Utilization of the Veterans Affairs' Transgender E-consultation Program by Health Care Providers: Mixed-Methods Study

Patient Characteristics Associated with Receiving Gender-Affirming Hormone Therapy in the Veterans Health Administration

Purpose

This study aimed to examine patient characteristics associated with receipt of gender-affirming hormone therapy in the Veterans Health Administration (VHA).

Methods

This cross-sectional study included a national cohort of 9555 transgender and gender diverse (TGD) patients with TGD-related diagnosis codes who received care in the VHA from 2006 to 2018. Logistic regression models were used to determine the association of health conditions and documented social stressors with receipt of gender affirming hormone therapy.

Results

Of the 9555 TGD patients, 57.4% received gender-affirming hormone therapy in the VHA. In fully adjusted models, patients who had following characteristics were less likely to obtain gender-affirming hormones in the VHA: Black, non-Hispanic versus white (adjusted odds ratio [aOR]: 0.61; 95% confidence interval [CI]: 0.52-0.72), living in the Northeast versus the West (aOR: 0.72; 95% CI: 0.62-0.84), a documented drug use disorder (aOR: 0.56; 95% CI: 0.47-0.68), ≥3 versus no comorbidities (aOR: 0.44; 95% CI: 0.34-0.57), and ≥3 versus no social stressors (aOR: 0.42; 95% CI: 0.30-0.58; all p<0.001). Younger patients aged 21-29 years were almost 3 times more likely to receive gender affirming hormone therapy in the VHA than those aged ≥60 (aOR: 2.98; 95% CI: 2.55-3.47; p<0.001).

Conclusion

TGD individuals who were older, Black, non-Hispanic, and had more comorbidities and documented social stressors were less likely to receive gender-affirming hormone therapy in the VHA. Further understanding of patient preferences in addition to clinician- and site-level determinants that may impact access to gender-affirming hormone therapy for TGD individuals in the VHA is needed.

Evaluating an Electronic Consultation Platform to Support Pediatric Primary Care Providers in Caring for Transgender and Nonbinary Adolescents

Background: An electronic consultation (e-consult) platform was implemented to support pediatric primary care providers (PCPs) in providing gender-affirming care to transgender and nonbinary (TNB) adolescents. Following implementation, a study was conducted to (1) explore how access to this e-consult platform impacts PCP confidence and referral patterns, (2) describe the content of questions, and (3) evaluate PCP's perspectives regarding platform usability. Methods: Following each submission, providers completed a 17-item survey. A total of 20 providers submitted 38 e-consults and 26 follow-up surveys between October 2021 and December 2022. Results: All PCPs reported a high overall value and increased confidence caring for TNB adolescents. Nearly one in five (19%) felt it allowed them to avoid submitting a specialty referral. Mean System Usability Scale score was 78.2 indicating good usability. Conclusion: This e-consult platform shows great promise in increasing PCP confidence providing gender-affirming care adolescents. More widespread utilization could help improve access to care and decrease specialty care referrals.

Providing essential gender-affirming telehealth services to transgender youth during COVID-19: A service review

The COVID-19 pandemic has had significant effects on service delivery for transgender and gender diverse youth. Many in-person services were suspended in response to the need to follow quarantine and social-distancing guidelines, at both the state and national levels. In response, our pediatric gender clinic adopted a rapid implementation of telehealth services to provide access to gender affirming care. However, there exists little guidance on how to provide gender-affirming care via these platforms. In this article, we provide a narrative review of the development of a full-scale model for delivering telehealth services to transgender and gender diverse youth and their families during the COVID-19 pandemic. We also discuss the benefits and drawbacks of telehealth services for transgender and gender-diverse youth and focus on the continued need for advocacy around systemic barriers to care.

Pediatric Primary Care Providers' Perspectives on Telehealth Platforms to Support Care for Transgender and Gender-Diverse Youths: Exploratory Qualitative Study

BACKGROUND

Access to gender-affirming care services for transgender and gender-diverse youths is limited, in part because this care is currently provided primarily by specialists. Telehealth platforms that enable primary care providers (PCPs) to receive education from and consult specialists may help improve the access to such services. However, little is known about PCPs' preferences regarding receiving this support.

OBJECTIVE

This study aimed to explore pediatric PCPs' perspectives regarding optimal ways to provide telehealth-based support to facilitate gender-affirming care provision in the primary care setting.

