by Guest Contributor Michael Hoeben * He/Him/His, Trans/HIV Bridge & Retention Coordinator, Western North Carolina Community Health Services
Critchfield’s (2020) article highlighting the benefits of leveraging telehealth to optimize transgender (“trans”) patient care experiences and overall access to life-saving hormone replacement therapy (HRT) offered an excellent snapshot of the potential for telehealth to transform modern medicine. As a trans man, I have dealt with the same issues detailed in this discussion, including being laughed at by my provider during a vaginal exam and foregoing doctor visits altogether simply to avoid the anxiety of navigating an often discriminatory health system. As Clapp stated, there is certainly “room for telehealth” in best meeting the needs of “some marginalized populations.” Furthermore, as Weschler articulated, telehealth should be “a small part of a larger shift in the ecosystem of access for transgender folks nationally,” which is why I feel it appropriate to weigh in on behalf of the role that Federally Qualified Health Centers (FQHCs) play in reducing health disparities and inequities for the entire family of marginalized persons and populations.
My name is Michael Hoeben. I am a transgender man currently privileged to serve as the Transgender/HIV Bridge & Retention Coordinator at Western North Carolina Community Health Services (WNCCHS) where I have been a patient since 2014. Located in Asheville, NC, WNCCHS is an FQHC that is well-known regionally for offering high-quality, culturally competent transgender health services since 2007. Under current COVID-19 constraints, WNCCHS has also implemented telehealth services, as we anticipate telehealth will likely redefine the future of healthcare delivery, particularly in revolutionizing our ability to care for rural patient populations who face similar barriers to both our trans and HIV positive patients. Personally, I am ecstatic that Plume exists and even more invigorated by the fact that trans-centered services are gaining mainstream use and acceptance; at the same time, there are two major factors that emphasize the importance of FQHCs in closing the trans-competent care gap, including costs and impact.
First, at a price tag of $120/month, Plume is undoubtedly a feasible choice for many trans, nonbinary, and gender nonconforming persons seeking medical transition resources. However, there are those for whom this cost is a symptom of a broken system wherein cash dictates care. WNCCHS currently has list of 420+ active trans patients, nearly 90% – yes, 90% – of whom have incomes equal to or less than 200% of the federal poverty level (FPL). For many trans patients, FQHCs are the only affordable option for accessing HRT, as the core FQHC mission is to provide safe, effective, quality healthcare to all patients regardless of patient ability to pay.
To illustrate, WNCCHS uses a sliding fee scale to determine per visit cost. For instance, an uninsured trans patient earning less than $12,500 will pay about $10 per visit (labs included). While hormone costs vary according to market prices, our on-site pharmacy provides affordable drug prices for both insured and uninsured patients (My last 3-month supply of HRT cost about $50. Also, WNCCHS recently launched the TRANSition Assistance Program (aka “TAP) to cover HRT co-pays and costs with syringes kits provided free of charge by our local community partner, Tranzmission, to further minimize the economic burden of medical transition. In short, considering the employment and economic inequalities affecting the trans community, cost is, unfortunately, a significant determinant of transitioning options, which is why FQHCs are so integral to protecting and promoting the physical and psychological welfare of the entire LGBTQ+ spectrum, as well as ensuring the wellbeing of other marginalized groups, including undocumented persons, people living with HIV (PLWH), and so on.
Second, and most important, is the issue of impact. Plume’s scope is clearly limited to HRT services, which is undeniably crucial, but inadequate in meeting total human health needs. As a trans man, I would forfeit food to make sure my HRT was not disrupted; so, I entirely get that Plume provides an invaluable piece of the trans care puzzle. Still, there are risks in solely prioritizing HRT, as trans people are human beings requiring access to affordable whole person-centered primary care. Like Plume, WNCCHS uses an informed consent model for HRT initiation, which means that trans adults benefit from same-day access to reduced cost HRT, as previously noted. Additionally, trans patients also have access to primary, dental, and behavioral health services, which means they can receive HRT, be tested and treated for sexually transmitted infections, complete their annual exams and screenings, get their teeth cleaned, and receive mental health counseling at a single site using the same sliding fee scale approach. WNCCHS similarly recognizes the value of transgender representation and thus employ trans and queer providers and staff as part of our unflinching commitment to empowering diversity and inclusion in all its facets.
Simply stated, the message to my trans sisters, brothers, and others is this: HRT may be vital to your care, but do not forget that HRT is one element of the total health equation. You are a human being and, like all human beings, deserve access to preventative and comprehensive healthcare.
Like telehealth-based HRT, WNCCHS’s hybrid healthcare model is paramount in shifting the national health system and in striving towards the realization of healthcare as a fundamental human right. This process of progress, like the individual transition journey, is one that requires perseverance and resilience. Mistakes will be made along the way and WNCCHS is far from perfect in always meeting trans patient needs – but we try and we strive to do and to be better. In doing this work, as a transgender man, husband, and father, I have a profound respect for walking this path together, as my and my child’s safety, security, and quality of life are inextricably tied to societal transformation. Effectively addressing the root causes of trans patients’ healthcare-related distress demands authentic inclusion and compassionate care in telehealth and traditional healthcare settings.
My hope is that the efforts of WNCCHS and other FQHCs are understood as a positive driver of this much-needed social change, as it is in this exposure to the unfamiliar and unknown, in having these conversations and contacts, that those outside of the LGBTQ+ community are also transformed. Again, I openly applaud and celebrate Plume, as I am deeply proud of my people; but I also ask that we not overlook or diminish the role of community-based health centers in this shared struggle for greater healthcare equality and equity.