Virtual care, also known as telemedicine or telehealth, has historically been underused due to concerns about quality of care, insufficient regulatory frameworks, lack of technological infrastructure, and its limited inclusion in public health insurance programs in countries with publicly funded health systems like Canada [1-3]. In 2020, the COVID-19 pandemic forced health care institutions to adapt services for remote delivery and drove Canadian provincial and territorial governments to rapidly strengthen public health insurance coverage for virtual care [4-6].

Moving forward from the pandemic, transgender (trans) and nonbinary (TNB) communities may benefit from increased access to virtual care [7]. People who are trans have a gender identity that differs from the sex they were assigned at birth [8,9]. People who are nonbinary, who may or may not identify as trans, have gender identities beyond woman or man [9]. TNB people often struggle to find health care providers who are clinically and culturally competent to address TNB health issues [8], and clinics that specialize in gender-affirming care (eg, hormone therapy) tend to be limited to major urban centers [7,9]. TNB people also frequently report experiences of stigma and discrimination while traveling to and accessing health care, leading to care avoidance and unmet health care needs [8,10]. Virtual care could help address these concerns by allowing TNB people to access a broader array of both general and gender-affirming health services and practitioners, regardless of their place of residence [1,7,11]. Travel costs and lost income would also be reduced by virtual care delivery [1,7,11,12]. Current gender-affirming virtual care options like Connect-Clinic [13] in Ontario show promise in this regard, but they are still limited, with demand far exceeding supply [7]. Moreover, gender-affirming care is only one subset of the health care needed by TNB patients.

Despite its promise, the adoption of virtual care must be approached with caution as current research on its benefits and drawbacks is relatively limited and provides mixed results [1,3,6,14]. Access to virtual care may be particularly limited for TNB people who lack a reliable internet connection, lack safe confidential spaces where they can access virtual care, or lack the digital literacy needed to effectively use online health services [11,12,14-17]. Although public funding of virtual care has expanded in Canada, it is still limited [6]. For instance, at the time of writing, most jurisdiction codes only cover care delivered via video call and not via secure text messaging [3], and some provinces place a cap on the number of virtual appointments that physicians can bill to public health insurance [6]. Along with parallel for-profit models of telemedicine, this limited coverage could translate into socioeconomic disparities in virtual care access for TNB people [2-4,15].

With the goal of informing postpandemic virtual care practice and policies, this paper draws on data from a national survey of TNB people in Canada conducted during the COVID-19 pandemic to examine how preferences indicated for postpandemic in-person versus virtual care varied based on sociodemographic, health-related, and social characteristics. We also drew on qualitative data from open-text fields to elucidate the reasons for participants’ preferences.

This paper identifies factors that may influence postpandemic preferences for virtual versus in-person care among TNB people in Canada. While most participants preferred in-person care, around 1 in 3 (weighted 32.7%) indicated a postpandemic preference for virtual care. Lack of access to virtual care during the pandemic was associated with postpandemic preference for in-person care, highlighting the importance of identifying and addressing the challenges that certain populations disproportionately face while attempting to access telemedicine. Participants who were aged 14-19 or ≥50 years were more likely to prefer in-person care over virtual care compared with other age groups. Other research has shown a lower level of digital literacy among older adults as a factor contributing to preference for in-person care [11,15-17]. Given that all participants in this study completed the survey online and therefore likely had substantial digital literacy, our finding of a similar age-related preference suggests that additional factors may be at play. Consistent with previous findings [16], chronic conditions and anxiety symptoms were associated with preferring virtual care over in-person care, suggesting that telemedicine offers a promising alternative for those whose health conditions prevent them from safely and comfortably attending in-person appointments. Older adults, with a higher prevalence of chronic conditions compared with the general population [25], may therefore particularly stand to benefit from telemedicine.

Previous research predicted that unsupportive home environments could compromise the privacy and sense of safety necessary to access virtual care [11], and our results in general support this with regard to a lack of support for gender identity or expression in the home. Having gender-unsupportive romantic partners was associated with preference for in-person care. Associations with gender support from parents or guardians were less clear, which may be because relevance is age dependent. Privacy issues may in part explain why participants preferring virtual care were less likely to be adolescents (age 14-19 years), who may have no option but to live with family or roommates, including those who are unsupportive (or who do not know). However, we did not measure whether our participants were actually living with their romantic partners, or their parents or guardians at the time of participation. Regardless, these privacy concerns highlight how a move to virtual care could disadvantage those in unsafe or unsupportive home environments, especially younger people who may not have the freedom or financial means to live on their own.

