“Gripping onto the last threads of sanity”: transgender and non-binary prisoners’ mental health challenges during the covid-19 pandemic

Abstract Background Covid-19 has had an especially detrimental impact on mental health of people with intersectional marginalized identities. Yet, research evidence on this impact is lacking, with efforts to generate it stymied by pandemic restrictions. Aims To explore how a socially excluded gender minority group—transgender and non-binary (TGNB) prisoners—experienced, and coped with, the pandemic stressors. Methods The data were collected via correspondence with 15 TGNB prisoners in England and Wales in April-October 2020 using an exploratory person-centred qualitative longitudinal approach and examined using reflexive organic thematic analysis. Results The pandemic and its restrictions to support structures and health care detrimentally impacted TGNB prisoners’ mental health and wellbeing. TGNB prisoners experienced added stressors associated with their intersecting incarceration and gender minority positions, including prolonged solitary confinement and reduced access to gender-affirming health care. Environmental resources for problem-focused, emotion-focused, socially supportive and disengagement coping were reduced by the prison pandemic regime, with adaptive coping through positive distraction and engagement with TGNB/LGBTQ community particularly affected. Conclusions During a pandemic and beyond, greater support and innovative practices are needed to improve the TGNB prisoners’ access to gender-affirming care and to TGNB/LGBTQ community, to protect their mental health and wellbeing.


Introduction
Research on the pandemic indicates a surge in demand for mental health care (Holmes et al., 2020;Pierce et al., 2020) with worse outcomes for women, the young, the socially disadvantaged, and people with existing mental health conditions (O'Connor et al., 2021).Groups with intersecting inequalities are likely to suffer more severe consequences (e.g., for LGBTQ youth, see Salerno et al., 2020), as, rather than being a "great equaliser," this pandemic, like ones before, increases preexisting socio-economic (Maestripieri, 2021) and health inequalities (Bowleg, 2020).
In this paper, we focus on the effects of the pandemic on mental health of a population at the intersection of social exclusion and gender: transgender and non-binary (TGNB) prisoners.Prisoners are especially vulnerable to the pandemic's adverse effects on physical and mental health (World Health Organization, 2020) because of prison conditions (e.g., overcrowding (MacDonald, 2018), poor ventilation (European Centre for Disease Prevention & Control, 2020), inadequate infrastructure and healthcare (Heard, 2019)) and because many prisoners possess preexisting physical and mental health needs (Fazel & Seewald, 2012).Additionally, regime restrictions aiming to reduce virus transmission, while protecting physical health, may negatively impact prisoners' mental states (Suhomlinova et al., 2022).
We contribute to discussions of the pandemic's intersectional impact on mental health here by examining how pandemic stressors affecting the general population, such as the experience of, and worry about, one's own illness and the illness of others, financial insecurity, and social isolation and loneliness (C enat et al., 2021), manifest in prison contexts and compound incarceration stressors (Porter, 2019) and minority stressors (Tebbe & Moradi, 2016) chronic for TGNB prisoners.We address two research questions: 1. How do TGNB prisoners experience the pandemic stressors?2. What strategies do they employ to cope with these stressors?
We explore these in the context of transmission-controlling measures introduced by Her Majesty's Prison and Probation Service (HMPPS) within English and Welsh prisons.These measures echo those taken by prison systems worldwide (Byrne et al., 2020).This included: visitation ceasing; social distancing; isolation for symptomatic, newly-transferred, and shielding prisoners; reduced time out of cell (0.5-2 h a day); suspension of nonessential activities, such as education, religious services and gymnasium; provision of personal protective equipment; testing; and construction of additional accommodation (Suhomlinova et al., 2022).Some measures were short-lived (e.g., halt to prison transfers), most lasted a year (e.g., reduced out-of-cell time, end March 2020-end March 2021), with minor relaxations and reversals (e.g., visits restarted in mid-2020 and halted the following winter).

Methods
To address our questions, we used an exploratory person-centred qualitative longitudinal approach, tracking the respondents intensively over a relatively short time frame to generate rich, situated data (Neale, 2016).

