Telemedicine provides expanded access to gender-affirming care for youths
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Telemedicine visits for gender-affirming care in minors rapidly increased during the COVID-19 pandemic and may be able to expand access to care in the future, according to data from two studies published in Transgender Health.
Survey data from 40 pediatric endocrinologists attending the Pediatric Endocrine Society Transgender Health Special Interest Group virtual meeting on April 24, 2020, showed the percentage of providers conducting telemedicine appointments for gender-affirming care increased from 12.5% before the COVID-19 pandemic to 91.7% during the pandemic’s first few weeks. Janet Y. Lee, MD, MPH, MAS, assistant adjunct professor of pediatrics and medicine at the University of California, San Francisco, told Healio that the shift to telemedicine could greatly improve access to care.
“Because of the pandemic, there are more data now emerging regarding the use of telemedicine for gender-affirming medical care of transgender and gender diverse youth,” Lee said. “I absolutely expect that telehealth will be incorporated long term into the care of transgender and gender diverse youth in the post-pandemic era.”
Still, barriers to care remain. Survey respondents listed several institutional challenges they faced with telemedicine.
There was also mixed reaction among minors receiving treatment. In separate survey results published in Transgender Health, most of the 57 transgender minors (63.8% transgender male; mean age, 15.6 years) reported satisfaction with telemedicine, but also reluctance to forgo in-person visits entirely.
“Our data suggest that early in the pandemic, gender-diverse adolescents were satisfied with receiving gender care via telemedicine,” Gina M. Sequeira, MD, MS, an assistant professor of pediatrics at the University of Washington and co-director of the Seattle Children’s Hospital Gender Clinic, told Healio. “Despite this, when given the option for in-person care or telemedicine, youth had a preference for in-person care, especially for their first gender clinic visit.”
Telemedicine barriers
Not all providers moved fully to telemedicine during the early weeks of the pandemic. About 67.6% of the pediatric endocrinologists surveyed continued to see some transgender youths in person, mostly for physical exams to determine puberty onset or for education about testosterone injections, whereas 21.4% of respondents opted to delay testosterone injection training until after stay-at-home orders were lifted.
Providers had different approaches to prescribing gender-affirming hormones with telemedicine. Of the respondents, 12.5% did not start gender-affirming hormones during the first few weeks of the pandemic, citing institutional barriers, an inability to obtain signed consent forms, and legal barriers preventing the prescribing of testosterone via telemedicine. Respondents from two institutions said they were not starting hormones due to the local political environment and fear of medical-legal repercussions. Several participants reported working with their institutions to reduce barriers to prescribing hormones virtually.
“We were not surprised by the findings that members of our Pediatric Endocrine Society Transgender Health Special Interest Group prioritized providing gender-affirmative medical therapy to transgender and gender diverse youth,” Lee said. “If anything, we were proud to see how our colleagues across the country had continued to provide access to this essential care for transgender and gender diverse youth.”
There were also barriers to providingmultidisciplinary care with a mental health provider. Only 35.3% of pediatric endocrinologists said they were able to conduct a shared multidisciplinary visit, primarily due to the telemedicine delivery platform used.
Most respondents reported advantages to telemedicine, saying minors felt more comfortable at home, it was easier to incorporate caregivers into the appointment, and it reduced geographic barriers. Some disadvantages included confidentiality concerns, adolescents’ discomfort with video, inability to perform a physical exam, lack of technology access and reimbursement concerns.
Pros and cons of telemedicine for gender-affirming youths
Transgender youths also reported benefits and challenges with telemedicine for gender-affirming care. One of the three major themes participants focused on was the benefits of being able to conduct appointments virtually, including time saved not traveling and remaining in their own space at home. Most youths were comfortable using telemedicine, saying it was similar to an in-person visit and that they felt comfortable conducting visits from home. With respect to telemedicine’s usability, some respondents said the technology was easy to use, others had some technology-related issues with the platform and difficulty receiving paperwork. Some also had concerns about confidentiality during appointments.
Of the youths, 84.8% said they were satisfied with telemedicine and 87.9% said they would be willing to use it againin the future. However, most reported preference for in-person visits for specific services, such as the first gender care visit (79%), sexual health care (86%) and initial consultation with a surgeon (90%). By contrast, only 47% of participants preferred in-person follow-up visits, and 52% expressed a preference for in-person social work support or fertility preservation discussions.
“I was surprised by the preference for in-person care given how comfortable many youth are with technology-based communication,” Sequeira said. “We are currently conducting a follow-up study to this one, which I’m hopingit will help us better understand the reasons for these preferences.”
The future of remote gender-affirming care
While there was a preference for some in-person visits, nearly all youths said they would like to have the option of using telemedicine for all gender-affirming services in the future. Lee and Sequeira said providing telemedicine services could greatly improve access to gender-affirming care, especially for those living in rural areas.
“I envision a hybrid model of care that will incorporate both in-person and virtual visits, which will likely expand access to care, particularly to those living far from pediatric and adolescent gender centers,” Lee said.
While there were plenty of benefits to remote delivery of gender-affirming care, Sequeira expressed concern that barriers may appear after the pandemic.
“The future, as it relates to telemedicine, still remains a bit uncertain,” Sequeira said. “Because there are many legislative and health system-level factors that impact our ability as providers to use telemedicine, I suspect we, in addition to our patients and their families, will need to continue to advocate for its availability after the pandemic. I am hopeful that the data from our study, which suggests many youths desire to have the option of receiving gender care via telemedicine, may be a helpful tool in these efforts.”
For more information:
Janet Y. Lee, MD, MPH, MAS can be reached at janet.lee@ucsf.edu.
Gina M. Sequeira, MD, MS, can be reached at gina.sequeira@seattlechildrens.org.
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Lee JY, et al. Transgend Health. 2021;doi:10.1089/trgh.2020.0151.
Sequeira GM, et al. Transgend Health. 2021;doi:10.1089/trgh.2020.0148.
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