By August, Felicity Giles knew it was time. Her happiness was long overdue. The 36-year-old trucker changed her name, adopted the middle name Saoirse—freedom in Gaelic—and started looking into transitioning medically. “It was an attempt to break from who I was and who I grew up as,” she told me on the drive to her trucking company’s office. At the start of 2021, she spent weeks calling Planned Parenthoods in Fort Worth, Texas, where she and her spouse live. But the pandemic meant waitlists were backlogged for months, forcing Felicity to wait at least until March for a consultation and likely longer to begin taking estrogen. She “called them every day” and still couldn’t get on the waitlist.
Scrolling through Twitter one night, Felicity read about Plume, a new subscription telehealth service that makes it easier for trans people to access hormones, lab work, and letters for surgeries and name changes. Three days after she paid the $99-per-month subscription fee, Felicity met by video with a team of clinicians. They asked her a few questions and chatted about hormone replacement therapy (HRT) options. Later that day, Plume connected her with a local physician who prescribed her estrogen and dutasteride, a testosterone blocker. That night, Felicity picked up her first dose.
Plume is one of dozens of telehealth services catering to trans clients that have cropped up in the last two years. It’s a niche market aimed at eliminating the barriers trans people face to accessing healthcare. According to a 2015 study, a third of trans people report that health care providers have harassed them or denied them treatment on the basis of their gender identity.
Trans telehealth services believe they can change that—and turn a profit. Unlike federally subsidized brick-and-mortar clinics, these digital outfits are backed by venture capital, which sees a lucrative opportunity in the pandemic-driven telemedicine boom. Everyone is trying to cash in, from Amazon’s recent investments in health care startups to Apple’s attempts to build its own primary care service.
Plume launched in 2019 with $14 million from funders like Craft Ventures, a backer of Elon Musk’s SpaceX; it’s available in 33 states. Folx picked up $25 million from firms including Bessemer Venture Partners, a backer of Pinterest, LinkedIn, and Yelp—it’s offered HRT in 17 states since January and is expanding to include skin- and hair-care products. Euphoria, a suite of health, finance, and transition-tracking apps promoted as the “Adobe equivalent” for transition, has garnered more than $250,000 from major funders like Chelsea Clinton.
Each of these services has crowned itself the “first” in trans telehealth. All have trans or nonbinary CEOs, and Folx and Plume boast numerous trans clinicians on staff. Their websites are sleekly designed and millennial-minded; their social media pages feature photos and videos of trans influencers against soft pastel backgrounds, sharing stories of body autonomy and trans joy.
A.G. Breitenstein, Folx’s CEO, says services like hers allow “our community to access health care privately and not have to walk through the gantlet of what we know will be a trans-focused attack on health care services.” But these services are expensive, and while patients’ insurance may cover the cost of medication, none of the startups accepts insurance toward subscription fees. Breitenstein argues Folx’s model makes it “more patient-centric,” enabling it to provide supplies and resources that might not be covered by insurance; Folx will soon expand its offerings to include skin-and hair-care products and STI kits, and already provides the generic version of the HIV preventative PrEP at $90 a month.
Both Folx and Plume operate under the “informed consent” model, in which patients have greater autonomy over their hormone use and dosage. Informed consent, adopted as a standard in 2011 by the World Professional Association for Transgender Health, still isn’t the norm across the United States. In many states, trans people must first seek out mental health evaluations in order to secure hormones; until 2013, the American Psychiatric Association classified gender dysphoria as a mental disorder.
“We knew that folks needed care who weren’t getting it, period,” says Jerrica Kirkley, co-founder of Plume, half of whose clients are uninsured. “And this was a way that [we] could do that in an extremely efficient way, versus training every health care provider…This is a way to push the edge of policy, push the edge of culture.” Trans telehealth does seem in many ways like a next logical step given the state of health policy today. And, I have to admit, it has crossed my mind to try it.
