Mental Health Outcomes Among Transgender People in South Africa During the COVID-19 Pandemic: A Cross-Sectional Analysis of Service Disruptions and Social, Structural, and Relational Correlates

Purpose: We examined how sociodemographic, structural, and violence-related factors and disruptions in HIV services and gender-affirming care (GAC: nonmedical supplies, therapy/counseling, medications/hormones, surgeries) were associated with suicidal ideation and moderate/severe anxiety and depression symptoms among South African transgender people. Methods: In September–November 2021, surveyors sampled populations with high HIV risk to understand COVID-19 pandemic experiences. We analyzed sociodemographic, structural (housing, food, financial insecurities), and violence correlates of suicidal ideation and anxiety and depression symptoms. We estimated associations of disruptions in HIV services and GAC with suicidal ideation and anxiety and depression symptoms, adjusting for identified correlates. Additional analyses were stratified by HIV status and age (15–24, 25–30, >30). Results: Among 194 transgender people, 27% ( N = 190) reported suicidal ideation and 37% ( N = 178) reported anxiety and depression symptoms. Factors positively associated with suicidal ideation included living with disabilities, increasing educational attainment, unemployment, financial and housing insecurity, and emotional violence; social and structural vulnerabilities affected nearly all HIV and age strata. Correlates positively associated with moderate/severe anxiety and depression symptoms comprised age, housing insecurity, and economic violence. Disruptions in gender-affirming therapy/counseling, medications/hormones, and/or surgeries were positively associated with moderate/severe anxiety and depression symptoms (overall; people without HIV; aged 15–24, 25–30) and suicidal ideation (aged 15–24). In those reporting HIV service disruptions, suicidal ideation (overall, aged 15–24) and anxiety and depression symptoms (overall, aged 25–30) were higher. Conclusions: Social and structural inequalities were associated with suicidal ideation; GAC and HIV service disruptions were mostly associated with moderate/severe anxiety and depression symptoms. Improving transgender people’s mental health requires reducing inequalities while preserving care linkages and access.