METHODS

PCPs who had previously requested support from the Seattle Children's Gender Clinic were recruited to participate in semistructured, 1-hour web-based interviews. Overall, 3 specialist-to-PCP telehealth modalities (tele-education, electronic consultation, and telephonic consultation) were described, and the participants were invited to share their perspectives on the benefits and drawbacks of each modality, which modality would be the most effective, and the most important characteristics or outcomes of a successful platform. Interviews were transcribed and analyzed using a reflexive thematic analysis framework.

RESULTS

The interviews were completed with 15 pediatric PCPs. The benefits of the tele-education platform were developing a network with other PCPs to facilitate shared learning, receiving comprehensive didactic and case-based education, having scheduled education sessions, and increasing provider confidence. The drawbacks were requiring a substantial time commitment and not allowing for real-time, patient-specific consultation. The benefits of the electronic consultation platform were convenient and efficient communication, documentation in the electronic health record, the ability to bill for provider time, and sufficient time to synthesize information. The drawbacks of this platform were electronic health record-related difficulties, text-based communication challenges, inability to receive an answer in real time, forced conversations with patients about billing, and limitations for providers who lack baseline knowledge. With respect to telephonic consultation, the benefits were having a dialogue with a specialist, receiving compensation for PCP's time, and helping with high acuity or complex cases. The drawbacks were challenges associated with using the phone for communication, the limited expertise of the responding providers, and the lack of utility for nonemergent issues. Regarding the most effective platform, the responses were mixed, with 27% (4/15) preferring the electronic consultation, 27% (4/15) preferring tele-education, 20% (3/15) preferring telephonic consultation, and the remaining 27% (4/15) suggesting a hybrid of the 3 models.

CONCLUSIONS

A diverse suite of telehealth-based training and consultation services must be developed to meet the needs of PCPs with different levels of experience and training in gender-affirming care. Beyond the widely used telephonic consultation model, electronic consultation and tele-education may provide important alternative training and consultation opportunities to facilitate greater PCP independence and promote wider access to gender-affirming care.

Patient and parent perspectives on the utility of telemedicine for initial surgical gender care consultations: A cross-sectional survey

Introduction

The COVID-19 pandemic has expanded the use of telemedicine to patient populations that were previously constrained to in-person visits. Few studies have investigated the role that telemedicine plays in shaping the care of these patient populations. This project explores the impact of telemedicine for one such population: patients and parents of gender-diverse individuals seeking gender-affirming surgery.

Methods

A 10-question survey using previously validated questions was completed by 34 patients and 9 parents of patients (aged 15-31) who received virtual care at the Center for Gender Surgery at Boston Children's Hospital between March 2020 and April 2021. The survey was divided into two parts. The first section collected demographic information. The second assessed participant perspectives on remote surgical gender care through a series of Likert-type and open-ended questions.

Results

A total of 100% of the respondents felt that their telemedicine visit was convenient; 60% (18) of the patients and 87% (7) of the parents stated that they look forward to future use of this modality. Free responses highlighted common perspectives on remote surgical gender care, including the increased accessibility of gender-affirming care through telehealth, the limitations of telehealth for addressing physical and relational aspects of gender care, patients' desire for autonomy and privacy during telehealth visits, and parents' desire to be involved throughout their children's gender journey.

Conclusion

These results demonstrate the unique ability of telemedicine, if implemented thoughtfully, to enhance outcomes for patients seeking surgical gender affirmation.

A New Virtual Reality: Benefits and Barriers to Providing Pediatric Gender-Affirming Health Care Through Telehealth

Purpose

Access to early, multidisciplinary, gender-affirming health care significantly improves the psychosocial well-being of transgender and gender diverse youth. The Doernbecher Gender Clinic (DGC) is an interdisciplinary pediatric gender clinic consisting of endocrinology, psychology, and social work. Following the initiation of modified operations in March 2020 due to the COVID-19 pandemic, the DGC converted all interdisciplinary new patient appointments to telehealth. The purpose of this article is to (1) describe the model of care implemented during modified operations, (2) compare the number of new patients seen before and after modified operations, and (3) to contextualize this information with data from a patient satisfaction survey.

Method

Retrospective chart review was used to determine how many interdisciplinary new patient appointments occurred before and during modified operations. Additional variables included age, gender, visit modality (phone or video), geographic location, and number of caregivers who participated. In addition, patients and families who attended appointments since modified operations were invited to complete a prospective survey regarding their experience and satisfaction with these appointments, and the narrative responses to questions about advantages and disadvantages were analyzed thematically.

