Transgender telemedicine and the communal twenty bucks

Apologies to anyone who already knows this, but the timelines on academic publishing are really weird. Teaching in media and film I often explain this to students, because if they want to write about a recent film or TV series there won't be any academic lit to draw on for a year or two, since it takes time to wind its way through review. My latest article – about a telehealth company who specialize in prescribing hormones for trans people - is something I started writing around January of 2022, and in the interim period the topic went from being kind of topical to being uncomfortably topical. 

In late 2020/early 2021 I started seeing posts on formerly-Twitter about a telehealth service called 'FOLX' (they stylize their name all in caps). I'm trans, I'm on hormones, and I know it can be a giant pain in the ass to access them, especially if you live outside a major city. A service to mail people hormones, on paper, doesn't sound like a bad idea, and there's some research that emerged during the more acute phase of the pandemic that supports the use of telemedicine for trans people. FOLX is a start-up funded by venture capital, though, and as a lot of trans people pointed out, they charged a premium for the meds.  

Lots of FOLX’s approaches to marketing were familiar in ways which made me uneasy. The language in their advertising copy was consciously resonant with how online trans communities talked, and they relied heavily on ideas about ‘community’. For-profit ventures don’t have ‘accountability’ in any meaningful way, though, and especially with the prescriptions being more expensive than they would be if people picked them up elsewhere, I was primed to be suspicious of the idea that any company meaningfully cared about the community. I wasn’t the only person to have this reaction. Niko’s tweet (below) kind of got to the crux of it, for me, and she went on to write a great piece in the now sadly shuttered Bitch magazine which I cite in the article.

So, my latest article is looking at how FOLX used discourses about community, especially on social media, to market themselves. I looked at the copy on FOLX’s website, in particular the ways it changed over time, as well as media coverage they got, both in popular and trade publications (focused on financial and healthcare industry news). Commentary about FOLX sometimes used phrases that drew on more radical queer histories of restructuring or subverting systems, with the company described as ‘putting the power and control back in the hands of the community’ or arguing ‘it’s about time we build a platform for ourselves’. There was a big focus on the need for a service like this, the fact that the trans community are badly underserved by existing healthcare systems. I also found a lot of emphasis on joy and euphoria, that the kind of services the company provided were offering ‘joyful, affirming healthcare’ and the founding the company was ‘a labor of love’. This reflects how many trans people talk about their hormones, and so here there’s an echo or affinity between how the company present themselves and what kind of talk we see in the community.

Discussions about community came through in other ways too. FOLX markets through social media and influencers, and one text opened with a discussion about a trans man whose attempts to access HRT were repeatedly stymied until he heard about FOLX from an account he followed on Instagram. This immediately read to me as a parallel to how people often figure out how to get their hormones more generally. In theory you should be able to just chat to your GP, but in practice you often have to ask around, rely on knowing someone who can point you towards a sympathetic and competent doctor, or towards resources to DIY it. It’s not that I think this anecdote didn’t happen but including it within media coverage feels to me like a conscious attempt to situate FOLX within those kinds of community interactions, with influencer marketing a fast-track to that.

FOLX also offered something they called ‘The Care Fund’ which was essentially a formalised mutual aid fund administered by the company to provide care for 100 trans people a year, with a focus on supporting BIPOC trans and nonbinary people. Initially, the fund was proposed as a way for ‘brands to walk the walk’ with the idea that ‘bigger companies who use LGBTQ+ people in their Pride campaigns can donate a bigger sum of money’. The first iterations of the Care Fund page on FOLX’s website in March 2021 stated they wanted to ‘radically redistribute financial resources’, adding ‘we are actively fundraising through corporate and wealthy donors in an effort not to have to rely on community funding’. By mid-April 2021, they’d dropped the line about actively approaching corporate and wealthy donors. By early June 2021, the fund was for ‘redistributing financial resources from allies in and out of the LGBTQIA+ community’. There’s a joke that’s not really a joke about the trans community shuffling the same $20 back and forth between our Go Fund Me’s, and that does appear to be where FOLX landed within only a couple of months – the language on the Care Fund page becoming more and more tepid, no longer aiming to do anything ‘radically’, no longer planning to apply any pressure to large corporates who make a big deal of their rainbow friendliness in June then drop it in July. The Care Fund, notably, tended not to rate a mention in the articles in trade publications.

Speaking of trade publications though, what we see in those is a something which I think underpins my fundamental discomfort with much of FOLX’s marketing, which often situated using their services as a community good. While coverage in general interest outlets would highlight the need for FOLX because trans people were badly underserved by existing healthcare systems, trade publications would frame trans healthcare as an as-yet untapped or under-tapped market that offers potentially significant financial returns for savvy investors – a ‘deca-billion opportunity’ according to one. FOLX is more expensive than alternatives, and don’t accept insurance, Medicare or Medicaid. Customers have to pay out of pocket. FOLX advertise prices ‘from’ $59 a month, but actually range much higher than that, depending on what you need. There’s an uncomfortable tension here where in some instances the medications they’re providing are discussed as a kind of consumer good, where higher prices are due to ‘choosing a complex set’, but of course what makes this such a fantastic ‘deca-billion opportunity’ is that it isn’t really meaningfully a choice – you need the meds. As long as the broader healthcare system is a binfire for trans people, FOLX has a captive audience. Their continued growth and profitability relies on the other options remaining inaccessible, or so bad people will find a way to pay the premium.

In the period between FOLX launching, me writing the article, and the article being published, though, there was a huge uptick in anti-trans bills in the USA where FOLX is based, which made access to HRT much more fraught. I’ll be honest, I didn’t really intend to write something this topical, and it does feel a bit weird to be critical of a company who are probably making it possible for some people to access their hormones when they otherwise couldn’t. There’s probably always going to be a market of people who find telemedicine is better for them, or prefer FOLX’s offerings for various reasons, and it’s not that I don’t think they should exist, but I do think there needs to be a healthy scepticism of claims about their community-mindedness. The idea that FOLX is a panacea for the failures of the broader health system to adequately serve trans people seems optimistic at best and profiteering at worst, and I think we can and should dream bigger than letting a for-profit company help us shuffle the communal twenty bucks around.

If you’d like to read the full article, you can find it here or if you don’t have institutional access, just reply to this email and I’ll be happy to sort you out with a copy.