Information and communication technology-based health interventions for transgender people: A scoping review

In the recent past, there has been a strong interest in the use of information and communication technology (ICT) to deliver healthcare to ‘hard-to-reach’ populations. This scoping review aims to explore the types of ICT-based health interventions for transgender people, and the concerns on using these interventions and ways to address these concerns. Guided by the scoping review frameworks offered by Arksey & O’Malley and the PRISMA-ScR checklist, literature search was conducted in May 2021 and January 2022 in three databases (PubMed, CINAHL and Scopus). The two searches yielded a total of 889 non-duplicated articles, with 47 of them meeting the inclusion criteria. The 47 articles described 39 unique health projects/programs, covering 8 types of ICT-based interventions: videoconferencing, smartphone applications, messaging, e-coaching, self-learning platforms, telephone, social media, and e-consultation platforms. Over 80% of the health projects identified were conducted in North America, and 62% focused on HIV/sexual health. The findings of this review suggest that transgender people had often been regarded as a small subsample in ICT-based health projects that target other population groups (such as ‘men who have sex with men’ or ‘sexual minority’). Many projects did not indicate whether transgender people were included in the development or evaluation of the project. Relatively little is known about the implementation of ICT-based trans health interventions outside the context of HIV/sexual health, in resource limiting settings, and among transgender people of Asian, Indigenous or other non-White/Black/Hispanic backgrounds. While the range of interventions identified demonstrate the huge potentials of ICT to improve healthcare access for transgender people, the current body of literature is still far from adequate for making comprehensive recommendations on the best practice of ICT-based interventions for transgender people. Future ICT-based interventions need to be more inclusive and specified, in order to ensure the interventions are safe, accessible and effective for transgender people.


Introduction
In recent years, there has been strong interest in the use of telemedicine to deliver healthcare. Telemedicine (sometimes referred to as 'telehealth' or 'e-health' [1]), in its broadest sense, refers to the use of information and communication technologies (ICTs) in the delivery of health services at a distance [2]. The use of telemedicine has surged during the COVID-19 pandemic due to the restriction of in-person interactions. Clinicians around the world have used different ICT-based platforms, including computers, mobile phones, and the Internet to address some of the challenges faced by developing and developed countries in providing high-quality, accessible and cost-effective health care services [3][4][5].
One of the most notable advantages of telemedicine is increasing access to health care services for geographically dispersed, disadvantaged and stigmatized populations [6] such as transgender people [7,8]. Transgender is generally defined as an 'umbrella term that describes persons whose gender identity, gender expression or behaviors does not conform to that typically associated with the sex to which they were assigned at birth' [9]. The transgender population is incredibly diverse, and the definition of transgender is culturally specific [10]. Transgender people may include individuals who undergo gender affirmation surgery and/or receive gender-related medical interventions like hormone therapy, and who identify as having no gender, more than one gender or alternative genders [11]. For these reasons, it is difficult to estimate the actual population of transgender people. Some previous epidemiological and clinic-based studies have estimated that between 0.1 and 2% of the population identified as being transgender or other forms of non-cisgender identities [12][13][14].
It is well documented in the literature that due to intersecting forms of social marginalization and legal exclusion, transgender people are disproportionally affected by a wide range of human rights violations and adverse health outcomes [15]. Transgender people, especially those who are from a minority ethnic group, are disproportionately affected by gender-based hate crimes [16]. Minority stress research has shown that stressful events experienced by transgender people have made them more vulnerable to mental health problems such as depression, anxiety and suicidal ideation [17][18][19]. A lack of support systems in the society for transgender people can also contribute to their higher risk for substance misuses, HIV and other sexually transmissible infections (STIs) [17,[20][21][22].
Despite the increasing social acceptance of sexual and gender diversity in various parts of the world, transgender people often experience barriers to accessing adequate healthcare [23][24][25][26]. Some major barriers that impede transgender people's access to healthcare include discrimination in healthcare settings, a shortage of gender care specialists, a lack of adequate health insurance, poverty, and societal stigma [27][28][29][30]. Telemedicine can address some of these barriers, for instance, by offering transgender persons flexible, safe, private and comfortable ways to connect directly with transgender health specialists virtually, thereby reducing the risk of discrimination experienced by transgender persons in the process of seeking healthcare [8].
There is an incipient body of literature that advocates for the use of telemedicine to improve transgender people's health outcomes. Studies have shown an increased acceptance of telemedicine among transgender people and clinicians [31,32], and suggest that telemedicine can help promote HIV and sexually transmissible infection (STI) testing and care and improve psychosocial wellbeing, by simplifying access to gender-affirming hormone therapy [7,33,34] and perioperative care to individuals who undergo gender affirmative surgeries [35]. Some recent literature reviews on the use of digital and mobile health interventions have suggested that such interventions can effectively promote transgender youths' health [36,37], increase HIV testing rates [38], and deliver gender-affirming care [34]. However, these reviews either focused on younger transgender people or a particular health issue (i.e., HIV testing or gender-affirming care). Our article aims to extend the existing literature by exploring the types of ICT-based health projects/programs and interventions that have been used to deliver health services to transgender people of different ages and the concerns on using these interventions and ways to address these concerns.

