As health care services worldwide reconfigure and adapt to the COVID-19 pandemic, some clinics have closed, while others have limited hours available to see patients. Many have moved to telehealth visits. New patients who are interested in seeing a provider may not be able to secure a first appointment, while established patients may find that their follow-up appointments and surgeries are being rescheduled or postponed.
For the person who’s receiving transgender affirming care, this has the potential to impact chest and facial surgery, voice therapy, primary care, mental health, and hormone therapy, to name a few. To find out how the COVID-19 pandemic is impacting trans-affirming care, Terri Wilder spoke with Joshua St. Louis, M.D., M.P.H., a family physician and HIV specialist, core faculty at the Lawrence Family Medicine Residency in Lawrence, Massachusetts, where he maintains a primary care practice that focuses on HIV, viral hepatitis, addiction medicine, and transgender care.
The mission of the Lawrence Family Medicine Residency is to create and nurture learning environments where physicians are inspired to develop expertise in family medicine and to dedicate themselves to the care of individuals, families, and communities, especially those who are underserved. St. Louis is also a fellow at Physicians for Reproductive Health.
Terri Wilder: Can you tell me about Lawrence Family Medicine Residency, and a little bit about your practice?
Joshua St. Louis: Absolutely. The Lawrence Family Medicine Residency is a family medicine training program in Lawrence, Massachusetts, which is an industrial city about 30 minutes north of Boston. The residency program was founded a few decades ago at this point, to essentially create a primary care workforce for the city of Lawrence.
Lawrence is an interesting place, in that the vast majority of our patients are from the Caribbean, either the Dominican Republic or Puerto Rico; and most prefer Spanish as their primary language in interacting with the health care system. The residency program was founded because there was such a dearth of primary care providers in the city in the ’80s and ’90s. And today, the residency program, which is part of the Greater Lawrence Family Health Center, takes care of approximately 60,000 patients in the Lawrence community.
I trained at the Lawrence Family Medicine Residency and graduated in 2018 and stayed on as a core faculty member in the residency. So I maintain a primary care practice there. And I also supervise resident physicians who are learning to be primary care physicians that have a particular focus in caring for an underserved patient population.
I did additional training during my residency program in HIV primary care, as well as in gender-affirming hormone therapy for transgender people—as well as addiction medicine and reproductive health. And those serve as primary focus areas for my teaching of residents. I also round at our local community hospital, Lawrence General Hospital, on the inpatient medicine service, the ICU service, as well as labor and delivery and inpatient pediatrics. So, I supervise residents in those places, as well.
TW: How many transgender patients does the Lawrence Family Medicine Residency serve?
JSL: Our transgender care program started when I was a resident—so, about four years ago, at this point. And when we started, it was me and one other resident caring for three patients. Since then, we’ve expanded to care for just about 150 patients at this point. And that care team consists of, at last count, seven attending physicians and 15 residents who are learning to provide gender-affirming care.
TW: How has COVID-19 impacted your transgender care program?
JSL: COVID-19 has had a significant impact on our transgender care program, as it has on our entire clinic. Lawrence first started seeing cases of COVID-19 about three to four weeks ago. And our clinic very quickly responded to the crisis.
Our clinic, which consists of six clinical sites, about 120 clinicians caring for 60,000 patients, transitioned in about 48 hours to, I would say, about 95% telehealth medicine. Right now, we only have two clinic sites that are open. We are only seeing walk-in patients who are concerned that they have COVID-19. And those clinics are being staffed by an absolute skeleton crew. So, the vast majority of our care is happening now by telemedicine to help protect both patients and providers.
Obviously, that has been a huge transition for every patient in our clinics. And that has very much included our transgender patients, who previously were having in-person care and have now been transitioned to telehealth.
TW: When your transgender patients are being asked to use telehealth, have there been any challenges to using that kind of mode of health care delivery?
JSL: Yeah. It’s definitely been challenging, I think, for both patients and providers. I think patients are a little bit confused initially—especially those who have not really heard of telehealth or understand what it is. And so, a lot of the initial visits are spent talking to patients to try and explain that we are trying to recreate a usual clinic visit via either video or phone; and that patients should have the same expectations for their visits from us as they would for an in-person visit.
I think when most patients initially hear that visits are going to be by telehealth, they actually don’t think of it much as a visit, and more just like a phone call. And so, reasonably, many patients are very fearful that this is going to lead to disruptions in the care that they expect to receive from us. And that’s been particularly true for our transgender patients, who, I think, are very fearful that the COVID-19 crisis is going to lead to disruptions in their care.
We have been working really, really hard to make sure that it does not lead to disruptions; and also to make sure that they know that we intend to continue providing them excellent care—the same as we would if we were able to see them in person.
TW: For the patients you see who need transgender affirming care, is there anything that you’ve had to do a different way for your transgender patient? I’m just thinking about things like the impact of surgery, mental health, even getting access to hormones. Have any of those things, the delivery of those, had to change? Or have they been delayed? Or cancelled? Or postponed?
