Gender-Affirming Care Without Walls: Utilization of Telehealth Services by Transgender and Gender Diverse People at a Federally Qualified Health Center

Abstract

Purpose:

This article characterizes a telehealth program implemented during the COVID-19 pandemic for transgender and gender diverse (TGD) patients at Fenway Health, a federally qualified health center in Boston, Massachusetts, specializing in gender and sexual minority health care. Telehealth is well positioned to meet TGD patients' health needs by allowing them to conveniently and safely engage in care.

Methods:

The COVID-19 pandemic has presented the opportunity to reimagine the way that Fenway Health provides care, by pivoting almost completely to a virtual model in response to this public health emergency. From March through August 2020, TGD patients (n=3189) from 24 U.S. states utilized our telehealth medical and behavioral health (BH) services.

Results:

Fenway Health cared for close to as many unique TGD patients during this 6-month period via telehealth as it did via in-person services during calendar year 2019 (3794 medical patients in 2019 vs. 3033 in March through August 2020 [95%]; 946 BH patients in 2019 vs. 911 in March through August 2020 [96%]). TGD patients who utilized telehealth had a similar demographic profile as those who used in-person services.

Conclusion:

Fenway Health quickly pivoted to telehealth during the COVID-19 pandemic enabling gender-affirming care for TGD communities. By increasing access to clinicians trained in gender-affirming care, telehealth helps ensure that TGD patients regardless of geographic location can access crucial health services. Given the dearth of gender-affirming health care services across the United States, permanently removing state licensure requirements and payment parity for telehealth could ensure access to more gender-responsive care across state lines.

Introduction

Despite progress in care guidelines and protocols for transgender and gender diverse (TGD) people, many TGD people remain largely invisible to their care providers and experience delays in access to care. TGD patients often face stigma, barriers to accessing care, and related health disparities. Factors including financial constraints, transportation difficulties, public accommodations discrimination, and more prevalent depression or anxiety often create an increased burden for patients, preventing them from attending appointments and following through on treatment recommendations that would help them achieve their health goals.^1–5 As health care focuses on improving quality and outcomes while lowering costs, it is critical to develop entry points to increase access to services.

Advancements in telecommunication have transformed the way we communicate, conduct business, and created a “new normal” for interactions. Nearly every service industry, such as travel, food, and banking, has embraced a mobile and virtual strategy. People have come to expect similar accessibility in health care and are increasingly deciding where they get care based on the ease of their digital experiences.^6,7 While telehealth has the potential to respond to these needs, lack of reimbursement, complex licensing requirements, and high costs of adopting and sustaining technologies have limited widespread telehealth uptake and scalability.⁸

Health care systems are facing unprecedented challenges during the COVID-19 pandemic. Future global pandemics will also significantly affect health outcomes and strain health care systems; therefore, telehealth represents one of the greatest necessities and opportunities. Due to COVID-19, there has been a relaxing of regulations, state licensure requirements, and reimbursement parity for telehealth services.^9,10 Telehealth is well positioned to meet patient demands for online and mobile tools to conveniently and safely engage in care. The U.S. Health Resources and Services Administration defines telehealth as the use of electronic information and telecommunication technologies to support and promote long-distance clinical health care, patient and professional health-related education, public health, and health administration.¹¹ Health Information technology has immense potential for improving health care quality through innovative solutions in service delivery as well as cost reduction.

In the 2015 U.S. Transgender Survey, 23% of respondents reported not seeking needed health care in the past year due to fear of gender-related mistreatment.¹² For low-acuity, nonurgent, and chronic disease follow-up, telehealth is well poised to reduce barriers, save patient and clinician time, and improve patient health outcomes. Care that traditionally takes place in brick-and-mortar settings can now be conducted virtually. By increasing access to clinicians trained in gender-affirming care, telehealth helps to ensure that regardless of geographic location, TGD patients can receive culturally responsive health services. Access to affirming outpatient care can encourage patients to engage in primary and preventative services and reduce visits to emergency rooms. The efficiency of telehealth visits enables time and monetary savings for patients, who no longer have to contend with driving, parking, taking public transportation, or even time off from work. Moreover, telehealth provides a window into a patient's world that the care team would never see during an in-person visit.

