Telehealth Versus In-Person Injection Instruction for Adolescents and Young Adults Initiating Gender-Affirming Testosterone Therapy

Abstract

Purpose:

The purpose of this study was to compare the clinical acceptability of testosterone levels, time to treatment, and postinstruction questions/problems between in-person and telehealth injection teaching for adolescents and young adults (AYA) initiating gender-affirming testosterone therapy.

Methods:

A retrospective cohort study was conducted using electronic medical record data from a large pediatric gender health clinic. Patients who received subcutaneous testosterone prescriptions between March 15, 2018, and March 14, 2022, were included. The study compared patients receiving in-person versus telehealth injection teaching. Data were collected on demographics, testosterone levels at 3 and 6 months, time from prescription to treatment, and post-instruction contacts. Statistical analyses included t-tests, chi-square tests, logistic regression, linear regression, and zero-inflated negative binomial.

Results:

The study included 278 patients, with 136 (48.9%) receiving in-person teaching and 142 (51.1%) receiving telehealth teaching. There were no significant differences in baseline characteristics between groups. Clinical effectiveness, indicated by testosterone levels at 3 and 6 months, revealed no significant difference between instruction methods (p = 0.768 and p = 0.350). Time to treatment initiation was comparable (in-person: 15.34 days; telehealth: 18.02 days), with no significant difference in adjusted analysis (p = 0.204). Post-instruction contacts were slightly higher in the telehealth group (2.87 vs. 2.42, p = 0.040), but injection-related questions were rare and similar between groups (p = 0.650).

Conclusion:

Telehealth instruction for testosterone injection is as effective as in-person teaching methods for AYA initiating gender-affirming care. The findings support the continued use of telehealth to enhance access to gender-affirming care, particularly in light of its clinical efficacy and patient acceptability.

Introduction

The COVID-19 pandemic has transformed the landscape of health care delivery, necessitating a rapid shift to telehealth services. This shift has been particularly significant for the ∼700,000 adolescents and young adults (AYA) in the United States who identify as transgender and gender diverse (TGD) and face substantial barriers to health care access.^1,2 Among the critical aspects of health care for many TGD individuals is gender-affirming hormone therapy (GAHT), which helps align their physical characteristics with their gender identity.

Masculinizing hormone therapy can be a vital option for some TGD individuals who were assigned female at birth and generally involves the administration of testosterone via intramuscular or subcutaneous injection, patch, cream, or gel.³ Subcutaneous injections, in particular, can be performed by patients after they receive injection instruction from a health care provider, usually provided during one or more clinic visits.

COVID-19 pandemic-induced restrictions led to a temporary shutdown of nonemergency onsite health care services, including gender-affirming care. As a result, many clinicians adopted telemedicine to continue offering these services.^4–7 This transition to virtual appointments postponed procedures such as gender-affirming surgeries and bloodwork. Some clinicians also opted to delay the initiation of GAHT.⁸

Even prior to the health care challenges presented by COVID-19, AYA who identify as TGD have faced significant barriers to accessing health care, including stigma, a lack of knowledgeable providers, and logistical challenges such as travel distance and time.^9–12 Historically, instruction for administering gender-affirming hormone injections like testosterone has been conducted in-person, creating additional hurdles for those with limited access to specialized care.

To ensure the continued delivery of high-quality gender-affirming care, our institution developed a comprehensive telehealth-based injection teaching program,¹³ which offers the potential to remove some of the aforementioned barriers to care. Despite the apparent advantages of telehealth for patient education and training, there is a notable gap in the literature regarding the clinical outcomes of virtual injection training for AYAs initiating GAHT. A recent call to action highlighted the need for outcomes research in this area.¹⁴ This study aims to address this gap by comparing whether serum testosterone levels align with clinical expectations given dosing (clinical acceptability), time to treatment, and the incidence of post-instruction questions or problems between in-person and telehealth injection teaching.

Materials and Methods

Study population

This retrospective cohort study utilized data from the electronic medical record (EMR) of a large pediatric academic health system. Individuals were eligible for inclusion in the study if they attended the health system’s gender health clinic and received a prescription for subcutaneous testosterone for gender-affirming care between March 15, 2018, and March 14, 2022. Patients were excluded if they did not have documented injection teaching in the EMR, received injection teaching outside of the health system, or were prescribed testosterone enanthate autoinject (Fig. 1). This study was approved and granted a waiver of informed consent by the Children’s Hospital of Philadelphia Institutional Review Board.

