Increasing LGBTQIA+ Access to
Sexual and Reproductive Care with Telehealth
Telehealth can improve access for everyone, including lesbian, gay, bisexual, transgender, queer, intersex,and asexual+ (LGBTQIA+)1 people, to a wide range of sexual & reproductive health services – including
contraception, medication abortion, STI care, gender-affirming care (GAC), prenatal and postpartum care,and perimenopause and menopause care.2 However, obstacles remain that need to be overcome.

ÍTelehealth is safe, effective, and reliable, and has proven to be an
important tool for expanding access to health care in general, tospecific communities such as in rural areas, and especially during
the recent pandemic.3

Despite the safety and efficacy ofthese telehealth services, legislativeand insurance restrictions
obstruct access:ÍImplementing telehealth in GAC can increase access to careand improve provider knowledge and engagement.4 During theCOVID-19 pandemic, telehealth expansion helped mitigate delays inthe delivery of gender-affirming care.5ÍÍ

One study found that patients in general preferred telehealth forsexual and reproductive health care in a primary care setting, andespecially for contraceptive counseling.6

Bans on insurance coverage forabortion and GAC, including
under Medicaid, limit access anddisproportionately impact those
who already face significant
barriers to receiving quality care.

ÍAlthough proven to be safe andeffective, telehealth for medicationabortion care is increasingly
restricted by medicallyunnecessary state regulations. Asof October 2023, 20 states have
implemented either telehealthbans for medication abortion careor have in-person requirementsthat effectively serve as telehealthbans. In addition, many of thesestates have gestational age bansthat further limit access to care.11, 12

ÍProviders and LGBTQIA+ patients have both reported high levelsof satisfaction with HIV prevention and treatment services via
telemedicine, which has been proven to be an effective strategy for
expanding HIV care to rural or remote areas.7

ÍNotably, telehealth models for medication abortion care are equally
as safe as in-person models and could enable patients to accessabortion care earlier in their pregnancy.8, 9

ÍImplementing telehealth for gender-affirming care can increase
access to care and improve provider knowledge and engagement.10
This is especially important amidst ongoing political attacks onaccess to gender-affirming care.

PROBLEM:

LGBTQIA+ people encounter systemic inequities when navigating the U.S. health care system,
including discrimination, cost, and lack of trained providers.

More than 1 in 5 (23%) LGBTQI+ adults have
postponed or avoided medical care due todisrespect or discrimination by providers, including more than 1 in 3 (37%) transgender or
nonbinary individuals.13
ÍÍ

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In a recent survey, 88% of LGBTQ+ intersexrespondents reported experiencing
discrimination from a doctor or healthcare provider in the past year – including
refusal of care, harsh language, or physicalabuse.14
Intersex patients who have experienced
non-consensual surgery are over four times
more likely than other intersex patients todelay preventive and emergency healthcare due to mistrust of medical providers.15

LGBT individuals are more likely to be uninsured thannon-LGBT individuals, and 59% of LGBTQ people livein states that do not have LGBTQ-inclusive insurance
protections.16, 17Í

Multiple studies show that even with insurance,
LGBTQ adults are still more likely to report avoiding necessary medical care due to cost – and due
to fear of discrimination.18, 19, 20

ÍIntersex LGBTQ+ people are twice as likely as
non-intersex LGBTQ+ people to postpone or defer
necessary care due to cost in general.21ÍOnly two states ​​have Medicaid coverage of all
five key gender-affirming care services (GAC):
gender-affirming surgery, hormone therapy, voice/communication therapy, fertility services, andmental health counseling.221

Transgender youth face compounding barriers whentrying to access puberty blocking medications andgender-affirming hormones. Young people may facedifficulty finding local providers who are experts ingender-affirming care (GAC), or may not be able toaccess care in their state at all.

These obstacles are especially heightenedfor LGBTQIA+ people in rural areas, which
already face health care challenges such as
hospital closures and declining numbers ofproviders – especially for specialty services.
For example, transgender adults in rural
areas are over three times more likely thantransgender adults overall to have to travel
25 miles or more for routine care.23
Transgender, non-binary, and genderexpansive individuals face unique barriers
to accessing gender-affirming care,abortion, and contraceptives, including
cost, distance, lack of insurance, lack ofgender-affirming clinicians, misconceptions,and difficulty locating accurate
information.24, 25, 26

CONTEXT:As of October 2023, 22 states have passed banson gender-affirming care for youth, and 39 states
total have considered such bans.27, 28

ÍOne study found that transgender girls – and notably, Black and Latine transgender girls – experience greater barriers to care than transgenderboys: they were less likely to be insured, least
likely to have a medical provider, least likely to beout as transgender to a provider, and most likely
to report experiencing gender-based problems
with health care.29

Comprehensive sexual and reproductive health care is especially important for LGBTQIA+
communities as they often have a greater need for certain services than their heterosexual orcisgender counterparts.