Fenway Health (Fenway), a federally qualified health center (FQHC), located in Boston, Massachusetts, has a multidisciplinary model of care that includes comprehensive primary medical, behavioral health (BH), optometry, and dentistry. Since 1971, Fenway has been working to improve health and wellness for the people in our neighborhoods, (LGBTQIA+) communities, people living with HIV/AIDS, and the broader population. Fenway's inception was part of the free clinic movement by students who believed that “health care should be a right, not a privilege.”¹³ In 2019, Fenway providers cared for 33,600 patients who made over 167,000 patient visits. Fenway's Transgender Health Program has been a leader in TGD care for several decades and has seen its TGD patient population steadily increase.¹⁴ In 2019, Fenway cared for over 4200 TGD patients, which is a 110% increase since 2015 (Fig. 1).

FIG. 1.

Unduplicated TGD patients, 2010 to 2019. TGD, transgender and gender diverse.

Methods

The COVID-19 pandemic has presented the opportunity to reimagine the way that Fenway provides care. Like many other health care organizations, Fenway had to pivot its care almost completely to a virtual model in response to this public health emergency. This rapid transition has required significant flexibility, innovation, and resourcefulness in ensuring that patients still have access to the care they need while not putting patients or care teams at risk by coming into the health center. Within weeks, Fenway transitioned from all in-person visits to >95% telehealth visits (Fig. 2). Since video telehealth visits enable a more satisfactory and comprehensive experience for both the patient and clinician, the majority of telehealth visits are now conducted via video instead of phone.

FIG. 2.

Pivot of gender-affirming care from in-person to telehealth.

Given Fenway's established expertise in TGD care, the organization operates much like a magnet health center drawing patients from across Massachusetts and the United States, making telehealth services even more essential for continuity of care. From March 2020 through August 2020, TGD patients from 24 states utilized Fenway's telehealth services (Fig. 3). Technology can address barriers, including language barriers, in ways that in-person experiences may not. Our linguistic interpretive services, available in many languages, including American Sign Language, can seamlessly merge into a telehealth visit.

FIG. 3.

TGD patients accessing Fenway telehealth services from 24 U.S. states in 2020.

The physical effects of SARS-CoV-2 infection have been well publicized; less attention, however, has been given to the pandemic's mental health toll.¹⁵ As COVID-19 continues and cases increase, demand for BH services will likely increase due to depression, posttraumatic stress, anxiety, and substance use related to social isolation, financial uncertainty, fear of illness, and loss of loved ones. The need for culturally responsive BH services will only continue to increase, particularly for centers of excellence in gender-affirming care. TGD communities have also experienced new barriers to medically necessary treatment, including delays and cancelations for gender-affirming surgeries, with a resulting adverse mental health impact.

BH services

Fenway's BH Department, one of the larger BH departments at a FQHC, offers psychotherapy (individual, couples, and group), psychiatry, addictions treatment and recovery services, case management, violence recovery counseling and advocacy services, support groups, a same-day walk-in service, and acupuncture services, and it is integrated into the health center's primary care model. The COVID-19 crisis required service delivery changes to maintain the health and safety of patients and staff. Collaboration of cross-departmental teams resulted in a fast pivot to telehealth care that has enabled uninterrupted BH service delivery. With the exception of the acupuncture service, all other BH services and programs have continued despite COVID-19. There are over 75 psychiatrists, psychotherapists, and medical case managers delivering care virtually. Intake and diagnostic assessments are conducted via telehealth to allow new patients to engage in BH care. This shift to telehealth demonstrates that BH clinicians have the tools and effective workflows in place, which in turn enable them to remain responsive to the needs of both new and established clients.

BH has a same-day walk-in service that provides low-barrier gender-affirming psychotherapy five days a week, with no scheduled appointment necessary. This service is utilized by patients who have difficulty keeping scheduled appointments and serves patients engaged in medication-assisted treatment for opioid use disorders. In addition, the walk-in service functions as a diversionary resource for patients who would otherwise utilize emergency room and inpatient services. In response to COVID-19, the walk-in service pivoted to a telehealth “walk-in” model. Fenway created a virtual service that replicates the patient experience of “physically walking in,” whereby patients are greeted by patient services staff at a virtual “front desk,” who confirm the patients' identity and eligibility, and then moves them into private “therapy rooms” before notifying a clinician. By using the Zoom breakout feature, Fenway is able to serve more than one patient at a time. BH also retained audio-only access for patients who prefer that modality or lack the technology needed for Zoom. Since its inception in April 2020, monthly average telehealth “walk-in” service provision consisted of 18 walk-in clinic sessions. The workflow reflects efforts to make the walk-in telehealth experience as similar to the in-person service as possible, while also maintaining patient confidentiality.

The COVID-19 pandemic caused disruptions in gender-affirming surgeries cancelled across the United States. In response, virtual support groups were created for TGD patients experiencing surgical delays to access support. The groups are well attended and could not have occurred without the use of telehealth technology. Overall, Fenway's BH Department has strived throughout this process to develop a sustainable, low-threshold telehealth care pathway that TGD communities will use for the duration of the COVID-19 crisis and beyond.

