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The global incidence in the treatment of transgender people is increasing. During the COVID-19 pandemic, many consultations had to be cancelled, postponed, or converted to a virtual format. Telemedicine in the management of transgender health care could support physicians.
The aim of this study was to analyze the acceptance, use, and barriers of telemedicine in transgender health care in times of SARS-CoV-2 in Germany.
This prospective cross-sectional study was based on a survey of gynecological endocrinologists and transgender patients undergoing gender-affirming hormone treatment in Germany during the COVID-19 pandemic. Descriptive statistics were calculated, and regression analyses were performed to show correlations.
We analyzed responses of 269 transgender patients and 202 gynecological endocrinologists treating transgender patients. Most believed that telemedicine was useful. Physicians and patients rated their knowledge of telemedicine as unsatisfactory. The majority of respondents said they did not currently use telemedicine, although they would like to do so. Patients and physicians reported that their attitudes toward telemedicine had changed positively and that their use of telemedicine had increased due to COVID-19. The majority in both groups agreed on the implementation of virtual visits in the context of stable disease conditions. In the treatment phases, 74.3% (150/202) of the physicians said they would use telemedicine during follow-ups. Half of the physicians said they would choose tele-counseling as a specific approach to improving care (128/202, 63.4%). Obstacles to the introduction of telemedicine among physicians included the purchase of technical equipment (132/202, 65.3%), administration (124/202, 61.4%), and poor reimbursement (106/202, 52.5%).
Telemedicine in transgender health care found limited use but high acceptance among doctors and patients alike. The absence of a structured framework is an obstacle for effective implementation. Training courses should be introduced to improve the limited knowledge of physicians in the use of telemedicine. More research in tele-endogynecology is needed. Future studies should include large-scale randomized controlled trials, economic analyses, and the exploration of user preferences.
The global incidence in the treatment of transgender people is increasing. Approximately 15,000 to 25,000 persons in Germany are affected [
Due to pandemic containment measures, many patient appointments had to be cancelled or were switched to telephone or video counseling. However, the clinical care of patients had to continue. This made it even more difficult for transgender people to access hormone interventions and sex-affirming operations [
Surveys were conducted among gynecological endocrinologists (specialists and trainees) who provide gender-specific hormone treatments to transgender patients. In addition, we evaluated the perspectives of transgender patients undergoing gender-affirming hormone therapy (GAHT) regarding the use of digital health applications in the form of telemedicine in the times of COVID-19 during their GAHT. The responsible ethics committee of the University of Jena was informed of the study and did not object to it (registration No. 2019-1456-Bef). Web-based surveys were conducted by members of the Youth Working Group Forum of the German Society for Gynecology and Obstetrics (DGGG). In order to investigate the identified areas of interest, a panel of experts administered the study questionnaire during two separate online meetings based on individual literature searches, similar to the standard operating procedures drafted by the EULAR (European League Against Rheumatism) recommendation working group [
The main sections were as follows: (1) epidemiological data of respondents, (2) basic use of digital health applications, (3) knowledge and use of telemedicine, and (4) barriers and benefits of tele-endogynecology.
We aimed to shorten the interview duration using the surveys to a maximum of 15 minutes in order to keep the dropout rate as low as possible and to motivate the respondents, as much as possible, to answer all of the questions [
Exclusion criteria included the following: patients under 18 years of age, patients not currently undergoing GAHT, physicians without the medical designation of gynecological endocrinology, physicians not performing GAHT, and digital refusal to participate in the study.
The results were analyzed using SurveyMonkey and SPSS Statistics for Windows (version 27.0; IBM Corp). Descriptive statistics included quantities, percentages, median scores, and ranges for ordinal variables. The chi-square test was applied for the analyses of influencing parameters.
From November 2020 to March 2021, a cross-sectional, self-administered, web-based survey regarding the acceptance, use, and barriers of telemedicine in times of SARS-CoV-2 in transgender health care in Germany was completed by gynecological endocrinologists and transgender patients in Germany. Of the 2287 physician questionnaires that were sent out, 286 (12.5%) were returned. Of the 286 responses, 84 (29.4%) were excluded from the analysis because fewer than half of the questions were answered. The final response rate for physicians was 8.8% (202/2287). In the period from November 2020 to March 2021, 333 out of 421 (79.1%) transgender patients participated in the study. Of the 333 responses, 64 (19.2%) were excluded from the analysis because fewer than half of the questions were answered. The final response rate for patients was 63.9% (269/421).
