In the face of threats to medication abortion, reproductive care and gender-affirming health care, telemedicine providers are lifelines for many patients.
Providers of reproductive and gender-affirming care have long been pushing for an increase in the use of telemedicine. Patients want it too: telehealth implementation comes with decreased costs, wait times and travel. For stigmatized issues like abortion and gender-affirming care, it also ensures patients and providers alike face less harassment, and makes niche treatments more widely accessible.
To understand the telehealth landscape and how it impacts reproductive care, Ms. spoke with telehealth abortion, contraceptive, and gender-affirming care providers about how the pandemic and the fall of Roe have affected their work.
“The pandemic moved us like 10 years ahead of where we would have been otherwise, which I like to think [is] one of the very few things that’s good that came out of the pandemic,” said telehealth abortion care provider and Certified Nurse-Midwife Leah Coplon. But thanks to the overturning of Roe last June, advocates note that restrictions on telehealthcare are coming back into play.
Post-Roe and post-Trump, reproductive and LGBTQ+ healthcare has been further restricted and stigmatized. In a record-setting uptick, at least 200 anti-LGBTQ+ bills were introduced in state legislatures across the country in 2022, many of which target access to gender-affirming care for trans youth (and adults, in some cases). More than 635 anti-abortion bills have been introduced in the past decade alone. But in places where that healthcare is still protected, the COVID-19 pandemic has had a surprisingly positive impact on its accessibility. The necessity of social distancing loosened restrictions on telemedicine, and in many cases, those restrictions are not being put back into place.
Telehealth Abortion Care
The Guttmacher Institute reports that, in 2017, medication abortions accounted for 39 percent of all abortions performed. By 2020, medication abortion usage accounted for 53 percent.
Coplon attributes the rise in telehealth medication abortions to COVID, but the continued use of it, she says, “is due to people’s understanding and acceptance, and also providers being more comfortable with providing pills without having the testing that we prior thought we needed.”
She would know. Since 2016, Coplon has been part of a coalition of researchers, lawyers and other clinicians looking at telehealth medication abortion and ways to increase access to telehealth services. She now serves as the director of clinical operations at Abortion on Demand.
In 2018, state policies enacted to support reproductive health were almost triple the number restricting reproductive healthcare. It was the first year in at least two decades where protections outpaced restrictions.
Restrictions were eased even more when the COVID-19 pandemic made social distancing necessary, and lawmakers loosened restrictions, allowing more healthcare to be practiced online via telehealth. However, the landscape completely changed again in June of this year when the Supreme Court overturned the longstanding precedent of Roe in their Dobbs decision. Now, 18 states have abortion bans, 14 of which are total or near total. Eight other states have abortion bans on the books that are currently blocked, and there has been a push from anti-abortion groups to rescind access to telehealth medication abortions altogether.
Telemedicine abortion has many benefits beyond preventing the spread of COVID-19—which may be why anti-abortion groups have been so quick to target it. Telehealth can make abortions more accessible for those who want and need them, and they tend to be cheaper and easier to schedule quickly. Even before Roe’s fall, patients would sometimes have to travel out of state or drive hours to the only abortion clinic in their state. Now, people living in states with bans must travel an average of 276 miles each way. States without bans have seen a swell of out-of-state patients seeking legal abortions. Bloomberg News estimated Illinois could face an 8,000 percent increase in abortion seekers. Planned Parenthood of Illinois estimated an increase of 20,000-30,000 out-of-state patients. Some clinics are struggling to keep up. For these clinics and patients, Coplon notes, telehealth can make a huge difference in the post-Roe era.
Not only can telehealth provide appointments within just a day or two of scheduling, as opposed to the potentially weeks-long waits at clinics in some overburdened states, it can also help reduce the overall burden on those in-person clinics—freeing up space for their own clients.
“I don’t see telehealth filling that niche for people who need to travel,” Coplon said. “What I really see it as is for people who are in a safe state already and who want telehealth… can find this as an option to reduce the burden on these in-person clinics that are seeing a surge of patients. I think that telehealth can really reduce the burden.”
Others disagree. Plan C, a public health campaign that aims to normalize at-home medication abortions, was recommended as a way to find reputable information on abortion, birth control and other reproductive healthcare by all reproductive care providers we spoke to. They write that patients in states with bans are still accessing at-home medication abortions via “creative options like mail forwarding services, driving across state borders or using General Delivery addresses,” and that some patients might order pills in advance in case of a future unwanted pregnancy.
In states like Texas, where patients must travel an average of 7.4 hours to reach the nearest clinic, “creative options” may be the only affordable or feasible option for some.
Dr. Sophia Yen also practices telehealth medicine for people who can get pregnant—but her work aims to prevent pregnancy before it even happens. A specialist in teenage healthcare, Yen teaches at Stanford University and is a co-founder of Pandia Health, an online birth control delivery company. Yen said she has seen demand for her telehealth contraceptive services increase threefold since Roe was overturned.
Like the other telemedicine providers Ms. spoke with, Yen is certain telehealth care is here to stay—but still worried by restrictions that Republican-held state legislatures have placed on it. Some states, she noted, still require medically unnecessary phone or video calls and in-person visits. “The legislators don’t understand what is needed to make a medical decision,” Yen said. “They should leave medicine to doctors.”
