Telehealth, Ease of Access, and the Medical Consumer Boom

Informed consent vs. closing the sale

This is part two of a multi-part investigative series. Read part one here:

Part Two: Telehealth, Ease of Access, and the Medical Consumer Boom

Jordan¹ realized he wanted to transition during the pandemic – not an uncommon phenomenon, he told me.

“You know, you’re at home on your phone, just scrolling through Instagram, and you’re seeing the same stuff you would have before, but now it’s basically intensified,” he said. “If you don’t have much else going on, the message that would normally be coming at you as like a little hint, a little reminder, is now coming at you with flashing red lights. This was the case for me and a lot of people I know.”

And what was that message? For Jordan, a longtime member of the Chicago queer community and therapist-in-training, it was about the freedom resulting from gender transition. “Alignment, acceptance, euphoria,” he told me.

Gender conformity and transition weren’t unfamiliar topics for Jordan. Prior to the pandemic, he had lived as a butch lesbian, and he had many friends who identified similarly. During a graduate school practicum, he’d learned about pediatric gender-nonconformity, and his class had even watched video content by the young drag performer Desi Napoles. Going to live drag shows and chatting about RuPaul’s Drag Race were both things Jordan did frequently.

“I knew plenty of trans people – like, tons of them – just living normal, happy lives. But even then, I think it was kind of scary to consider that I might be one of them,” he said.

It wasn’t until Jordan’s classes shifted online with the arrival of lockdown that he allowed himself the mental space to consider this intimidating prospect. He found himself lingering longer and longer over each video, infographic, and meme he encountered on the topic of transness or transgender rights. Had he always been uncomfortable in his body, sometimes to the degree that it negatively impacted his ability to function? Yes, he had. Growing up, had he been more inclined toward typically “boyish” or “masculine” pursuits than feminine ones? Yes. Did he feel that the misalignment of his body with his gender identity had impacted his social or romantic lives?

This last question hit home with particular intensity for Jordan. A few years before the pandemic, he had been engaged to a woman back in his progressive hometown on the East Coast. He’d felt sure they were destined to live a long and happy life together, if only they could overcome the intimacy issues they were having.

“I started binding in high school,” Jordan told me, referring to the practice of compressing one’s breasts in order to achieve the appearance of a flat chest. “And I’ve been pretty religious about wearing some form of chest binder ever since. And that didn’t always fly with my ex.”

Jordan’s fiancée couldn’t understand why he wanted to wear the binder at all times, including in the bedroom. When things came to a head, he’d floated the idea of gender transition. His fiancée didn’t take it well, and the relationship ended. “After that ugliness, the question of my gender identity kind of just stayed locked up in a little box.”

Jordan couldn’t have guessed that a global pandemic would be precisely the thing to start him questioning again. But here he was, scrolling his feed, watching YouTube videos, and following countless trans influencers on Instagram and TikTok. He described consuming this content as “liberating,” as though he’d been holding his breath for years and was finally allowing himself to exhale again.

By early 2021, Jordan had made up his mind to transition: “I had gotten to the point where I wasn’t just decided on it, but I felt like I couldn’t wait a second longer.” But the pandemic was still raging, and most gender-affirming care clinics had staggeringly long waitlists. With many hospital administrators working remotely, Jordan found it was a struggle just to get a real human being on the phone. He waited nearly an hour on hold at a popular LGBTQ+ primary care clinic with locations throughout Chicago, only to be told that the next available appointment wasn’t for another four months.

“I hit a real low point then,” he told me. “My thoughts went really dark.” Jordan feared he would become another statistic, one of the many trans people denied the right to live as their chosen gender who, according to sources like the Trevor Project and the Human Rights Campaign, choose to end their lives as a result.

