Facilitators and barriers to using telemedicine for gender-affirming care in gender-diverse youth: A qualitative study

Abstract

Introduction
Access to gender-affirming care (GAC) is limited for gender-diverse (GD) youth, with the potential for further limitations given the current political climate. GAC has been shown to improve the mental health of GD youth and telemedicine (TM) could increase access to GAC. With limited data on the acceptability and feasibility of TM for GAC among GD youth, we sought to further explore their perspectives on the use of TM in their care.

Methods
We used a semi-structured interview guide, with prompts developed to explore participants’ knowledge of TM, identify factors that influenced use, and advantages or disadvantages of use.

Results
Thirty GD participants aged 13–21 years old participated in TM. While TM was not the preferred option for medical visits, it was recognized as a practical option for providing GAC. Various actual and perceived disadvantages noted by youth included, technical issues interrupting the visit, not receiving care equivalent to that of an in-person visit, having to see themselves on the screen, family members interrupting visits, and meeting new staff while connecting to a TM visit. The advantages, however, were an increased autonomy and convenience of TM, especially when used for specific aspects of GAC.

Discussion
The use of TM in GAC could be optimized by limiting camera use, eliminating/reducing staff involvement, being sensitive to privacy issues, and alternating TM with in-person visits. Clinicians should be cognizant of patient preferences and concerns and be flexible with visit types.

Full text

Facilitators and barriers to using
telemedicine for gender-affirming care in
gender-diverse youth: A qualitative study
David J Inwards-Breland
1
, Debra Yeh
1
, Maja Marinkovic
1
,
TR Richardson
2
, Bixby Marino-Kibbee
2
, Ava Bayley
3
,
and Kyung E Rhee
1
Abstract
Introduction: Access to gender-affirming care (GAC) is limited for gender-diverse (GD) youth, with the potential for
further limitations given the current political climate. GAC has been shown to improve the mental health of GD youth
and telemedicine (TM) could increase access to GAC. With limited data on the acceptability and feasibility of TM for GAC
among GD youth, we sought to further explore their perspectives on the use of TM in their care.
Methods: We used a semi-structured interview guide, with prompts developed to explore participants’knowledge of
TM, identify factors that influenced use, and advantages or disadvantages of use.
Results: Thirty GD participants aged 13–21 years old participated in TM. While TM was not the preferred option for
medical visits, it was recognized as a practical option for providing GAC. Various actual and perceived disadvantages noted
by youth included, technical issues interrupting the visit, not receiving care equivalent to that of an in-person visit, having
to see themselves on the screen, family members interrupting visits, and meeting new staff while connecting to a TM visit.
The advantages, however, were an increased autonomy and convenience of TM, especially when used for specific aspects
of GAC.
Discussion: The use of TM in GAC could be optimized by limiting camera use, eliminating/reducing staff involvement,
being sensitive to privacy issues, and alternating TM with in-person visits. Clinicians should be cognizant of patient pre-
ferences and concerns and be flexible with visit types.
Keywords
Telemedicine, transgender, gender diverse, gender-affirming care, adolescents
Date received: 10 October 2023; Date accepted: 21 January 2024
Introduction
Transgender stigma and discrimination often limit critical
resources such as access to healthcare and affect this vulner-
able population’s physical and mental health, particularly
gender-diverse (GD) youth.
1–3
The proposed mechanism
of how stigma can affect access to gender-affirming care
(GAC), is through minority stress: distal (discrimination),
and proximal minority stress (internalized transphobia)
which can culminate in poor mental and physical health.
Minority stress research has shown that when occurring
within a healthcare setting, access to care is limited.
2–5
Without appropriate gender-affirming mental health and
medical care, many health disparities can arise. GD youth
often experience significant health problems such as depres-
sion, anxiety, suicidality, substance abuse, and continued
discrimination related to inadequate access to appropriate
care.
6
Moreover, the exponential rise in antitransgender
youth legislation around the country has and will continue
to limit access to GAC, while worsening mental health
issues in this vulnerable population.
