The Future of Transgender Healthcare Is Online

M, who is non-binary and transgender, first sought care for gender dysphoria at their local Planned Parenthood clinic in South Carolina. (Because M has not disclosed their transgender status at work, they requested anonymity for this story.) The staff there was very caring, they said, but the clinic was underfunded and understaffed, with a long waiting list for follow-up appointments. "It was almost like musical chairs," said M, "with more people than seats." When M began taking hormone therapy for gender transition, delays in care led to month-long lapses in hormone prescriptions, resulting in an emotional and physical roller coaster.

All of that changed when M reached out to QueerMed, a telehealth practice that provides trans-focused medical care online, via videoconference and other tools, in five states across the Southeast. Within a week, M. had an intake visit, a review of recent blood tests, and a prescription waiting at their local CVS. "I don't feel I have to jump through any hoops—it's all through an app on my smartphone,” said M. “I can access labs, forward labs, send secure texts to the doctor's practice." The result is care that M said feels both less intrusive and more personalized. "It's really good."

The demand for affirming, competent transgender care far outsrips what’s available, and in rural areas, physicians able to provide that care are often few and far between. By bringing doctors as close to patients as their nearest high-speed internet connection, telehealth offers a potential solution to that gap.

On the whole, transgender people travel further and receive less insurance coverage for their healthcare than do other sexual minorities. A study of rural sexual minorities found that 14 percent of transgender and non-binary people lived more than an hour's drive from their primary care providers, compared to only 5 percent of their gay, cisgender counterparts. And respondents to the 2015 US Transgender Survey said they were more likely to travel long distances for transition-related care than for routine care.

Other studies have show that transgender people were much more likely than cisgender people to have no health insurance, and about a quarter of those responding to a question about barriers to care reported the cost of gender-confirmation therapy (including hormonal and/or surgical therapy) was the main problem in not receiving it.

Once they make it into a provider's office, transgender patients are likely to have a negative experience related to their transgender status. According to the US Transgender Survey, one third of respondents who had seen a healthcare provider in the past year reported having a negative experience with a provider related to being transgender, and almost a quarter said they'd avoided seeking needed health care due to fear of being mistreated on the basis of their gender identity.

The American Academy of Family Physicians and other associations of primary care physicians are increasingly encouraging their members to provide transition-related care to patients with gender dysphoria. But many unspecialized physicians hesitate, citing fear of making mistakes and lack of knowledge, and in some cases, acknowledging bias.

As a result of all of these factors, transgender people living in rural and exurban areas are often faced with a vacuum of physicians willing to perform the bread-and-butter work of transition-related care: prescribing and adjusting hormone replacement therapy and related medication, ordering and reviewing laboratory results, responding to concerns about medication side effects, and monitoring patients' overall health within the context of transition. And while medical educators are beginning to catch up with the demand for trans-competent doctors, there’s still a long way to go.

Watch Broadly profile Rachel Waverly, a former US Army solider who believes her discharge was based on issues surrounding her gender identity:

Before opening QueerMed in mid-2017, Dr. Izzy Lowell ran a brick-and-mortar clinic specializing in transgender medicine for two years. When she made the change to telehealth, reaching rural patients became one of her main goals. “That's the population that I think has the least access," she said.

At the heart of video telehealth is a live, two-way interaction between a patient and a provider, using technology similar to a Skype call. Because there's no physical contact with the provider, there's no physical exam—though if the provider thinks an exam is necessary, the patient can be referred to a local provider or an emergency room—and visits to laboratories for blood tests and to pharmacies for prescription medications take place locally.

The technology essentially removes the geographic barrier to specialty health care for marginalized populations, said Yadin David, a biomedical engineering consultant and founder of the Center for Telemedicine and e-Health Law. "[For people] who think, 'I'd never be able to make it to the medical center, it's too far, it's too expensive, I don't have a car, I cannot leave the home,'" he said, telehealth offers an opportunity to get better, more appropriate and faster care.

The scope of medical care provided via telehealth can be focused or broad: while Lowell exclusively provides care related to medical transition, Dr. Katie Bast provides gender-affirming primary care as one of several physicians contracted with telehealth practice SteadyMD.

Bast opened Mosaic, an LGBTQ-inclusive brick-and-mortar clinic in Indiana, in mid-2016. She sees about 400 transgender patients in person, and began recruiting patients for her online transgender-focused practice in mid-2017. Through SteadyMD's concierge model, Bast functions as her telehealth patients' primary care physician for a monthly fee of $79. The fee covers routine "visits" with her, inclusive of transition-related care, and easy access to her at other times via secure text messaging. The fee does not cover laboratory tests or medications, and the practice does not accept insurance.

Guy Friedman, co-founder and CEO of SteadyMD, said there's been high demand for the service from all regions of the US and several other countries. However, Bast can only provide care to people who live in states where she has a medical license—and because licensure can take months, she is currently only able to provide telehealth services to patients in Indiana and California.

Lowell's model is different in that she exclusively provides services related to gender transition, and she recommends that her patients maintain a separate relationship with a primary care provider to meet their other medical needs. Her practice accepts several forms of insurance, and she is currently licensed in five states in the southeastern US. She said that, for patients paying out of pocket, her services generally cost approximately $800 to 900 per year for the first year of care, and $300 to 500 per year for following years.

For patients like Allyson Douglas, who lives in Columbia, South Carolina, telehealth has offered a better quality of care than that available locally. Prior to joining Lowell's practice in late November 2017, she was seeing a general practitioner who, while welcoming and competent at prescribing hormones, was not a specialist in transgender care. "There's so much ambiguity as far as trans health is concerned,” Douglas said. “Discovering [I had access to somebody for whom] this was their mission, their specialty, was pretty exciting.”

Some of Lowell’s patients have told her that if it weren’t for her practice, they wouldn't receive transition-related care at all. Others would have to pay more for less consistent service; M said they paid much more out-of-pocket for services at Planned Parenthood than they did to see Lowell. And still others would have to drive upwards of four hours round-trip to their closest alternative.

Although few of Lowell's patients see downsides to receiving care online rather than in person, Yadin David notes that telehealth services may not always be as cost-effective for physicians to provide—and the costs they incur may ultimately be passed on to patients. Furthermore, he said, even when broadband home internet connections are available, they are widely variable in quality, and may not reliably transmit the information needed to make certain diagnoses. And across all kinds of medical care, telehealth has some drawbacks compared to in-person visits.

And while seeing a transgender medical specialist online may guarantee an affirming interaction with a physician, patients are not guaranteed that interactions with ancillary health care providers at their local facilities—laboratory and pharmacy staff, for example—will be as positive.

To Bast, that less represents a challenge than it does an educational opportunity: "Prior to my patient's arrival at their spot," she said, "I can call ahead, and doctor to pharmacist, doctor to lab tech, doctor to phlebotomist, say, 'I'd like to introduce you to my patient coming in. This is a transgender patient, and let me explain to you what that means, and how to be friendly and welcoming."

Keren Landman is a practicing physician who specializes in infectious diseases and public health. Follow her on Twitter.