A total of 202 gynecological endocrinologists and 269 patients completed the surveys. Most patients (n=115, 42.8%) were between 21 and 30 years old. The majority (n=187, 69.5%) of the participating patients had been undergoing GAHT for more than 24 months. Most of the GAHTs among the study participants were being carried out in the context of the transformation from female to male (n=148, 55.0%).
Of the 202 physician respondents, almost one-third were between 41 and 50 years old (n=69, 34.2%) and most of them were specialists in the field of GAHT (n=175, 86.6%). One-quarter of them were still in training to become gynecological endocrinologists (n=51, 25.2%) and around two-fifths were between the ages of 21 and 30 years (n=32, 15.8%). The smallest proportion of these respondents were over 60 years of age (n=25, 12.4%). Almost all of the physicians were women (n=148, 73.3%). A total of 44.1% (n=89) of the physicians worked in a private practice, 32.2% (n=65) were clinicians in a university hospital, and about one-quarter worked in a nonuniversity hospital (n=48, 23.8%). Details of the participants are given in
Out of 269 patients, 82.5% (n=222) reported using apps several times a day on a smartphone, 9.7% (n=26) used apps once daily, and 6.2% (n=17) used apps once weekly. Only 1.5% (n=4) of the patients stated that they never used apps. A total of 91.1% (n=245) of the patients were able to use digital health applications. In addition, 79.9% (n=215) said that the use of digital health applications can have a positive impact on their disease treatment, while 20.1% (n=54) disagreed. The higher the age of the patients, the lower their overall app usage (
At the time of the survey, patients were most likely to use video consultations (n=214, 79.6%), informative digital health applications (n=210, 78.1%), and symptom checkers (n=115, 42.8%). Therapy-based digital health applications and self-drawn blood samples with digital access to the results showed different levels of acceptance: 58.7% of patients (n=158) said they had no interest and 41.3% (n=111) could imagine a future application of these techniques, respectively. Physicians were most likely to use therapy-based digital health applications (n=160, 79.2%), digital diaries (n=134, 66.3%), and video consultations (n=132, 65.3%). Self-drawn blood samples with digital access to the results showed different levels of acceptance: 57.4% of physicians (n=116) said they had no interest and 42.6% (n=86) could imagine a future application of this technique. The majority of gynecological endocrinologists rejected the use of symptom checkers (n=61, 30.2%). Details of the participants are given in
Details of the participants in the study. Numbers of respondents are reported on the plot bars.
Respondents' attitudes to video consultation hours. Numbers of respondents are reported on the plot bars.
A total of 71.3% (n=144) of the 202 physicians rated their knowledge of telemedicine as 4 (unsatisfactory), 5 (bad), or 6 (very poor). The minority (n=58, 28.7%) rated their knowledge of telemedicine as 1 (very good), 2 (good), or 3 (satisfactory). At the time of the survey, the majority (n=175, 86.6%) of the physicians did not use telemedicine, but 69.3% (n=140) said they would like to use it. A total of 89.1% (n=180) of the physicians pointed out that they do not use telemedicine due to barriers. According to the respondents, the main obstacles to the introduction of telemedicine were the purchase of technological equipment (n=132, 65.3%), administration (n=124, 61.4%), poor reimbursement (n=106, 52.5%), lack of data security (n=92, 45.5%), less participation by colleagues (n=67, 33.2%), technical comprehension of patients (n=55, 27.2%), and poor internet connection (n=52, 25.7%) (
Out of 202 physician respondents, 74.8% (n=151) considered telemedicine to be useful in gynecological endocrinology in transgender patient care management. When asked which interactions should occur within telemedicine, 82.2% (n=166) answered doctor-doctor interactions, 66.8% (n=135) answered doctor-patient interactions, and 35.6% (n=72) answered physician-assistant interactions (multiple answers were possible). The preferred therapeutic phases for the use of telemedicine in the treatment of transgender patients were the follow-up phase (n=150, 74.3%), first contact (n=68, 33.7%), and preventive examinations (n=39, 19.3%). Participants were asked to provide specific digital tools that could support endocrinological care for transgender patients undergoing GAHT. The most frequently selected topics were teleconsulting (n=128, 63.4%), video consultations (n=90, 44.6%), and tele-diagnostics (n=75, 37.1%). This was followed by online appointments (n=64, 31.7%), e-learning (n=45, 22.3%), patient apps (n=37, 18.3%), digital screening (n=35, 17.3%), portable devices (n=22, 10.9%), and other instruments (n=9, 4.5%) (
This study was the largest nationwide survey on the use of telemedicine in the field of gynecological endocrinology for the promotion and implementation of tele-endogynecology for the treatment of transgender patients in Germany. For this purpose, transgender patients undergoing GAHT and gynecological endocrinologists performing GAHT were interviewed. The two surveys evaluated the perspectives of patients and gynecological endocrinologists on the acceptance of, attitudes toward, and possible barriers to the use of telemedicine applications during GAHT and the impact of the COVID-19 pandemic on their use. The survey contained the following main topics: (1) epidemiological data of respondents, (2) basic use of digital health applications, (3) knowledge and use of telemedicine, and (4) barriers and benefits of tele-endogynecology.
