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By Hannah Critchfield
Taylor made the video call from the car.
The vehicle was as familiar as an office by now – before the pandemic hit, it was where 27-year-old Taylor changed into dresses before going out with friends, and where they wiped the makeup off their face before returning home each night. It was still the only place Taylor was sure they wouldn’t be called by their birth name by one of the many family members they are now quarantined with.
It was a 30-minute conversation and medical consultation – the licensed physician, who themselves was transgender, asked Taylor a few questions, briefed them on the process, and sent a prescription to a nearby Walmart.
The same day, Taylor picked it up. Just like that, after months of trying to find a doctor who could consult them, Taylor began hormone therapy for the first time.
A growing number of transgender people in North Carolina and nationally are using telehealth to seek transition-related care, particularly for hormone replacement therapy (HRT), a treatment process in which a person takes hormones to change their physical characteristics to more closely align with their gender identity.
Telehealth use has spiked in general during the pandemic, as many in-person visits shifted to video consultations to prevent the spread of COVID-19, and both federal and state governments waived certain HIPAA and Medicaid requirements, as well as bumping up reimbursement to support the practice.
But there are many reasons why a transgender person might prefer telemedicine for hormone therapy, even without a pandemic.
Not every transgender person seeks out HRT in their journey to live in a way that feels authentic to their gender identity. For those that do, being able to access health care virtually helps overcome some of the traditional barriers that may arise when a transgender person seeks a doctor.
A third of all transgender people who participated in the 2015 U.S. Transgender Survey reported having at least one negative experience while seeing a health care provider related to being transgender that year, such as being verbally harassed or refused treatment because of their gender identity.
“There are a lot of people who are afraid to sit in a waiting room,” said J. Clapp, executive director of the LGBTQ Center of Durham. “It’s exceptionally uncomfortable for marginalized people, because you wonder whether or not the person sitting next to you is actually supportive of who you are. That’s the importance of telehealth.“
Angel Collie, assistant director at the Center for Sexual and Gender Diversity at Duke University, echoed this.
“Many people have reported having someone at the front desk use their deadname,” said Collie, referring to the act of calling a transgender person by the name they used prior to their transition. Many say it’s, a practice that can be both emotionally and physically harmful by exposing the person to the risk of discrimination
“And then they’re forced to choose, ‘Am I going to get up and out myself, or am I going to not receive the service or care that I came here for today?’
“These are all experiences that I’ve certainly had, or I have worked with people who have had them,” Collie added.
And outside concerns of discrimination, finding a doctor who can provide culturally competent, affirming transgender care can be difficult.
“What many trans people are finding is that they have to spend the majority of the time educating their provider, as opposed to having that time for themselves to be able to ask the questions that they have,” they said. “And if they do get that chance, the providers might not even be able to answer it.”
Health care specifically for transgender people, Collie said, is often considered an “extracurricular” aspect of medical education.
“In North Carolina, at Duke, you have the Child and Adolescent Gender Care Clinic. But one of the things I’ve heard folks who do that work say is that people are driving from all over the state just to access these services. And the program is often at capacity – it can be a waitlist and difficult to get an appointment.”
An affirming app for hormone therapy
Last month, the first app specifically for providing transgender people virtual and safe access to hormone therapy launched in North Carolina.
Known as Plume, the platform was founded by Dr. Jerrica Kirkley, a doctor of family medicine, and Dr. Matthew Weschler, a physician and master of public health, who met while they were both graduate students at the University of North Carolina in Chapel Hill.
It pairs people seeking gender-affirming hormone therapy with licensed medical professionals through a HIPAA-compliant app. Many of the care providers are themselves transgender people.
“At the advisor level, the leadership level, the co-founder level and the team level, we’re 50 percent trans or more. Our clinical team is predominantly trans,” said Soltan Bryce, head of growth at Plume and a North Carolina native. “We deeply believe in the value of trans people doing this work.”
Once a person downloads the app, care coordinators, who are also transgender, chat with them and walk them through the medical intake form process. They then undergo an initial consultation about the telehealth program with coordinators, and a physician, if desired, via a live video chat. If the transgender person is interested in signing up, they schedule a formal virtual doctor’s visit. Within a week or two, people are seen by video-visit with a licensed medical professional, who is able to prescribe medication with a local pharmacy that day.
They’re able to continue follow-up visits and lab monitoring virtually throughout the program.
Telehealth apps like Plume offer a huge benefit: The doctor providing affirming care doesn’t have to be in the same state as the person they serve (though Plume does employ providers licensed in every state where they offer the app).
“Primarily what the digital platform and the telehealth angle allows us to unlock is that convenient, immediate, safe access to care, which is a huge barrier for the trans community,” said Bryce. “Especially in a state where HB2 sort of casts a long shadow, I think that access piece can’t be highlighted enough.”