LGBTQIA+ people, including
individuals who do not identify as
women, make up as many as 16%of U.S. abortion patients, despite
comprising only roughly 7% of theadult population.30, 31
ÍLesbian and bisexual cisgender women who have beenpregnant are more likely thanheterosexual cisgender women
who have been pregnant tohave had an abortion,32 and in
the U.S., about 500 transgender and nonbinary individuals
received abortions in a clinicalsetting over the course of ayear.33

ÍHowever, one study estimatedthat only 23% of all U.S. clinics
offering abortions also provided transgender-specific healthservices, meaning transgenderpeople who can get pregnant, including transgendermen, may have to see multiple
providers to fulfill their sexualand reproductive health careneeds.34

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ÍQueer cisgender women areless likely than heterosexualcisgender women to receive
clinical contraceptive
counseling.35, 36
ÍDuring the COVID-19
pandemic, queer cisgenderwomen were more likely
than heterosexual cisgenderwomen to report pandemicrelated delays or cancellationsof contraceptive or othersexual and reproductive
health care.37

Intersex people often struggle
to find providers who are willingto care for them:
Í55% of intersex respondents
had a health care providerrefuse to see them becauseof their sex characteristics orintersex variation, and 51%
of intersex respondents had
specifically been refused
family-formation care (suchas fertility care or assistedreproductive technology) for
these reasons.40

A national survey found that while 78% of transgenderindividuals wanted hormone therapy related to gendertransition, only 49% had ever received it.38
ÍFor transgender and gender diverse people living inrural areas, the barriers intensify: one study found that
25% of participants had no access at all to gender-affirming primary care, and about 10% had been refusedcare by a doctor.39

2

PROMISE:

Telehealth presents an opportunity to center equity in the delivery of sexual & reproductive
health care for LGBTQIA+ people to improve access to care and ensure that these communities
can make informed decisions about their lives.

During the COVID-19 pandemic,
increased telehealth use washigher among LGBT+ people
compared to non-LGBT+people.41 Notably, transgenderand non-binary individuals havehigher odds of using telehealthfor contraceptives versus
cisgender individuals.42

Transgender and gender-diverse people have reportedhighly positive perceptions of telehealth-delivered
gender-affirming care (TGAC), and improved access togender-affirming care via telehealth.44, 45 Specifically,transgender and gender-diverse youth and theircaregivers have found TGAC highly acceptable.

Many transgender, non-binary,and gender-expansive people
prefer medication abortion– which can be provided via
telehealth – to procedural
abortion, as they view it asless invasive, more private, andwithout anesthesia required.43

ACTION:ÍA survey looking at transgender youth found thatnearly half of participants expressed interest in receiving TGAC.46

ÍOne study found that more than 90% of both transgender patients and their caregivers thought thattelehealth was the same or better than in-person
visits for visit convenience, privacy, provider communication, and the ability of the provider to pay
attention and listen.47

Í

In one survey, 98% of transgender respondents usedtelehealth in 2022.48

There are concrete programmatic and policy changes that can increase health equity for
LGBTQIA+ individuals and expand access to sexual and reproductive health care via telehealth.

ADVOCATES AND POLICYMAKERS
ÍWork to expand telehealth, andto ensure telehealth is treated andcovered the same as in-person careto ensure full access for everyone,
including LGBTQIA+ people;

Í

Advocate for anti-discrimination
policies based on sexual orientation,
gender identity, and sex characteristics, as well as protections forpatient autonomy, particularly interms of access to reproductive andgender-affirming care given theongoing and escalating attacks onthese types of health care.

RESEARCHERSÍ

Study how LGBTQIA+
individuals are or are notusing telehealth to accesssexual and reproductive
health care, and to provide
evidence to support newinterventions that could
foster telehealth usagethat works for LGBTQIA+
patients.

TELEHEALTH PROVIDERSÍEnsure online forms areinclusive for sex assigned atbirth, gender identity, andsexual orientation;ÍEncourage providers to take
LGBTQIA+ health education
training as part of telehealthworkflow;ÍEnsure proper pronouns toidentify and interact withclients.49

BOTTOM LINE:
Telehealth has the potential to enhance sexual and reproductive health care access for LGBTQIA+
individuals if providers, programs, and policies prioritize equity in implementation.