But then one day Jordan’s feed offered a glimmer of hope: trans influencer Schuyler Bailar released a video promoting a popular LGBTQ+ telehealth company with a business model similar to popular telehealth sites like Hims, Hers, and Fridays: a medical patient signs up for an account, completes a medical history intake form, and is then connected via live chat, video, or telephone to a healthcare professional licensed in their state. After the telehealth visit, the clinician identifies a treatment plan, typically involving prescription medications manufactured by a U.S.-based compounding pharmacy licensed to work with the telehealth company; depending on the state the patient resides in, they may pay for their treatment plan out of pocket or qualify for insurance coverage.

Most telehealth companies endeavor to streamline care for common medical issues: anxiety, depression, weight loss, sexual dysfunction, etc. But this one was unique in that it specialized in LGBTQ+ healthcare – gender-affirming healthcare in particular. Jordan was elated. He’d finally found a way to access the HRT that would help him begin his gender transition without the interminable wait. “The idea that I wouldn’t even need to leave my house to get gender-affirming care was just so exciting to me,” he told me.

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Jordan signed up, and within a week he was scheduled for his first appointment. He was feeling on track at last, finally moving towards a goal he’d had most of his adult life but had only recently allowed himself to embrace. He didn’t expect what happened next: a telehealth consultation so disorienting that he would only describe it to me on the condition that I anonymized him in this article.

“It was really weird, like something out of an episode of TV,” he told me, and proceeded to describe sitting down to a video chat with a licensed nurse practitioner who was a trans woman. This in and of itself was not unexpected – the company boasts that the lion’s share of its providers identify as some form of LGBTQ+ – but her bullishness about getting Jordan on testosterone was.

“I sat down and told her I wanted to start, and that I had some questions,” Jordan said. “Like my mind was made up, but I also wanted to know about side effects, safe administration, stuff like that. And she kind of just hurried me through it. She was so focused on making sure I answered yes to all her questions, posing them differently if I hesitated and sometimes even approaching me like I was naive and hadn’t done my research and if I had, I’d be saying yes faster. When I asked her what dosage she thought would be best for me with my height and weight, she told me I should be on the highest one to see results the fastest because I had been binding for over a decade. That didn’t make sense to me: I wanted to know about, you know, the medical side of things. Testosterone wasn’t like a car I was trying to buy.”

Jordan received what he’d wanted – a prescription for testosterone cypionate – but the provider’s saleswoman-like approach was so off-putting that it took him several weeks to start injections. And even after he’d begun to see the physical changes he’d longed for – muscles, a squarer jaw, hair on his chin – there was still a sense of uncertainty clawing at the back of his mind. Was he on the right dose? Was he moving too fast? Was there something he needed to know about his body’s reaction to the testosterone that the provider hadn’t told him? No amount of reminding himself that he’d met with a licensed medical practitioner could negate how uneasy it made him that he had to remind himself of this fact in the first place.

“It feels weird even sharing this because, like, this was supposed to be a happy outcome,” Jordan told me. “I got what I wanted, and I got it quickly. I don’t want to badmouth a company that’s apparently doing good, especially when trans rights are so viciously under attack across the country. But it’s hard not to feel kind of like a science experiment. Did I get medical treatment, or did I get a pitch? And who’s going to follow up with me?”

Shortly after his first appointment, Jordan’s care was switched to a different medical practitioner. Jordan appreciated that this new doctor was not as sales-forward as the LNP had been, but still found their meetings too short: he disliked having to offer a rapid-fire “CliffNotes” of his experience on T, and would sometimes stumble when the doctor deferred to him on matters of dosage. He appreciates having his point of view considered – a rarity in the medical field, where past paradigms saw patient testimony overwritten by expert knowledge – but he says he’d be more comfortable with a treatment plan that integrates a combination of his view and the doctor’s, especially when it comes to medical advancements about which he lacks expert knowledge.

“I’m in school to be a therapist, not a doctor – maybe that’s why I have this hypochondriac reaction every time my joints are creaky or I feel depressed or angry or I’m sick for longer than a week,” Jordan said. “I’m always like Oh god, is it the T? It’s made this very euphoric process of my transition have this kind of anxious tinge to it.”

“I wanted to know about the medical side of things. Testosterone wasn’t like a car I was trying to buy.”

