For Many Trans People, Telemedicine Is the Best Shot for Decent Health Care
Finding adequate health care can be a challenge for trans people. Telemedicine can help, but some trans medical needs still require an in-person visit.
For many trans people, access to health care is a fraught issue. Just finding a provider who has the cultural competence to respect trans patients’ identities and pronouns while providing basic health care can be a major struggle. Finding one who specializes in gender-affirming care — medical care that acknowledges and provides support for transgender people’s gender identities, and may include providing transition-related medical services like hormone replacement therapy and surgeries — is even more difficult.
The situation is even tougher for trans people in rural areas, where getting good health care can mean traveling for hours to the closest LGBTQ-focused health clinic — a hardship that’s much more difficult for low-income trans people who can’t afford to take a day off of work to see the doctor.
One possible solution? Telemedicine. As clinics across the country look to improve their trans-focused services, connecting with clients remotely has become increasingly appealing. At small queer-run clinics like QueerDoc and QueerMed, and more established clinics like Maine Family Planning, telemedicine has rapidly become a reliable way to connect trans people across the country to high-quality care from knowledgable providers who specialize in their community’s needs. Telemedicine startups are also taking note of the needs of trans patients. Although the sexual health telemedicine platform Nurx does not offer any trans-specific services, the organization works to make its birth control, STI testing, and PrEP offerings inclusive to people of all genders; Alpha Medical has a similar policy of inclusion. (Hers, another major telemedicine platform, did not respond when reached for comment for this story.)
“Telemedicine has the ability to raise the bar for the quality of trans health care by funneling care to people who know what they’re doing.”
“The bar is really low a lot of times in gender-affirming care. If someone is just kind of nice to us, but doesn’t really know what they’re doing, we’re still thrilled that they’re nice,” says Dr. Crystal Beal, the founder of QueerDoc and a non-binary person.
Even in dense urban centers, it can be difficult to find a provider who specifically focuses on trans healthcare — let alone providers who are also transgender. “Telemedicine has the ability to raise the bar for the quality of trans health care by funneling care to people who know what they’re doing,” says Dr. Beal. QueerDoc patients are able to have the rare experience of receiving gender-affirming care from gender diverse providers — and thanks to telemedicine, Dr. Beal has been able to expand the clinic’s reach beyond its location in Seattle to reach into all of Washington, as well as Alaska and Idaho. (Because telemedicine laws vary from state to state, and doctors must be approved by each individual state before they can legally offer their services there, telemedicine platforms tend to start in a few states and scale up as funding allows).
Certain trans health services, like hormone replacement therapy, are an ideal fit for telemedicine. Like birth control pills — an item provided by many major telemedicine platforms, including Nurx, Hers, and The Pill Club — hormone replacement therapy involves a regular course of hormones, available as both shots and pills. Although patients undergoing hormone replacement therapy do need blood tests to assess the efficacy of their regimen, it’s far easier for many to get their blood drawn at a local lab and have the results sent to a telemedicine provider for analysis and assessment than it is to physically get themselves to a doctor’s office for the entire process.
But there is one significant roadblock to shifting trans healthcare to an online-only basis — specifically for trans men and transmasculine people who take testosterone. Because the hormone can be used not just for gender confirmation purposes but as a steroid, it’s currently a controlled substance. That means doctors are required to see patients in person at least once before prescribing testosterone remotely — a requirement that prevents online-only platforms like Nurx from adding hormone replacement therapy to their slate of services. “We don’t want to say, ‘We’re going to provide affirming care for trans women only,’” says Jessica Horwitz, Nurx’s vice president of clinical services, noting that trans men are frequently left out of the conversation already.
Fortunately, there’s a chance that regulation could change soon. Last October, Congress passed the SUPPORT Act, which requires the Drug Enforcement Administration (DEA) to set up a registration for providers interested in prescribing testosterone and other medications through telemedicine. What that registry will look like, or how expensive it might be to sign up for, is still unclear, but once it is in effect, providers who register should be able to prescribe testosterone and other controlled substances through a telemedicine platform right from the start.
If the SUPPORT Act registry winds up being prohibitively expensive for independent providers, it may mean that fully internet-based trans health care will become the domain of well-funded startups like Nurx, rather than independent providers like Dr. Beal. But even if that’s the case, providers are still hopeful that removing the in-person visit requirement for testosterone could radically change the trans community’s ability to access high-quality care.
In the meantime, clinics that provide gender affirming care through telemedicine are making do. At Maine Family Planning, where telemedicine for trans clients will launch by January 2020, the clinic’s 18 locations statewide provide a combination approach. Patients can receive in-person care from any of the clinics, while remotely connecting to providers who specialize in gender-affirming care via telemedicine. At the online-only QueerDoc, Dr. Beal has come up with a number of creative ways to help clients access an initial in-person visit, including registration fairs where they’re able to connect face-to-face with new clients and have a brief consultation, volunteering within the community, and, in the case of Alaskan patients, partnering with an Anchorage-based clinic that can serve as a point of contact.
“Any time we can get more access for more people is amazing,” says Dr. Beal. Whether trans people are accessing gender-affirming care in person, through a combination of in-person and online visits, or purely online, anything that makes it easier for them to get quality gender affirming healthcare is ultimately a win for the community.