mHealth for transgender and gender-expansive youth: an update on COVID, venture capital, and the cultural in/congruence of revenue-driven sustainability models

Abstract

Interactive communications technologies (ICTs) are key sites of self-discovery, community formation, health education, and creative expression among the 0.7-3.2% of young people who identify as transgender and genderexpansive (TGE). mHealth interventions intended for TGE users are situated within-and, increasingly, informed bythis rich online milieu. ICTs permit socially isolated users to transcend the limitations of their physical environments, in which TGE social bonds, gender-affirming hormone therapy (GAHT) providers, or physical safety, may be lacking. This is particularly true of TGE youth, who may lack autonomy or in-person support (1). A diverse, innovative range of ICT interventions serves the genderaffirmation needs of TGE users. As noted by Skeen et al. (1), these interventions can be classified along distinct lineages: (I) academic medicine, often via NIH-funded clinical trials; (II) human-computer interaction, user experience (UX) design, and adjacent subfields; and (III) TGE-led community technologies, often developed via hackathons and crowdfunding.Since the initial, July 2020, publication of that scoping review (1), upheavals have occurred within TGE mHealth, with implications for mHealth self-sustainability, broadly. Most can be traced to the COVID pandemic, which disproportionately burdened marginalized subpopulations. Jarrett et al. surveyed transgender and nonbinary respondents across 76 countries from April-August 2020, 55% of whom reported diminished access to gender-affirming care due to the pandemic; 38% were less able or unable to live in accord with their genders at all (2). In the U.S., the Centers for Disease Control and Prevention recommended the suspension of in-person appointments. Federal regulations that had restricted reimbursement for telehealth services and barred cross-state practice were relaxed (3,4). These changes vastly expanded access to telemedicine, permitting TGE young people to access primary care, counseling, and GAHT initiation virtually, or via hybrid models of care, typically extensions of established providers (3,4). Presently, telehealth cannot replace key aspects of in-person (particularly presurgical) consultation (3), which most TGE youth prefer for GAHT initiation (4). And an "either/or" approach to such questions overlooks the possibility of telehealth-supported specialist consultations and similar hybrid models (4). Emerging evidence shows promise in the acceptability, usability, patient satisfaction, and cost-effectiveness of gender-affirming telehealth, particularly among TGE youth who feel unsupported by their parents (3,4).Where TGE eHealth in the COVID era departs most radically from the past is in its abrupt, recent, turn toward venture capital (VC)-backed commercialization. Exemplifying this turn are the telehealth services Folx and Plume. Forgoing any brick-and-mortar presence, both offer GAHT initiation, maintenance (4), and wraparound care tailored for sexually and gender-diverse patients, Letter to the Editor

Adapting mHealth Interventions (PrEPmate and DOT Diary) to Support PrEP Retention in Care and Adherence Among English and Spanish-Speaking Men Who Have Sex With Men and Transgender Women in the United States: Formative Work and Pilot Randomized Trial

“…Although most technology-based HIV prevention tools being developed have focused on MSM, a few mHealth interventions have been tailored specifically for transgender women. In a cross-disciplinary scoping review of mobile technology interventions to improve HIV prevention and care in transgender and gender diverse youth, Skeen and Cain [ 49 ] highlighted the importance of gender affirmation as a key social determinant of health for transgender youth, and several interventions have been guided by the gender-affirmative framework [ 50 ], which centers the interactive process in which a person receives social recognition and support for their gender identity and expression. In this review, behavioral self-monitoring and access to HIV prevention services were the most frequent features across disciplines.…”

Protocol for a scoping review of literature on digital sexual, reproductive, and gender health care for LGBTQI+ youth

“…1) information delivered online on websites (e.g., World Health Organisation [WHO], 2022; Magee et al, 2012) or through online education programmes (e.g., Mustanski et al, 2015;Lacombe-Duncan et al, 2021); 2) advice and support online which may involve use of telecommunication such as video calls, live chats, email, or text services with charity or community-based organisation staff or peers (e.g., Radix et al, 2022;Skeen & Cain, 2022); and 3) clinical care provided online, such as STI/HIV self-sampling kits and test results (e.g., Bauermeister et al, 2015;Estcourt et al, 2017;Hottes et al, 2012;Ling et al, 2010;Brugha et al, 2011);PrEP (ePrEP;Kincaid et al, 2021); partner notification (PN) and testing options (e.g., Golden et al, 2022;Flowers et al, 2021;Mimiaga et al, 2008); and consultations (eConsult) and telemedicine (e.g., Sequeira et al, 2021;Lucas et al, 2023).…”