Jordan is not alone in feeling like something is lost in the patient-forward model of telehealth: the “informed” part of the phrase “informed consent,” a requirement for any medical protocol and a necessary component of medical ethics. When a patient consents to a given medical treatment, they want to know what they’re consenting to: side effects, failure rates, and all. Though any medical intervention will always carry with it some degree of risk, it’s reasonable to expect that a given patient will want to take far more conservative risks when it comes to her health than she might take with her investments – provided she has the capital, of course – or, say, the software she’s patenting.

The body is not a startup, though this would be news to the health optimizers and self-experimenters of the tech and wellness worlds. There, the desire for bodily sovereignty converges with our down-and-out culture’s sense of urgency to produce a milieu that fetishizes taking high – and frequently uninformed – risks in pursuit of elusive rewards. For a paradigmatic example of this, one need look no further than tech founder and “immortal unc” Bryan Johnson, a centimillionaire whose stated sole purpose is “not dying.” Johnson reportedly spends over $2 million a year on longevity efforts for himself, and has drawn criticism for allegedly “snorting” stem cells and drafting his own son to serve as his “blood boy.”

In the documentary film about Johnson’s quest for immortality, Don’t Die: The Man Who Wants to Live Forever, Johnson frames his endeavors as a practical, even heroic, response to a set of unjust conditions. He was, like the rest of America, so overworked that his health was in a shambles and he barely knew his own family; he was estranged from the Mormon religious community he’d grown up in and struggling to conceal the fractures in his marriage; he was seeking professional help yet only finding professional self-interest. So he decided to take his health into his own hands and start experimenting on himself with gene therapies, fat injections, and a course of rapamycin, which is a drug typically used to slow cell growth in cancer patients.

Johnson postulates that his self-experimenting could maybe someday be of help to the non-millionaire public. How this could happen is unclear, given that Johnson is in the habit of blocking longevity scientists who suggest he allocate some of his personal fortune to fund medical research that could replicate his findings in a laboratory setting – first, by expanding his experimental group of one.

In many ways, Johnson is like the telehealth patient who arrives at his scheduled video chat with an exact sense of the treatments he wants. But unlike a telehealth patient, Johnson’s wealth places him in a realm beyond that of the average consumer of virtual medicine. He works with a team of specialists in the field of longevity, some of whom look so young it renders their research interest in looking younger a tad suspect. These specialists are compensated very well by Johnson to sustain his experimental enterprise; they function less as empirical researchers than as doctors-on-demand to suggest ways Johnson might go about not dying, and – more importantly – to prevent him from dropping dead in the process.

The subjectivity of the medical consumer emerges as a cross between the cavalier founder/self-experimenter and the pay-on-demand viewer of digital entertainment. There’s a desired outcome, a sense of urgency, and a willingness to endure a little risk in order to bypass the indignities of achieving that outcome via more traditional routes. If a consumer knows she wants to lose weight, has struggled her entire life to do it, and knows there’s a product that can alleviate her life’s struggle, what’s the sense in forcing herself to endure the embarrassment of an in-person visit to a doctor who may or may not be sympathetic to that struggle, who may throw up guardrails or even gaslight the consumer for a set of totally arbitrary professional reasons?

Medical care is not a social service in the United States: it’s a consumer good whose affordability, like any consumer good’s, is dictated by market forces of supply and demand. The availability of medical care – from the basics of primary care to the costly personalized longevity protocol of Bryan Johnson – hinges upon the financial resources (and often social standing), of a given consumer. Naturally, this reality exposes the medical field to the many conflicts of interest and iniquities one might find in any realm of the profit-driven private sector. So the medical consumer thinks something like the following: If medicine is already stacked against me, and in the interest of doctors and pharmaceutical companies, why should I play their game? She willingly enters a different paradigm, one in which she pays for the health she wants on demand, without any of the unnecessary friction.