Data collection
The data were collected as part of a broader project about the lived experiences of TGNB prisoners, which commenced in July 2019 and continued until October 2021.The project utilized a letter-writing method of data collection.
Although purposive correspondence between researcher and respondent is rarely used as a data gathering strategy, it has been successfully employed to gain rich descriptions of lived experiences of people marginalized by social stigma (e.g., individuals who self-harm (Harris, 2002) or suffer from eating disorders (Kralik et al., 2000;Letherby & Zdrodowski, 1995)) or residential location (e.g., inhabitants of remote rural areas (Frank et al., 2022;Rautio, 2009)).The strategy is becoming increasingly popular with penologists (Alarid, 2000;Stamper, 2020;Vannier, 2020), due to the difficulties of research access to prisons, and has been used to study prisoners' COVID-19 experiences in Scotland (Maycock, 2021).Letters arguably allow for greater reflexivity than conventional methods of eliciting information and are a common means of communication with the outside world for prisoners, who (like those in England and Wales) have restricted access to telephony and no Internet access (although brief messages could be forwarded to and from them using a special email service).Many prisoners keep in contact with family and friends through letters; some have pen pals; and the Prison Service encourages the practice (any letter, however, may be censored, of which prisoners are aware).
Participants for the project were recruited via advertisement in the national prison newspaper Inside Time, which invited adult transgender and non-binary prisoners to write to the researchers (postage-free) with expressions of interest.The researchers responded with personalized letters, including the project information brochure and consent form.Once the signed consent form was received, the participant was assigned to a research team member who continued individual correspondence.Each consecutive letter from the researchers contained questions asked of all respondents, exploring a particular aspect of their experiences (e.g., daily routine, relationships), and person-specific questions and comments relating to the individual's previous letter.By the time of this writing, we received over 300 letters, containing half a million words.Of 21 respondents at the start of the project, three were released, three dropped out for reasons unknown to us, and 15 were current at the start of the pandemic, when we added a COVID-19 module to the project.It was fortuitous that the project used correspondence method, as we otherwise would not have been allowed to collect data on prisoners during the pandemic, due to the HMPPS moratorium on external primary research in prisons from March 2020 until summer 2021.
To explore our respondents' experiences of the pandemic, we issued three letters.(Each respondent was sent the same version of three letters, for consistency).In the first letter, posted in early April 2020, twelve days after the introduction of prison regime restrictions, we invited participants to reflect on the changes in their lives brought by the pandemic, without posing any specific questions.The responses to this letter and the information provided in regular correspondence since the start of the lockdown, together with the emerging academic and public policy evidence on the pandemic in prison, formed the basis for our second letter.In that letter, posted at the end of April 2020, we included 33 questions (not counting the elaborating sub-questions) about the impact of regime changes on their daily lives and gender presentation, their perceptions of measures introduced to reduce the risk of coronavirus transmission, and their anxieties, concerns, and ways of coping with them.We published a preliminary analysis of the responses in an online media outlet for "newsworthy" academic research and circulated copies of the article to our respondents.The analysis of responses and publicly available information on the unfolding situation in prisons, in turn, informed the design of 111 questions posed in the third letter, posted in August 2020.In the letter, we asked for detailed updates on the matters covered in the second letter and added new themes, concerning the impact of restricted regimes on their relationships with staff and other prisoners and on prison landscape and soundscape.The draft letter was reviewed by an academic expert in public health and a Prison Service researcher; both contributed additional questions.
Over the course of three letters, our questioning mimicked a repeated measures design.While the questions were not identical across the letters (e.g., the second letter asked "How has the regime change affected your contact with friends and family outside the prison?," and the third inquired "How has the lockdown changed your communications with family and friends?"), they probed the common areas and allowed to capture changes over time.
Questions were open-ended and similar in style to reflective interviewing (Roulston, 2010), to ensure that they could be answered from a personal perspective and encouraged participants to raise issues beyond the question's content.This approach-alongside the fact that we included questions tailored to each participants' unique experiences and responsesallowed us to develop a person-centred approach to data collection.