RHITES.ORG31. While this fact sheet aims to use the most inclusive language to represent LGBTQIA+ communities, the acronym(s) change throughout the document to accurately represent theresearch and studies cited throughout.
2. KFF. Telemedicine in Sexual and Reproductive Health. November 2019.
3. Gajarawala, S. & Pelkowski, J. Telehealth Benefits and Barriers. The Journal for Nurse Practitioners. February 2021.
4. Stoehr, J., Jahromi, A., Hunter, E., & Schechter, L. Telemedicine for Gender-Affirming Medical and Surgical Care: A Systematic Review and Call-to-Action. Transgender Health. April
2022.
5. Kloer, C., Lewis, H., & Rezak, K. Delays in gender affirming healthcare due to COVID-19 are mitigated by expansion of telemedicine. February 2023.
6. Srinivasulu, S., Maze, M., & Jones, H. “I totally didn’t need to be there in person”: New York women’s preferences for telehealth consultations for sexual and reproductive healthcarein primary care. Family Practice. April 2023.
7. Rogers, B., Sutten Coats, C., Adams, E., Murphy, M., Stewarts, C., Arnold, T., Chan, P., & Nunn, A. Development of Telemedicine Infrastructure at an LGBTQ+ Clinic to Support HIV
Prevention and Care in Response to COVID-19, Providence, RI. AIDS and Behavior. April 2020.
8. Grossman, D. & Grindlay, K. Safety of medical abortion provided through telemedicine compared with in person. Obstetrics & Gynecology. October 2017.
9. Chong, E., Shochet, T., Raymond, E., Platais, I., Anger, H.A., Raidoo, S., Soon, R., Grant, M.S., Haskell, S., Tocce, K., Baldwin M.K., Boraas, C.M., Bednarek, P.H., Banks, J., Coplon, L.,
Thompson, F., Priegue, E., & Winikoff, B. Expansion of a direct-to-patient telemedicine abortion service in the United States and experience during the COVID-19 pandemic. Contraception. March 2021.
10. Stoehr, J., Jahromi, A., Hunter, E., & Schechter, L. Telemedicine for Gender-Affirming Medical and Surgical Care: A Systematic Review and Call-to-Action. Transgender Health. April
2022.
11. Guttmacher Institute. Interactive Map: US Abortion Policies and Access After Roe. June 2023.
12. Guttmacher Institute. State laws and policies: medication abortion. March 2023
13. Center for American Progress. Discrimination and Barriers to Well-Being: The State of the LGBTQI+ Community in 2022. January 2023.
14. Center for American Progress. Key Issues Facing People With Intersex Traits. October 2021.
15. Wang, J., Dalke, K., Nachnani, R., Baratz, A., & Flatt, J. Medical Mistrust Mediates the Relationship Between Nonconsensual Intersex Surgery and Healthcare Avoidance AmongIntersex Adults. Annals of Behavioral Medicine. August 2023.
16. Gallup. In U.S., LGBT More Likely Than Non-LGBT to Be Uninsured. August 2014.
17. Movement Advancement Project. Equality Maps: Healthcare Laws and Policies. June 2023.
18. Nguyen, K., Trivedi, A., & Shireman, T. Lesbian, Gay, And Bisexual Adults Report Continued Problems Affording Care Despite Coverage Gains. Health Affairs. August 2018.
19. KFF. Update on Medicaid Coverage of Gender-Affirming Health Services. October 2022.
20. Casey, L., Reisner, S., Findling, M., Blendon, R., Benson, J., Sayde, J., & Miller, C. Discrimination in the United States: Experiences of lesbian, gay, bisexual, transgender, and queer
Americans. Health Services Research. October 2019.
21. Center for American Progress. Key Issues Facing People With Intersex Traits. October 2021.
22. KFF. Update on Medicaid Coverage of Gender-Affirming Health Services. October 2022.
23. Movement Advancement Project. Where We Call Home: Transgender People in Rural America. November 2019.
24. Fix, L., Durden, M., Obedin-Maliver, J., Moseson, H., Hastings, J., Stoeffler, A., & Baum, S. Stakeholder Perceptions and Experiences Regarding Access to Contraception and Abortion for Transgender, Non-Binary, and Gender-Expansive Individuals Assigned Female at Birth in the U.S. Archives of Sexual Behavior. May 2020.
25. El-Hadi, H., Stone, J., Temple-Oberle, C., & Robertson Harrop, A. Gender-Affirming Surgery for Transgender Individuals: Perceived Satisfaction and Barriers to Care. Plastic Surgery. November 2018.
