Not every doctor’s office runs an Instagram account that posts tips about how to approach sex with trans people alongside updates about which insurance it accepts. But Folx, an LGBTQ-focused online health care startup that launched in 2020, doesn’t want to be anything like your traditional provider. The company’s website—designed by the same agency that crafted the looks of Hinge and Supergoop—is part digital magazine, part retailer, part influencer hub. One entry on the Library page, which is full of guides and listicles, boasts “The Top 10 Most Iconic Moments in Transgender Healthcare History.” The Folx store is stocked with merch that a well-intentioned mom might wear to a Pride march.
Folx is just one entry in a growing list of digital health companies offering gender-affirming services, and one of a handful founded by a trans or nonbinary person. The staple service of trans telehealth is hormone therapy, but each company also offers its own unique smattering of mental, sexual, and reproductive health care. The business model has been around for a few years—in 2018 Vice declared that the “Future of Transgender Healthcare Is Online” and offered a now-quaint description of video visits that use “technology similar to a Skype call.” But its market has only grown in the wake of the COVID telehealth boom on the one hand, and the right’s ginned-up anti-trans moral panic on the other.
Indeed, trans people’s status as a convenient political bludgeon has made an already precarious path to health care even more treacherous. Restrictions on access to gender-affirming care have multiplied in recent years—39 percent of trans youth live in states that have passed bans on care for minors. Even so, the anti-trans machinations of state legislatures are, practically speaking, really just further additions to long-existing barriers all too familiar to trans people, like a systemic lack of knowledgeable, accessible providers. The providers that do meet bare-minimum thresholds of competency and access often encounter demand so intense that their waiting lists bloat to months, sometimes even years, of backlog. And when trans people successfully navigate this maze, what usually awaits us on the other side is even more obstacles. In a 2022 study, nearly half of trans people—of the ones who made it to a doctor’s office—reported being harassed or denied treatment in the previous year. Unlike lots of the problems tech startups profess to solve, this one is very real.
It’s in this context that trans telehealth markets itself as taking heroic aim at a many-headed hydra, with branding that asserts a sense of community and system-altering disruption. Folx, the self-described “first digital healthcare company designed by and for the LGBTQIA+ community,” hosted a virtual “Pride Camp” last month, which featured programming that ranged from a “DIY Zine Workshop” to “Body Positive Voguing.” Plume, which describes itself as “the first health technology company fully dedicated to the trans community,” hosts digital events focused on social justice. One example: “Unpacking Privilege: From Ally to Accomplice.”
The message from both is clear: “We’re not just your doctor. We’re your community.” Getting your health care from someone who actually cares about you—genuinely, deeply—is a far-off fantasy for most Americans, cis or trans. That’s why the siren call of these companies is so appealing. But what does it mean to conflate transactions with communal offerings, and how much can you even offer within the confines of a screen?
Jerrica Kirkley, Plume’s co-founder and chief medical officer, told me that the startup’s “goal is to transform health care for every trans life.” Kirkley says she initially tried to open a community health center in Denver for trans patients but was forced to take a different route because of red tape. After years of seeing patients drive for five or six hours just to access gender-affirming care, she was convinced of the need for telemedicine.
Though TERFs, right-wingers, and liberals who are “just asking questions” might argue that gender-affirming care is too easily accessible, especially for trans youth, trans telehealth has clued venture capitalists in to the fact that obstacles do indeed abound, and that these barriers represent an enormous opportunity for profit. Plume has raised $38 million in VC funding since launching at the end of 2019. Folx went live a year later and has since racked up a total of $59.4 million in funding. Carrot Fertility, which emphasizes family planning but also covers gender-affirming care, clocks in at $114 million. It’s no wonder there’s so much venture capital flying around: In 2022 the gender-affirming hormone therapy market alone reached an estimated $1.6 billion.