Analytic approach
We used a hybrid (inductive and deductive) approach to thematic analysis.First, to gain a holistic understanding of the pandemic experiences in prison, we used an inductive approach and undertook Reflexive Organic Thematic Analysis (Braun & Clarke, 2019).Two researchers independently coded the data in Word and then agreed the final map of the entire data corpus, in the form of a structured Word document.The map contained text extracts, arranged by 103 emergent codes, which were grouped into 14 themes, such as "Practical impact of regime restrictions" (with codes covering specific areas, such as out-of-cell time, access to education, canteen), "Psychological impact of regime restrictions" (with codes reflecting various emotions, such as fear, anxiety, boredom), and "Coping with COVID-19" (with codes for specific mechanisms, such as exercise, work, hobbies).
Next, we coded the data in NVivo, using, as first cycle codes, the emergent codes from the inductive analysis.We then narrowed our focus to the conceptual area of stress and coping and did the second cycle, or pattern, coding using a priori codes derived from the literature.As codes for stressors, we used the four categories of stressors identified in the research on pandemic-affected populations (C enat et al., 2021), namely, the stressors associated with the experience of, and worry about, (a) one's own illness and the illness of loved ones, (b) job loss and financial insecurity, (c) difficulties accessing/acquiring necessities, and (d) social isolation and loneliness.As codes for coping, we used the four standard categories of coping: problem-focused, emotion-focused, socially supportive, and avoidant (e.g., Fluharty et al., 2021).

Ethics
The project was approved by HMPPS National Research Committee and received ethical approval from the Ethics Committees of the University of Leicester, Northumbria University, and The Open University.All participants provided written informed consent.The quotations from letters are reproduced verbatim and referenced to the participant's chosen pseudonym and letter number.

Results
To address our research questions, we present our results in two sections, focusing, respectively, on stressors and coping strategies of TGNB prisoners.

Stressors
Here, we examine how TGNB prisoners perceived the stressors common to all pandemic-affected populations and how these stressors have been refracted by conditions of confinement specific to TGNB prisoners, combining incarceration (Porter, 2019) and minority stressors (Tebbe & Moradi, 2016).We structure our results around the four categories of stressors, as explained in Methods.

Illness
Unlike the general pandemic-affected populations (Luo et al., 2021), most of our respondents did not express strong fears of the coronavirus: What will be, will be.I'm not unduly concerned (Wildgoose/C2) I'm not concerned about my health, no point worrying until I have it (Rachel/C2) Like half of TGNB individuals in the general population (Koehler et al., 2020, p. 18), some respondents had risk factors associated with increased COVID-19 mortality; however, only a few of those felt fearful: I am extremely concerned as I have underlying health complaints and although I was offered a shielding programme that would have still been staff and prisoners entering my cell with food, meds, cell checks etc with no P.P.E.(Jess/C2) Others, such as a transgender woman with "70% lung capacity," who wrote that, if infected, there was "no hope of making it through to the other side of it except in a coffin," disclosed: covid-19 situation isn't really bothering me as I'll either get it or I wont (Jerika/C2) The diversity of attitudes may be attributed to several factors.Firstly, existing hardships of prison life might have inured respondents to new dangers: Being a at high risk prisoner because of the meds I'm on does concern me if I do catch it, but if I worried about everything bad that could happen I'd never leave my cell (Winter Rose/C2) Secondly, respondents reacted to the objectively low number of suspected/ confirmed cases in their prisons (e.g., only one respondent became symptomatic, but remained healthy).Thirdly, given that in the general population frequent exposure to COVID-19 news was a significant stressor (Xiong et al., 2020), insufficient information and updates given within and about prison establishments could lull respondents into a false sense of security: We feel less concerned about COVID-19 in prison because theres not the same intense media coverage about it, therefore we don't look at COVID-19 as a threat to our life as much as we should do (Poppy/C2) Respondents were considerably more anxious about their loved ones, although this was evenly split, as half wrote that they were "not overly worried" (Hotaru/C2), explaining that: as cold as it sounds there's nothing I can do anyway so I try not to think about it too much (Winter Rose/C2) The rest were apprehensive because of their loved ones' vulnerable positions: I am very anxious and concerned about family who are in the age bracket-for example my nana who has vascular dementia aged 87.I know she probably die if she get COVID-19 and that would destroy me (Proudandfabulous88/C2) These worries were intensified for those with only a few remaining close ties due to social rejection-a majority among TGNB people generally and in our sample-because their potential and real losses weighed heavier: my father died of COVID-19 after being admitted to hospital with other complaints.I now have no one personal, such as family outside (Jess/C2)