I recently asked a friend who’s active in the peptide gray market how difficult it would be to get a prescription for retatrutide, a non-FDA approved GLP-1 agonist, from a telehealth platform like Hers or Fridays. “Very easy,” she said, without batting an eye. “Today, you can have an RX within the hour. You join, have a telehealth call or FaceTime, and that’s it.”

There’s no doubting the convenience of this, and it certainly fits neatly with the aims of the medical consumer. But as my friend and I spoke, I couldn’t help remembering Jordan’s ordeal. When I checked in with him again recently, he’d just celebrated two years on testosterone. He was seeing plenty of the physical changes he’d longed for, but he was also experiencing symptoms that worried him. Rapid fat gain totaling nearly 80 pounds despite no changes in diet or exercise. Irregular thyroid levels. Periods of insomnia or “sped up” cognitive activity that were causing him to miss whole nights of sleep in a row.

“Do I think it’s the T?” he wondered to me via text. “I don’t know. I don’t want to believe it is. There are so many ways that HRT’s helped me, too – like really helped me become who I am. But at the same time, that hypochondriac at the back of my head can’t stop worrying. And I just feel like I can’t ask. Some trans friends, when I’ve brought this up, tell me asking would be like setting our entire cause back. I can’t imagine going so far down this rabbit hole and then realizing that I need to detransition or something. That would be the ultimate mindfuck.”

Jordan is in a bind not altogether different from any consumer of peptides. With FDA approval for many compounds either far on the horizon or nonexistent, average consumers who have been able to gain access to these compounds have felt their connections tenuous at best. Raising complaints or even bringing up symptoms can sometimes feel like a surefire way to jeopardize one’s access to a compound that has now become an immensely valuable facet of the consumer’s life. Telehealth is convenient and practically frictionless, but the costs are still prohibitive for many. At Hims, insurance isn’t accepted; at Hers, consumers are warned that weight loss drugs are only covered for those with type 2 diabetes. Medical expertise is also out of reach for vast swaths of the population, and regarded as a fiction (and a friction) by many.

So, what’s the answer? What’s the affordable, readily accessible treatment plan that strikes the perfect balance between doctor and consumer, expert knowledge and lived experience? Is there such a thing as unbiased expert knowledge? What about unmanipulated lived experience? (We can certainly be sure that there’s no such thing as objective subjectivity.)

These are probing philosophical questions with no ready answers, but they do reflect the state of affairs in today’s peptide world. There’s no contesting that medical consumerism rules the day in the ever-expanding frontiers of wellness and longevity, a fact which has its upsides and downsides. The real threat to the longevity – pun intended – of peptides in the research world isn’t so much public enthusiasm for them, or even the willingness to experiment with compounds whose long-term effects are unproven. It’s the senses of urgency and desperation, the influencer marketing pushes and the cognitive biases, the distortions of the truth and the abandonment of the scientific method in favor of shoddy experimental practices, the dogged pursuit of instant results. It’s the experimentation without guardrails, the ubermensch approach that willfully forgets why every randomized controlled trial requires not only time, but experimental and control groups and well calibrated tools of measurement.

It’s certainly true that there are corruption and self-interest aplenty in the medical and research fields. Doctors who brush off patient concerns or not-so-subtly pressure them into opting for the prescription du jour are complicit in the more coercive aspects of medical consumerism. When the doctor becomes a yes man – or worse, a salesperson – then it’s safe to say any pretense of expertise has long since flown out the window.

Still, the existence of such cynicism doesn’t mean the entire medical field is deserving of condemnation, nor the scientific method. Failures to practice ethical medicine are precisely that: failures in the practice, not evidence of failure in the practice itself. As a culture, we find ourselves at a crossroads: How do we restore a panicked public’s faith in science? How do we separate research interests from consumer ones and remind clinicians that healthcare is, at base, about health?

Stay tuned next week for part 3 of this series, we’ll learn more about the medical consumer to gray market pipeline, and how certain Research Use Only sites have been dodging FDA warnings to continue peddling untested cures.

1. Name and some identifying details changed to protect the respondent.