7,8
Despite a previous
increase in gender-affirming multidisciplinary programs
1
UC San Diego School of Medicine, Department of Pediatrics, La Jolla,
CA, USA
2
Rady Children’s Hospital, San Diego, CA, USA
3
UC San Diego, La Jolla, CA, USA
Corresponding author:
David J Inwards-Breland, Morehouse School of Medicine, Department of
Pediatrics, 50 Hurt Plaza, Suite 630, Atlanta, GA 30303.
Email: dinwardsbreland@msm.edu
Data Availability Statement included at the end of the article
RESEARCH/Original Article
Journal of Telemedicine and Telecare
1–9
© The Author(s) 2024
Article reuse guidelines:
sagepub.com/journals-permissions
DOI: 10.1177/1357633X241231015
journals.sagepub.com/home/jtt

for youth across the United States,
9
access to care continues
to be limited for GD youth, particularly in the wake of legis-
lative bans on care.
6,7
Medical GAC, which includes the use of gender-
affirming hormone therapy and puberty blockers, has
been shown to significantly improve mental health in GD
youth. Tordoff et al. found a significant decrease in depres-
sion symptoms and self-harm/suicidal behavior with receipt
of GAC.
10
Turban et al. and others reported similar associa-
tions between the receipt of pubertal blockers and decreased
risk of suicidal ideation.
11,12
Given the lifesaving potential
of GAC for gender dysphoria, better access to GAC is
needed.
One avenue that has not been widely adopted is the
use of telemedicine (TM) for GAC. Since the COVID-19
pandemic, the use of TM for many conditions including
reproductive health, HIV, eating disorders, mental health,
and GAC has increased.
13–21
One study found TM to be a
feasible modality to increase access for marginalized com-
munities to vital healthcare.
20
Youth perspectives on the use
of TM have shown limited acceptability; the preferred
method for health care was often in-person.
22
However,
during the peak of the COVID-19 pandemic, TM became
more acceptable to youth and caregivers, and GD youth
were willing to use it in the future.
15,23
This study also
determined GD youth were more willing to use TM for
ongoing GAC rather than new visits.
23
TM has the potential to decrease health disparities for
GD youth by providing wider access to GAC. With
limited data on the acceptability and feasibility of TM for
Table 1. Semi-structured interview questions about telemedicine.
Telemedicine: The practice of medicine using technology to deliver care at a distance. For example, a medical provider in one location uses
telecommunications (like Zoom) to deliver care to a patient at a distant site, like your home.
1. What do you know about telemedicine? (If they do not know about it, give them the definition above)
2. Have you ever used TM for your medical or mental health care and in what way did you use it (PCP (primary care providers),
subspecialist, therapist, etc.)?
a. If you have never used telemedicine
(i) What do you think are the benefits of using it for your gender care?
(ii) What are the reasons why you would NOT use TM for your gender care?
(iii) What are reasons why you personally would use TM for your care?
(iv) Can you think of situations where TM can be used for gender care?
(v) (If not already brought up) Are there any special reasons or situations where you would worry about your
confidentiality?
(vi) Can you tell me about any technical issues that can occur with TM?
(vii) How do you feel about seeing your image on the screen if you had a TM visit?
1. If they do not like seeing their image, ask why and what could make it better.
(viii) How can parent(s) help you use TM or prevent you from using TM?
(ix) What are ways to increase the use of TM for gender care?
(x) What can the clinic staff do to make your experience with TM better or worse?
(xi) What can the provider do to make your experience with TM better or worse?
b. If you have used telemedicine
(i) Was use of TM for the visit your or provider’s choice?
(ii) What are the reasons why you used TM for your gender care?
(iii) Tell us what you think are the benefits of using it for your gender care?
(iv) What are reasons why you would NOT use TM for your gender care?
(v) Can you think of situations where TM can be used for gender care?
(vi) Are there any special reasons or situations where you would worry about your confidentiality?
(vii) What role did parents/guardians play in your use of TM? Was the experience better or worse for your
TM visit?
(viii) Can you tell me about any technical issues that can have or can occur with TM?
(ix) How do you feel about seeing your image on the screen if you had a TM visit?