Job loss and financial insecurity
In England and Wales prisoners prevented from working by regime restrictions continued to receive their (meagre) pre-pandemic wages.Although some experienced pay cuts due to forced change of work (e.g., from education assistant to cleaner), our respondents' financial situations did not significantly alter and was not a stressor for most: Being in prison has helped with most of my concerns with Covid-19.I don't have to worry about work, losing my job or my home (Winter Rose/C2) Yet, cessation of work was stressful as a loss of purposeful activity and outof-cell time.While a few respondents continued employment as keyworkers (e.g., cleaners, laundry operators, printers) and enjoyed 3-4 extra out-ofcell hours during the workweek, the rest suffered from forced idleness that exacerbated lockdown distress: Most of us don't really do anything, maybe sleep alot more or watch tv.A few try to keep active with in-cell exercises or hobbies like Art & writing.Other than that there isn't anything to do, everyone is bored and frustrated (Hotaru/L15)

Difficulties accessing or acquiring necessities
All prisoners suffered a shortage of products normally available to buy in prison, but for TGNB prisoners, the difficulties were especially acute, when they were unable to purchase the items essential for their gender presentation, such as make-up or prosthetics: things have got progressively worse as ordering clothes, make up, etc have gone to no existant (Jess/C3) Transgender prisoners also reported a unique stressor-impeded access to showering-affecting respondents with no in-cell shower (half of our sample): Before lockdown I used to wait for showers to be empty before showering, now we are unlocked in 3's or 4's and have to shower with others which is agrivating my anxieties around my dysphoria (Jess/C2) Yet, the biggest stressor was impeded access to GAHC.Globally, it affected between a third (Restar et al., 2021, p. 9) and a half (Koehler et al., 2020, p. 16) of TGNB individuals.For our respondents, it threatened to extend the already years-long waiting times for treatments, exacerbated for those awaiting diagnoses (Suhomlinova and O'Shea, 2021).
I was meant to start on T-blockers, but that hasn't happened yet.I guess as its not critical it goes on the back burner.Its not good for my mental state (Winter Rose/C2) Internationally, 61% of TGNB individuals feared that the pandemic will worsen future access to GAHC (Koehler et al., 2020, p. 16), and this fear was a significant stressor for our respondents: I have anxiety þ fears COVID-19 will stop/prevent my medical transition.I fear I'll be forgotten by the healthcare, the NHS and the gender clinics (Hotaru/C2) The stress for Hotaru had already become unbearable: a month before the lockdown, she "attempted and almost succeeded in performing [her] own Orchiectomy" (Hotaru/L6).Similar attempts were reported by Skyee (a month before the lockdown) and Jerika (a year into the lockdown).The lack of communication and uncertainty compounded fears: my first appointment on 21st April 2020 with GIC didn't happen nor have they sent me a letter to say sorry or explain what happened [ … ] I waited 2 hours in GP surgery and they never phoned nor answered phone or replied to GP email (Eve/C3) While telemedicine alleviated access restrictions in the community (O'Brien & McNicholas, 2020), in prison its roll-out was hindered by inadequate access to digital technologies (Centre for Social Justice, 2021), costing some respondents their long-awaited consultations: booked in 4 video call tho' Zoom not available in prison was just a telephone conference & then was told doesn't count as appointment ☹ (Brittany/C3)