FIG. 1.

Consort diagram. The initial study population consisted of all individuals seen at the gender health clinic who were prescribed subcutaneous testosterone for gender-affirming care between March 15, 2018, and March 14, 2022.

Data collection

Data were manually retrieved from the EMR by trained personnel with periodic quality checks performed by the lead investigator to ensure accuracy and completeness. Collected variables included demographic characteristics, puberty blocker use, testosterone prescription details (dosage, frequency), number and type of injection teaching sessions, serum testosterone laboratory levels at 3 and 6 months, and the number and type of post-teaching interactions with the clinic. Participant data were collected from the time of the initial subcutaneous testosterone prescription through 6 months after the first dosing of testosterone. Receipt of the first dose of testosterone was defined as the first injection teaching date, as the instruction process involves the provision of the first testosterone dose for both in-person and telehealth modalities. For patients who were initially prescribed a nonsubcutaneous formulation, such as gel or cream, follow-up began at the time of receipt of a subcutaneous testosterone prescription.

Exposure

The primary exposure was the method of testosterone injection teaching—either in-person at the clinic or remotely via telehealth. A description of the two teaching modalities can be found in Supplementary Appendix SA1. During the initial months of the study period, the clinic’s standard education process recommended two in-person teaching sessions. This process was then revised to recommend only one teaching session, with additional sessions available upon patient request. Starting in March 2020 with federal shutdown orders, all medical visits for testosterone initiation and injection teaching were offered via telehealth only. After this ∼1-month period, the decision for telehealth versus in-person visits was at the discretion of providers and/or patients.

Outcomes

Clinical acceptability of serum testosterone levels was assessed 3- and 6-months (±30 days) post-initiation of testosterone by a clinician specializing in gender-affirming care who was blinded to teaching modality. Patients are not instructed when to have labs drawn relative to their testosterone injection. Patients who discontinued testosterone prior to either the 3- or 6-month labs were censored for that outcome.

For patients initiated on the low to standard testosterone dose of 50 mg weekly,³ serum testosterone levels were considered clinically acceptable if they were between 250 and 1000 ng/dL. Clinical acceptability for patients who were started on a lower dose or who were concurrently on puberty blockers was based on whether there was a reasonable increase in testosterone from baseline given the time interval since initiation. Specifically, for patients on puberty blockers, a gradual rise in testosterone was expected, with clinically acceptable levels reflecting an incremental increase consistent with the induction of puberty. For patients on a lower dose or frequency of testosterone (e.g., <50 mg weekly), clinical acceptability was determined by whether testosterone levels increased within expected ranges based on clinical experience and typical pharmacokinetic patterns, considering the patient’s individualized treatment plan and the duration since therapy initiation.

Time to treatment was calculated as the number of days between the initial subcutaneous testosterone prescription and the first testosterone injection. Patients with a time to treatment >90 days were censored from this outcome analysis as treatment delays >90 days are likely due to external factors.

Post-instruction contacts were defined as patient- or parent-/guardian-initiated contact with the gender health clinic specifically related to testosterone therapy and were assessed from the receipt of the first dose through 6 months. Each contact was classified by contact method (telephone, EMR portal message, or in-person visit) and the primary reason for the contact. Contacts were classified as (1) Problem/question about injection (e.g., “Is it OK if a drop of medication comes out after I perform the injection?”), (2) side effect (e.g., “I get a red, itchy bump after I perform the injection”), (3) other clinical question (e.g., “Now that I’ve started testosterone, will my periods stop without other medication?”), (4) administrative (e.g., refill requests), and (5) routine visits (e.g., the standard of care follow-up, either in-clinic or via telehealth).

Covariates

Additional variables collected included the patient date of birth, race, ethnicity, insurance type (private, medical assistance, or other), sex assigned at birth, and gender identity. Race and ethnicity, collected during visit registration, were included as proxy measures accounting for the intersectional effects of racism and discrimination.