1. If they do not like seeing their image, ask why and what could make it better.
(x) What are ways to increase the use of TM for gender care?
(xi) What did the clinic staff do to make your TM experience better or worse?
(xii) What can the provider do to make your experience with TM better or worse?
(xiii) With the use of TM the provider cannot perform physical exam. What are the advantages and disadvantages to NOT
doing a physical exam?
(xiv) What medical needs or care was not answered for you with TM?
(xv) Would you choose TM visit in the future again, why, or why not?
2Journal of Telemedicine and Telecare 0(0)

GAC among GD youth, we sought to explore GD youth’s
perspectives on the use of TM in their care. We were par-
ticularly interested in their knowledge of TM, factors that
influenced use (provider, staff, and parent/guardian), and
the advantages or disadvantages that would influence
regular TM use.
Methods
Study design
We conducted a qualitative study using semi-structured
interviews with GD youth and young adults to explore
their perspectives on TM. Individual interviews were
chosen to preserve the privacy and safety of our partici-
pants. Due to the COVID-19 pandemic, these interviews
were conducted via Zoom.
Setting and participants
From April to December 2021, participants were recruited
from the Center for Gender Affirming Care (CGAC) at a
large children’s medical center which is the primary pediat-
ric health center for approximately 900,000 children.
24
Our
CGAC, established in 2012, has served >1200 patients to
date. At the time of this study, all TM visits were provided
by either medical providers or licensed clinical social
workers (LCSW). Eligible youth received informational
flyers in the clinic during a clinical visit and those
meeting inclusion criteria were invited to participate.
Inclusion criteria were: (1) self-identifying as transgender
and/or nonbinary; (2) age 13–26 years; (3) receiving
medical care at our center; and (4) English or Spanish
speaking. Eligible participants ≥18 years completed an
informed consent process in person or via Zoom. Parents/
Guardians of the eligible participants <18 years completed
an informed consent process, and the minor completed an
assent process in person or via Zoom. Signed consents/
assents were shared with the researchers via secure email.
Purposive sampling was utilized (by inviting non-White/
masculine identified participants) to ensure perspectives
represented a wide range of ages, races, ethnicities,
gender identities, and experiences within our medical
center until we reached our goal of 30 participants.
Participants received $25 compensation after completing
the interview and survey. The study was approved by the
Human Research Protections and the University of
California, San Diego Institutional Review Board.
Data collection
We used a semi-structured interview guide with prompts
developed to explore participants’experiences and perspec-
tives on using TM for GAC (Table 1). Participants were
asked open-ended questions about their knowledge of and
preference for TM, perceived advantages and disadvan-
tages, technical issues (either experienced or theoretical),
and to brainstorm ways to improve the experience. All
interviews were conducted by two members of the team
(D.Y. and T.L.R.) via Zoom and in English (per participant
preference). Interviews were concluded once the team
reached thematic saturation, where no new major themes
were identified. Each participant also completed a short
demographic questionnaire in English. All interviews
were audio-recorded, and then transcribed using a profes-
sional transcription service.
Data analysis
Interviews were deidentified and transcribed verbatim.
ATLAS.ti
©
was used for analysis. Two primary coders
(D.M.Y. and T.L.R.) independently coded all transcripts
using inductive thematic analysis.
25,26
The coders met
weekly and reviewed all transcripts, developed and
revised the codebook, and reached a consensus on any
coding discrepancies. The larger team (D.I.B., M.M.,
B.M.K., A.B., and K.E.R.) reviewed coding applications,
categories, and themes for validation. Given the wide age
range of participants, themes were reviewed by age group
(13–17 years and 18–26 years old), and no variation in
responses was observed. Thus, results were reported for
the group at large with any themes/comments that were spe-
cific to one age group highlighted in the text. The research
team was comprised of physicians experienced in qualita-
tive research, members of the lesbian, gay, bisexual,
transgender, queer, intersex, and asexual community, and
Table 2. Participant demographics.