COVID-19 opens a door
Plume began in Colorado in July 2019 and is now in 10 states – it launched in North Carolina on June 1.
But creators said they’ve seen a dramatic uptick in people using their services in the last few months across the states in which their services are available – which cumulatively hold about 50 percent of the national transgender population – due to COVID-19 shutdowns and cancellation of services health care providers deemed “non-essential.”
“A lot of clinics had to close their doors, some at best temporarily, but many permanently, at smaller private practices and family practices that weren’t ready to go to telemedicine,” said Kirkley. “We can keep our services going business-as-usual, since we’re set up on a fully virtual model to begin with. I think a lot of people have come to us for that reason.”
Taylor, who asked that we only use their first name out of fear of discrimination, had been seeking hormone therapy for about a year – they’d turned 26 and lost coverage under their parent’s health insurance shortly after realizing they identified as transgender. The realization had ended – amicably, they said – Taylor’s relationship with their live-in fiancé, prompting Taylor to move back to Salisbury and in with their parents. They’d only recently purchased new health insurance after finding multiple jobs in the area, and had searched for months for a provider who was taking on new patients and could adequately talk to them about transitioning with HRT.
“I still was having trouble finding any, like actual people who could talk to me about gender, and affirming my gender,” Taylor said. “For instance, I tried calling Planned Parenthood a little bit after I moved here to see if they could help me, and they were entirely filled up; they couldn’t take on new people.”
Then COVID-19 hit, and their appointment with a provider was canceled.
“It was getting pretty stressful,” Taylor recalled.
Taylor resigned to the idea of having to wait until they moved out of the house and COVID-19 subsided to get hormone therapy. But then an ad for Plume popped up on Facebook.
“And being able to start the same day I saw a doctor was just like really cool, because, it felt like I actually finally made progress,” said Taylor. “After a full year of just like, sitting still, of everyone calling me a man and a ‘dude,’ of my parents is calling me by my birth name every day.”
The effects of gender-affirming care
Taylor won’t start seeing physical changes for about two months. (After learning this from their virtual meeting with a physician, Taylor said they felt they could start hormone therapy now – the delay gives them time to move out of their parent’s home. “I didn’t want my parents and my grandpa, who lives with us, to see the changes going through me,” they noted.)
But already, they said the treatment has had an impact on their everyday life.
“The way the pills I have are directed, I’m supposed to just put them under my tongue and let them dissolve,” said Taylor. ”That entire process has been kind of relieving, ‘cause for five to 10 minutes, I have this thing melting in my mouth that’s sort of like an embodiment of everything that I’m striving to reach in my life.”
“It’s sort of like a meditative thing,” they said. “It’s been so exhausting to keep up with the facade [at home]. But that moment is like one of the more nice parts of my day, because I get to reflect on being trans, and how this pill is in my mouth because I am trans.”
Transgender people experience thoughts of suicide at a disproportionally higher rate than cisgender people in the United States – over 30 percent of transgender adults report such thoughts in a given year, versus 10 percent of cisgender adults.
The founders of Plume hope that creating easier access to the care will help alleviate some of the mental health challenges transgender people face, particularly around the distress of experiencing gender dysphoria.
“Access to care, and then actually the care itself, are two distinct things that really allow trans folks to flourish in the face of some of those statistics,” said Bryce. “HRT can be the difference that keeps people here.”
Plume costs $99 a month, and does not require insurance or accept insurance for cost of services. The fee doesn’t include the around $20-a-month cost of medication, but covers the initial visit, follow-up visits, and the lab work needed about three times a year for people on hormone therapy.
“I think it creates the possibility of having some of that process, which can be so daunting, centralized,” said Collie, who is not affiliated with the company. “So folks aren’t having to go to so many different places and kind of tell their story over and over again, and continue that outing process. I can’t imagine what it would have been like to have this when I was coming out.“
Barriers to care remain for transgender people who do not have access to the internet, as in some of the more rural parts of North Carolina, or who still cannot afford to pay.
Clapp of the LGBTQ Center of Durham, who had not heard of Plume and did not comment on it, said they have another reservation about telehealth.
“The challenge with telehealth is, of course, that it eliminates some jobs,” Clapp said. “That’s not what I want to do. But I do think having there be room for telehealth for some marginalized populations would be great.”
The Plume team said it’s optimistic that the increase in telehealth nationally signals a shift – they’ve believed telehealth can work for a long time, and this is a chance to demonstrate it.
“It’s very exciting to be the first platform really dedicated to the transgender community,” said Weschler. “That’s an exciting threshold to break through, and we hope that it is just a small part of a larger shift in the ecosystem of access for transgender folks nationally.”