It is important to note that our quantitative results only captured the overall preferences of the sample, and closer examination of qualitative results showed heterogeneity. For example, some participants reported that anxiety prevented them from accessing in-person care, whereas others had more anxiety surrounding virtual care. While this heterogeneity was expected, the broad operationalizations used for some of our variables may have obscured salient differences. For instance, participants were categorized based on identity as disabled, which does not capture the wide diversity in disability experiences. Accordingly, some participants with physical disabilities cited barriers to accessing in-person care, whereas others reported that disabilities like autism made virtual care less accessible. Similar variability was found for mental health and other chronic conditions. Future studies would benefit from examining these conditions with more nuanced and detailed categorization, for instance, by distinguishing between the types of disabilities, chronic conditions, and mental health conditions.

Another limitation of this study was that, because the survey focused broadly on the COVID-19 experiences of TNB people, only a few questions assessed virtual care experiences. Thus, some key factors like the ability to find a private space to access virtual care were not directly measured. Further, the survey’s online administration mode may have introduced selection bias favoring those with preferences for virtual care. In general, although this study used the largest national sample of TNB people in Canada during the COVID-19 pandemic, the results should be interpreted with caution and are not generalizable to all TNB communities given that participants were a subset of a convenience sample.

A strength of this study was its use of qualitative responses to elucidate and elaborate upon quantitative results. While open-ended survey items generally do not produce the rich data of a true qualitative study, these responses highlighted how the factors under study could not be discussed in isolation from one another. Rather, our limited quotes suggest that they act together, for example, the ways a chronic health condition intersects with geographic barriers to require repeated public transit trips that then exacerbate the health condition. This suggests that future research should draw on an intersectionality theoretical framework to explore these processes of interaction and how they may relate to social power [26]. Future qualitative research would contribute to a deeper understanding of the processes through which virtual care preferences and access play out across intersections of gender, race, disability, chronic disease, age, and socioeconomic status, and a mixed methods intersectional approach would aid in the development of more nuanced and well-rounded virtual care policies and programs.

Some participants expressed through open-text responses that their TNB identity was relevant to their virtual care preferences, mentioning gender dysphoria, transphobia in healthcare, or misgendering. Similar proportions of participants who did and did not avoid virtual care during the pandemic due to their TNB identity reported postpandemic preference for virtual care. This finding suggests that those who avoided virtual care due to their TNB identity, for instance, due to anticipated discrimination [8], may similarly avoid in-person care. However, many participants did not mention their gender, with some explicitly stating that their preference was unrelated to their TNB identity. Because many of our quantitative findings and open-text responses were related to non-TNB-specific factors, they may be applicable to the broader population.

The heterogeneity within our results suggests that flexibility in choice regarding modality of care delivery may best support the diverse needs of patients, particularly those in TNB communities. For example, because some participants justified preferences for in-person care based on anxiety, chronic conditions, and parental support, while others used these factors to justify virtual care preferences, practitioners should be prepared to deliver care via virtual or in-person means, if feasible. Flexibility should also be afforded in terms of the mode of virtual care delivery. Some TNB participants experienced dysphoria when seeing themselves on a video call, but others may have been more concerned with practitioners misgendering them based on how their voice sounded over telephone appointments.

Depending on the province or territory in Canada where physicians practice, they may face limitations on the types and modes of services they can bill to public health insurance, which may influence the care options that they are willing or able to provide [3,6]. In certain jurisdictions, physicians have daily caps on the number of virtual appointments they can bill to public health insurance [6]. While previous studies found that patients often want care delivered over secure text messaging, when possible, few jurisdictions in Canada offer publicly funded texting services [3]. Only certain types of care are publicly insured, with, for instance, walk-in appointments not being covered in Nova Scotia [6]. Additionally, many changes made in the Canadian virtual care policy in response to the COVID-19 pandemic are still temporary [6]. To improve care quality and access, policymakers and funders may consider implementing permanent funding schemes that cover a wider range of services and reward physicians similarly for the same services delivered via different modes.

Although virtual care may be valuable to address existing disparities in care access for TNB-specific and nonspecific services, both virtual and in-person care options will remain important after the pandemic. Researchers and care providers should continue to identify populations for whom virtual care is particularly beneficial, identify the barriers that may prevent them from accessing it, and propose and appraise interventions designed to overcome these disparities.