Age of participants N=30 (%)
13–17 years 14 (47)
18–21 years 16 (53)
Race and ethnicity*
Hispanic, Latine, or Spanish origin 7 (23)
American Indian or Alaskan native 1 (3)
Asian 3 (10)
Native Hawaiian or Other Pacific Islander 0 (0)
Black or African American 3 (10)
White or Caucasian 18 (60)
Two or more races 2 (7)
Prefer not to say 1 (10)
Other 0 (0)
Gender identity*
Female or transfemale 9 (30)
Male or transmale 15 (50)
Nonbinary 4 (13)
Gender fluid 3 (10)
Genderqueer or gender nonconforming 0 (0)
Other 0 (0)
*Total percentage exceeds 100% due to selection of multiple options by
participants.
Inwards-Breland et al. 3

Table 3. Gender-diverse youth perspectives on telemedicine use and feasibility.
Advantages of telemedicine
Subtheme Quote
Convenience/ease “…I think it’s easier for people to do telemedicine, especially when they don’t have the
availability to carpool or to drive. …for my example, …I can’t drive right now to places just
cause …I don’t have my license …and to drive, I have to be with someone or someone has to
take me somewhere”
“…you wouldn’t have to leave your home. I know that much. I know you don’t have to have a
ride to go get care. I know a lot of kids, especially the kids who have gotten into the gender
clinic themselves without parents’help, don’t have necessarily a car or ride to get there and
they can’t really get there on their own.”
“…it’s easier to access, I think. If people don’thave…good transportation…”
“…I just graduated …I was up at San Francisco State University. So …I couldn’t be constantly
flying back home for appointments every couple months. …I have animals, so I would have to
drive all the way back down rather than fly with them. So [telemedicine] definitely made
that-that easier.”
Autonomy/independence (all
participants ≥18 years old*)
“Telemedicine would help with kids that have less supportive parents because they can, like, be in
charge of, like, talking to the doctor without, you know, relying on the parents to drive them to
the doctor.”
“you don’t have to worry about taking someone (in-person visit) who’s not suppor tive with you.”
“Definitely, if it’s in confidence, I feel like that’s a lot easier because if they haven’t come out to a
select family member that would have an issue with it, they can have their meeting in the room
and still be comfortable and kind of go from there.”
More comfortable with TM visit* “I think physical exams …are sometimes uncomfortable. So …if you’re not too fond of that, …
you can just do telemedicine and not necessarily …have a physical exam.”
“[telemedicine is] more mellow and toned down and …you don’t walk in there knowing you’re
going to have to do something you dislike. It’s honestly just, it’s kind of more, like, comfortable.
[Telemedicine] less effective, but it’s more comforting”
“…if someone’s…afraid of the doctor, then I think that [telemedicine], might be more
comfortable for them.”
“It’s just a waste of time. …that’s the benefit of a Telehealth …you don’t have to do the whole
like, …check-in, do vitals, all of that.”
“Because some might not feel comfortable going out because of how they identify or how they
look…”
Disadvantages of telemedicine
Lack of perceived knowledge of a
telehealth visit despite having a
good working knowledge of video
conferencing
“I don’t really know much about it besides I went on a zoom call and they …were telling me all
these things, like, to check my own weight and …see how tall I am.”
“I don’t know much about it but I know it’s like what we’re doing right now except a doctor’s
appointment.”
“Really it’s just what you would normally do on …in a doctor’s visit, but through a Zoom call.”
Unable to monitor physical changes
with medication
“…it’s important to have the doctor …be there to make sure …there’s not something wrong
with you, you know.”
“…you don’t feel as confident in the exam as you would if you were there in person. ”
“[they] couldn’t really …do any physical tests like height weight or anything.”
No privacy from parents or family
members at home and different
from confidentiality
“I feel …people wouldn’t like telemedicine because they can’t get any privacy at home because
[of] their family members are super nosy. And they would prefer to be able to, …their doctor
in person because they know that they’ll be in a separate room from their parents, and that, …
there’s no way that their …family members or their parents …are going to be able to, …
eavesdrop.”
“…I don’t think I’m- not on your guys’end but like …I mean …like, my house is fairly small and I
don’t know how far my voice carries or, like, if my brother’s listening to this right now from the
other room.”