Kate Steinle, Folx’s chief clinical officer, told me that “being able to do something wildly different in health care” is what drew her to Folx. Both Folx and Plume advertise access to clinically and culturally competent providers—experts in the medical and social needs of trans patients, and who might even be trans themselves. They also operate under the “informed consent” model, which emphasizes patient autonomy in decisions about whether and how to pursue care. This stands in contrast to the norm of requiring mental health evaluations to determine the appropriateness of gender-affirming care—a remnant of the medical establishment’s not-too-distant history of regarding transness as a mental disorder.
Though low-cost and free clinics with these same benefits exist, they are often overflowing with demand and too few and far between. Alejandra Caraballo, a clinical instructor at Harvard Law School’s Cyberlaw Clinic and a former staff attorney at the Transgender Legal Defense & Education Fund, told me, “In some ways, [trans telehealth] has been a critical lifeline for a lot of people who can’t access gender-affirming care in other contexts, particularly rural trans patients.”
It’s an appealing escape hatch, but one operable only by those who can afford it. Membership at Folx—which doesn’t include the cost of prescriptions or visits with your clinician—is $39.99 a month, whether or not you’re insured. With insurance, Plume costs $32 a month, a cost also not inclusive of the price of prescriptions or visits. For $99 a month, you can self-pay for Plume membership without insurance, which covers clinician visits but not prescriptions. Neither Folx nor Plume accepts Medicare or Medicaid.
Considering the numbers, it’s worth asking: Is there anything particularly communal or “transformative” about velvet roped care for those with the money to pay for it? If the answer is yes, that speaks, more than anything else, to the impossible conditions faced by trans people. And given our dire straits, there are stakes to conflating private concierge services with our long history of community agency. In the face of endless barriers, trans people have always fought to exercise control over our bodies and existence. Notable examples pepper our history, from projects to secure housing and do-it-yourself autonomous transition to collectives that gather funds for all kinds of necessities. Trans telehealth is a buoy that will benefit some, while trans agency is a foundational skill set that requires constant upkeep and practice.
To be fair, trans telehealth recognizes that membership fees are exclusive. During my conversations with each company’s top clinical brass, it was clear that cost was on their minds too. As an alternative to the direct-to-consumer subscription model, Folx allows employers to take on the cost of membership for employees. And rather than charge membership fees at all, Carrot works with employers to determine the amount of “Carrot funds” available to each employee—pools of tens of thousands of dollars that can be used to reimburse members for specific kinds of care. This may sound promising, but it’s worth considering that no one is lessening systemic barriers to gender-affirming care by making access in effect an even more rarefied luxury. To wit: Only those with the right cushy jobs—Grindr and Discord offer Folx, while Carrot counts Zoom, Snapchat, Salesforce, and Peloton among its clientele—benefit from this model. In the U.S., health care is already functionally a privilege tied to employment; employer-sponsored trans telehealth escalates this status quo by creating an even smaller circle of benefactors.
And even the lucky few are arguably being sold short. Carrot markets its services as revolutionizing care by exiting the outdated, inequitable world of insurance altogether. In its operations, though, it’s nearly indistinguishable from traditional insurance—Carrot has providers it considers in-network (a list that includes Folx and Plume—which, incidentally, are also in-network for some major insurers, like Aetna) and its own formulary of covered prescriptions and other care that it covers. In other words, more of the same.
Stipulated, the Carrot facsimile has certain advantages. Carrot funds can be used to pay for an assortment of care that traditional insurance would not cover—like packers and the cost of traveling to a faraway clinic. Carrot insists that its services tackle “the barrier posed by the limitations of insurance coverage,” including “gatekeeping” and offering “only the most basic formularies.” But customers feel that there are some glaring omissions. Jazz Pouls, a data scientist whose workplace offers Carrot as a benefit, says she has spent “countless hours” fighting to get Carrot to be more inclusive of the care needs of transfemmes. Though Pouls successfully lobbied for coverage of tucking kits and body shapers, she hasn’t been able to persuade Carrot to add facial-hair removal services to its “comprehensive” formulary. The only difference between hours spent arguing about coverage with an insurance disrupter and hours spent arguing with a traditional insurance provider is the added weight of the pretense and promises that things would be otherwise.