Social isolation and loneliness
The conditions and time of confinement affect the level of stress (Rodriguez et al., 2021), and whilst pandemic restrictions influenced social isolation and loneliness generally (Grabowski et al., 2021), prisoners were subjected to greater restrictions.From March 2020 to March 2021, prisoners were confined to cells (usually on their own, in a singleoccupancy cell), measuring, on average, "10'L Â 7'w Â 8'h" (Jerika/C2) (i.e., 14.4 cubic metres), for 22-23 h a day.This amounted to "prolonged solitary confinement," violating the Mandela rules for the treatment of prisoners (United Nations Office on Drugs & Crime, 2015) and Article 3 of the European Convention on Human Rights (Suhomlinova et al., 2022).
Social isolation and loneliness in general populations are associated with increased all-cause mortality, cardiovascular disease, depression and anxiety (Leigh-Hunt et al., 2017).Prolonged solitary confinement is an extreme case of isolation and leads to even greater psychological deterioration (anxiety, depression, self-harm, and suicidal ideation) (Luigi et al., 2020, p. 6).The letters exemplified these effects: i'm depressed its driving me mad sat in a cell all day (Brittany, C2) Mental health of many people (including me) deteriorated (Fayth/C3) Struggling, have self harm on a number of occasions in secret (Eve/C2) I know quite afew people with autism and other mental conditions who are really struggling with being lock up for so long.Not having as much contact with mental health is adding to the problem and a lot of people can't cope (Winter Rose/C3) Some respondents, however, positively remarked that less time out of cells meant "fewer opportunities for any sort of victimisation" (Fayth/C3) of TGNB prisoners: I love this lockdown no one upsets me as don't see many peaple at all (Sharron/C1) A transgender woman, who stopped femininely "presenting" before the lockdown due to sexual and verbal abuse, wrote: Oddly I've started presenting again as less people out to give me greif (Rachel/C2) Reduction in harassment, however, was not universal, as some reported a "massive increase in verbal bullying," targeting "more vulnerable and mental health and elderly" (Eve/C3), similar to a wider pandemic spike in anti-LGBTQ hate crime (ILGA-Europe, 2021).

Coping strategies
Here, we explore how TGNB prisoners employed problem-focused, emotion-focused, socially supportive, and/or avoidant coping strategies to deal with the pandemic stressors and how these strategies have been shaped by the environmental resources available to them.

Problem-focused coping
While all respondents attempted active coping by trying to protect themselves against the infection (e.g., "taking every measure" to socially distance themselves from others (Jerika/C1)), their ability to do so was hindered by prison protocol.For instance, before masks were decreed mandatory for prisoners in the late 2020, prisoners were: banned from wearing PPE and home made masks have [been] taken off prisoners with threat of IPE [disciplinary punishment] for use (Jess/C2) Emotion-focused coping Emotion-focused strategies were more common.Early in the lockdown, some respondents coped by positive reframing: things could be better, but they could also be a lot worse.I am lucky enough to have things in my room to keep me occupied, such as TV, X Box and keyboard and I have letters from yourselves and penpals so I consider myself more fortunate than some here (Jess/C1) Yet, as time passed and regime restrictions persisted, this coping mechanism proved unsustainable.
Some respondents used acceptance coping and adopted a fatalistic attitude, learning to live with their reality: I feel its [infection] unavoidable in this enviroment so I've accepted the risk þ chance I could get it back in the early February (Hotaru/C2) While the use of humor for coping was uncommon, some participants occasionally quipped: can't be bothered [to dress] … my Dressing gown has become my Depressing gown (Brittany/C2) Turning to religion to cope and trying to find comfort in one's spiritual beliefs was commonly noted.Its mental health benefits were, however, reduced due to the loss of communal worship as religious practices became a private endeavor: since I can't go to the chapel/place of worship for buddhist meditation I do the meditation in my cell (Proudandfabulous88/C2) Still, some prisons found creative solutions to sustain a feel of faith community: In lieu of Sunday Service our chaplaincy team are typing out services/prayers etc which everyone can read at a set time so we all go through it together (Jerika/C2)