But not everyone sees the services as revolutionary, citing price tags—Plume’s $99-per-month fee is typical—suggestive of a focus on profiting from those who can shoulder the cost, rather than dismantling the conditions that push many trans people toward concierge telemedicine in the first place. (That $99 doesn’t include the cost of testosterone or estrogen, which Plume clients must buy from local pharmacies.)
Last fall, University of Minnesota PhD student Qui Alexander was approached by Plume to become a “community collaborator.” Looking at the company’s website, they saw the familiar face of a clinician who had once prescribed them testosterone. Alexander crowdfunded their top surgery and receives hormone therapy through university insurance; they turned down the offer, questioning whether these services could ever be sufficiently accessible and affordable, particularly to Black and brown trans people. “I wonder what it would look like to have an anti-capitalist resource center to help get people basic things that they need to [live] as trans people,” they say.
Trans activist Dean Spade is the author of Mutual Aid, a 2020 book on community care as a driver of social change. Spade envisions a model of trans health that “starves all the systems because we’re providing everything for each other,” he says, rather than relying on “medical and legal systems that want to tell us who we are, and how we can become legitimate in their eyes.”
Historically in the United States, trans health innovations were locked behind university doors. In the 1960s, Reed Erickson, a wealthy trans man, helped fund the country’s first gender clinic at Johns Hopkins and supported doctors—like Donald Laub at Stanford’s Gender Dysphoria Program—who assisted with name changes and helped patients access HRT and gender-affirming surgeries. But getting an appointment at Stanford’s program was difficult: hopeful patients had to fill out an exhaustive 14-page exam (with a No. 2 pencil only) that asked intimate questions about their sex lives, as well as seemingly unrelated ones on military experience, religion, and family gender roles. The exam was essentially used to deterimine whether patients were ready to fulfill the role of upstanding heterosexual citizens. Trans writer and activist Lou Sullivan was rejected from the program—he suspected, he wrote in his diaries, because he was gay, and there wasn’t yet mainstream documentation of gay trans men.
It’s no wonder, given the myriad barriers to entry, that trans people—then and now—have taken health care into their own hands. Alongside the pandemic rise of telehealth, there’s been a renewed wave of support for t4t care: shorthand from the era of Craigslist personals ads that’s come to connote care by and for trans folks. Two trans people in love—that’s t4t. Community-funded mutual aid like needle exchanges, chest binder drives, microgrants—that’s t4t too. One of the largest such projects, the New York–based For the Gworls, has raised over $1 million toward rent and surgeries for Black trans people. Such efforts expand on a history of trans mutual aid dating back at least to STAR, the 1970s safe house for trans women set up by activists Marsha P. Johnson and Sylvia Rivera.
Trans health care has always been a “patchwork system,” says Erikx DiSantis, a 34-year-old transmasculine film producer in Los Angeles. “This is really leaning into the long history of trans health care, which has primarily existed outside of federal- or state-sanctioned care,” they say. “You think back to trans folks getting hormones from friends, or on the street, or through veterinary means.”
Or through underground clinics. In 2001, two trans women in Olympia, Washington, one of whom was a doctor, launched an orchiectomy clinic in a repurposed barn. Inspired by Jane, a Chicago collective of pre-Roe abortion providers, they charged about $500, enough to cover rent—and a fifth of the typical cost to safely remove trans women’s testes. Today, crowdfunding for surgeries, hormones, and living costs is ubiquitous. Reddit, Instagram, and TikTok posts serve as de-facto guidebooks to finding gender- affirming surgeons.
For Felicity, whose insurance covers her HRT, Plume was well worth the $99 a month. Two months after she began HRT, the Federal Aviation Administration ordered her to submit a new medical certificate proving estrogen wouldn’t affect her competence as a recreational pilot. (“To put this really bluntly,” Felicity says the FAA essentially asked her, “Are you insane?”) She reached out to Plume, and her doctor quickly wrote an explanatory letter. Within a week, her certificate was updated and she was back in the air. (Since then, her spouse has started receiving hormones through Plume, too.)