Medical department

Fenway's Medical Department is certified as a National Committee for Quality Assurance Level 3 Patient-Centered Medical Home, a designation that emphasizes care coordination and communication in primary care for patients. Fenway's Medical Department includes programs and services such as Internal Medicine, Infectious Diseases, Transgender Health, Pediatrics, Family Medicine, and Women's Health. The Family Medicine Program provides services to patients across the lifespan. There are over 100 medical staff, including physicians (both MD's and DO's), NP's, PA's, nurses, and medical assistants delivering care virtually. Telehealth services include gender-affirming care, COVID-19 triage and management, acute and chronic care, and preventative health visits.

Fenway's Transgender Health Program continues to expand and comprehensively address the needs of its rapidly growing TGD patient population. Fenway considers gender-affirming medical care to be an integral part of primary health care. All medical providers at Fenway are trained in and provide gender-affirming medical care, including hormone therapy. The Medical Department has provided monthly support groups for the TGD community; TGD community members are welcome to attend regardless of whether they received medical care at Fenway.

Fenway has a long-standing contract with Quest Diagnostic Laboratories (Quest) to provide phlebotomy and laboratory services. Before and during the COVID-19 pandemic, patients could access these services at any of our clinical locations as well as any of the locations in the nationwide Quest network. Our electronic health record is interoperable with the Quest system, allowing our providers to electronically order laboratories and automatically receive laboratory results in real-time.

Gender-affirming medications require interaction with a pharmacy. Telehealth visits may inadvertently create barriers to accessing gender-affirming medications, in which case TGD people may resort to finding their own hormone sources without a prescription.¹² To ensure continuity of care and minimize nonprescribed hormone use, TGD patients utilizing Fenway's telehealth services can pick up prescriptions at one of Fenway Health's two pharmacies, receive prescriptions shipped at no cost to any Massachusetts address, or have a prescription sent electronically to any other retail or mail order pharmacy.

Privacy and confidentiality

There may be privacy and safety risks during telehealth visits for TGD patients that are not present for cisgender patients. For example, TGD patients may not have disclosed their gender identity, and may not feel comfortable discussing gender-affirming care, with the people they live with. The patient may be in a situation where a phone or video visit is not private, so confidentiality cannot be assured. Staff should confirm the patient's correct name and pronouns to be used during the visit. Confidentiality should be prioritized at the onset of the visit by ensuring that it is safe for the patient to speak over the phone or video and reminding them that their health information will be kept safe. When conducting visits, care teams need to be trained to understand that telehealth may not be a safe time for discussing gender-related care as others may be in the room or listening in, so the care team should gauge the level of privacy during the session and tailor the discussion accordingly. As a strategy, providers ought to schedule time to work collaboratively with TGD patients to develop a tailored safety and confidentiality plan for future gender-affirming care telehealth visits that are responsive to the patients' personal needs, particular living situation, and privacy constraints.

Technology

Fenway's telehealth platform is Zoom's health care encrypted product, which is Health Insurance Portability and Accountability Act compliant and does not save protected health information.¹⁶ Each Fenway clinician has a dedicated Zoom account used to deliver care and has control over admitting and removing patients from their Zoom session.

Patient confirmation and appointment reminders help communicate important information and reduce no-show rates. ProviderTech, our appointment reminder vendor, delivers text message reminders that allow patients to confirm their appointment in advance of the visit. The day before the visit, a text reminder is sent encouraging patients to test their Zoom compatibility, which helps ensure a positive and seamless telehealth experience. The morning of and 1 hour before their visit, an email and text reminder are sent. The email and text contain links to their telehealth visit and self-assessment screeners.

Patient reported outcomes (PROs) are health data provided directly by the patient on health behaviors, mental health, and chronic disease management using validated assessments. Research has shown that patients share more sensitive information on tablet or computer than when asked by a provider, even when they know that their provider will see the assessment.^17,18 Actively involving the patient through self-assessment is paramount to patient-centered care. PROs have been proven to improve health outcomes because they allow for capture and detection of health problems or behaviors that may otherwise be missed.¹⁹ Fenway's electronic patient reported outcomes (ePRO) system, developed by University of Washington, is an open-source platform that uses standards to bidirectionally communicate with Fenway's electronic health record, athenahealth Practice.²⁰ Before telehealth, Fenway patients completed screeners during their visits on electronic tablets. Screening telehealth patients remains critical; therefore, Fenway has ensured that screeners are available via telehealth. Before a patient's virtual visit, a link to the screeners is sent by text, so the patient has adequate time to complete these and the clinician can access the screening data before the visit. PRO's functionality includes presenting screeners in multiple languages, as well as an alert system for care teams. If a patient scores out of range on a particular screener, the system will immediately send a real-time alert message to the clinical team.