Technical issues “Um, wi-fi. If the wi-fidoesn’t work and then it’s pretty much not doable.”
“…I guess like in, um, connectivity issues can happen in your house, you know, um, …Zoom
possibly being down or like you have to update Zoom …someone could be late to an
appointment because of that and yeah.”
(continued)
4Journal of Telemedicine and Telecare 0(0)

providers of medical and mental health care for GD youth.
Participants were later invited to review the themes through
member checks to ensure an accurate representation of their
perspectives. The majority (28 out of 30) expressed interest
in participating in the process, and three participants
responded with questions but ultimately did not want to
change the findings or thematic groupings.
Results
In total, 30 GD youth, aged 13–21 years (average 18 ±
2.15) were recruited. The majority (60%) identified as
White, and 23% identified as Latine which mirrors the
racial/ethnic demographics of our patient population.
Most participants (50%) identified as male/transmale,
30% as female/transfemale, 13% as nonbinary, and 10%
gender fluid (Table 2). Most participants preferred
in-person visits (22/30).
All participants knew what TM was because of its wide-
spread use at the onset of the COVID-19 pandemic. Early
on, patients had to adapt to TM if they wanted to continue
to receive medical and mental health care, as in-person
visits were limited. Subsequently, some participants pre-
ferred TM due to the lack of a COVID-19 vaccine and
out of concern for their own safety as well as mandated
by the health institutions. This participant noted:
…it was kind of like a mutual decision because we were …still
in …intense lock down. I don’t, …know if like the gender
Clinic was open for patients to like, [to] come in or not.
Participants identified many advantages and disadvan-
tages to using TM for GAC. Despite a few disadvantages,
many saw a benefit to continuing the use of TM in the
future (Table 3).
Advantages of TM
There were many advantages to using TM for GAC, most
centered around increased practicality, and ease.
Participants appreciated the convenience of TM visits,
citing transportation issues (i.e., long travel times, lack of
Table 3. Continued
Advantages of telemedicine
Subtheme Quote
Bypass ancillary staff “I would say for me, I just prefer going straight to the doctor’s just because I …want to–…get it
done….”
In-person preference “…I liked in person more …Just because I …felt more …. All right, I can’tfind a word for it but I
…felt more comfortable, I should say.”
“…I think in general …going to appointments physically and talking to the people directly
face-to-face is just what I prefer.”
“[I] like the comfort of [in person] appointment. And that it’s more relaxing and convenient
when I’m anxious how the appointment’s gonna go.”
“I think in general, I like coming in …because it’s nice to, …be in a place where like, I know, …
the physician and I don’thaveto,…, be meeting new people. And also we’re on our computers
all day every day at this point, so any chance to get out of the house is nice.”
Confidentiality versus privacy using telemedicine
No concerns around confidentiality “I haven’t had a reason yet to feel like it’s not secure if that makes any sense.”
“I feel pretty comfortable with …the doctors I do have appointments with. So I don’t think that’s
really much of an issue.”
“…I personally am comfortable with [telemedicine]. I live with my mom and my brother, which
I’m out too and they’re both supportive. I don’t live with my dad …He’s not, he doesn’t really
know about this stuff. So the only times I would feel uncomfortable would be on the rare
occurrence that I’m, …at his house, like doing medicine stuff. But I mean, for me personally, I’m
not super worried about it in terms of like my family members finding out”
Future of telemedicine for gender-diverse youth
Provider allowing patients to turn off
camera
“Probably just allowing me to …turn off my camera.”
“…not having to have the camera on, is a big one, …I guess just like not being required to have it
on the whole time.”
Offer telemedicine appointments “They always ask …would you like …to use …telemedicine, or …do you want to come in
person? They always ask.”
“…I think just offering it as an alternative, …if someone’s uncomfortable …maybe they’re not
cis passing and they’re …afraid of being misgendered…”
* We examined results by age group and found no major differences but if there were differences that more commonly pertained to one group, we have
indicated in Table.