Protocol and research questions
The review was guided by the frameworks developed by Arksey & O'Malley [39] and the PRIS-MA-ScR checklist [40]. The full protocol of this scoping review has been published elsewhere [41]. The overarching research question that guided this review was: What does the extant research say about the delivery and receipt of transgender health services through digital means? In particular, the following questions were explored: 1. What ICT-based health projects/programs have been documented in the literature and how have these projects/programs been used to deliver healthcare for transgender people?
2. What is lacking in the current body of literature on ICT-based health projects/programs for transgender people?
3. What are the concerns about effective ICT-based health projects/programs for transgender people and ways to address these concerns?

Search strategy
We initially searched PubMed, CINAHL and Scopus for articles published in English, with additional grey literature explored using Google Scholar and citation mining, in May 2021. Our multilingual team also performed a trial search in the Chinese-language e-journal database, Airti Library, in the early stage of the review which returned no relevant publications, so we decided not to include the database. Search terms were developed iteratively through team meetings and trial searches and were grounded on three concepts: telemedicine (e.g., m-health, e-health, digital health, telehealth), transgender persons (e.g., transgender, gender diverse, transman, transfeminine, gender non-binary), and delivery of health care (e.g., health service delivery, health promotion, consultation, and access to care). A supplementary search was conducted in January 2022 to identify more recent articles published between May and December 2021. The complete search strategy is presented in S1 File.

Inclusion criteria
Publications were only included in the review if they: 1) contained a detailed description of the development, implementation or evaluation of a particular ICT-based health project/program (i.e., services, interventions or research) that used digital means to improve the delivery of healthcare for transgender individuals (in other words, opinion pieces that only discussed the pros and cons of ICT use in a general sense, articles using ICT only as a means to recruit transgender participants, and research that studied the general attitudes of using ICT among transgender participants without describing a particular ICT-based project/program were not included); 2) successfully recruited or aimed to recruit transgender people, or if transgender people were direct recipients of the service/intervention/research project (i.e., articles discussing skills development for healthcare workers were not included); 3) were written in English.

Selection of articles and data charting process
Duplicates were removed following the search. Article screening, reviewing and data extraction tasks were shared by all members of the team. First, titles and abstracts of the non-duplicated articles were shared equally to screen out papers that did not meet the inclusion criteria. The title and abstract of each article were reviewed by two members independently to minimise misclassification. Then, the full text of the shortlisted articles was shared equally between team members and was reviewed rigorously to screen out any remaining papers that should be excluded. Data extraction was performed alongside full-text article review and was guided by a pre-developed framework which consisted of publication information (authors, article type, country and year of publication), types of ICT intervention used, target audience, total number of participants, total number of transgender participants, enablers and challenges described, recommendations, limitations of study methodology, and key takeaways of the study. During the review and data extraction process, any doubts that arose in regard to the process were discussed in team meetings.

