(032) Direct-to-Consumer Telemedicine Companies Offering Gender Affirming Hormone Therapy
Authors: Jesse E , Dubin J , Basti N , Ramchandra J , Gupta S , Bowen D , Brannigan R , Bennett N , Halpern J , Thirumavalavan N 
Published: May 2023

Abstract

Introduction
As direct-to-consumer telemedicine (DTCT) companies increase virtual services for gender affirming medical therapy, examination of platform practices is essential to ensure the field’s standard of care is being met and cost-effective care is being offered. This is especially important considering the reduced access to care and potentially increased vulnerability of the gender-diverse population.

Objective
We aimed to describe the gender care services offered by DTCT companies for gender affirming medical therapy and to compare them to the current standards of care. We also compared the associated costs of each platform with those that may be encountered for similar care at a tertiary care center.

Methods
Google was queried in March 2022 to identify DTCT platforms offering gender affirming medical therapy. Platforms based outside the US were excluded. Websites were reviewed for information regarding the transgender affirming medical therapy and associated costs. Using a single institution’s online cost estimator, pay-per-service costs for similar care was estimated at a tertiary care center for a patient without insurance, with private insurance, and with Medicaid. The estimated costs for the first year of therapy with either oral estradiol or intramuscular testosterone were calculated and compared between each platform and the tertiary center. Services provided by DTCT platforms were also compared to those recommended by the World Professional Associated for Transgender Health (WPATH) Standards of Care, Version 7.1.

Results
Six transgender care DTCT platforms were identified: Folx, True U Clinic, QueerDoc, Queer Med, Trans Clinique, and Plume. All platforms offered gender affirming hormone therapy and several other gender care services (Table 1). All platforms utilized an Informed Consent Model for gender affirming therapy. None of the platforms offered mental or behavioral health services. Laboratory assessments for treatment monitoring were recommended at least quarterly upon treatment initiation, and typically reduced in frequency with ongoing care. Several platforms offered monthly membership payment plans ranging from $59 - $139/month and varying in service inclusion, while other platforms offered pay-per-service plans. The estimated first-year cost for initiation of hormone therapy via the DTCT platforms without insurance ranged from $1,022 to $1,428 for oral estradiol therapy and $1,184 to $1,668 for intramuscular testosterone therapy. In comparison, estimated first-year costs for estrogen and testosterone therapy at the tertiary center without insurance were $1,184 and $1,216, respectively (Figure 1). Estimated first-year costs were lower for a patient at the tertiary center with private insurance or Medicaid.

Conclusions
DTCT companies offer virtual care for gender affirming medical therapy for transgender, non-binary, and intersex people. Platforms utilized an Informed Consent Model and regular follow up with laboratory assessment, practices which appear to be consistent with the guidelines presented by WPATH. For patients without insurance, the first-year costs of gender affirming hormones are similar through DTCT platforms and a tertiary care center. There is a likely a cost benefit in receiving care through a tertiary center for patients with private insurance or Medicaid. DTCT companies can greatly expand access to transgender and gender affirming care.

Disclosure
No