Using virtual care for the provision of trans related care
Abstract: The pandemic caused by SARS-CoV-2 has resulted in an increase in the use of virtual care technologies. Prior to the pandemic, the Ontario Telemedicine Network (OTN) allowed primary care via videoconference only for patients in a designated health care centre. With the development of pandemic-related virtual care codes, OTN as well as other virtual care platforms can be used to provide care to patients at home. Primary care providers have asked whether virtual care is an appropriate modality to support trans people seeking gender confirming health care. I argue that virtual care is well-suited to provide meaningful and full-service interventions for trans people. Virtual care provides access to people otherwise marginalized by geography and poor access to gender-affirming care.
At Connect-Clinic, I have been providing virtual care to trans people since June 2019; with the expansion of virtual care codes to provide care at home, Connect-Clinic has become more accessible to trans people in Ontario, and the program has undergone rapid growth.
Rationale for Clinical Approach:The usual model for trans related care in Ontario, and in Canada more generally, is based on in-person clinical encounters, however, in-person visits are not always necessary. Prior to launching Connect-Clinic, I hypothesized that video encounters could provide most of the necessary provider-patient interactions involved with taking a gender history and determining readiness for hormones or surgery. Contraindications to hormones or surgery can be determined via history taking and blood work review. Video conferencing provides a mechanism for the provider to confirm the safety of the intervention for the patient. Consent forms can be electronically shared and signed by the provider and patient prior to initiating treatment.
Traditional protocols have included in-person history taking and physical exam which includes blood pressure measurement, weight and abdominal exam (for example see WPATH Standards of Care; Coleman, 2012). However, the necessity of physical exam prior to hormone administration has long been debated (Vardi, 2008). For example, weight and height can be measured by the patient, and blood pressure can be measured at home if the patient has a cuff, or at a pharmacy. Even though some pharmacies have removed their cuffs during the pandemic, I have followed other disciplines such as Obstetrics and Gynecology and opted to defer blood pressure measurement in otherwise normotensive people. Abdominal exam is suggested by the protocols to rule out liver pathology, but this can also be done via blood work. Arguably other physical exam measures – such as routine cancer screening and STI screening – are related to general primary care but are not intrinsically-related to trans care and thus should not be a barrier to hormone initiation or surgery referral.
Discussion: Telemedicine is an excellent option for care provision for people in rural or remote communities, but also for people in urban and suburban environments that lack access to culturally appropriate care. Because so much of trans related care requires conversation and history taking, video conferencing is a suitable platform. There is a public (and physician) perception that virtual care is not as valuable as in-person care, however, studies have shown that patient satisfaction with virtual care can be very high (McGrail, 2017; WIHV, 2019). I have been able to develop meaningful relationships with patients solely through virtual means, and my sense is that patients experience trust in me; research is being undertaken to assess patient experiences.
Virtual care provides benefits to both providers and patients: providers can work from a home office thus avoiding commute times and overhead costs; while the patients can also avoid long commutes, waiting rooms and increased interactions with medical staff. Connect-Clinic has increased availability to trans health care providers, and as the clinic grows, may decrease long wait-times for trans related care.
Psychological safety for trans people may be increased by video conferencing, especially when patients access telemedicine from their homes. Prior to the pandemic, Connect-Clinic patients used OTN video visits through their primary care providers offices, hospitals, and participating pharmacies. In this format, we had the experience of OTN sites refusing to house trans-related care because of transphobia, as well as the experience of onsite facilitators using pronouns and names related to OHIP data and not to the patient’s gender identification. It seems that virtual care from home has increased the psychological safety of our patients, but this has not yet been studied.
Recommendation: Trans-related care provided via virtual means results in benefits to both patients and providers. Virtual in-home care should continue for trans patients across the province, however, this will require long-term changes to the policies surrounding virtual care billing.
Dr. Mary Kathleen Greenaway is a family physician in Toronto who provides virtual care for transgender patients in Ontario.
References
Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., ... & Monstrey, S. (2012). Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. International journal of transgenderism, 13(4), 165-232.
McGrail, K. M., Ahuja, M. A., & Leaver, C. A. (2017). Virtual visits and patient-centered care: results of a patient survey and observational study. Journal of Medical Internet Research, 19(5), e177.
Vardi, Y., Wylie, K. R., Moser, C., Assalian, P., Dean, J., & Asscheman, H. (2008). Controversies in sexual medicine: is physical examination required before prescribing hormones to patients with gender dysphoria?. The Journal of Sexual Medicine, 5(1), 21-26.
Women’s College Hospital Institute for Health Systems Solutions and Virtual Care (WIHV), 2019. Enhanced Access to Primary Care: Project Evaluation Final Report. Retrieved from: https://otn.ca/wp-content/uploads/2019/08/eapc-evaluation-report.pdf