This project characterizes ongoing quality improvement efforts to evaluate the delivery of care; therefore, it does not meet the definition of research and does not require review by an Institutional Review Board.

Results

Demographic characteristics of TGD telehealth users were similar to demographics of TGD patients who used in-person care in 2019. From March 2020 through August 2020, 3189 TGD patients accessed telehealth services at Fenway (Table 1). The Medical Department saw 3794 patients in 2019 and 3033 patients in the 6-month period in 2020, representing 95% of the medical volume seen in the entire previous year. Similarly, the BH Department saw 946 patients in 2019 and 911 patients in the 6-month period in 2020, representing 96% of the BH volume seen in the entire previous year.

Table 1.

Demographics of Transgender and Gender Diverse Patients Who Attended a Telehealth Visit from March Through August 2020

Race	TGD patients with medical telehealth visit		TGD patients with behavioral telehealth visit		TGD patients with any telehealth visit
	N	% of TGD patients with medical telehealth visits	n	% of TGD patients with behavioral telehealth visits	N	% of TGD patients with any telehealth visits
American Indian or Alaska Native	15	0.5%	8	0.9%	16	0.5%
Asian	135	4.5%	36	4.0%	143	4.5%
Black or African American	176	5.8%	50	5.5%	184	5.8%
Multiracial	181	6.0%	63	6.9%	185	5.8%
Native Hawaiian/Pacific Islander	19	0.6%	5	0.5%	20	0.6%
White	2222	73.3%	657	72.1%	2339	73.3%
Not reported	285	9.4%	92	10.1%	302	9.5%

Ethnicity	n	%	n	%	N	%
Hispanic/Latinx, nonwhite	70	2.3%	19	2.1%	73	2.3%
Hispanic/Latinx, white	95	3.1%	37	4.1%	103	3.2%
Hispanic/Latinx, missing race	133	4.4%	42	4.6%	136	4.3%
Not Hispanic/Latinx	2735	90.2%	813	89.2%	2877	90.2%

Age	n	%	n	%	N	%
12 and under	6	0.2%	1	0.1%	6	0.2%
13–17	96	3.2%	23	2.5%	101	3.2%
18–24	971	32.0%	243	26.7%	1014	31.8%
25–29	761	25.1%	245	26.9%	811	25.4%
30–39	773	25.5%	258	28.3%	815	25.6%
40–49	202	6.7%	66	7.2%	209	6.6%
50–59	130	4.3%	42	4.6%	135	4.2%
60+	94	3.1%	33	3.6%	98	3.1%
Total	3033		911		3189

TGD, transgender and gender diverse.

The Medical Department cared for TGD telehealth patients ranging from younger than 12 years of age (0.2%) to older than 60 years of age (3.1%), with the largest population in the 18- to 24-year-old range (32%) (Table 1). Most TGD telehealth medical patients identified as white (73%) and non-Hispanic/non-Latinx (90%). Patient gender identity was almost equally divided among trans women/female (n=863), trans men/male (n=888), and gender diverse (n=898). Patients accessing BH care had a similar demographic profile, with the exception that a greater proportion of BH telehealth users identified as gender diverse (37%) than trans women/female (24%) or trans men/male (25%).

In total, 11,486 visits were completed through telehealth with a smaller percentage (0.8%) for specialty services such as dermatology (Table 2). The majority of Fenway's telehealth visits with TGD patients were anchored in our BH (5644 visits) and Medical (5736 visits) departments (Table 3).

Table 2.

Telehealth Visits Among Transgender and Gender Diverse Patients by Service Type from March 2020 Through August 2020

Service type	n	% of completed TGD patient telehealth visits
Medical primary care	5661	49.3%
Behavioral health	5631	49.0%
Other specialty	88	0.8%
Nonclinical services	47	0.4%
Gender-affirming medical care	31	0.3%
Optometry	22	0.2%
COVID-19 care	6	0.1%
All completed telehealth visits	11,486

Table 3.

