Electronic Thesis and Dissertation Repository

Thesis Format

Integrated Article


Master of Science


Epidemiology and Biostatistics


Bauer, Greta R.


Background. Transgender and non-binary (TGNB) populations experience disproportionally high levels of anxiety and depression; it is imperative we investigate how the COVID-19 pandemic may have impacted the mental health of TGNB communities. Methods. Among a Canadian sample of TGNB persons aged >=15 years, we used multiple linear regression to examine whether interruptions in gender-affirming care were associated with anxiety and depression, and whether that effect was modified by pre-pandemic mental health. Results. Anxiety and depression levels were high both pre-pandemic and during the pandemic. Approximately a quarter of TGNB persons experienced interruptions in hormonal care. After adjusting for confounders, there was no association between interruptions in gender-affirming care and anxiety. However, interruptions in hormonal care was associated with increased depressive symptoms during the pandemic, and this effect was modified by pre-pandemic depression. Conclusion. Interruptions in hormonal care may have increased depressive symptoms in an already highly-depressed group of TGNB persons.

Summary for Lay Audience

The World Health Organization (WHO) declared the coronavirus disease (COVID-19) a global health pandemic on March 11th, 2020. Since then, there have been major social, health and economic changes. The shut down of “non-essential” businesses contributed to increased unemployment rates, school closures forced students and teachers to adapt to a virtual learning environment, and disruptions in health-care systems resulted in an increase in unmet health care needs. Evidently, the COVID-19 pandemic has resulted in an increasing number of disruptions to daily life for individuals globally. This has raised concerns about whether these changes have contributed to increased mental health challenges; especially for marginalized populations, such as the transgender and non-binary (TGNB) community. Given that TGNB Canadians have previously experienced inequities in health care access and socioeconomic disadvantages, COVID-19-related disruptions may disproportionally affect this population.

Gender dysphoria is the feeling of distress that some TGNB persons experience due to their gender identity differing from their sex assigned at birth. Gender-affirming care is a medical intervention that can help alleviate this distress. This type of healthcare is available in Canada and it includes treatments such as, puberty blockers, hormone therapy and surgeries. Importantly, there have been documented benefits and improvements in mental health, including anxiety and depression, after receiving gender-affirming care.

This thesis used data from Trans PULSE Canada; a study that collected data on the health and well-being of Canadian TGNB persons aged >=14 years pre-pandemic (2019) and one year later, during the pandemic (2020). In this study, we found that TGNB persons were experiencing high levels of anxiety and depression symptoms both pre-pandemic and during the pandemic. Pandemic anxiety severity was not different from pre-pandemic levels; however, depression symptoms during the pandemic were higher compared to pre-pandemic. We also found that interruptions in gender-affirming care was not linked to anxiety levels during the pandemic. In contrast, interruptions in gender-affirming care, specifically interruptions in hormonal care, played a role in increased depression during the pandemic, wherein interruptions in hormonal care played a greater role on pandemic depression for those who were less depressed pre-pandemic.