Socially-supportive coping
Opportunities for interpersonal support were severely limited by restrictions, and support from prison staff dwindled, due to staff shortages and staff's own stress.Respondents wrote that, although some staff members were compassionate: most staff just want to lock us in and leave us! (Jess/C2) While prisons introduced welfare checks, respondents found those perfunctory: usually they say hi … , welfare check, are you okay, I just say yes as I dont tell them how I feel and if I self harm anymore (Eve/L5) Support from prison healthcare also reduced: I don't have medical access or support.It is all focused rightly on COVID-19 but even before that healthcare doesn't really bother with me.My experiences are that healthcare doesn't want to bother or care for people like myself.We're not a priority here (Hotaru/C2) Although additional psychological support for prisoners was recommended (European Committee for the Prevention of Torture & Inhuman or Degrading Treatment or Punishment (CPT), 2020), HMPPS could only provide a paper-based "self-help tool", advising prisoners to "look after themselves" (House of Commons & House of Commons, 2020, p. 5): Since the lockdown we've had flyers on how to cope with the anxietys but little else really (Hotaru/C2) and "distraction packs" (e.g., puzzles, colouring) (which, in some prisons, stopped a few months into the pandemic (Hotaru/C3)): there is no interaction at all from mental health other than distraction packs (Eve/C3) Support from contacts on the outside was relatively low pre-pandemic, as a significant proportion of TGNB prisoners experienced familial rejection.This rejection is a stressor in itself, but also reduces the protective buffering derived from social support and is associated with increased suicidality (Klein & Golub, 2016).During the pandemic, this support was further hampered by the visitation ban and a poor quality of video calls.Lacking kinship/friendship ties, many relied on visitors from charitable organizations for practical and emotional support (Amelia/C2), but video calling was not extended to such visitors (Eve/C2).
Transgender community participation moderates the impact of gender minority stressors, helping to reduce suicidality, depression, and anxiety and increase emotional resilience (Sherman et al., 2020).Pre-pandemic, some prisons had LGBTQ forums, which provided a degree of emotional and practical support.These forums stopped for the entire lockdown year.Some prisons provided links to external LGBTQ support, such as adding LGBT þ switchboard to prison phones (Brittany/C3), but this was not universal and a poor substitute for a local community.
TGNB prisoners had very few friends in prison and sorely missed contact with them: At this point the worst bit is not being able to sit down and have a proper conversation with anyone (Winter Rose/C2) Most friends were other TGNB prisoners, often scattered around prison wings.Since the restricted regime precluded association with prisoners outside one's own landing, separation spanned the entire lockdown year: struggling with isolation from friends who form my key support structure … as they are on wings isolated from me (Fayth/C3) struggling emotionally and psychologically isolated on this wing as the only transgender while the other 3 are on the same wing different from me (Eve/C3)

Disengagement coping
Rather than using avoidant strategies, respondents favored adaptive strategies of positive distraction (Waugh et al., 2020), such as turning to available work or other activities.The main resources for self-distraction were television (with all prisoners having TV in cell, and some prisons introducing extra channels during the pandemic), DVDs and books from the library (although libraries were closed, some prisons created mini-libraries on each wing), distraction and education packs, game consoles, and in-cell physical training.These distractions helped to alleviate stress to some extent: I'm doing a lot of in cell training, drawing and puzzles from news papers which helps pass the time (Winter Rose/C2) I use music to manage stress and anxieties, not just playing CD's, radio etc, but also playing my keyboard (Jess/C2) Yet, as the time went by, the power of these distractions wore off: Those who stayed employed emphasized that, during the pandemic, their work had been "very important" to them (Wildgoose/C3) and gave them "focus and purpose" (Rachel/C3).Some even volunteered for (unpaid) cleaning jobs: im keeping myself busy with all the voluntary work … , instead of worrying mentally and emotionally about COVID-19 (Poppy/C2) Work provided both mental distraction and physical activity, helping to reduce anxiety.