Overview of included articles
The initial search yielded 790 non-duplicate articles. After reviewing the titles and abstracts, 704 articles were excluded, leaving 86 for full text review. At this stage, 33 articles were included in the preliminary analysis. The supplementary search in January 2022 yielded additional 176 articles. After a further review, a total of 14 additional articles met the inclusion criteria and were included in the final analysis (i.e., final sample size = 47 articles) (Fig 1). All articles were published between 2014 and 2021, but more than half of these papers (n = 26) were published in or after 2020. The 47 articles covered a total of 39 ICT-based projects, of which the characteristics are summarised in Table 1. Majority of these projects 34 (87%) were conducted in North America (USA, n = 32; Canada, n = 2), while three projects were conducted in Asia (Thailand, n = 1; Thailand + India, n = 1; and Indonesia, n = 1), and one in Australia. Over half (59%) of the projects had an experimental design (RCT, n = 15; quasi-experimental, n = 8). The earliest project identified was conducted in 2010 [80] but most (82%) began participant recruitment in or after 2015. Among all projects, 24 (62%) focused on improving HIV and/or sexual health, and 9 (23%) focused on gender-affirming care.

Characteristics of participants in the literature
Among the 39 ICT-based projects, 15 (38%) specifically targeted transgender people. There was one project which referred to 'transfemale and gender-nonconforming people' as 'MSM' (men who have sex with men) [42], and another project [43] which categorised 'transgender' (a gender identity) as a 'sexual identity' that was regarded as mutually exclusive with respect to being 'gay' and 'bisexual' (c.f. transgender people can be of different sexual orientations [10]). Some projects, despite stating that transgender people were one of their target audiences, only recruited a small number of transgender people or did not specify how many transgender people were reached or targeted. Among the projects that reported the transgender sample size, a total of 5927 (n = 1 to n = 1828) transgender people were recruited, and among them, 4338 (n = 0 to n = 1828) received an ICT intervention (e.g., they were assigned to the intervention arm of an experimental study) ( Table 2).

ICT-based interventions involved
Videoconferencing 13 (33) Only 13 (33%) projects reported the age of transgender people recruited and 5 projects included transgender people under 18. The youngest and oldest participants recruited were documented as being 12 and 60+ years old, both being transgender patients of a health clinic [44]. Participants' ethnic backgrounds followed the ethnic demographics of North America, with most projects having recruited participants who were reported as black/Latino/Hispanic or white.