JSL: Absolutely. I think all of that above. Talking just about gender-affirming hormone treatment, which is the bulk of our practice for our trans patients, things have changed significantly. For trans folks who are already on gender-affirming hormone therapy and have been stable, many of them only really require lab monitoring once or twice a year at this point. But of course, many of those patients are due for those labs. And so, we review with each patient by phone the risks of delaying labs versus the benefits of avoiding coming into clinic, where they could potentially be exposed to someone with COVID-19.
In general, most of our patients are fairly healthy, and it’s very reasonable for them to delay those labs. And so, most of those visits have been talking to those patients about creating a safe plan for changing when we’re going to do their labs.
For folks who are not yet on a stable hormone regimen or are in the sort of early phases of a hormone regimen, where doses are frequently changed, we have changed some of our protocols to make them safer to do by telehealth. For example, one of the medicines we very commonly use for trans women to block the effects of testosterone is called spironolactone. That medicine requires very close lab monitoring, because it can change the levels of some electrolytes in the blood quite dramatically. And so, for many patients, what we’ve suggested is actually using alternate medicines instead of that medicine, so that we can avoid them having to come into the lab and potentially put themselves at risk of a COVID-19 infection.
So, we’ve been trying really hard to think outside the box of how we can continue to provide really excellent gender-affirming care to patients, while also keeping them safe, isolated in their homes, as we would recommend for any other patients in our practice right now.
For new patients, we are seeing them by telehealth visit. We’re doing their initial transgender intake with them by phone. Many trans patients, before starting hormone therapy—if that’s what they desire—will need to have labs drawn just to make sure that they don’t have any pre-existing medical conditions that could make hormone therapy potentially dangerous. And so, what we are doing is we are doing a really thorough review of that person’s history and medical chart, essentially to see if we can forego those labs so that those don’t represent a hindrance to them starting hormone therapy if that’s what they want.
The truth of the matter is that many of the new trans folks I’ve talked to on the phone in the past few weeks feel like they would rather wait until the pandemic is over before starting forward in their hormonal transition, if that’s what they choose; just because I think the world is in such chaos. And I think a lot of patients are feeling like they kind of want to stay put. That being said, I’ve had a great number of patients who I’ve talked to in the past few weeks who still feel like they want to move forward with starting hormone therapy. And we’ve been able to do that by phone so that they don’t need to come in and get labs.
TW: Great. Another service that could be impacted is gender-affirming surgery. And I’m wondering if you have any patients right now who were preparing to have surgery and what has happened with that.
JSL: Yes, absolutely. All of our local referral centers where we send folks for gender-affirming surgeries have unfortunately had to put their surgeries on hold. Because almost all hospitals in Massachusetts have cancelled all elective surgeries at this point. And, unfortunately, gender-affirming surgery falls under that bucket for most people. That means that our surgical centers have been really, really proactive about reaching out to patients—having phone visits with them to really just make sure that people understand this is a delay, not a cancellation. And they’ve been trying really hard to give folks really concrete timelines for when they might expect those surgeries to be rebooked.
So, on the one hand, it’s been obviously very frustrating for patients, and for us as providers, to see things like surgeries be cancelled, because we know how incredibly important surgeries can be in the lives of many trans patients. On the other hand, I think my surgical colleagues have done a really excellent job of trying to keep very open lines of communication on patients, just so that patients understand that they’re not being abandoned in their care.
TW: I wanted to ask about the emotional impact of having a trans-affirming surgery delayed or postponed. I know that the whole process can take a really long time just to even get to the actual date. And I’m just wondering: Is it possible you may see increases in depression, or even suicidal ideation, because this is such an important event in the life of a person who is trying to align their gender identity?
JSL: No, absolutely. And you know, I think it has been devastating for many patients, for all the reasons you just described. And I think one of the issues is that, certainly in our practice, we consider gender-affirming hormone therapy and gender-affirming surgeries to be lifesaving care. Right? We know from a number of large studies that these are the interventions that decrease rates of things like suicidal ideation and suicide attempts for trans folks, who are at such high risk for those conditions. And we know that providing gender-affirming care helps to treat that and to mitigate those risks. And so these delays have been devastating for people. They really have been—in much the same way that many of these delays have had devastating effects on all of our patients, and in varied ways.
And so, as primary care providers, we are working really hard to make sure that the lines of communication stay open, and that we’re checking in with our patients much more frequently, just to even, you know, provide emotional support over the phone as much as we’re able to, and just trying to make sure we identify folks who may be having some sort of decompensation early, and connecting them to appropriate care. But it’s been really, really challenging.
TW: Does your trans program have a behavioral health team?
JSL: We do. Our behavioral health team is pretty robust in our community health center. And they’ve also transitioned entirely to telehealth. We’re actually able to do video-enabled warm handoffs with them during patient visits now. And so, if I’m having a telephone visit with a trans person who is perhaps at risk of decompensation in terms of their mood, I’m able to pull in one of my behavioral colleagues right into that visit and sort of seamlessly transition into a visit with that person.