Kellan Baker, the executive director of the Whitman Walker Institute, isn’t surprised when innovators start to resemble the thing they are meant to transform. “That is often what happens with disruption. You find out that the system works in a specific way because there’s a lot of pressures that encourage or force it to work that way.”
Carrot also doesn’t include gender-affirming surgery in its coverage. Despite it being the care she can least afford, Pouls is unable to use her $20,000 in Carrot funds to pay for surgery of any kind. She told me that the omission makes Carrot “feel more like an employer PR tool than a material benefit.” That’s not that far off from how the company appears to see itself. Recruitment and retention are a major marketing focus for Carrot, a choice that suggests that Carrot’s most important customers may be employers, not their trans employees. In interviews, Carrot CEO Tammy Sun often refers to employer-sponsored benefits’ “halo effect,” a powerful virtue signaling opportunity. According to Sun, even if they never use a benefit themselves, “people who see their LGBTQ coworkers receiving benefits have a sense of goodwill toward their employer, and believe that their company is sensitive toward its workers’ needs.”
Carrot isn’t alone in failing to facilitate surgery. Although Plume and Folx both offer referrals, letters of support, and member-specific advice, neither is poised to engage with surgery directly. It seems that trans telehealth, years into its boom, cannot and will not dismantle barriers to the most maligned, cost-prohibitive gender-affirming care. This speaks to one of the model’s core limitations: Trans people’s health needs are not miraculously confined to care that can be accessed through a screen. “It’s fine if you get your hormone therapy through a digital health system,” said Baker. “But what happens when you have to go to the emergency room? What happens when you have something that comes up that needs to be managed by a specialist and we’ve let the entire rest of the health care system off the hook?”
According to a research letter in the Journal of the American Medical Association, one-fourth of clinics in states that have enacted barriers to gender-affirming care have closed since 2021. Trans telehealth shields some individuals from the brunt of this assault, but the model itself is not necessarily secure. Ten states already ban prescribing testosterone via telehealth, and Florida is in the process of appealing a federal judge’s ruling that blocks the state from banning the prescription of gender-affirming hormones via telemedicine altogether. The very attacks on access that have made trans telehealth urgent and lucrative in the first place might also be its downfall. And by segregating trans health care into a concierge service, trans telehealth emboldens the biggest assault on access of all: the project of undermining gender-affirming care’s legitimacy and necessity. Isolating trans health care from the standard health system sends the message that it’s a somewhat ridiculous luxury that comes with cushy tech jobs—like a home office stipend or a gym membership—or an exotic purchase made ad hoc by certain consumers.
I asked Caraballo about whether trans telehealth can live up to its ad copy’s visions of heroic transformation. She isn’t sold on the idea: “It just feels like it ties the success of the community to the success of some private individual or private company. And I don’t think that’s what the definition of queer liberation is.” No one should be shocked to learn that companies are in the business of making money. But trans people also shouldn’t expect the invention of a shiny new health care business backed by venture capital to meaningfully address the inequities created by the system of health care as a business, no matter how slick the marketing.
Threats to trans health care will continue to evolve. It’s possible that state-level attacks will be outrun by more draconian federal policy in the coming years. And even if the fixation wanes, trans people will still be left with the long-existing obstacles that already burdened our health—insurance barriers, mental health evaluations, steep costs, too few providers, gatekeeping. Though trans telehealth will undoubtedly carry some past the snake pits of the current emergency, it will never end the emergency altogether. We cannot afford to make the mistake of neglecting or starving our history of mutual care under the glittering promises of disrupters. The steadfastness and ingenuity that made transition possible long before the era of startups and telehealth will continue to ensure our existence long after the market moves on.
Trans people have always taken care of trans people—with mutual aid, by sharing meds and information, when we nurse each other after surgery, by taking care into our own hands, and by reinforcing in one another a vast sense of possibility. In defiance of gatekeepers, in defiance of financial barriers, in defiance of outright denial, we shepherd one another into existence. Regardless of the lifelines we may grab hold of along the way, whatever better future exists for the taking will come from remembering the power in the sheer force of our collective will. And there’s no app for that.
