DTC Telemedicine Expands Access to Gender-Affirming Therapy

Mary Chris Jaklevic

October 27, 2022

Direct-to-consumer telemedicine services that provide gender-affirming hormone therapy appear to follow evidence-based guidelines and charge about the same as brick-and-mortar medical centers, according to researchers who reviewed the platforms' websites.

Dr Erin Jesse

The findings suggest that virtual care "may be a good option" for transgender, nonbinary, and intersex people, who often report difficulty finding physicians they trust, Erin Jesse, MD, a fifth-year urology resident at University Hospitals Cleveland Medical Center, who is the first author of the study, told Medscape Medical News.

Jesse's group presented their findings October 27 at a joint scientific meeting of the Sexual Medicine Society of North America and the International Society for Sexual Medicine, in Miami. The results have not been published in a peer-reviewed journal.

New direct-to-consumer telemedicine companies have emerged with gender-diverse staff and services tailored to the needs of these individuals. They offer "a more inclusive feel" than might be encountered at a physician's office, Jesse said.

Confirming that these companies adhere to standards of care and cost-effectiveness "is especially important considering the reduced access to care and potentially increased vulnerability of the gender-diverse population," she and her colleagues wrote.

From a Google search in March, the team identified six US-based platforms that offer gender-affirming medical therapy: FOLX, True U Clinic, QueerDoc, Queer Med, TransClinique, and Plume.

From information posted on the companies' websites, the researchers determined that all aligned with the World Professional Association for Transgender Health's Standards of Care in two areas: use of an informed consent model to ensure that patients have sufficient information and understanding to decide on their own treatment, and endorsement of frequent laboratory monitoring of hormone levels in early stages of treatment.

The team also compared the costs listed on the websites for the first year of therapy to the costs of similar care at a tertiary center, as determined using University Hospitals Cleveland Medical Center's online estimator.

The platforms offered various pricing models, including fee-for-service and monthly membership plans ranging from $59 to $139. For individuals without insurance, estimates ranged from $1022 to $1428 for oral estradiol and from $1184 to $1668 for intramuscular testosterone from the online companies, compared with $1184 and $1216, respectively, at the tertiary center.

Although some platforms accept insurance, the researchers were not able to evaluate the cost of using private insurance or Medicaid, Jesse said. She noted that transgender individuals are more likely to lack insurance than are cisgender patients.

The team also assessed the scope of services. All companies offered legal help with changes to names and gender markers, such as "M" and "F." Three or more companies offered preexposure prophylaxis to prevent HIV infection, treatment for erectile dysfunction, referrals for surgery, and medical letters of support for surgery.

Two offered puberty blockers, although the researchers were unable to determine the risk of adolescents obtaining treatment without proper assessments, because details of those services are not disclosed on websites, Jesse said.

An avenue of further research would be to interview patients to learn how platforms operate in practice and whether patients are properly assessed before treatment. "Those sorts of questions we can't answer just by looking at the websites," she said.

However, Charlotte Hoffman, JD, senior policy counsel for the National Center for Transgender Equality, an advocacy group, said she does not harbor concerns about patients being treated inappropriately simply because care is virtual. All clinicians who provide gender-affirming care face potential repercussions, such as malpractice lawsuits or state disciplinary action, if they veer from treatment guidelines, she said.

"I don't necessarily take the premise that telehealth is inherently worse than in-person care as a given," Hoffman said.

During the COVID-19 pandemic, Hoffman added, direct-to-consumer telemedicine has expanded access for individuals in rural areas, people with disabilities, and those who live in places where in-person providers of transgender care face public hostility, although individuals without the resources to pay may still be left out.

What might happen to that access if telemedicine restrictions that were loosened during the pandemic are reinstated is unclear, she said.

The researchers and Hoffman have disclosed no relevant financial relationships.

Joint scientific meeting of the Sexual Medicine Society of North America and the International Society for Sexual Medicine. Presented October 27, 2022.

Mary Chris Jaklevic is a healthcare journalist in the Midwest.

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