COVID-19 Vaccine Hesitancy in the LGBTQ+ Population: A Systematic Review

"The systemic oppression of the LGBTQ+ population, including exclusion from research, healthcare access, and healthcare policy has led to mistrust and lack of or misinformation, contributing to vaccine hesitancy. Developing and enacting strategies addressing vaccine hesitancy is of utmost moral and clinical significance."

Lesbian, gay, bisexual, transgender, and queer (LGBTQ+) communities are marginalised and systemically discriminated against, leading to socioeconomic and healthcare disparities. These disparities became worse during the COVID-19 pandemic, with LGBTQ+ people potentially having increased exposure, economic disparities, and barriers to care as compared with cisgender heterosexual people. Despite the availability of safe and effective COVID-19 vaccines, LGBTQ+ communities still face challenges due to inequitable access and vaccine hesitancy. Various studies have explored and tried to address factors influencing vaccine hesitancy. However, the LGBTQ+ population remains under- and misrepresented in many of these studies. In an effort to guide interventions and policy changes, this paper reviews literature on the impact of the COVID-19 pandemic on the LGBTQ+ population, as well as reasons for, and recommendations to address, vaccine hesitancy.

The inclusion criteria for the July 2021 literature search were survey studies in English among LGBTQ+ that aimed to evaluate COVID-19 vaccine acceptance/hesitancy. There were only 28 surveys (9 studies) that had a nonbinary option in the questionnaire. Among those, the vaccine acceptance rate in the nonbinary population subgroup was mentioned in 3 surveys (3 studies). Multiple limitations made drawing any inference from those datasets challenging. However, some findings emerged; for example:

• One study among sexual and gender minority men and transgender women found that medical mistrust and social concern regarding COVID-19 vaccine stigma was significantly associated with decreased COVID-19 vaccine acceptance and that altruism was significantly associated with increased vaccine acceptance.
• A study based on data from an online survey found that 9 out of 10 LGBTQ+ people wanted to be vaccinated against COVID-19. The most common concerns were potential side effects (59%), long-term safety (54%), and previous negative experiences with healthcare providers (19%). Previous negative experiences were more likely to delay vaccination for one in four transgender and one in three genderqueer respondents.
• In an online community survey among LGBTQ+ people, 85.3% of the respondents reported a desire to be vaccinated as soon as it is available to them. However, 40.8% of the respondents did not know where to be vaccinated.

The researchers argue that, in order to rebuild the confidence of LGBTQ+ people in COVID-19 vaccines, governments, policymakers, and healthcare providers need to start by acknowledging, and then resolving, the disparities this community experiences. Recommendations include:

• Ensure access to COVID-19 vaccination: Traditional healthcare systems and healthcare providers may seem to be inaccessible to an individual - either because of one's fear of discrimination, negative past experiences, or concern about cost due to lack of health insurance. Survey data collected by the Tegan and Sara Foundation found that many queer people were hesitant or fearful of engaging with the healthcare system because of negative past experiences. Creating safer and respectful experiences within traditional healthcare systems and making COVID-19 vaccines accessible in the workplace are among the options presented here. For example, a LGBTQ+ health organisation in Boulder, Colorado, United States (US) addressed the higher rate of vaccine hesitancy among the local LGBTQ+ population by launching its own vaccine clinic, enabling people to get vaccinated in a safe space.
• Build trust and address misinformation: Trust in the healthcare system, media, and the government are important predictors of vaccine acceptance level in a population. Trust in authorities is lower in LGBTQ+ communities, potentially due to authorities' long history of marginalisation and systemic discrimination and violence against these communities. Thus, various LGBTQ+ trusted sources such as local supportive LGBTQ+ chapters, advocacy groups, community leaders, and specific public figures could be leveraged as trusted sources for relaying accurate COVID-19 vaccine information. In addition, health officials can use media platforms to deliver specific health information to their intended audience. For example, they can provide information on why moderately to severely immunocompromised people with HIV/AIDS should receive a third COVID-19 vaccine dose and directly address misinformation such as vaccine's cost and side effects.
• Use behaviour modifiers: For instance, promoting vaccination as a social norm can motivate the public to get vaccinated. This is a similar strategy to that used to encourage voting; after vaccination, people may get a pin, ribbon, or a badge showing support for immunisation and acknowledging their vaccination status. Social networking means that individuals are more likely to get vaccinated if their friends, family members, or members of their social network support vaccination.
• Provide patient-centred care: It is the responsibility of all the health staff members to make a patient feel safe and respected. To do that, health staff need to be educated about LGBTQ+-specific medical concerns and care - e.g., through training and retraining using LGBTQ+-centric competency modules and online/print guides on communicating with LGBTQ+ patients. Health staff should exercise an empathetic and nonjudgmental approach to build trust, assure confidentiality, and provide a safe, nondiscriminatory environment for the patient. Healthcare administrators, providers, and patient advocates should also work together to ensure equitable, safe, nondiscriminatory, and optimal health care for LGBTQ+ patients.
• Collect data for health equity: The LGBTQ+ population needs to be adequately represented in healthcare research studies. Thus, sexual orientation and gender identity data collection needs to be prioritised in COVID-19 vaccine studies and tracking tools. Collection of LGBTQ+-relevant health information will help healthcare providers understand LGBTQ+-specific concerns, including COVID-19-related concerns, and formulate policies tailored to individual LGBTQ+ needs, including addressing healthcare disparities. In addition, vaccine hesitancy is a dynamic, multifaceted problem, so longitudinal surveillance tools can help to design and adapt response strategies and programmes. The collection of gender and sexuality-based survey questions should be optional and anonymised, and practical measures to prevent any potential breach of protected health information or patient identifiers should be implemented. In addition, various authors have noted a lack of uniformity in identifying sexual orientation and gender identity. It is crucial to establish universal guidelines for identifying and collecting such information to leverage the data effectively.
• Implement public health and vaccine policies that address systemic and structural oppression of LGBTQ+ people.

In conclusion: "The LGBTQ+ population has suffered from systemic discrimination, oppression, and structural health inequities. These injustices escalated further during the COVID-19 pandemic....To address COVID-19 vaccine hesitancy in the LGBTQ+ population, a collaborative effort be- tween federal governments, healthcare policymakers, healthcare providers, and mass media providers is needed to build trust; listen to and address community-specific concerns; providing uniform, consistent, transparent, and accurate information on vaccine safety and efficacy; and make the vaccine more the accessible including providing safe spaces for vaccination and other healthcare needs."