Statistical analysis

Baseline characteristics were compared between the in-person and telehealth groups using t-tests and chi-square tests. Post hoc analyses were not performed due to a lack of statistically significant differences in baseline characteristics. An unadjusted analysis of outcome measures was performed using chi-square, Mann–Whitney U, and t-tests.

Adjusted analyses were performed on all outcome measures, initially controlling for race (categorized as white or other), ethnicity, type of insurance, age at the start of testosterone therapy, and use of puberty blockers. Covariates were selected based on their potential to confound the relationship between the method of instruction and clinical outcomes. Some covariates were excluded from adjusted models when cell sizes were small and standard errors were inestimable. Adjusted analyses were performed using logistic regression to assess the clinical acceptability of testosterone levels, linear regression to assess time to treatment, and a zero-inflated negative binomial model with bootstrapping (n = 1000) to assess the number of post-instruction contacts. Diagnostic tests, including assessment of residuals, were performed to confirm the appropriateness of each selected statistical model.

Results

Study population

The final sample comprised 278 patients, with 136 (48.9%) receiving in-person teaching and 142 (51.1%) receiving telehealth teaching. About 85.3% of the patients in the pre-COVID-19 period received in-person teaching, and 97.2% of patients who were seen beginning of March 2020 received telehealth teaching. The cohort was primarily white (71.2%), non-Hispanic (88.5%), had private insurance (79.5%), and did not use puberty blockers prior to initiation of testosterone (93.2%). Four patients stopped all testosterone therapy during the study period, two from each education group. No patients in the telehealth teaching group received a second teaching session, while 30 (22.1%) in the in-person group received a second in-person teaching session. Table 1 shows the demographic characteristics of the study population by education modality. There were no significant differences in baseline characteristics between the two groups in the full cohort. Among the 19 patients who received puberty blockers, individuals who received telehealth injection teaching were significantly younger at the time of puberty blocker initiation (p = 0.01).

Table 1.

Demographic Characteristics of Eligible Individuals by Teaching Modality

	Teaching modality
	In-person (n = 136)	Telehealth (n = 142)	Total (n = 278)	p
Race, N (%)				0.7415
Asian	3 (2.2%)	4 (2.8%)	7 (2.5%)
Black/African American	6 (4.4%)	13 (9.2%)	19 (6.9%)
Multiracial	5 (3.7%)	6 (4.2%)	11 (4.0%)
White	100 (73.5%)	98 (69.0%)	198 (71.2%)
Other	20 (14.7%)	19 (13.4%)	39 (14.0%)
Unknown	2 (1.5%)	2 (1.4%)	4 (1.4%)
Ethnicity, N (%)				0.9916
Hispanic	11 (8.1%)	11 (7.7%)	22 (7.9%)
Non-Hispanic	120 (88.2%)	126 (88.7%)	246 (88.5%)
Unknown	5 (3.7%)	5 (3.5%)	10 (3.6%)
Gender Identity,a N (%)				0.3091
Male	115 (84.6%)	124 (87.3%)	239 (86.0%)
Female	0 (0%)	1 (0.7%)	1 (0.4%)
Trans male	12 (8.8%)	7 (4.9%)	19 (6.8%)
Gender nonbinary	6 (4.4%)	9 (6.4%)	15 (5.3%)
Agender	1 (0.7%)	0 (0%)	1 (0.4%)
Gender queer	2 (1.5%)	0 (0%)	2 (0.7%)
Gender nonconforming	0 (0%)	1 (0.7%)	1 (0.4%)
Insurance, N (%)				0.3754
Private insurance	110 (80.9%)	111 (78.2%)	221 (79.5%)
Medical assistance	22 (16.2%)	30 (21.1%)	52 (18.7%)
Other	4 (2.9%)	1 (0.7%)	5 (1.8%)
Received puberty blockers, N (%)				1
Yes	9 (6.6%)	10 (7.0%)	19 (6.8%)
No	127 (93.4%)	132 (93.0%)	259 (93.2%)
Initial testosterone prescription, N (%)				0.9827
Testosterone cypionate	135 (99.3%)	142 (100%)	277 (99.6%)
Testosterone enanthate	1 (0.7%)	0 (0%)	1 (0.4%)
Mean age at testosterone start (SD)	16.46 (1.80)	16.54 (2.17)	16.50 (2.00)	0.7513
Mean age at puberty blocker start (SD)b	13 (1.73)	11 (0.94)	11.95 (1.68)	0.0095

Percentages represent column percentages.

