Trans health care, already under attack, faces new obstacle with end of Covid public health emergency

As states across the U.S. introduce anti-trans legislation, transgender and nonbinary people face increasing restrictions in their ability to access gender-affirming care. Now experts say the government’s plans to end the Covid public health emergency on May 11 could further jeopardize the health and safety of trans people across the country.

“These targeted political attacks … are another public health emergency,” Crystal Beal, a physician and founder and CEO of telemedicine provider QueerDoc, said at a media briefing on Thursday. “Couple these with the end of the public health emergency, and more trans people will die.”

The most immediate concern with regard to the end of the public health emergency centers on changes to telehealth practices that could impact trans men and others who may take testosterone. During the pandemic, telehealth providers were permitted to prescribe gender-affirming prescriptions for testosterone due to the suspension of the Ryan Haight Act, which typically requires patients to make an in-person visit in order to receive a prescription for controlled substances. The Covid-era change gave more people access to testosterone via virtual appointments.

Now, as the end of the public health emergency approaches, the  Drug Enforcement Administration has proposed a rule that would allow clinicians to prescribe a drug like testosterone one time via telehealth, but then require patients to make an in-person visit after 30 days for a refill.

But finding adequate, in-person gender-affirming care can be difficult if not impossible in many parts of the country. In rural areas, trans people travel significantly farther than their urban counterparts for in-person care. While 9% of all transgender people travel 75 miles or more for gender-related care, in rural areas, almost a third of transgender people travel that far, according to data from the Movement Advancement Project.

“Imagine having to travel [that far] just to see your provider. That’s what is at stake here,” said Rodrigo Heng-Lehtinen, executive director of the National Center for Transgender Equality, which held the briefing on Thursday.

When trans people do arrive at in-person care appointments, they often face discriminatory or inappropriate treatment. Nearly half of trans people say their health-care providers know “not too much” or “nothing at all” about trans health, according to a recent survey by the Washington Post and the nonprofit KFF, and one in six say they’ve had a provider refuse to give them hormone treatments.

Heng-Lehtinen referred to the problem sometimes called “trans broken arm syndrome”: a trans person will seek care for an ailment completely unrelated to their gender, yet the provider insists on connecting the problem to hormones. It’s experiences like this that have made telehealth flexibility so important for trans people: Their options when it comes to providers are no longer restricted by how far they are able to travel.

“If you can find a provider who’s clinically competent, you’re much more likely to continue to show up in that care, to engage in your care, and to engage in your whole health, too,” said Dallas Ducar, the CEO of health care center Transhealth in western Massachusetts.

Ducar helped to found Transhealth, which offers both in-person and virtual care, with the goal of making care more accessible to people who live farther from major hubs like Boston. Yet since the pandemic, she has seen an increase in the number of patients from eastern parts of the state looking for telehealth from informed providers — a sign of just how much unmet demand there is even in more populated areas.

Recent research has shown the large majority of parents and young trans patients were satisfied with telehealth care provided during the pandemic.

Clinicians expect access to gender-affirming care to immediately decline with the expected requirement for more in-person examinations, according to Ducar. Requiring more in-person care means trans people will face the additional hurdle of spending even more money to access that care. In a recent survey from the Movement Advancement Project, nearly half of respondents who received gender-affirming care said they had spent $5,000 or more out-of-pocket, and one-third spent at least $10,000.

As automatic Medicaid re-enrollment ends with the public health emergency, many transgender people may also lose access to insurance. Transgender adults are more often uninsured and report more cost-related barriers to care than cisgender adults.

Experts worry about the “cascading effect of losing access to such vitally-needed health care,” said Heng-Lehtinen. Transgender adults and youth already consider and attempt suicide at higher rates compared to cisgender people.

The DEA has yet to finalize its proposed new rules for telehealth prescriptions of controlled substances. Public comments for the proposal close on March 31.

“The lack of access to affirming care steals hope, but telehealth could keep that hope alive,” said Debi Jackson, an activist and parent of a trans child, Avery, at the media briefing.

Jackson knows all too well how important such care can be. Studies show that gender-affirming care can have immense mental health benefits for adolescents.

“I didn’t need studies to tell me how beneficial it could be,” Jackson said. “I could see it in front of my own eyes.”

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