So, it’s been really great to see the technology rise up to support us during this difficult time. But I really can’t overstate the degree to which these delays are devasting to our trans patients.
TW: During a pandemic like COVID-19, obviously stress is very high in the community, and people might be using different methods to cope, including substances. Are you seeing an increase in substance use or any other mental health issues with your trans patients?
JSL: Absolutely. I think the increased sort of stress and anxiety around the situation definitely is pushing people who have substance use disorders towards more dangerous patterns of use. One of my other hats in the clinic is as part of our substance use disorder team. And so, we’re seeing this really across the board. It’s affecting our cisgender folks as much as it is affecting our trans folks.
Luckily, we have really tried to remove barriers as much as possible to connecting patients who are at risk of a substance use disorder or relapse—to connect those patients with care as soon as we’re able to do so. An example I can give is that, starting about two weeks ago, we are now allowed to initiate buprenorphine for treatment of opioid use disorder, via a telephone visit, which previously was not allowed under the law. And so, we’ve been able to connect patients very quickly to treatment for substance use disorders via phone. But, unfortunately, we’re doing that because we are seeing worsening of people’s substance use disorders and increases in things like relapses and overdoses right now.
TW: What do you think are the top social-service needs for your transgender patients during this time?
JSL: Oh, gosh. All of them. One of the things to me that is super, super important for our trans folks right now is just increased touchpoints with the health care system. We know from so many large studies that trans folks are particularly underserved with regard to health care, and that many trans people have had very negative experiences with the health care system over the years, including discrimination and even abuse from health care providers.
I think in a time of crisis like this, when there are so many changes happening, and health care is less accessible than it was before, I think it’s so important that we as providers reach out to our trans patients and just let them know that we’re still here for them, and that we’re still able to provide them care, and that they’re not being abandoned, and that we still consider their gender-affirming care to be a lifesaving treatment. And that is absolutely one of the most important things we need to be able to support right now.
To your previous question, thinking about mental health and thinking about civility, I think that a pandemic is a destabilizing event for anybody who has a mental illness of any kind. And so I think the increased availability of our mental health colleagues is incredibly important right now for everybody—and, in particular, for our trans patients.
TW: Does your trans program offer support groups?
JSL: We do not have any support groups within our health center—and that’s, in part, because we partner with a few local community organizations that already were offering those groups. And so, we prefer to partner with our community organizations to do that.
So, unfortunately, many of those groups have not been able to meet because of social distancing. But I know a number of them have switched to sort of electronic ways of continuing to hold those support groups. So, they do still exist, to some capacity. But I think the capacity is more limited than it was before.
TW: Got it. I’m wondering if you’ve had any of your trans patients test positive for HIV in the past few weeks and, if yes, what has been the process of linking them to care during this pandemic.
JSL: Yeah. So, as far as I know, we have not had any new diagnoses since the pandemic began. But I will say that our HIV team is being really thoughtful about how we can quickly link those patients to care—which, admittedly, was something we were always working on, anyway. And so I think whether you’re in a pandemic or not, if you’re providing care to people with HIV, one of the most important things is fast linkage to care.
Our program is supported under the Ryan White program. And so we have a lot of support staff, including case managers and peer navigators, who are really, really able to help us with this. And I think right now we have great capacity for that because so, so many of those care providers have been transitioned very seamlessly to telehealth. And so, we have been working on workflows of how we can, via telehealth, quickly link people to care.
It hasn’t happened yet. I imagine that it will. And I feel like our program is prepared to manage that when it does happen.
TW: I’m just wondering if there’s anything else that you think is important to share about your program for trans folks; or if you have a story of maybe one of your clients that shows resilience in this time?
JSL: Yeah, absolutely. I mean, I’ve been thinking actually about an interaction I had with one of our nurse practitioners, who is learning to provide gender-affirming care right now. And I was precepting a visit with her by phone of a trans individual who I think is 60 years old, and only came out as trans within the past month or so.
Obviously, that’s been a huge breakthrough for this person. This person really, really connected with this nurse practitioner who’s been providing their care. And they were scheduled this past week for a visit to discuss considering moving forward with transition. Obviously, they were both really excited for that in-person visit and were both so just crushed to have to have it by phone.
But in the end, the visit ended up being so positive for the patient. One, because they realized that they were able to start hormones, even without an in-person visit. And they were just so, so thrilled to be able to do that. And, you know, it just provided a nice moment for a nurse practitioner who’s been working so incredibly hard in these difficult times to just hear this lovely feedback and praise from this patient, who’s thankful for the work that we were doing.
So I think for me and for the people that I’m working with, I think continuing to have visits with our trans patients has been such a highlight of the past weeks. Because they’ve been, in general, good and happy interactions. And that’s something that’s helping us to sort of keep in good spirits, when so many of the other visits and clinical interactions we are having around COVID-19 are just so devastating.
TW: Great. Well, I want to close by thanking you for your service. I know that this is a stressful time. And the world is really thankful for medical providers on the front line.
JSL: Thank you.