^a All patients assigned female at birth.

^b Among the 19 patients who received puberty blockers.

SD, standard deviation.

Clinical acceptability of serum testosterone levels

There were substantial missing laboratory data: 60 (44.1%) patients in the in-person group and 59 (41.5%) patients in the telehealth group had testosterone labs available at 3 months; 52 (38.2%) patients in the in-person group and 42 (29.6%) patients in the telehealth group had testosterone labs available at 6 months. Only one patient in the in-person teaching group was censored due to testosterone discontinuation at the 6-month time point; the remaining three patients who discontinued treatment did not have labs to be censored. There were no significant differences between the groups in the number of missing serum testosterone labs at either 3-or 6 months (p = 0.756 and p = 0.162, respectively). About 17.4% of patients had labs available at both 3 and 6 months, 25.5% had labs at 3 months only, 16.5% had labs at 6 months only, and 40.6% did not have labs at either time point. There was not a significant difference in the distribution of the presence of labs (p = 0.063).

The majority of patients with completed labs reached clinically acceptable serum testosterone levels at both time points: 93.3% (56) of in-person and 93.2% (55) of the telehealth patients at 3 months, and 84.6% (44) of in-person and 90.5% (38) of telehealth patients at 6 months. Of those patients with clinically unacceptable serum testosterone levels, most were deemed too low, but in the telehealth group, one patient had levels that were too high at 3 months and two patients had levels that were too high at 6 months. In the unadjusted analysis, there were no significant differences in clinical acceptability of serum testosterone levels at 3 or 6 months (p = 1 and p = 0.592, respectively). Results of the unadjusted analyses for all outcomes can be found in Table 2. There were similarly no significant differences at 3 and 6 months when the adjusted analysis (Table 3) was performed (p = 0.768 and p = 0.350, respectively).

Table 2.

Unadjusted Outcome Measures

	Teaching modality
	In-person	Telehealth	Total	p
Three months: Clinically acceptable T levels, N				1
Yes	56	55	111
No	4	4	8
Three months: Mean T levels, ng/dL (SD)	435.61 (189.74)	432.25 (209.55)	433.94 (198.96)	0.927
Six months: Clinically acceptable T levels, N				0.592
Yes	44	38	82
No	8	4	12
Six months: Mean T levels, ng/dL (SD)	372.82 (170.80)	454.20 (225.88)	408.80 (200.11)	0.057
Mean time to treatment in days (SD)a	15.34 (15.59)	18.02 (15.99)	16.72 (15.83)	0.17
Mean postinstruction contacts (SD)	2.42 (1.70)	2.87 (1.90)	2.65 (1.82)	0.04
Mean contacts by reason (SD)
Question about/problem with injecting	0.18 (0.47)	0.13 (0.40)	0.15 (0.43)	0.416
Side effects	0.17 (0.65)	0.25 (0.70)	0.21 (0.68)	0.298
Other clinical question about medication	0.15 (0.49)	0.29 (0.63)	0.22 (0.57)	0.037
Administrative	0.59 (1.04)	0.95 (1.16)	0.77 (1.12)	0.006
Routine follow-up	1.34 (0.77)	1.23 (0.93)	1.28 (0.86)	0.301

^a Among those initiating treatment within 90 days.

T, testosterone.

Table 3.

Adjusted Models Assessing Clinical Acceptability of Serum Testosterone Levels at 3- and 6-Month Post Injection Instruction

	aOR	95% CI	p
3 Months
Teaching modality
In-person	Reference
Telehealth	1.248	0.274–5.760	0.768
Race
White	Reference
Other	2.929	0.609–13.717	0.162
Ethnicity
Hispanic or Latino	Reference
Non-Hispanic or Latino	1.554	0.196–10.393	0.659
Use of puberty blockers
No	Reference
Yes	NA	0–NA	0.994
Age at testosterone start	1.203	0.775–1.938	0.422
6 Months
Teaching modality
In-person	Reference
Telehealth	1.89	0.519–8.007	0.35
Race
White	Reference
Other	1.612	0.317–6.690	0.526
Ethnicity
Hispanic or Latino	Reference
Non-Hispanic or Latino	1.743	0.270–8.691	0.519
Use of puberty blockers
No	Reference
Yes	0.234	0.031–2.190	0.165
Age at testosterone start	0.863	0.643–1.191	0.333

aOR, adjusted odds ratio; CI, confidence interval; NA, not applicable.

