health at the U.S. Department of Health and Human Services. In this role, she helps coordinate the agency’s public health response to gender-based violence. Alongside the Director of Gender-Based Violence, the office’s work has helped manage the agency’s implementation of the White House’s U.S. National Plan to End Gender-Based Violence and has centered developing intersectional responses to violence prevention efforts.
Before joining the Office of the Assistant Secretary for Health, Madeline worked at the agency’s Office for Civil Rights, where she served as a Special Assistant to the Director. Prior to joining the administration, Madeline received her Masters in Public Health (MPH) at Emory University, where she earned a degree in Global Health and a certificate in Human Rights. After moving to Atlanta for her MPH, she worked as an ORISE Fellow in the Centers for Disease Control and Prevention’s (CDC) Division of Violence Prevention. While at the CDC, Madeline conducted a cross-initiative scan of the division’s violence policies and used the results to develop branch-wide guidance for sub-recipient evaluation. Madeline got her start in health policy work in 2015, when she founded a sexual violence prevention organization that helped build support and raised funds to build a stand-alone Sexual Assault Forensic Nurse Examiner Clinic in Tuscaloosa, Alabama. In January of 2023, Madeline also launched a mutual aid fund, The Alabama Survivors Fund, to help victims of sexual and domestic violence at the University of Alabama meet their healthcare, legal, and academic needs.