Addressing Transgender and Gender Diverse People in the E-Health Service i²TransHealth: A Qualitative Process Evaluation

Introduction/Background *
Transgender and gender diverse (TGD) people from rural areas often lack access to specialized trans health care services. To bypass rural health care deficits, they have to commute to metropolitan areas for appointments with trans-informed health care providers, often on a frequent basis. This can significantly impede access to appropriate trans health care. E-health services are capable of greatly reducing long commutes and waiting times. At the same time, scientific evaluation is needed of how digital and outpatient treatment concepts can be implemented integratively in trans health care.

Specific Aim *
To better address treatment-seeking TGD people from rural or suburban regions, we developed i²TransHealth, an interdisciplinary, internet-based trans health care service. Within a randomized-controlled pilot study, TGD service users can try a new care model consisting of bi-weekly video consultations and 1:1 chats with a study therapist, as well as emergency crisis intervention by a local physician network. To assess implementation success, we qualitatively examined which aspects of the i²TransHealth e-health service were helpful to which group of people and under what circumstances.

Materials and Methods *
In a qualitative process evaluation, four semi-structured group interviews were conducted with intervention participants (n = 4), participating network general practitioners (n = 6) and psychiatrists (n = 7), and study therapists (n = 5). After an open-ended introduction, the guided interviews elicited statements about specific treatment experiences, assessments of the i²TransHealth network and infrastructure, and special events. Data were analyzed according to Kuckartz's qualitative content analysis. From the guideline and contextual knowledge of the RCT, we deductively derived main categories and inductively added subcategories.

Results *
The results indicate that both intervention participants and project members rate i²TransHealth positively. Essential aspects turned out to be the treatment of TGD people, professional function of health care providers, use of the e-health platform, and specifically video consultations. Moreover, e-health systems in general, project public relations, networking with and within the project, networking with TGD community and counseling centers, as well as infrastructure and care reality, especially in remote regions lacking specialized trans health care, were considered relevant. Challenges remain, but i²TransHealth can provide confidential, low-cost, barrier-reducing access to trans health care.

Conclusion *
The process evaluation provides preliminary evidence that the implementation of e-health services can be a useful measure to reduce barriers to trans health care. As a pioneering project for German-speaking countries, i²TransHealth can be applied to health care concepts in other countries. E-health services offer a great opportunity to reach underrepresented TGD people from rural areas who would otherwise not be offered any or inadequate health services.