Results

Chart review revealed a similar number and make up of new patient appointments before and after the initiation of modified operations. The percentage of patients residing in other urban areas outside of the Portland metro increased over the course of the three time periods, but not to a significant degree. Survey results suggest that both telehealth and in-person visits have advantages and disadvantages with regard to (1) access and (2) comfort. Families appear to differ with regard to their priorities in each area.

Conclusion

Telehealth has the potential to provide quality pediatric gender-affirming health care without sacrificing the benefits of an interdisciplinary team-based approach.

Telemedicine for Gender-Affirming Medical and Surgical Care: A Systematic Review and Call-to-Action

Telemedicine has facilitated the delivery of affordable and accessible health care. However, little has been discussed about its use in gender-affirming care (GAC). Telemedicine has the potential to overcome many barriers encountered by transgender individuals such as limited geographic access to care and financial constraints, which have both been exacerbated by the COVID-19 pandemic. Telemedicine may also enhance opportunities for training in gender-affirming surgery. A systematic review of the literature on telehealth and GAC was performed. Identified uses of telehealth included: an electronic teleconsultation service, a virtual peer health consultation service, and an open online course on LGBT+ rights and health care for health care providers and laypeople. As the medical and health care communities adjust to the new reality of health care, efforts should be made to effectively incorporate telemedicine into GAC.

Providing Gender-Affirmative Care During the Severe Acute Respiratory Syndrome Coronavirus 2 Pandemic Era: Experiences and Perspectives from Pediatric Endocrinologists in the United States

Transgender and gender diverse (TGD) youth are at risk of worsened health disparities during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. Health care delivery by pediatric endocrinologists, including rapid implementation of telemedicine services, during the pandemic has not been documented. The Pediatric Endocrine Society's Transgender Health Special Interest Group met virtually to survey practice patterns during the SARS-CoV-2 pandemic. The majority of pediatric endocrinologists continued to provide most aspects of medical transition; however, we also identified several barriers to care. Overall, the survey results demonstrated that telemedicine can be utilized as an effective way to provide gender-affirming medical care to TGD youth.

Need for Inclusive Consideration of Transgender and Gender Diverse People in E-Health Services: A Systematic Review

Many transgender and gender diverse (TGD) people use the internet to find ways out of isolation, network, and share information on health-related topics. Thus, e-health services could reduce the health burden of TGD people and facilitate access to health care. Following the PRISMA guidelines, we conducted a systematic review on e-health approaches that could improve trans health care (i.e., services directly for TGD people or training programs for health care professionals, HCPs) and their effectiveness, acceptability, and feasibility. We searched PubMed, Web of Science, and PubPsych databases for publications from January 2000 to June 2021 with final updates before publication. The systematic review identified e-health services across 27 studies from 8 different countries. Few studies evaluated e-health services exclusively for TGD people. However, use of an e-health service was found to be effective and beneficial: TGD people improved in health-related outcomes, and HCPs improved in professional expertise. Service users find e-health services helpful and easy to integrate into their daily lives. Recommendations for further development of e-health services in trans health care are provided. In the future, given the rapidly evolving e-health research and care field, new treatment approaches for TGD people should be subject to ongoing evaluation and development.

Sex Hormone Suppression and Physical Activity: Possible Implications for Transgender Individuals

Purpose

Transgender individuals tend to be less physically active than cisgender individuals, and the primary focus of these physical activity barriers have been psychosocial in nature. Very little attention has been given to the role that changes in the sex hormone milieu (such as that occurring during gender-affirming hormone therapy) play on physical activity. The purpose of this study was to explore the effects of sex hormone suppression using a gonadotropin-releasing hormone agonist (GnRHa) on physical activity levels and patterns.

Methods

Female and male rats received 4 weeks of sex hormone suppression using the GnRHa goserelin acetate (GA) or received a placebo as a control (CON). Animals were then allowed free access to voluntary running wheels, and activity was recorded throughout the treatment period.

Results

Female rats receiving GA (F GA) had a significantly lower total wheel running distance than female CON (F CON, 53±11 km vs. 113±28 km, respectively, p=0.042), and male rats receiving GA (M GA) had a significantly lower total wheel running distance when compared with male CON (M CON, 31±7 km vs. 69±18 km, respectively, p=0.037). Differences in daily wheel running distances were first observed at day 18 between F GA and F CON (p=0.037) and at day 2 between M GA and M CON (p=0.021).

Conclusion

Reduced sex hormone availability reduced wheel running activity in female and male rats. Understanding the role that sex hormone manipulation has on physical activity may be an important consideration in promoting physical activity in transgender individuals receiving treatments that reduce sex hormone availability.