Inwards-Breland et al. 5

gas money, and difficulty parking) were no longer a barrier
to receiving GAC. One participant noted:
…I think it’s easier for people to do, especially when they
don’t have the availability to carpool or to drive. …for my
example, …I can’t drive right now to places just cause …I
don’t have my license …and to drive, I have to be with
someone, or someone has to take me somewhere.
TM visits were easier for patients and their families who
had busy schedules and could not spend time traveling to
the clinic. Several participants also noted they were more
comfortable in their homes. For older youth attending
in-state colleges, TM allowed them to continue their GAC
while at school.
…I just graduated…I was up at San Francisco State
University. So …I couldn’t be constantly flying back
home for appointments every couple month. …I have
animals, so I would have to drive all the way back down
rather than fly with them. So, telemedicine definitely made
that-that easier.
TM was regarded as offering more autonomy or inde-
pendence to participants because it allowed them to
choose the level of parental involvement with which they
were comfortable. Parents/guardians of the minors could
attend the entire visit or part of the visit, depending on
the preference of the youth and parent. Young adults had
the flexibility to conduct visits when a parent/guardian
was not at home. Young adults also reflected on how TM
was an effective way to see a provider for specialized
GAC when they did not have supportive parents or were
not out to their parents but were still living at home. This
young adult noted:
You don’t have to worry about taking someone who’s not
supportive with you.
Disadvantages of TM
As mentioned above, most participants preferred in-person
visits over TM, regularly citing the comfort of an in-person
visit as a top priority. These youth preferred connecting
with a known provider face-to-face and put them at ease
during the visit. Some GD youth noted the in-person modal-
ity helped decrease their anxiety leading up to the visit, as
they were sometimes unsure how the visit would go via
Zoom. However, for in-person visits, they were put at
ease prior to and during the visit and it felt more personal
and predictable.
[I] like the comfort of [in person] appointment. And that it’s
more relaxing and convenient when I’m anxious how the
appointment’s gonna go.
An in-person visit enabled more clarity when receiving
their GAC and played a key role in establishing trust with
their provider.
Despite having a significant working knowledge of
common videoconferencing platforms such as Zoom,
some participants still had limited knowledge about con-
ducting TM visits.
I don’t really know much about it besides I went on a zoom
call and they …were telling me all these things, like, to
check my own weight and …see how tall I am.
Many also did not know what to expect from the TM
visit and did not enjoy the process because it reminded
them of a virtual school. The experience with clinic staff
assisting them to start the TM visit was thought to be an
inconvenience at best, and at worst, a detriment to their
care. They did not want to interact with people they did
not know and felt anxious about seeing new people at the
start of the TM encounter. Many patients wanted to
bypass this step and see their provider directly.
I would say for me, I just prefer going straight to the
doctor’s just because I …want to–…get it done….
Nevertheless, a vocal minority found the clinic staff
useful in helping to navigate the Zoom platform. They
appreciated assistance with logging on and ensuring that
they were in the right place.
Interestingly, very few participants were concerned
about technical issues with TM and most issues mentioned
were theoretical. The technical issues either experienced or
thought to occur were internet connection (Wi-Fi) issues
and updates in the Zoom software. This participant said:
…I guess like in, um, connectivity issues can happen in
your house, you know, um, …Zoom possibly being down
or like you have to update Zoom …someone could be
late to an appointment because of that and yeah.
Interestingly, many participants reported the inability to
perform a physical exam was both a major advantage and
disadvantage of TM. Despite the ability to defer exams in
in-person visits for participants uncomfortable with their
bodies, the lack of physical exams provided an opportunity
to have a more comfortable visit without anxiety. This
minor participant noted:
I think physical exams …are sometimes uncomfortable. So
…if you’re not too fond of that, …you can just do telemedi-
cine and not necessarily …have a physical exam.
Nonetheless, even those who preferred no physical exam
recognized the limitations of not having one. Many partici-
pants were concerned about the possibility of something
6Journal of Telemedicine and Telecare 0(0)

going wrong with their GAC and the provider not being able
to physically monitor the effects of the medication or discover
the issue via TM. Moreover, GD youth did not feel confident
in their own self-examinations to advise the provider of
changes they were seeing. This participant noted:
…you don’t feel as confident in the exam as you would if
you were there in person.
