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‘Life and Death’ for Patients: Startups Fill LGBTQ Wellness Gap

Services aimed at the trans community are a matter of “life and death” as government policies aim to restrict support.

When Jonas Quinn, a 35-year old trans woman, sought treatment for gender dysphoria two years ago, they said the doctor rebuffed them, calling it a phase they would grow out of.

“I’d been considering it for a decade so that’s a hell of a phase,” Quinn said.

In December, they subscribed to Plume, a telehealth platform that provides hormone replacement therapy, or HRT, a process in which a person takes estrogen or testosterone to align their physical characteristics with their gender identity. A week after signing up, Quinn had a video-chat appointment with one of Plume’s in-house physicians and got a prescription for estrogen patches that day.

Pervasive discrimination, high costs and scant knowledge of sex-specific care for transgender patients by traditional medical providers, are among the significant barriers faced by queer and trans individuals seeking gender-affirming care. When U.S. lawmakers loosened telehealth restrictions at the height of the Covid-19 pandemic, it led to the rapid adoption of telemedicine and presented a key opportunity to reach LGBTQ individuals, a community that historically has been under-served in health care. And it couldn’t have come at a better time. 

Some 18 million U.S. adults — about 5.6% of the population — identify as being part of the LGBTQ+ spectrum, according to a January Gallup poll. While the group is becoming more visible and vocal, hostility from far-right groups has reached record proportions. U.S. state legislatures have introduced 129 anti-transgender bills so far this year, according to the Human Rights Campaign. At least 34 bills are targeting transgender individuals’ ability to seek medical care, particularly for youth. In March, Arkansas became the first state to ban health care professionals from administering gender-affirming care to minors, overriding a veto by Republican Governor Asa Hutchinson.

As the government pulls support, investors are backing an emerging crop of digital health startups focused on queer and trans people. Denver-based Plume raised $14 million in new funding, led by Craft Ventures, in February. Folx Health, based in Boston, raised $25 million that same month, led by Bessemer Venture Partners. Smaller startups include Violet, a New-York based firm that helps connect cultural minorities, including BIPOC and LGBTQ members, with doctors and that’s backed by The Venture Collective and the Robin Hood Foundation. And also Queerly Health, a New York-based digital platform founded in 2018 that connects LGBTQ people with vetted physicians. 

Even without a pandemic, there are other reasons a transgender person might opt for virtual care, said Jules Gill-Peterson an associate professor of English and Gender, Sexuality and Women’s Studies at the University of Pittsburgh. “Discrimination and transphobic violence has fueled a lot of distrust of the medical community,” she said.

Plume employs doctors — many of whom are transgender — that are trained to care for their patient’s unique needs. The startup has providers licensed in the 33 states where the app is currently offered, including Florida, New York and Texas; however, the doctors aren’t required to be in the same state as the patient receiving care. That’s significant because more than half of LGBTQ people in the U.S. live in majority-rural states, according to a study by the Movement Advancement Project, an independent, nonprofit think tank. Since launching in 2019, Plume has provided gender-affirming care to 5,000 patients across the country.

But, unlike local health centers, Plume and Folx don’t offer primary-care services, making some experts wary that preventative care will go by the wayside.

“It’s really important we don’t compromise our standards of care in order to advance these new technologies,” said Peter Meacher, chief medical officer at Callen-Lorde, one of the largest LGBTQ community health centers in New York. “Primary care is the bedrock of a good health system and should factor it into whatever model we create,” he said. “It needs to include a connection with someone who is going to think beyond the immediate need of HRT: checking their blood pressure or reminding them of colon cancer screenings.”

Traditional health care can also be expensive and the telehealth startups can often offer services at a lower rate. Quinn, the trans woman who signed up for Plume, estimated that visiting a regular clinic would have cost upwards of $500, between the insurance premium and copays for multiple visits to see a primary care doctor and specialists that offered no guarantee of a prescription. With Plume, Quinn paid $135 in total. The cost of medications — which varies from $5 to $50, according to the company — isn’t included. Though insurance may cover medication, it can’t cover the membership fee.

“For me, it made more sense to use a cheaper alternative while also seeing a doctor that is very supportive and knowledgeable,” Quinn said. “You don’t have to have that awkward conversation where your primary care provider tells you that you don’t actually want to transition and sends you to an endocrinologist with little to no current knowledge of HRT.”

Myles Jean-Gilles is 22-year old a Black trans man who began taking testosterone therapy in March through Folx, after learning about it on Instagram. Launched in December, Folx offers remote hormone replacement therapy through a subscription model. Treatment starts at $119 a month and includes virtual doctor’s appointments, lab testing, messaging with clinicians and home-delivery of estrogen pills and testosterone injectables. Folx is available in 12 states and plans to expand across all 50 by the end of the year, according to founder and Chief Executive Officer A.G. Breitenstein. Folx also offers treatment for erectile dysfunction and plans to release sexual health offerings including a preventative HIV medication.

Initially concerned about the cost, Jean-Gilles said he received a year’s worth of free treatment as part of a grant program Folx offers to queer and trans individuals who can’t afford care. The company has pledged to award 75% of grants to the BIPOC community.

“Finally having the ability to take that step myself, after seeing so many trans people live their truths and seeing their journeys, it felt really amazing,” he said.

In a win for the trans community earlier this week the Biden administration reversed a Trump-era regulation that allowed health care workers, hospitals, and insurance companies that receive federal funding to refuse to provide or cover care for LGBTQ individuals. While activists applauded the move as a start to combat discrimination, many believe Congress must pass the Equality Act — which would expand civil rights laws to include sexual orientation and gender identity — to secure lasting protections.

Meacher, of Callen-Lorde, believes services like the startups are a step in the right direction. “If there is not a way to access healthcare in a way that is affordable and affirming, then people will find ways to do it outside of the health system and we very often see bad outcomes with ‘do-it-yourself’ methods,” he said. “There’s potential to do some real good here. For many in the queer and trans community this is life and death.”

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