Like many others in high-risk communities, the COVID-19 pandemic has disproportionately affected the transgender and non-binary community (TNB) – individuals who do not identify with their sex assigned at birth. In both Ontario and abroad, the TNB community experiences higher rates of violence, unemployment, poverty, discrimination, depression and suicide compared to the general population.
In the past two years, the pandemic has introduced additional stressors on this already vulnerable community through the deferment of transition-related surgeries, cancellation of in-person LGBTQ2S+ support groups and concerns about access to hormones. However, COVID-19 has also led Ontario to expand its billing codes for virtual doctor visits. For TNB patients, the move to increase coverage for telemedicine services has resulted in increased access to primary care services – particularly gender-affirming hormone therapy.
“Prior to the pandemic, for clinics in Ontario, the initial intake visit to begin hormone therapy had to be in person,” says Kate Greenaway, a family physician based in Toronto who runs Connect-Clinic, a fully virtual telemedicine service that exclusively provides gender-affirming care (GAC). “That was a really big barrier to people in rural and remote communities in Ontario, but not right now.”
Self-referrals to Connect-Clinic from patients interested in hormone therapy have increased so much that the practice, which began with just Greenaway, has now expanded to five physicians and still has an ever-growing wait list.
The demand highlights an unaddressed need for GAC through primary care settings in Ontario. Feminizing and masculinizing hormone therapies that include estrogen and testosterone, respectively, help TNB patients develop physical changes that match their gender identity. In the case of masculinizing hormones, this can include voice-deepening and body-hair growth. With feminizing hormones, this can include breast development and decreased muscle mass.
A growing body of research has shown that GAC including hormone therapy and surgery reduces depression and suicidality and improves the overall well-being of TNB patients that seek medical transition. Locally, a study of 380 transgender people in Ontario conducted by TransPULSE, a national community-based research project into the health and well-being of trans and non-binary people in Canada, revealed that among individuals who desired medical transition, those on hormone therapy were about half as likely to have suicidal thoughts.
Despite its benefits, there are significant barriers to accessing GAC. One is the lack of primary-care physicians who can competently provide it. A Canadian study found that 63 per cent of transgender respondents had to educate their doctor about transgender health care; 11 per cent said their doctor was not at all knowledgeable. Additionally, experiences of transphobic discrimination in health-care settings have led many TNB patients to avoid the health-care system.
In a separate TransPULSE study among transgender patients in Ontario with a family physician, approximately 40 per cent had experienced discriminatory behaviour from a family physician at least once, including refusal of care or refusal to examine specific body parts, being ridiculed and the use of demeaning language.
“I’m often hesitant to come out to my physicians as non-binary out of fear that it will negatively impact my care,” says Alex, a non-binary person, who has had to wait several months to begin testosterone therapy and attributes the long journey to systemic transgender and non-binary discrimination, including a lack of physician knowledge.
Telemedicine can address access barriers by connecting patients with the limited number of family physicians providing hormone therapy, regardless of their location in Ontario, sparing patients from longer wait times that can worsen gender dysphoria. It also removes distance barriers that can often act as an additional financial constraint, especially given that the majority of TNB patients in Ontario live below the poverty line. Furthermore, care happens in a space theoretically free of transphobia with physicians trained to work with LGBTQ2S+ patients.
For trans and non-binary patients, increasing coverage for telemedicine services has resulted in increased access to primary care services.
“As someone that has struggled with trauma in the past, there is something valuable about the virtual platform in providing a little bit of safety through distance,” says Alex, who explains that virtual visits have allowed them to attend doctor’s visits that otherwise would not have been accessible because of chronic illness and physical disabilities.
Given its relative recency, there is limited Canadian data on the efficacy of virtually managed gender-affirming hormone therapy. However, studies abroad suggest it is both beneficial and welcomed by many TNB patients. A study in Italy reported improved mental health scores in those with access to telemedicine endocrinology visits during the pandemic. Similarly, a study in the United States reported that almost half of transgender youths surveyed were interested in receiving GAC virtually.
