A new qualitative evaluation of the i²TransHealth e-health intervention shows promise for expanding transgender and gender-diverse healthcare access in remote regions of Germany, while also underscoring persistent structural challenges that must be addressed as digital care models scale.
Published on January 24, 2026, in BMC Health Services Research, the study examined the implementation of i²TransHealth, an innovative digital care model developed in northern Germany to connect transgender and gender-diverse adults with gender-affirming, interdisciplinary healthcare through video consultations, chat support, and a network of locally trained general practitioners and psychiatrists.
The intervention was designed to address well-documented access barriers facing transgender people in rural and underserved areas, including long travel distances to specialized clinics, shortages of transgender-informed providers, limited referral pathways, and insufficient local crisis support. Researchers note that these gaps can contribute to delayed or interrupted care and increased psychological distress.
The evaluation was conducted as part of a larger randomized controlled trial involving 174 adult participants and complements previously published effectiveness and cost-effectiveness analyses from the same project. Rather than focusing on clinical outcomes, this qualitative process evaluation explored what helped or hindered real-world implementation. Researchers conducted four online focus groups with service users, study therapists, general practitioners, and psychiatrists.
Improved Access and Continuity of Care
Participants consistently reported that i²TransHealth improved access to transgender-informed care, particularly for individuals living outside major urban centers. Service users highlighted the flexibility of video consultations and the value of having dedicated study therapists who provided guidance, reduced distress, and helped navigate the healthcare system.
The study’s service user group included transgender men, transgender women, and nonbinary or genderfluid participants ranging in age from their early twenties to late forties, living in small towns, mid-sized communities, and cities. Many described chat-based communication as especially helpful, allowing ongoing contact with care teams without the need for frequent or costly travel.
Ongoing Challenges for Providers and Patients
Despite these benefits, the evaluation identified significant obstacles. Healthcare providers cited heavy administrative workloads, time constraints, and technical issues as barriers to sustained engagement. Therapists reported high workloads that raised concerns about the long-term sustainability of the model without additional staffing or institutional support.
The study also found that many participating general practitioners and psychiatrists had limited prior experience providing transgender-specific care and had only begun doing so after joining the i²TransHealth network. While training and networking improved confidence, providers emphasized that digital care alone cannot replace in-person services for complex cases.
Both users and clinicians noted limitations in video consultations, particularly when assessing nonverbal cues or supporting individuals experiencing severe psychological distress. Participants stressed the continued importance of in-person care and specialized referrals, which remain scarce in many regions.
The Bottom Line
The authors conclude that e-health interventions like i²TransHealth can significantly enhance access to gender-affirming care when integrated into broader healthcare networks. They emphasize that long-term success will require expanded provider training, improved digital infrastructure, and sustained institutional and government support.
As telehealth continues to reshape healthcare delivery, the study offers insight into how digital models can help bridge longstanding gaps in transgender healthcare while highlighting the limits of technology in the absence of systemic investment.