Time to treatment

The mean time to treatment in the in-person group was 15.34 days (SD = 15.59) and 18.02 days (SD = 15.99) in the telehealth group. There was no significant difference between the groups in either the unadjusted (p = 0.170) or adjusted (p = 0.204) analyses (Table 4).

Table 4.

Adjusted Model Assessing the Relationship Between Teaching Modality and Time to Treatment, Defined as the Number of Days Between Issuance of the Testosterone Prescription and the Receipt of First Dose

	β	95% CI	p
Teaching modality
In-person	Reference
Telehealth	2.512	−1.375 to 6.399	0.204
Race
White	Reference
Other	−0.842	−5.380 to 3.696	0.715
Ethnicity
Hispanic or Latino	Reference
Non-Hispanic or Latino	2.753	−3.286 to 8.792	0.37
Insurance
Medical assistance	Reference
Private insurance	0.61	−4.592 to 5.812	0.817
Other	−6.569	−21.496 to 8.358	0.387
Use of puberty blockers
No	Reference
Yes	5.472	−2.769 to 13.713	0.192
Age at testosterone start	0.368	−0.692 to 1.428	0.494

For this model, analysis was limited to individuals who received treatment within 90 days (n = 268).

Postinstruction contacts

Patients in the in-person group contacted clinical staff an average of 2.42 times (SD = 1.70) after injection teaching compared to 2.87 times (SD = 1.90) in the telehealth group (p = 0.040). The most common reason for contact in both groups was routine follow-up (in-person: 1.34, SD = 0.77; telehealth: 1.23, SD = 0.93) followed by administrative (in-person: 0.59, SD = 1.04; telehealth: 0.95, SD = 1.16). Questions about or problems with injecting were rare in both the in-person (0.18, SD = 0.47) and telehealth (0.13, SD = 0.40) groups, and there was no significant difference between the groups in the unadjusted analysis (p = 0.416). In the adjusted model (Table 5), there was no significant difference between the telehealth and in-person groups in the number of postinstruction questions about or problems with injecting (p = 0.650).

Table 5.

Adjusted Model Assessing the Relationship Between Teaching Modality and the Number of Postinstruction Questions about or Problems with Testosterone Injection

	aIRR	95% CI	p
Negative binomial model
Teaching modality
In-person	Reference
Telehealth	0.74	0.20–3.15	0.65
Race
White	Reference
Other	1.04	0.50–2.72	0.903
Ethnicity
Hispanic or Latino	Reference
Non-Hispanic or Latino	1.72	0.52–6.73	0.342
Insurance
Medical assistance	Reference
Private insurance	1.76	0.73–6.97	0.237
Other	1.09	0.00–6.92	0.942
Use of puberty blockers
No	Reference
Yes	0.7	0.00–2.81	0.654
Age at testosterone start	0.87	0.68–1.05	0.145

	OR	95% CI	p
Logistic (zero inflation) model
Teaching modality
In-person	Reference
Telehealth	0.81	0.00–20,229.06	0.885

The majority of individuals did not have any postinstruction questions during the study period; therefore, a zero-inflated negative binomial model was used. The top portion of the table shows the negative binomial model, representing the incident risk ratio of each additional postinstruction question among those individuals who had postinstruction questions. The bottom portion of the table shows the logistic (zero inflation) model, representing the odds ratio of having zero postinstruction contacts due to the teaching modality.

aIRR, adjusted incident rate ratio; OR, odds ratio.

Discussion

This study found no significant differences in the clinical acceptability of serum testosterone levels at 3 and 6 months, time to treatment, and the number of postinstruction questions about or problems with injecting when comparing telehealth and in-person instruction for testosterone injections in AYA. To our knowledge, this is the first study to compare clinical outcomes of telehealth teaching of injection technique for gender-affirming care. Our study begins to fill an important gap in the literature, as evidence is lacking regarding telehealth’s clinical effectiveness for gender-affirming care.