Attendance Rates Among Telehealth Visits Scheduled with Transgender and Gender Diverse Patients from March Through August 2020

Attendance status	Medical telehealth visits		Behavioral telehealth visits
	n	% of scheduled TGD patient medical telehealth visits	n	% of scheduled TGD patient behavioral telehealth visits
Attended	5736	83.9%	5644	86.4%
No show	374	5.5%	538	8.2%
Canceled by patient	729	10.7%	349	5.3%
All scheduled visits	6839		6531

Accentuating the importance of continuity of care and chronic disease management, rates of patients with comorbidities accessing telehealth were higher compared to the rates for in-person services in the previous calendar year (Table 4), in particular patients with depression (61% via telehealth in 2020 vs. 57% in-person in 2019), anxiety (56% via telehealth in 2020 vs. 52% in-person in 2019), or diabetes (3% via telehealth in 2020 vs. 2% in-person in 2019).

Table 4.

Transgender and Gender Diverse Telehealth Patients with Chronic Illness from March Through August 2020^a

Chronic illness	n	% of TGD patients with any telehealth visitb
HIV	53	2%
Diabetes	100	3%
Depression	1945	61%
Anxiety	1792	56%

^a The patient counts in each cell are not mutually exclusive. Patients with more than one chronic illness are counted for each of their conditions.

^b The denominator for percentages in this column includes all TGD patients who attended a telehealth visit (n=3189).

Discussion

In response to the COVID-19 pandemic, Fenway operationalized gender-affirming telehealth for TGD patients in a period of weeks, a process that can normally take months to years to implement. Rapidly establishing a telehealth clinical model at Fenway was possible as a result of strong collaboration across all clinical and administrative departments. Although Fenway's telehealth program is nascent, the health center demonstrated that care delivered remotely is feasible and serves to reduce longstanding barriers to care that have contributed to health disparities in TGD communities within Massachusetts and across the United States.

Health care is increasingly turning to technology to help improve systems and processes that benefit patients and improve their health. Basic primary and preventative care is critical for better health outcomes; moreover, individuals accessing cultural responsive care achieve better health outcomes compared to those who do not. Technology can address logistical, financial, psychosocial, and safety-related barriers in ways that in-person experiences may not. There are many benefits to telehealth beyond the current pandemic. Telehealth offers TGD patients more control over their visit experience, providing a mechanism to separate oneself from negative clinical experiences. Furthermore, being able to access an organization specialized in gender-affirming care such as Fenway, regardless of where a TGD person lives in the United States, may enable patients who are deterred by distance and fear to engage in care.

During this period, 414 new TGD patients accessed care for the first time through our telehealth services, of whom 17% were from out of state. Presently, telehealth laws and regulations are dynamic and vary by state; federal-level support for telehealth moving forward appears strong.²¹ Fenway's efforts are ongoing to address different licensure requirements and reimbursement opportunities to sustain interstate telehealth services after the COVID-19 pandemic.

Limitations

While telehealth became a necessity for many people to access and remain in care during the COVID-19 pandemic, there are limitations to the types of care that can be provided via this modality. Significant limitations with telehealth include inequities in technology access and literacy. Connected devices, such as cell phones, may be unaffordable for some patients with financial constraints, thereby hampering their ability to use telehealth services. Inadequate broadband access continues to be a major barrier in many rural areas that prevents some populations from accessing telehealth services. In addition, there is a learning curve to effectively delivering care via telehealth and some clinicians may be less adept with this modality, which may adversely impact the quality of a patient's experience.

Conclusion

Telehealth has the potential to function as a great equalizer in gender-affirming care. It is paramount to meet patients where they are, particularly with TGD communities who may need to otherwise travel great distances to access culturally responsive care. Given the dearth of gender-affirming clinicians, permanently removing the state licensure requirements for telehealth could facilitate access to more culturally responsive care across state lines. Furthermore, sustained payment parity, such that all telehealth services are reimbursed at the same rate as in-person services, will enhance access to life-saving care for TGD patients.

Abbreviations Used

BH

behavioral health

FQHC

federally qualified health center

ePRO

electronic patient-reported outcomes

PROs

patient-reported outcomes

TGD

transgender and gender diverse

Authors' Contributions

C.G. envisioned the telehealth program and E.Y. directed the telehealth implementation. J.C. conducted the analyses; C.G. and E.Y. helped to interpret the data analysis; C.G. wrote the article with input and revisions by J.C., E.Y., D.T., J.T., A.G., A.B., and A.S.K.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

Cite this article as: Grasso C, Campbell J, Yunkun E, Todisco D, Thompson J, Gonzalez A, Brewster A, Keuroghlian AS (2022) Gender-affirming care without walls: utilization of telehealth services by transgender and gender diverse people at a federally qualified health center, Transgender Health 7:2, 135–143, DOI: 10.1089/trgh.2020.0155.