Practicing via telehealth has reduced her and her patient’s stress levels, says Yen. “I don’t have to commute. I can travel while doing work. I can go to conferences. Patients don’t have to commute. I don’t have to worry about catching COVID from my patients.”
Yen also acknowledges the limitations of telehealth—a provider cannot fully examine a patient, take their weight and blood pressure and check their throat. She warns that it is vital for patients to learn the limitations of telemedicine and how to find a good telemedicine provider. “If it were me, my daughter, my family, I would go in person for my annual checkups,” she said. “Anyone who says they can do primary care 100 percent by telemedicine is not giving you the best care unless they can listen to your lungs, check your throat, touch your abdomen and examine your entire body properly.”
But for birth control, she maintains in-person visits are not usually necessary and notes that the American College of Obstetricians and Gynecologists has long supported over-the-counter birth control.
Telehealth Gender-Affirming Care
LGBTQ+ healthcare has also benefited from the institution of telehealth. Like abortion care, it’s been subject to significant challenges and right-wing attacks, especially as legislation targeting queer and trans people is being proposed and implemented around the country.
Dallas Ducar is the CEO and founder of Transhealth, a clinic and resource for telehealth gender-affirming care accessible around the country. Transhealth offers various services, from telehealth appointments for gender-affirming care to support groups based on age, aimed at building community.
Founded in 2021 amidst the COVID-19 pandemic, Transhealth has relied on telehealth from the outset—and has been a critical resource for trans people in more rural areas. Ducar reported that focus groups conducted in Massachusetts identified the biggest challenge to receiving gender-affirming care “was the lack of access to reliable transportation, which can sometimes lead to deferring lifesaving care.” This was especially true for patients in the most rural regions, as well as low-income individuals.
While telehealth greatly expands accessibility nationwide, it comes with its limitations for some patients. Under the 1990 Anabolic Steroids Control Act, testosterone and any drugs meant to mimic it were added as schedule III-controlled substances. Testosterone’s status as a controlled substance means that telemedicine providers are not allowed to prescribe it to patients who live outside of their state—which can be especially detrimental to adolescents in states without gender clinics for trans youth.
“Senator Markey and Senator Warren are currently working on de-scheduling testosterone as a controlled substance. The hope is that we would then be able to allow free prescription testosterone across state lines without requiring a face-to-face meeting,” Ducar said. That change would mean anyone from around the country could make an appointment at an organization like Transhealth, be prescribed testosterone, and begin their treatment without having to travel across state lines.
Lawmakers are also making moves to secure telemedicine abortion and gender-affirming care in response to the overturning of Roe. Earlier this year, the Massachusetts legislature passed bill H.5090—which, on top of enshrining the right to reproductive healthcare and gender-affirming healthcare in the state constitution, also protects providers of telehealth abortion and gender-affirming care from prosecution in other states.
While the Supreme Court’s overturning of Roe did not directly reference gender-affirming care, the move alarmed providers nevertheless. “It’s uncertain at this time, we’re not really clear what the landscape will look like in the future,” Ducar said. “This is pretty unprecedented to say that one state will not cooperate with another state based on their laws, right? That gender affirming care could be considered a felony in one state and can be seen in another state—seen as lifesaving.”
While the legislative landscape seems uncertain, “Transhealth is poised for growth,” Ducar says. “We are—there’s such a need. [Transhealth hasn’t] advertised since day one. And telehealth has only allowed us to expand that access. The number one thing that trans and gender diverse people need is more access to good healthcare. Period. A place, whether it’s spiritual, whether it’s in person, that they can feel safe, that they can feel seen, that they can feel affirmed. And Transhealth and other organizations are committed to that.”
The Future of Telehealth
As the year unfolds, the regulations and limitations around telehealth will likely continue to change. Some companies expect telehealth to take off even further—startups that hope to make telehealth a part of everyday life are rising in number, and even Amazon is working on a fully contact-free service for minor diagnoses and treatments, such as rosacea, pink eye and motion sickness.
Alternatively, the newly-flipped House of Representatives may have other opinions. Currently, Medicare coverage makes telehealth resources readily available to a large number of Americans. Some extensions to that coverage will apply only through 2023 and need renewal, while others will end if the COVID-19 Public Health Emergency goes unrenewed. On Nov. 10, 2022, the White House’s Office of Science and Technology Policy posted a call for medical professionals’ recommendations for renewals, indicating that the future of telehealth may be an essential conversation in the following year.
And notably, a lawsuit brought by far-right groups in Texas seeking to reverse the FDA’s authorization of mifepristone, one of the two drugs used in most medication abortions, severely threatens access to abortion—and could potentially completely eliminate telehealth abortion services. A ruling is expected in the case sometime this month.
Legislation that could further legitimize telemedicine and reproductive or LGBTQ+ healthcare will likely be scrutinized even harder by the split Senate. Coplon suspects we will see “more bills proposed banning medication abortion, telehealth medication abortion, requiring mandatory ultrasounds or in-person dispensing.”
“But I think, or I hope, that in states where abortion is protected it will continue to be and these bills will not survive,” she said. Regardless, she’s preparing for what’s next. “In red and purple states,” she adds, “we may have many battles to fight.”