In line with previous surveys [
Respondents to our study indicated that the COVID-19 pandemic had a positive impact on attitudes toward telemedicine applications in the form of digital health applications. Not only was attitude toward telemedicine applications influenced by the COVID-19 pandemic, but user behavior was as well. More than three-quarters of the respondents said that the COVID-19 pandemic had increased their personal use of digital health applications. Transgender patients reported a higher use of these applications than physicians. As with the general population, during the lockdown, the internet and social media were useful in reducing isolation among transgender people and were also relevant for keeping in touch with associations and health care facilities with the support of telemedicine services [
In their study, Winter et al [
A study by Gava et al investigated endocrinological care of transgender patients during the COVID-19 pandemic [
There is a complete lack of knowledge about the attitudes toward, and opinions on, telemedicine by the medical staff who would administer the therapy and, thus, be responsible for its administration. It is precisely these attitudes toward acceptance and application and barriers to telemedicine in the treatment of transgender people that are important, as they can fuel the basis for enabling change and progress of telemedicine when the individual backgrounds are known by the doctors who perform the treatment. With our study, we were able to identify initial insights into the relevance, application, and potential barriers to the use of telemedicine by physicians treating transgender people and performing medical treatments in the form of hormone treatments. All the physicians in our studies reported being able to use telemedicine applications, regardless of age and gender, which is the first prerequisite for the implementation of these novel applications. The interviewed physicians in this study came from the field of endocrinological gynecology, and our survey reflected only their opinions. The survey was aimed at gynecological endocrinologists from all over Germany, especially doctors from Thuringia and Bavaria, who participated in the recruitment strategy. A self-selection bias and a nonresponse bias in this study were possible because the survey was probably answered predominantly by doctors and patients interested in telemedicine. The survey was conducted in the time of COVID-19, and prepandemic data are pending in this area, so further research on the development of the acceptance of telemedicine applications in general and in relation to tele-endogynecology is urgently needed. An online survey was deliberately used to increase the response rate, since respondents could complete it quickly, regardless of place and time, and to achieve a reduced effort for data management. However, it is expected that this online survey will lead to a positive bias toward users of telemedicine. To answer the questionnaire, knowledge of the field of telemedicine was required (eg, preferences for specific tools were requested). Given the limited knowledge of doctors in the field of telemedicine, distortions were likely. In addition, we expect there to be rapid technological developments in the field of telemedicine, so the predefined response categories may not have been exhaustive enough.
COVID-19 has increased the importance of contactless approaches to medical care. Already in 2020, when we conducted the survey, transgender patients and gynecological endocrinologists were willing to use tele-endogynecology. It is assumed that as a result of the pandemic there has been an increase in the willingness to speed up the use of telemedicine as part of social action and new standards in health care [
Our study showed that gynecological endocrinologists and transgender patients support the implementation of tele-endogynecology, and two-thirds of those want telemedicine incorporated into their clinical routine. The medical professionals expressed an even greater willingness to use telemedicine. Respondents welcomed a variety of telemedicine approaches. However, at the time of the survey, only a minority of the interviewed physicians used telemedicine in their clinical routine. In addition, most physicians considered their knowledge of telemedicine to be rather poor. The provision of high-quality telemedical care requires additional research, a reduction in existing obstacles, and training for professionals and generalists. Transgender patients are very open to treatment with telemedicine applications. The foundations have been laid, and the concepts in this area have great potential for the future and should be developed.
Details of the participants.
Usage of digital health applications before and after COVID-19 pandemic.
Knowledge and use of telemedicine.
Implementation of telemedicine in transgender health care management.
Checklist for Reporting Results of Internet E-Surveys
Deutschen Gesellschaft für Gynäkologie und Geburtshilfe (German Society for Gynecology and Obstetrics)
European League Against Rheumatism
gender-affirming hormone therapy
Quick Response
The authors would like to thank the participants, their teams, and all other supporters of this study. We also owe special gratitude to the Junges Forum der Deutschen Gesellschaft für Gynäkologie und Geburtshilfe.
None declared.