Other disadvantages noted included the inability to
assess vital signs or anthropometric measurements,
conduct in-clinic blood or urine sexually transmitted
disease screening, and receive vaccines.
Confidentiality
27
versus Privacy with using TM
A participant’s experience with TM was often affected by
those involved in their appointments. Outside influences
came from their provider, parents, and support staff in the
clinic. If they were comfortable with their provider, most
participants reported no concern regarding confidentiality
a
when using TM. They trusted the provider with the infor-
mation discussed during visits and did not have any
reason to feel that the TM platform was “not secure.”
However, some were worried that other people/family in
the house might invade their personal space during the visit.
A vast majority of the youth lived with parents/guardians
at the time of the interview, yet few felt they had no priva-
cy
b,28
with their provider noted by this participant:
…I don’t think I’m- not on your guys’end but like …I
mean …like, my house is fairly small, and I don’t know
how far my voice carries or, like, if my brother’s listening
to this right now from the other room.
Despite the concerns with privacy, there were no con-
cerns with confidentiality as stated by this participant.
I feel pretty comfortable with …the doctors I do have appoint-
ments with. So, I don’t think that’s…. much of an issue.
Future of TM for GAC
Overall, the GD youth felt that TM use would increase if
TM appointments were offered side by side with in-person
appointments. Many saw themselves alternating between
TM and in-person visits, but only if they were made
aware of that option when scheduling follow-up visits.
…I think just offering it as an alternative, …if someone’s
uncomfortable …maybe they’re not cis passing and they’re
…afraid of being misgendered….
A vast majority of participants viewed TM as optimal for
discussion-based visits with the medical provider or LCSW,
such as reviewing labs, adjusting doses, and reviewing
options and risks/benefits of gender-affirming surgeries.
Visits with our LCSW clinicians were also viewed as
more easily accessible via TM. Some participants disclosed
that TM visits created feelings of anxiety and gender dys-
phoria because they had to see themselves on the screen.
…not having to have the camera on, is a big one, …I guess
just like not being required to have it on the whole time.
To alleviate these concerns, they recommended patients
be allowed to turn off their cameras during the appointment.
Discussion
In recent years, TM has become a viable alternative to trad-
itional, clinic-based care, especially in pediatric transgender
medicine.
29
For patients/families dealing with obstacles like
transportation limitations, family, school, or work commit-
ments, as well as the growing prevalence of antitransgender
healthcare bans nationwide, TM offers a compelling alternative
to in-person visits. Patients may need to find providers who par-
ticipate in interstate licensing compacts and who may be able to
provide care. In our research exploring the TM-related experi-
ences of GD youth, the most cited advantages of TM were the
convenience of visits for those who live far away from the
clinic, who lack transportation, and who do not wish to have
a physical examination. Our results are in line with those of
Russell et al. who surveyed GD youth and caregivers during
the COVID-19 pandemic and found no significant differences
in communication quality, privacy, or overall satisfaction
between TM and in-person visits.
30
A similar study conducted
by Kahn et al. on the advantages and disadvantages of TM and
preferred visit modalities found participants liked the conveni-
ence, efficiency, and comfort in their own environment, and
found TM user-friendly.
31
In addition, these participants
found TM less scary because of social anxiety consistent
with our study results.
31
Like previously published opinions
of cisgender youth
15
and transgender and nonbinary patients
in Canada,
32
most of our participants preferred in-person
visits to TM. They shared that an affirming and comfortable
clinic setting was favored over TM appointments.
A few participants had apprehension about their ability
to maintain privacy during TM visits conducted at home
and feared that their conversation with the provider may
be overheard by family members. Most of our study parti-
cipants, however, did not have concerns about confidential-
ity during TM visits. Young adults may have less concern
about confidentiality since they do not need a parent/guard-
ian to consent to treatment. Overall, most of our study sub-
jects were supported by their parents/guardians, making
confidentiality less of a concern for them. Nevertheless,
GD youth and young adults without family support may
have different experiences with TM use.