The transition to telehealth for the instruction of testosterone injections represents a significant evolution in gender-affirming care delivery, underscored by the necessities imposed by the COVID-19 pandemic. Our findings indicate that telehealth is a viable alternative to in-person instruction, making it a valuable tool to improve access to health care for TGD AYAs. This aligns with prior studies demonstrating the efficacy of telehealth in various aspects of transgender care.^2–5 Telehealth’s equivalence to in-person instruction in clinical effectiveness and time from prescription to the first injection highlights its utility in circumventing logistical and systemic barriers that many TGD individuals face. Indeed, prior studies have shown that the use of telehealth improves access to gender-affirming care, particularly in rural settings.^15–17 Gender-affirming care provided by telehealth has also been found to be highly desired by patients and caregivers, with patients who experienced telehealth visits reporting high satisfaction levels.^18–20

Overall, our findings are also similar to other studies examining virtual injection teaching for other purposes, including diabetes management and contraception. Mishra et al. describe the results of a virtual diabetes management program implemented for patients in a COVID-19 isolation hospital ward. Virtual consultations included insulin injection instructions, and 74% of patients were judged to have understood the insulin injection instructions two weeks after the initial consultation.²¹ Telehealth instruction of self-injection technique was also explored for administration of the hormonal contraceptive depot medroxyprogesterone acetate (DMPA). In one study, 58% of patients who expressed interest in DMPA self-injection successfully performed the procedure after telehealth instruction. Of the remaining patients, 38.2% did not attend the scheduled telehealth visit, and only 3.8% decided not to self-inject after the visit.²² These studies illustrate that for patients who are willing and interested in self-injection, telehealth instruction can be a feasible and effective clinical tool. One important difference from the present study is the age of participants, which was 58 and 37, respectively, whereas in our study the mean age at testosterone start is 16.5 years, making this one of the first studies to examine telehealth injection teaching in an AYA population.

The slightly higher rate of postinstruction contacts in the telehealth group, while statistically significant (2.87 vs. 2.42, p = 0.040), was not clinically alarming. The most common reasons for contact in both groups were routine follow-up and administrative issues, with no significant differences in questions or problems related to injecting. This suggests that the increased contact in the telehealth group was not due to complications or misunderstandings related to the injection process. The absence of significant differences in postinstruction, injection-related problems, or questions between the two modalities underscores the capacity of telehealth to provide high-quality patient education. This is especially critical in gender-affirming care, where having multiple treatment modality options can significantly impact patient outcomes and satisfaction. Importantly, none of the patients in the telehealth teaching cohort required subsequent additional educational sessions, further supporting its effectiveness as a teaching modality. Although almost a quarter of the in-person teaching patients had a second session, this is likely due to the clinic’s prior educational process, which involved multiple teaching sessions for all patients.

Limitations

Our study has several limitations. The retrospective design may introduce selection bias, as patients who opted for (or had access to) telehealth might differ systematically from those who chose in-person instruction. However, the impact on the data is likely minimal, as almost all the patients in the pre-COVID-19 period received in-person teaching (85.3%), while the majority of patients who were seen beginning of March 2020 received telehealth teaching (97.2%), indicating that the selection of teaching modality was driven primarily by time period rather than patient choice.

Although a strength of our study is the presence of clinical outcomes, it is important to acknowledge that our clinic does not provide patients with recommendations regarding when to have blood drawn relative to testosterone injections, and it is often not possible to tell whether labs were drawn at peak or trough levels based on information in the chart. This limitation is present equally for both groups, however, and should not have any impact on the comparisons between the two treatment modalities. Additionally, the models used in this analysis are unable to account for changes over time in testosterone prescriptions, which could bias the results. Only a few patients had a change in prescription over the 6-month follow-up period, however, and this is therefore unlikely to significantly influence our findings.