26. Gridley, S., Crouch, J., Evans, Y., McCarty, C., Ahrens, K., & Breland, D. Youth and Caregiver Perspectives on Barriers to Gender-Affirming Health Care for Transgender Youth. Journal of Adolescent Health. May 2016.
27. Movement Advancement Project. BANS ON BEST PRACTICE MEDICAL CARE FOR TRANSGENDER YOUTH. October 2023.
28. Movement Advancement Project. LGBTQ POLICY SPOTLIGHT: BANS ON MEDICAL CARE FOR TRANSGENDER PEOPLE. April 2023.
29. BU School of Public Health. Gender Identity, Race Intersections ‘Really Matter for Access to Healthcare.’ June 2023.
30. Guttmacher Institute. As Many as 16% of People Having Abortions Do Not Identify as Heterosexual Women. June 2023.
31. Gallup. U.S. LGBT Identification Steady at 7.2%. February 2023.
32. Human Rights Campaign. Human Rights Campaign Fact Sheet: Lesbian, Bisexual, Queer Women Who Have Been Pregnant Are More Likely to Need Abortion Services; Demonstrates Impact Roe Reversal Would Have on LGBTQ+ People. June 2022.
33. Jones, R., Witwer, W., & Jerman, J. Transgender abortion patients and the provision of transgender-specific care at non-hospital facilities that provide abortions. Contraception.
January 2020.
34. Ibid.
35. Everett, B., Higgins, J., Haider, S., & Carpenter, E. Do Sexual Minorities Receive Appropriate Sexual and Reproductive Health Care and Counseling? Journal of Women’s Health.
January 2019.
36. Agénor, M., Pérez, A., Wilhoit, A., Almeda, F., Charlton, B., Evans, M., Borrero, S., & Bryn Austin, B. Contraceptive Care Disparities Among Sexual Orientation Identity and Racial/Ethnic Subgroups of U.S. Women: A National Probability Sample Study. Journal of Women’s Health. October 2021.
37. Lindberg, L., VandeVuss, A., Mueller, J., & Kirstein, M. Early Impacts of the COVID-19 Pandemic: Findings from the 2020 Guttmacher Survey of Reproductive Health Experiences.
Guttmacher Institute. June 2020.
38. American Medical Association. Health insurance coverage for genderaffirming care of transgender patients. March 2019.
39. Almazan, A., Benyishay, M., Stott, B., Vedilago, V., Reisner, S., & Keuroghlian, A. Gender-Affirming Primary Care Access Among Rural Transgender and Gender Diverse Adults inFive Northeastern U.S. States. LGBT Health. January 2023.
40. Center for American Progress. Advancing Health Care Nondiscrimination Protections for LGBTQI+ Communities. September 2022.
41. KFF. The Impact of the COVID-19 Pandemic on LGBT+ People’s Mental Health. August 2021.
42. Lindberg, L., Mueller, J., Haas, M., & Jones, R. Telehealth for Contraceptive Care During the COVID-19 Pandemic: Results of a 2021 National Survey. American Journal of Public
Health. June 2022.
43. Moseson, H., Fix, L., Ragosta, S., Forsberg, H., Hastings, J., Stoeffler, A., Lunn, M., Flentje, A., Capriotti, M., Lubensky, M., & Obedin-Maliver, J. Abortion experiences and preferencesof transgender, nonbinary, and gender-expansive people in the United States. American Journal of Obstetrics and Gynecology. April 2021.
44. Apple, D., Lette, E., Wood, S., Freeman Baber, K., Chuo, J., Schwartz, L., Petsis, D., Faust, H., & Dowshen, N. Acceptability of Telehealth for Gender-Affirming Care in Transgenderand Gender Diverse Youth and Their Caregivers. Transgender Health. April 2022.
45. D’Angelo, A., Argenio, K., Westmoreland, D., Appenroth, M., & Grov, C. Health and Access to Gender-Affirming Care During COVID-19: Experiences of transmasculine individuals
and men assigned female sex at birth. American Journal of Men’s Health. November-December 2021.
46. Sequeira, G., Kidd, K., Coulter, R., Miller, E., Fortenberry, D., Garofalo, R., Richardson, L., & Ray, K. Transgender Youths’ Perspectives on Telehealth for Delivery of Gender-Affirming
Care. Journal of Adolescent Health. June 2021.
47. Apple, D., Lett, E., Wood, E., Freeman Baber, K., Chuo, J., Schwratz, L., Petsis, D., Faust, H., & Dowshen, N. Acceptability of Telehealth for Gender-Affirming Care in Transgenderand Gender Diverse Youth and Their Caregivers. Transgender Health. April 2022.
48. Rock Health. Consumer adoption of digital health in 2022: Moving at the speed of trust. February 2023.
49. HHS. Telehealth for LGBTQ+ Patients. May 2023.

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