It is important to recognize that TM can both facilitate
and hinder patient care. This was also noted by our study
Inwards-Breland et al. 7

participants. The inability to have physical exams during
the visit was cited as both an advantage and disadvantage
of TM. Some participants felt reassured about the progress
made toward their embodiment goals and health when
examined by their doctor, while some found exams to be
distressing and preferred avoiding them. Our participants
favored TM appointments for discussing laboratory
results and ongoing mental health therapy but wanted to
alternate with in-person care. These findings deserve
further exploration in larger samples of GD youth.
One of the major disadvantages of TM reported by some
of our study participants was the use of the camera and
viewing their image could worsen gender dysphoria. This
may be specific to the GD patient population and clinicians
providing GAC should be cognizant and sensitive to the
patient’s needs around exacerbating dysphoria. One sug-
gestion to combat this discomfort is to reduce/eliminate
“camera-on”time if requested by the patient or if the pro-
vider notes discomfort with the visit and/or suggests the
patient hide their video from their screen allowing the pro-
vider the ability to see the patient. We suggest patients use
emojis and avatars to help the provider understand how the
patient is feeling or receiving the information they are pro-
viding and with appropriate legal, institutional policy, or
insurance billing requirements.
Despite the novel information generated during these
interviews, the study findings are limited by the small
number of participants; however, we were able to obtain
rich narratives and nuances through in-depth interviews.
Selection bias may have also affected our results as we pri-
marily recruited subjects who were already in care and who
were supported by their parents/guardians. Experiences of
GD youth who lack family support and access to GAC
may be different leading to different views about TM.
Another limitation is that most participants were White.
Although this reflects the patient population seen at our
CGAC, it does not reflect the diversity of the community.
To lessen this limitation, we sought to obtain more
diverse opinions by purposefully recruiting subjects from
racial/ethnic minorities and feminine embodiment to
augment those views in this study.
TM, though not a preferred choice for medical visits in
our sample, has emerged as a practical option for providing
GAC. The various advantages noted by youth were primar-
ily centered around the convenience and comfort of TM
when used for specific aspects of GAC. The often-cited
primary areas of concern were related to being anxious
about visits, encountering technical issues, and not receiv-
ing care equivalent to that of an in-person visit.
The use of TM in GAC can be optimized by limiting
camera use or suggesting the patient hide their video feed
on their screen, eliminating/reducing staff involvement
(unless there are technical issues around logging on),
being sensitive to privacy issues, and by alternating TM
with in-person visits. Clinicians should be aware of
patient preferences and potential concerns and work with
their health systems to provide flexibility with visit types.
Additional research, with a mixed-method approach and
larger sample sizes, is needed to further study the utility
of TM for GAC in youth and as an option for GD youth
to receive care in affirming states.
Acknowledgments
Our team would like to thank LaToya Reynolds for helping with
human subjects’incentives. All listed authors have contributed
substantially to this manuscript. This study was presented as a
poster at the Pediatric Academic Societies Meeting, Denver CO.
2022; a poster at the World Professional Association of
Transgender Health Scientific Symposium, Montreal Canada,
2022; and a poster at the Society for Adolescent Health and
Medicine National Meeting, virtual, 2022.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) disclosed receipt of the following financial support for
the research, authorship, and/or publication of this article. This work
was supported by funding from the University of California,
San Diego Department of Pediatrics Health Disparities Pilot Grant
2020 and the HIV Institute—Transgender/Gender Non-Binary
Community Health Research Scholarship, 2022.
ORCID iDs
David J Inwards-Breland https://orcid.org/0000-0001-8518-
7932
TR Richardson https://orcid.org/0009-0000-8946-2065
Data availability statement
The dataset generated during and/or analyzed during the current
study are available in the Figshare repository, https://figshare.
com/articles/dataset/Telemedicine-2_26_22_atlproj/25148261.
33
Notes
a. Confidentiality—refers to a duty of an individual to refrain
from sharing confidential information with others, except
with the express consent of the other party.
b. Privacy—the state of being free from unwanted or undue intru-
sion or disturbance in one’s private life or affairs; freedom to be
left alone.
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