And for Jasmine Lee, a Boston-based software developer, trans-run telehealth has meant more than just quickly accessing hormones—it’s helped bridge an educational gap with her primary care doctor, who had no experience with trans patients. After six months, when Lee could no longer afford Plume’s monthly fee, her Plume clinician was able to teach her primary doctor about transfeminine health, allowing her to continue with HRT. Jasmine’s doctor “didn’t know anything about it,” she tells me. “She was unable to do anything until I met with a doctor that specialized in HRT…so that she felt she was giving the best care possible.”
Although they’re skeptical of the current offerings, Nix Searcy, a 32-year-old data scientist, believes trans telehealth—done right—has “potential to be revolutionary” for accessing HRT. She thinks of Free the Pill, a nonprofit project advocating over-the-counter birth control, or Nurx, a sexual telehealth firm that accepts insurance, as road maps for transforming trans health. Everywhere they’ve lived, Searcy has faced difficulty getting estrogen. Sometimes she went to Planned Parenthood; other times, the cheapest, most reliable route was the gray or black market. There are websites that ship a variety of hormones and blockers to the US from as far as India, Russia, Turkey, and Vanuatu. For trans people taking hormones, irregular access can sometimes lead to larger health issues. While Searcy appreciates the services’ potential, she can’t help feeling that they’re cashing in on a vulnerable demographic. “If I’m trying to make a buck off of my trans friends,” they say, “I don’t think that’s t4t.”
Chris Barcelos, a professor of women’s, gender, and sexuality studies at the University of Massachusetts, Boston, characterizes concierge telemedicine as a form of “complicit care.” The firms provide “a needed service that is responding to really significant inequalities,” Barcelos says, but if they’re “not also dismantling the violence and inequality that trans people experience in the world and in health care more generally, then that’s ensuring a need for them.”
Even as for-profit telehealth provides care by trans clinicians for trans people, Barcelos cautions that apps that track gender transition metrics, for example, implicitly push us toward the “unmarked white category of gender,” potentially shaping our—trans people’s—conception of gender as a “stable and knowable” final destination that implicitly prioritizes white, cis-normative assimilation. “Venture capital,” they say, “is not part of our collective liberation.”
The marketing for Folx and Plume begs to differ. On a recent drive around East Hollywood, I spotted glossy, matte posters for Folx featuring many a familiar face—the numerous hot trans and queer influencers who pepper my Instagram feed, including a friend’s colleague. Online, I see a video of Folx’s New York subway ads: “You don’t conform to the binary. Your healthcare shouldn’t either.” The copy is snappy, borrowing phrases from queer and trans liberation movements.
Breitenstein has acknowledged that not everyone can afford a Folx subscription—$59 to $139 monthly, depending on the hormone type and stage of HRT —but says growth will help reduce costs: “The bigger we get, the more commercial power we have, and then we can demand lower prices.” Using donations, the company has begun to subsidize some trans folks for a year of hormones. So does Plume, which is partnering with For the Gworls, the mutual aid collective, to raise money for a similar program. It plans to fund 1 to 2 percent of applicants. Some online critics have jokingly called these efforts “HRT sweepstakes”:
Just saw someone doing a giveaway for 3 free months of HRT through folx like how do y’all sleep?
— Ex_Wife_Material (@thepplsbottom) June 12, 2021
If it’s going to maintain a foothold in the world of health care startups, trans telehealth will have to stay profit-driven—and if the country’s health care system becomes less of a traumatic and confusing maze for trans Americans, concierge telehealth options will lose their radical sheen. In the best-case scenario, the simple existence of trans-led telehealth will translate to easier hormone access across the board, vital education for doctors treating trans patients, and a shift of the medical needle towards trans bodily autonomy.
Still, certain forms of care—the lifegiving, day-to-day work of survival, separate from private or public medicine—can’t be replicated by telemedicine, no matter how tech or culturally savvy. When trans folks share extra hormones or chest binders, take care of each other after surgeries, celebrate moments of gender euphoria, and see one another for who we are, our truest, most beautiful selves, it’s a reminder that trans care, this boundless and ongoing project to stay alive, has always come from our community—for free.