Overview of ICT interventions involved
Among the 39 ICT-based projects, a total of 8 major types of ICT interventions were described. These interventions included videoconferencing, smartphone applications, text-messaging, social media, telephone calls, e-coaching, self-learning platforms and e-consultation platforms. It is important to note that some of these interventions overlapped with each other and some projects used more than one ICT intervention.
Videoconferencing. Thirteen projects involved the use of videoconferencing technologies. Using platforms such as Zoom, Google Meet and Doximity, clinicians had conducted synchronous video-chat or audio-only consultations to provide gender-affirming and other care such as HIV and sexual health care [32, 48,54], PrEP prescription [48,83], pre-and post-HIV test counselling [66][67][68]79], and behavioural counselling and support [46,58]. For example, the Open Door Health LGBTQ+ clinic in Rhode Island used Zoom for patient encounters during the pandemic [48]. In other community settings without in-house physicians, such as at the Gay City Wellness Centre in Seattle, PrEP consultations were conducted virtually with an off-site physician using a computer in the centre, and venepunctures were done by on-site staff members [83]. All of the available literature points to the fact that videoconferencing is a highly acceptable, satisfactory and feasible approach to promoting service accessibility among geographically dispersed communities, especially during the pandemic.
Smartphone applications. In eleven projects smartphone applications were used, mostly to promote HIV and sexual health through increasing PrEP awareness [52,72], providing HIV-and STI-specific information [47,52,53,69], and improving linkage to HIV and STI services [50,69,72,78]. Four projects specified that transgender people were involved in the development stage of these applications [47,52,53,57]. Overall, smartphone applications have been reported in the literature as being effective and acceptable in improving HIV-and STIrelated outcomes. Such applications typically consist of an education component that displays health information, and an activity component that includes games and self-risk assessments. Some applications, such as TechStep [57], HealthMpowerment 2.0 [47] and Trans Women Connect [52], also contained interactive functions such as polling and forums that allowed users to connect. Others, such as RUMAH SELA [69] and PrEPme [72], involved a messaging function for users to connect with a peer worker or health educator to ask HIV-related questions or to arrange PrEP appointments. Several incorporated smartphones' built-in capacities.
For instance, SMARTtest [78] used smartphones' cameras to help MSM and transgender women to interpret at-home HIV and syphilis test results. Users were then able to save and share the test results with doctors. Another app, Geopassport [50], assisted MSM and transgender women who had recently left prison to navigate HIV and related services. The application provided geolocation-based information and cash incentives when a person visited a service.
Messaging. Nine projects involved sending short messages through a telephone or computer, such as SMS, emails, or other instant messengers. Messaging was another common strategy to promote HIV prevention and care. Messaging in some cases was unidirectional and in other cases bidirectional, and participants were able to customise the types of messages they would receive and select the frequency and timing of messaging. For example, the interventions iTab [80], Text Me, Girl! [74], TechStep [57] and CARE+ SMS [81] sent pre-developed daily motivational text messages to participants in order to encourage adherence to PrEP or HIV treatment, and to promote emotional health. Some interventions, such as the PrEPmate study [42], utilised a bidirectional automated response system which required participants to respond to 'check in' messages asking about their PrEP use. Study staff then reached out to participants who indicated they needed further assistance or who did not respond to the messages within a set timeframe. Others, such as the weCare [76,77] and HealtheNav [73] projects combined text messaging and one-on-one coaching. Participants in these projects were able to communicate with a designated coach or health educator through text messaging. Overall, the literature indicates that text messaging, especially bi-directional messaging, is an acceptable, effective and personalised way to improve medication adherence and other HIV-related health outcomes [42, 76,77]. Moreover, bi-directional messaging also facilitates the collection of realtime data from participants and the provision of timely support [73]. e-Coaching. e-Coaching was mentioned in seven projects. In these projects, coaches (sometimes referred to as 'mentors' [50], 'cyberhealth educators' [76,77] or 'care navigators' [73]) who were trained peer workers, paraprofessionals or professionals communicated with participants regularly. With the exception of one project in which coaches only met with participants in person [50], coaches in all other projects identified and utilised different ICT tools, e.g., text messaging [57,62,73,76,77], video conferencing [58], phone calls [62], emails [88], apps [76,77] and social media [76,77,88] to connect with participants. In most projects, coaches were a rather casual point of contact who delivered personalised support to participants according to individual project aims. In the SMART project [58], however, coaches delivered more structural one-on-one counselling sessions to high-risk participants to encourage safer sex behaviors.
Self-learning platforms. Six different types of self-learning platforms were described in the literature. In general, these platforms consisted of education components which involved text, pictures and videos, and interactive components such as games, quizzes and forums. Some interventions, such as Singularities, incorporated elements of role-playing games and teenage players were able to learn about skills for preventing victimisation and bullying when completing various 'missions' in the game [59,60]. Nevertheless, the effects of self-learning platforms alone on positive health change appeared to be small or negligible. While studies like Singularities demonstrated some improvements in certain short-term outcomes (e.g., help-seeking and knowledge of online resources) in the intervention group, the study was not powered to find significant effects for most secondary and tertiary outcomes [60]. Other platforms, such as HealthMpower, successfully engaged with young, black cisgender and transgender people through a points-based rewards system which allowed participants to exchange points they earned from doing online quizzes and games with real prizes [43, 84,85], but there was only a marginally significant effect on change in safe-sex norms [85]. Similarly, the offline, HIV-clinic-based CARE+Spanish did not show any statistically significant effects on the medication adherence and viral loads of Spanish-speaking HIV-positive cisgender and transgender participants [86].
Telephone calls. Three projects described the use of telephone calls. Phone calls were used as an alternative strategy to connect with participants, such as when a transgender patient lacked access to the internet [54] or if they preferred to be contacted by phone over other strategies [62]. In some projects, telephone warmlines were run to engage with people who had questions with PrEP [72]. In the Together 5000 study [63], positive test results of lab-based athome HIV testing were delivered to cisgender and transgender participants over the phone by trained staff. The phone calls followed a standardised protocol that consisted of mental health assessment and provision of referrals to facilitate linkage to care. Based on evaluation with cisgender participants (no transgender persons were recruited in the evaluation), the authors found that in general at-home HIV testing with phone delivery of results could be an acceptable and feasible way to increase HIV testing access to geographically isolated people. Compared to email and online portals, phone calls were considered the more favourable means for staff to deliver emotional support to users preferring instant, live responses [63].
Social media. Three projects [62,76,77,82] involved the use of invite-only 'secret' social media platforms to connect transgender people. These projects found that social media provided a confidential and safe platform for meaningful exchange of information between peers, and in turn promote health by filling social support, resource and knowledge gaps for participants, especially for those who were younger. Projects such as weCare combined social media with one-on-one coaching and significantly reduced missed medical appointments and increased viral load suppression among cisgender and transgender participants with HIV [77]. e-Consultation platforms. Two projects [64,65] described the use of e-consultation platforms to link primary health providers with transgender health specialists. Using these platforms, clinicians who were not familiar with gender-affirming care were able to seek support from a wider network of specialists, thereby increasing the access and linkage of transgender people to appropriate care, especially for those who lived in rural areas. Moreover, analysing the questions that providers asked could also help researchers in identifying potential gaps in knowledge among primary care providers. However, some challenges included delayed response from specialists, and specialists may provide impractical recommendations because they did not understand the context and difficulties of under-resourced settings [64].

