Telehealth for Gender-Affirming Care: Challenges and Opportunities

Telehealth services for medical care were rarely available in the United States before March 2020 when stay-at-home orders went into place in response to the coronavirus disease 2019 (COVID-19) pandemic.¹ Gender-affirming care for transgender and nonbinary (TNB) individuals was no exception, and the pandemic created an opportunity for a new method of delivering gender-affirming health services for the TNB community.

This special issue of Transgender Health includes articles that describe various models of telehealth for gender-affirming care (LGBT-focused Federally Qualified Health Center, Planned Parenthood, Pediatric and Adolescent specialty care centers, the U.S. Air Force, and a student-run clinic) and types of services provided (primary care gender-affirming medical care, behavioral health care, voice coaching, and support groups) as well as the promises and challenges of this new mode of care delivery from both the patient (including youth and their caregivers) and provider (pediatric endocrinologists) perspectives.

Despite increasing access to in-person care, this collection clearly demonstrates that in the wake of the COVID-19 pandemic, telehealth may offer advantages as an additional modality for gender-affirming care. Since the emergency orders were put into place by the U.S. federal government and many states, telehealth has allowed for access to gender-affirming medical and mental health care for TNB individuals in geographic areas that may not have appropriately trained providers. In the article by Grasso et al. it is documented that Fenway Health center increased its reach to patients in 24 states.

In two articles by Sequeira et al. and Apple et al., we see very high rates of acceptability and satisfaction from both youth and their caregivers receiving telehealth services at large pediatric hospital-based multidisciplinary care centers; patients cite convenience and decreased travel burden as major benefits. Furthermore, telehealth visits may mitigate harm by reducing the exposure of TNB individuals to discrimination and victimization that still occurs in health care settings such as restrictions on bathroom use or misgendering by providers or staff.²

Poquiz et al. report innovations in telehealth support groups for TNB youth who identify as Black and Indigenous People of Color (BIPOC) and Grasso et al. created a virtual “walk-in” clinic for gender-affirming psychotherapy. Smalley et al. detail the development of a system starting before COVID-19 to provide medical, behavioral health, and voice therapy to individuals in the U.S. Air Force across 11 bases around the world using a single electronic medical record. Similarly, telemedicine-only services by subscription began to develop before the pandemic without the need to ever seek in-person care from companies such as Queer Med, Folx, and Plume, which have continued to rapidly expand throughout the pandemic.

This issue highlights many innovations and high levels of satisfaction with telehealth for gender-affirming care while also identifying disadvantages and challenges to implementation. Although telemedicine may increase access for some, as with any innovation it may have the impact of exacerbating existing inequities and creating new barriers for others. For example, individuals from minoritized ethnoracial groups and those who experience economic deprivation are less likely to have consistent access to computers, smartphones, and the internet, creating potential inequity in access to telehealth services.

The samples in the studies in this volume are largely white and, therefore, attitudes and experiences related to telehealth here may not generalize to other ethnoracial subgroups of the TNB population. In addition to technology-based issues, youth in both Sequeira et al. and Apple et al. studies report concerns about confidentiality in the telehealth format and significantly higher concerns from youth than their caregivers. Furthermore, the surveyed youth preferred in-person care and services for first medical visits, surgical consultation, and sexual health care, and for the SPARC support group, which may reflect these privacy concerns and desire for a different type of connection.

Multiple authors also detailed the challenges faced by patients in obtaining laboratory work, after-visit documents, and referrals that would normally be provided on-site at in-person visits. In addition, many youth experienced disruption in care due to providers continuing to require in-person visits for pubertal staging and testosterone injection teaching. Finally, many pediatric endocrinologists report not being able to conduct multidisciplinary visits through video due to the limitations of available telehealth platforms. These challenges highlight the importance of continued investment in high-quality in-person gender-affirming care and the need for further investigation of the appropriate boundaries for telehealth in TNB medicine.

Telehealth is a promising opportunity to provide flexible gender-affirming care to TNB individuals and may potentially mitigate existing inequities in accessing these vital services. However, several important questions remain. How will experiences with telehealth for gender-affirming care change our in-person practices? How will it impact the way we educate the next generation of care providers across disciplines? Will the regulatory environment change permanently to allow telehealth across state lines and will insurance companies continue to reimburse this care and, if so, will there be parity with in-person care?

Are there differences in long-term clinical and patient-reported outcomes for those receiving in-person only versus telehealth-only gender-affirming care versus some combination? How can we ensure that the expanded access theoretically provided by telehealth does not further exacerbate inequities experienced by BIPOC and other historically excluded groups among the TNB population? Certainly, having more opportunities to deliver gender-affirming care is a major advance, but telehealth can only improve access and quality of care for TNB individuals with more documentation of clinical experiences, quality improvement, and research in the years to come.

Abbreviations Used

BIPOC

Black and Indigenous People of Color

COVID-19

coronavirus disease 2019

TNB

transgender and nonbinary

Cite this article as: Dowshen N, Lett E (2022) Telehealth for gender-affirming care: challenges and opportunities, Transgender Health 7:2, 111–112, DOI: 10.1089/trgh.2021.0206.