There was a large amount of missing laboratory data in our dataset. Although it is standard of care for labs to be drawn at 3- and 6-month post-testosterone initiation, there are often significant barriers to care for patients which make it challenging to adhere to this schedule. Our clinic therefore performs a comprehensive assessment of physical and emotional changes during follow-up visits, which allows us to adjust care based on a combination of factors, ensuring that patients receive appropriate and individualized care even when labs are delayed. Importantly, there were no significant differences in missing data between the groups, indicating that this is unlikely to be a meaningful confounder.

Finally, our study population was predominantly white, non-Hispanic, and privately insured, limiting the generalizability of the results to more diverse populations, although the demographics are similar to other pediatric gender health clinical samples. Future studies should examine the clinical impact of telehealth teaching in a more diverse population to validate these findings.

It is worth noting that 124 patients were excluded from the analysis because there was no documentation of injection teaching in their charts. While some of these individuals had a documented reason for the lack of teaching (e.g., parent/guardian was a health care provider, patient had experience with injections from the management of a condition like diabetes, or patient chose to self-educate through YouTube), the majority did not. It is probable that many of these individuals received injection education outside of our health care network, and it was therefore not documented in their charts. This is an inherent limitation of relying on EMR data for research purposes, as missing data may reflect differences in care patterns, patient choice, or variations in documentation across individual providers.

The COVID-19 pandemic has necessitated the rapid adoption of telehealth across numerous medical disciplines, including gender-affirming care. It is likely that the trend toward hybrid in-person and virtual care will continue, with TGD youth expressing interest in telehealth visits for hormone refill appointments, routine laboratory monitoring, and primary care with a clinician trained in gender-affirming care.²³ Our study provides robust evidence supporting the continuation and expansion of telehealth services for GAHT, including injection education, even beyond the pandemic context.

Conclusion

This study is among the first to show that telehealth instruction for testosterone injection is an effective and feasible alternative to in-person teaching methods for AYAs initiating GAHT. By removing geographical and logistical barriers, telehealth can significantly enhance access to essential health care services for TGD AYA, a population that already faces substantial obstacles in obtaining care. Our findings support more generally the continued use and expansion of telehealth services to improve access to various aspects of gender-affirming care, particularly for patients facing logistical, geographical, and stigma-related barriers. In particular, the results of this study suggest that telehealth is an acceptable teaching modality for AYAs. Future research is needed to confirm these findings in larger, more diverse samples, to understand the impacts of offering this option on cost and clinical flow, and to examine outcomes for injection education for other aspects of gender-affirming care for AYA, such as DMPA for menstrual suppression and estradiol for GAHT.

Abbreviations Used

aIRR

Adjusted incidence rate ratio

aOR

Adjusted odds ratio

AYA

Adolescents and young adults

CI

Confidence interval

DMPA

Depot medroxyprogesterone acetate

EMR

Electronic medical record

GAHT

Gender-affirming hormone therapy

NA

Not applicable

SD

Standard deviation

T

Testosterone

TGD

Transgender and gender diverse

Authors’ Contributions

K.J.N.: Methodology, software, formal analysis, data curation, writing—original draft, and project administration. S.K.J.: Conceptualization, validation, data curation, and writing—review and editing. C.J.: Data curation and writing—review and editing. L.M.B.: Conceptualization, methodology, and writing—review and editing. K.D.: Conceptualization, writing—review and editing, and project administration. A.D.: Data curation and writing—review and editing. A.F.: Software, validation, and data curation. K.S.: Data curation and writing—review and editing. L.S.K.: Conceptualization, methodology, and writing—review and editing. M.D.L.: Conceptualization, methodology, and writing—review and editing. N.D.: Conceptualization, methodology, writing—review and editing, supervision, and funding acquisition.

Author Disclosure Statement

The authors have no conflicts of interest relevant to this article to disclose.

Funding Information

This study was funded by the Stoneleigh Foundation Fellowship (PI: N.D.) and Health Resources and Services Administration (HRSA) Leadership and Education in Adolescent Health (LEAH) (T71MC30798).

 

Cite this article as: Nightingale KJ, Jelinek SK, Jones C, Bevington LM, Darien K, Ding A, Fu A, Su K, Kocent LS, Langer MD, Dowshen N (2025) Telehealth versus in-person injection instruction for adolescents and young adults initiating gender-affirming testosterone therapy, Transgender Health 10:4, 325–333, DOI: 10.1089/trgh.2024.0130.