“I’ve heard from the late teens to early 20s subset of patients that this is the first time they felt like they had the agency to go and find who they wanted to care for them,” says Greenaway. “Previously, they were reliant on parents who might not necessarily agree to drive them to or schedule appointments.”
Robyn Hodgson, a registered nurse and transwoman who runs the London, Ont., InterCommunity Health Centre’s Transcare Clinic, agrees virtual transgender care is “clinically appropriate and has some very valid applications.”
However, she adds that there are circumstances where there is a need for in-person care. For example, post-surgical assessments following a transition-related surgery such as a vaginoplasty or mastectomy. Even then, Hodgson says that telemedicine can play a role in post-surgical assessments. “I’ve had patients send me photographs of their surgical sites through the EMR, which can help when they have questions or concerns and whether an in-person visit is warranted.”
Greenaway says that in such situations, she connects patients with family doctors, nurse practitioners, wound-care teams and, if needed, acute respite care.
For Hodgson, the break from social isolation many TNB patients experience is one benefit of in-person assessments.
“There is a segment of this population that lives in abject isolation,” she says. “When you’ve got someone early in their transitions, virtual visits may benefit them a lot because they don’t have that confidence. But at the same time, it’s our opportunity to help develop some of that confidence by having some of those in visits in office, in a re-affirming space. So, really, from a clinical standpoint, as a person with lived experience, it’s a mixed blessing.”
In a recent article Greenaway wrote for the Canadian Family Physician, Greenaway questioned the need for physical exams prior to hormone initiation; a topic of ongoing debate. For measurements such as height, weight and blood pressure, she is comfortable using patient-reported data. Furthermore, she asserts that the in-person abdominal exams performed to rule out hormone-related liver pathologies also can be appropriately assessed with blood work.
“It’s pretty rare to find a liver abnormality,” Greenaway says. “It happens, yes, but it is pretty rare so I question if the abdominal exam should really be the standard of care for all patients.”
Although Greenaway initially also had concerns about remote mental status exams and capacity assessments that ensure patients can properly consent to hormone therapy, she now feels just as confident making the assessments through videoconferencing as long as she can see the patient. “I have trouble building rapport and making connections with people without that measure of eye contact or physical cues,” she says. “Very rarely I’ve had patients who request telephone-only visits, in which case I explain that this isn’t a good fit for them.”
Both Greenaway and Hodgson agree that to continue improving virtual GAC access, focus should be placed on referral and billing.
“Billing doesn’t just affect doctors but patients, too,” says Greenaway. “Marginalized patients, whether it be transgender or newcomer populations, are less likely to be enrolled to a family physician’s roster, and without the current pandemic virtual codes, they would have not had access to many virtual services offered by many fee-for-service physicians.”
As of now, the telemedicine OHIP codes allowing for virtual care have been extended to September 2022 but their fate after that is uncertain.
“On the policy level, we need to look at everything from billing codes to funding models to make sure that the way they exist doesn’t then preclude somebody from getting care,” says Hodgson.
Hodgson also notes that more must be done to make telemedicine accessible to those without technology, in remote communities and the elderly. She also recommends establishing more telemedicine hubs – perhaps in government centres or hospitals in remote communities – where patients can access virtual care privately. “Even though they may have the technology at home, they may not have the comfort in their living environment to have an open discussion about their gender identity, with other people around them possibly listening in.”
“There is a segment of this population that lives in abject isolation.”
For Alex, who struggles with auditory processing, video encounters can sometimes be challenging, especially if there aren’t automatically generated captions. “It can sometimes be tricky, but for me, in comparison to having to physically go somewhere, it’s still just so much easier.”
Both Greenaway and Hodgson share their expertise with other providers to give them the tools and confidence they need to provide gender-affirming care through the Ontario Telehealth Network virtual consult services.
At Connect-Clinic, “We are filling a gap and I love the patients I get to meet,” says Greenaway. “But it also highlights the lack of gender-affirming care embedded into primary care.”