Concerns about ICT-based trans healthcare delivery and ways to address them
Below we present five concerns on delivering ICT-based transgender healthcare and ways to address them that we identified from the literature, based on critical appraisals of the methodologies and discussions of the individual papers. It should be noted that as the majority of the articles we reviewed only consisted of a small number of transgender people, the suggestions on addressing concerns summarised below are, to some extent, general and may apply to other LGBTIQ+ populations.
Content appropriateness and relevance. Adopting a user-centred approach is an essential component in maintaining the appropriateness and relevance of an ICT intervention [43,46,76]. Many projects consulted community members in the early stages, such as by conducting focus groups [42,80] or setting up advisory boards [47,52,53,57,62,74,89], to allow the target population to become an active part of the creative development of the intervention. Nevertheless, most of these projects did not specify the composition of the advisory boards. Only five projects indicated that the development of the intervention involved direct input from transgender people [47,52,53,57,74]. It has to be noted, though, that some of these projects only involve two [47] or three [52] transgender persons in the consultation process and it was unclear how their voices were adequately represented in the process.
Safety and confidentiality concerns. Confidentiality and safety of intervention recipients were concerns documented in the literature [32,46,48,63,73]. For example, some participants were concerned that unauthorised third parties could intercept or eavesdrop on technologydelivered health-related messages [46, 63,86]. This was partly because some of this communication was done at an inopportune time of day such as early in the morning or when clients were at work [63]. Some possible ways to create a virtual environment where people feel safe and comfortable to share their personal issues included setting up privacy protection components and clear instructions for users, such as advising them to use headphones [86]. For some younger transgender persons, they may feel uncomfortable seeing themselves on the computer screen possibly due to dissatisfaction with their own bodies [32]. In order to create a safer and more welcoming virtual setting, healthcare providers should assess each service recipient's comfort with the video function and allow them to disable the camera if needed [32]. Ongoing software updates and maintenance are also important [73] to keep ICT interventions secure, safe and relevant.
Limited literacy and access to technology. Several articles reported challenges in regard to recipients' literacy level and access to technology [42,46,48,86]. Some interventions enrolled only people with access to computers, smartphones and the internet [68]. Older people sometimes found it difficult to use technology-based services [46, 48,53]. Poor and unstable internet connections led to glitches that disrupted access to services [46, 79,90]. Appropriate assistance should be provided to help intervention recipients to overcome technical challenges, such as assisting disadvantaged people to address financial barriers related to the costs and access to equipment. Designing interventions using platforms familiar to the target populations (e.g., sending treatment information via social media platforms such as Facebook) was considered as another possible way to facilitate users to adopt a new intervention [76]. Multiple platforms should also be considered when attempting to reach transgender people of diverse backgrounds and needs [52].
Physical examinations and suboptimal interpersonal contacts. Suboptimal interpersonal contacts in virtual settings may hinder health providers' ability to perform complete physical examinations and take sample collections [32,83]. In one project, pathology tests were delayed for virtual consultations, and physical exams were replaced by visual assessments, patient self-exams and self-collected vital signs [48]. Getting parental consent for initiating gender-affirming hormones for transgender youth could also be challenging in an online setting [48]. Therefore, some younger transgender people may prefer in-person visits compared to videoconferencing for sexual health care, surgical consults, and initial gender care visits [32].
Infrastructural and legal support. The broader legal and health infrastructure affects the delivery of ICT-based transgender healthcare. A challenge described in some studies is the absence of adequate legal frameworks in some countries or localities that are supportive of remote care delivery [79,83]. Cross-jurisdictional telehealth could be a problem when clinicians are limited to practicing in specific jurisdictions with their licence [44]. Moreover, studies conducted in the USA highlighted ongoing concerns among providers and clients in regard to the billing of virtual care [48,76,83]. In relation to this, the USA Health Insurance Portability and Accountability Act (HIPAA) regulations had to be relaxed first so that many providers could adopt diverse technologies (including those that are not HIPAA compliant) to care for their clients during the COVID 19 pandemic [90].

