Telehealth Is Lifting Major Roadblocks to Trans Healthcare

Jason, a 32-year-old accountant living in Denver, figured that starting hormone replacement therapy during the coronavirus pandemic wouldn’t be an easy task. (Jason asked that VICE not use their last name for privacy reasons.) Colorado’s governor issued a “stay at home” order on March 25, leaving Jason less able to access medical appointments than they would have been before their city entered lockdown. What they didn’t expect was for their primary care physician to be entirely unreceptive to treating their gender dysphoria, instead advising Jason to wait until after the order was lifted to pursue HRT.

“I felt super discouraged,” said Jason, describing the "hurdles" their primary care doctor presented them with during a phone appointment, like waiting to do lab work and check their hormone levels and general organ function in person without providing a rationale as to why. "[My PCP] just generally seemed kind of squicked out when I brought [transition-related care] up. There was an obvious change in their demeanor. [They were] taken aback, distracting themself with things off camera, [and] got more distant. They said if I was a trans woman, it would be a different conversation"—Jason is nonbinary—"and they seemed confused by my being nonbinary and wanting to be on HRT.”

With some assistance from the Transgender Center of the Rockies, which provides counseling and medical services to trans and gender-expansive Coloradans, however, Jason was able to set up a telehealth appointment via Zoom with a gender-affirming provider at the Sheridan Community Clinic.

“They were really nice,” said Jason. “They asked me my pronouns, first and foremost.” After touching base with Jason’s endocrinologist, the provider discussed what Jason wanted out of medical transition and how they wanted to go about it. “It was very collaborative,” they said.

By the end of the call, their provider agreed to start Jason on estrogen patches and progesterone, which they hope will give them a more pear-shaped silhouette, thereby reducing their dysphoria. (Due to a benign brain tumor, Jason does not produce endogenous testosterone, and therefore has no reason to take a testosterone blocker like spironolactone.)

Jason got their prescription on Tuesday. They plan to pick up the medications from a drive-through pharmacy down the street from their house this weekend.

Access to gender-affirming care has always been fraught. In the National Center for Transgender Equality’s 2015 survey on trans Americans (the largest of its kind to date), one third reported a negative experience with a medical provider in the prior year, ranging from verbal harassment to outright denials of care. In many ways, access to transition-related healthcare has become even more fraught during the pandemic, as life-saving public health measures have forced hospitals to postpone all non-emergency surgeries, including gender-affirming procedures.

Still, patients and providers alike told VICE that access to new hormone prescriptions has not diminished; in many cases, it has improved, potentially pointing to a bright future for telehealth in treating trans individuals.

Before March, telehealth services weren't viable for most trans care providers, particularly those operating within LGBTQ care clinics that offer transition-related services on an informed-consent basis and treat many low-income patients. The difficulty in offering telehealth care was due to a requirement from the Centers for Medicare & Medicaid Services (CMS), the largest insurance provider in the United States, that mandated in-person visits.

The Trump administration decided to temporarily waive the rule on March 30, allowing the CMS to pay for telehealth appointments over the phone and over various video chat services. The decision coincided with healthcare providers all over North America suspending in-person appointments in an effort to slow the spread of the virus. As a result, telehealth use has skyrocketed; Blue Cross and Blue Shield of Massachusetts recorded over half a million telehealth visits with patients over the past six weeks, an increase of more than a hundredfold over its previous six-week average of 5,000.

Trans care providers told VICE that transitioning all of their in-person services to telehealth hasn’t been easy, especially for those who had no such infrastructure to do so prior to the pandemic. But remote appointments have been a boon to many of their patients.

Anna Kiesnowski, the Gender Affirming Services Manager at the Mazzoni Center, a medical provider in Philadelphia that specializes in LGBTQ care, said that new patient intake hasn’t dipped after the clinic switched from in-person to telehealth appointments. The option to pursue transition-related care remotely, Kiesnowski said, might have even improved the process for new patients, especially those who live hours away from Mazzoni or any other competent trans care provider.

“People who live further out, like two to three hours away, they can just sign in [online] and log in to their video appointment,” said Kiesnowski. “[Telehealth] has actually decreased the barriers.”

Telehealth is also beneficial for trans youth who require a parent or guardian with them at every appointment. Now, they don’t have to coordinate multiple schedules just to visit a provider anymore.

Even leaving the house can be a deterrent for many trans individuals seeking care, as a provider from Planned Parenthood of Greater New York, who asked to remain anonymous for privacy reasons, told VICE. Adults with intense dysphoria who can use telehealth services no longer need to worry about navigating public transportation, where they would also be vulnerable to public harassment and violence.

“Transfeminine patients often show up and change into gender-affirming clothing and makeup in the bathrooms,” the provider said. “It is not always safe for them to present like that on the buses and trains they have to take to get here, sometimes from hours away. At least one patient of mine is refusing to leave their home right now, so telehealth has been really helpful.”

Telehealth does present some obstacles for providers. Raymund Sison, the Director of Medicine at New York City’s Apicha Community Health Center, said that some of his trans patients do their hormone shots at the clinic, administered by a provider. Apicha is considering rolling out a telehealth service that would teach patients who don’t already feel comfortable doing their shots themselves how to do so at home.

The impossibility of lab work has also presented a problem, as trans care centers like Apicha typically monitor patients’ labs at three- to six-month intervals. When it comes to new patients who don’t have any labs on file, Sison and the Planned Parenthood provider told VICE that they now also accept any previous lab work done in the past six months. In the absence of such material, they are forgoing blood work for the time being in favor of getting their patients started on HRT, provided that they see no cause for concern in their patients’ medical histories.

Telehealth is not without its drawbacks for patients, either. Núria, a 32-year-old trans woman in Quebec whose name has been changed here for privacy, had a gender-affirming procedure the day before her hospital postponed all non-emergent surgeries. She told VICE she experienced some difficulty refilling her estrogen prescription and getting a new prescription for progesterone through telehealth. The issue likely wouldn’t have come up had her appointment been in-person, she said.

“Something didn’t go through to my pharmacy because of some technical issue, and it took me two weeks to get in touch with my doctor to have her scan my prescriptions and send them to my pharmacy again,” said Núria. “I had enough estrogen left so I didn’t run out, but if I hadn’t, I would have been 10 days without hormones.”

Despite the obstacles, she was able to get a new HRT prescription from her provider, as was Mattie Hernandez, a 29-year-old nonbinary individual in North Carolina. Through video conferencing software that they accessed from their home, Hernandez had an appointment with a provider at the University of North Carolina’s Transgender Health Program and received a prescription for estrogen patches 16 days later.

“I prefer telehealth to in-person visits,” Hernandez said. “It seems very time-efficient. The 30-minute meeting actually took only 30 minutes, instead of [the longer wait times that come with] sitting in a clinic waiting room because [a provider's office] overbooked.”

The patients VICE spoke with all said that they would like to see trans care continue to utilize telehealth once the more extreme public health measures like social distancing and clinic shutdowns are no longer necessary. The providers echoed that sentiment, hoping that the Centers for Medicare & Medicaid Services will make the temporary waiving of in-person appointments permanent.

Trans care has always been fraught, but, as changes to the provision of that care brought on by the coronavirus pandemic have demonstrated, telehealth makes medically necessary care like HRT that much more accessible to people who need it—people like Jason, who plans to take their first dose of estrogen and progesterone on Sunday.

“I’m super nervous, but excited to have less dysphoria,” they said. At a time when the future might be difficult to imagine, HRT, made possible through telehealth, has given Jason something to look forward to.

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