Information and communication technology-based health interventions for transgender people: A scoping review

In the recent past, there has been a strong interest in the use of information and communication technology (ICT) to deliver healthcare to 'hard-to-reach' populations. This scoping review aims to explore the types of ICT-based health interventions for transgender people, and the concerns on using these interventions and ways to address these concerns. Guided by the scoping review frameworks offered by Arksey & O'Malley and the PRISMA-ScR checklist, literature search was conducted in May 2021 and January 2022 in three databases (PubMed, CINAHL and Scopus). The two searches yielded a total of 889 non-duplicated articles, with 47 of them meeting the inclusion criteria. The 47 articles described 39 unique health projects/programs, covering 8 types of ICT-based interventions: videoconferencing, smartphone applications, messaging, e-coaching, self-learning platforms, telephone, social media, and e-consultation platforms. Over 80% of the health projects identified were conducted in North America, and 62% focused on HIV/sexual health. The findings of this review suggest that transgender people had often been regarded as a small subsample in ICT-based health projects that target other population groups (such as 'men who have sex with men' or 'sexual minority'). Many projects did not indicate whether transgender people were included in the development or evaluation of the project. Relatively little is known about the implementation of ICT-based trans health interventions outside the context of HIV/sexual health, in resource limiting settings, and among transgender people of Asian, Indigenous or other non-White/Black/Hispanic backgrounds. While the range of interventions identified demonstrate the huge potentials of ICT to improve healthcare access for transgender people, the current body of literature is still far from adequate for making comprehensive recommendations on the best practice of ICT-based interventions for transgender people. Future ICT-based interventions need to be more inclusive and specified, in order to ensure the interventions are safe, accessible and effective for transgender people.

Examining Health Care Mobility of Transgender Veterans Across the Veterans Health Administration

Purpose: Transgender veterans are overrepresented in the Veterans Health Administration (VHA) compared with in the general population. Utilization of multiple different health care systems, or health care mobility, can affect care coordination and potentially affect outcomes, either positively or negatively. This study examines whether transgender veterans are more or less health care mobile than nontransgender veterans and compares the patterns of geographic mobility in these groups. Methods: Using an established cohort (n = 5,414,109), we identified 2890 transgender veterans from VHA electronic health records from 2000 to 2012. We compared transgender and nontransgender veterans on sociodemographic, clinical, and health care system-level measures and conducted conditional logistic regression models of mobility. Results: Transgender veterans were more likely to be younger, White, homeless, have depressive disorders, post-traumatic stress disorder (PTSD), and hepatitis C. Transgender veterans were more likely to have been health care mobile (9.9%) than nontransgender veterans (5.2%) (unadjusted odds ratio = 2.02, 95% confidence interval = 1.73-2.36). In a multivariable model, transgender status, being separated/divorced, receiving care in less-complex facilities, and diagnoses of depression, PTSD, or hepatitis C were associated with more mobility, whereas older age was associated with less mobility. For the top three health care systems utilized, a larger proportion of transgender veterans visited a second health care system in a different state (56.2%) than nontransgender veterans (37.5%). Conclusions: Transgender veterans were more likely to be health care mobile and more likely to travel out of state for health care services. They were also more likely to have complex chronic health conditions that require multidisciplinary care.

Development of a telehealth intervention to promote care-seeking among transgender women of color in Washington, DC

BACKGROUND

Transgender women of color (TWC) are an underserved population who often experience high rates of HIV and barriers to care including stigma, violence, and trauma. Few health information technology interventions are tailored to serve TWC. The purpose of this study was to inform the development of a TWC-specific telehealth intervention to increase access to care.

METHODS

Formative qualitative semi-structured interviews and focus groups were conducted to develop a customized telehealth intervention for TWC. Participants were TWC ≥ 18 years living in the Washington, DC metropolitan area, with at least one structural barrier to care and clinicians ≥18 years who provide care to TWC. Transcripts were analyzed using thematic coding and content analysis; barriers for TWC were categorized into Individual, Organizational, and Environmental levels. Several day-long meetings with TWC and stakeholders were convened to develop the intervention.

RESULTS

Saturation of theme on barriers to care was reached with 22 interviews. Identified barriers to service receipt included survival, instability, temporal discounting, and prioritizing hormone therapy over care, incongruence between providers and patients, pessimism, and lack of cultural competency. Each was intentionally addressed with the telehealth intervention.

CONCLUSIONS

Data informed the development of an innovative and customized telehealth intervention for TWC. Through the integration of technology and peer consultant outreach, we developed a novel approach that can address population-specific challenges to care. Further development of this model may be able to improve health outcomes among TWC.