Discussion
Our analysis shows that the pandemic and associated restrictions elevated the incarceration and minority stressors for TGNB prisoners and reduced their coping resources.These conditions are likely to increase psychological distress and amplify the already elevated pre-pandemic levels of TGNB prisoners' self-harm/surgical self-treatment (Brown, 2010), suicidality (Drakeford, 2018), anxiety (White Hughto et al., 2018), and other mental health conditions (Van Hout et al., 2020).
Like other vulnerable groups, TGNB prisoners may be harder hit by the "dual pandemics" of COVID-19 and mental health issues (Banerjee et al., 2021).To reduce their impact, creative solutions, sensitive to the prison and healthcare systems resource scarcity, are required.In making our recommendations, we acknowledge that these are provided within the context of the limitations of our research.Our research participants were transgender women or non-binary prisoners residing in the male estate.Therefore, the identified stressors and coping mechanisms may reflect these gender and location biases, and the recommendations may not be pertinent to transgender men in either estate or to transgender and non-binary prisoners in the female estate.Nonetheless, the findings are enlightening, especially given the uniqueness of TGNB prisoners' voices and their limited representation in the evidence base.
Efforts to monitor TGNB prisoners' unique stressors need adjusting, in line with recommendations for non-incarcerated TGNB populations (Philip, 2021, p. 11).When pandemic restrictions moved most research online, the most marginalized groups, who lack Internet access, became less accessible to researchers, resulting in their underrepresentation in research and public policies.Our data collection method obviated this constraint; and we urge researchers to be sensitive to the participation barriers for the most deprived.More broadly, there is a dearth of knowledge about TGNB prisoners, particularly in relation to mental health, and more qualitative research is required to empower these prisoners and improve policy making (Gorden et al., 2017).Our work highlights the need to develop a stronger evidence base in this field, to empower marginalized groups by listening to their voices through research, and to engage specific groups within LGBTQIAþ community in dialogue about their experiences of stress and coping.
The efforts to reduce minority stressors should be focused on the arguably most significant unique stressor for TGNB individuals: access to GAHC.The pandemic propelled telemedicine globally, but its availability across settings and practice areas varies dramatically (Bhaskar et al., 2021).There is a growing recognition of the need to use telemedicine for transgender care (Asaad et al., 2020); and experiments during the pandemic demonstrate tele-healthcare's viability for initiating and continuing GAHC (Gava et al., 2020;Lock et al., 2022).Given the small numbers of TGNB individuals per prison and the dispersed nature of gender clinics, tele-GAHC could be resource saving.What constitutes essential medical care also needs to be redefined, given that denial or postponement of GAHC increases depression, anxiety and suicidality (van der Miesen et al., 2020), while undergoing gender-affirming interventions improves psychological wellbeing (Dhejne et al., 2016, p. 44), and hormone therapy increases quality of life and decreases depression and anxiety (Baker et al., 2021).
The importance of employment to mental health in the prison environment should be more strongly recognized, especially for this group.Employment affects mental health by fulfilling both material (financial security) and psychological (time structure, social contact, collective purpose, status, and activity) needs (Jahoda, 1981).Unemployment increases psychological distress, depression, anxiety (Paul & Moser, 2009), and suicidality (Amiri, 2021); and limited evidence shows psychological benefits of work, over and above the financial ones, for depression (Crowe & Butterworth, 2016) and well-being (Hussam et al., 2021).The reduction in employment contributed significantly to the experience of stress and the negative climate of the virus.The fact that prison work served as a buffer for psychological distress during the pandemic underscores the well-established non-pecuniary benefits of work for mental health and demonstrates the need to increase meaningful occupational opportunities for prisoners (HM Chief Inspector of Prisons, 1999).
Efforts to improve coping should be directed at building transgender community connections , taking into consideration intersectional nuances, such as the impact of location on the size and accessibility of the community (Sherman et al., 2020).In our context, some prisons have sizeable (10-12) TGNB populations, while others have a lone TGNB prisoner.For the latter, establishing contacts with the external TGNB community and other TGNB prisoners across the estate is crucial.Striving for "blended" TGNB care, in both modes of delivery and types of care (GAHC, mental healthcare and peer-support) (van der Miesen et al., 2020), is equally important.This also includes the need to facilitate identity through access to relevant gender-related necessities.Crossnationally, over a third of TGNB individuals reported reduced access to cosmetic supplies and body modifiers during the pandemic (Jarrett et al., 2021, p. 7).
In conclusion, this research has shed light on the pandemic stressors experienced by TGNB prisoners and the coping strategies they employ to tackle these stressors.This fills several important gaps in the literature because the experiences of prisoners in general, and of TGNB prisoners in particular, are significantly under-researched, despite the fact that their intersecting incarceration and gender minority positions placine TGNB prisoners at increased risk of adverse physical and mental health consequences.Indeed, these findings demonstrate that TGNB prisoners experienced a range of pandemic stressors, including prolonged solitary confinement and reduced access to gender-affirming health care.These stressors occurred within a context where resources for problem-focused, emotion-focused, socially supportive and disengagement coping were reduced by the prison pandemic regime.These findings provide an important opportunity for learning that extends beyond the pandemic, highlighting key recommendations that can help to enhance the future health and wellbeing of TGNB prisoners through greater support and more innovative practices within prison settings.

Disclosure statement
No potential conflict of interest was reported by the author(s).

I
'm suffering gaming addiction & a loss of drive to do anything (Fayth/C2) Prisoners without employment during the pandemic fared worse psychologically than those who continued working: Initial fear and isolation has now turned into tedious boredom and I just want to get back to work (Jess/C3)