Discussion
This scoping review is among the first to synthesise research on ICT-based interventions for transgender people. Our review has identified 39 ICT-based projects/programs, 8 types of interventions, and 5 common considerations for developing effective interventions for transgender people. Consistent with the broader literature [7,8], the range of interventions identified demonstrate the huge potentials of ICT to improve healthcare access for transgender people in relation to its flexibility and convenience. Nevertheless, while the body of literature has been expanding rapidly in the past two years, transgender people have too often been regarded as a small sub-sample in ICT-based programs and research. In some studies, transgender people have only represented as low as around 0.1% of the total sample size [73,78].
With such a small sample size, studies may not be adequately powered to detect the effectiveness of interventions for transgender people. Many studies did not specificize the involvement of transgender people in the design or evaluation process. Some studies [42, 43] even misclassified transgender people as men who have sex with men or transgender as a sexual identity. All these findings point to a lack of programs and research that are transgender people specified.
Three major gaps were noted in the literature. Firstly, relatively little is known about the implementation of ICT-based trans health interventions outside the context of HIV and sexual health. Although it has been widely argued that ICT can be adopted in other fields, such as mental health care, gender-affirming care and perioperative care for transgender people [8,35], only three studies discussed how ICT-based gender-affirming care could be provided in real-world clinical settings. This finding is consistent with a recent review on mobile-based interventions targeting transgender youth that most interventions have been focusing on HIV and sexual health care [37]. The three articles indicated some practical considerations regarding camera use [32], specimen collection, and consent process [48] that warrant future studies.
Secondly, there is a lack of global evidence, and how ICT-based transgender healthcare can be best used in resource-limited settings is yet unanswered. While this review included studies from Asia and Australia, most of the included articles were conducted in the USA. Implementing ICT-based interventions in resource-limited settings have both challenges and possibilities. On the one hand, there are barriers in relation to technology access, people's computer literacy, financial support, and regulation of telemedicine [91]. Poverty, human rights situations and socio-political contexts also likely affect transgender people's access to and experience of ICT-based interventions [92]. On the other hand, opportunities exist as healthcare is often provided directly by community peer workers or paraprofessionals in resource-limited settings, a tele-supervision model that links frontline workers to remote specialists may help improve access substantially [93]. This review included similar interventions in the USA that involved linking primary health providers with transgender health specialists, and interventions that supplemented frontline healthcare by community workers with teleconsultations with off-site physicians [83]. Future research can explore the most effective models of ICTbased interventions for transgender people living in different socioeconomic settings.
Thirdly, more data are needed to understand the access and experience of subpopulations of transgender people. The transgender population is highly heterogeneous and consists of differing races/ethnicities, ages and other intersectional characteristics. As the current literature is dominated by studies from the USA, the racial/ethnic profiles of participants in these studies resemble the demographics of the country which are dominated by white, black and Hispanic people. Interventions have often targeted transgender people who are younger (usually under 30 years), English or Spanish speaking, and who were assigned male at birth. Future studies could explore how to enhance intervention inclusiveness across diverse ethnic and language groups, such as Asian, Pacific Islander and Indigenous peoples, those assigned female at birth, and those who are older.
Although the current body of evidence is still far from adequate for us to make comprehensive recommendations on the best practice of ICT-based interventions for transgender people, the small body of literature has still provided some insights into effective interventions. Codeveloping interventions with target participants to improve the interventions' appropriateness is a case in point. Nevertheless, researchers and health providers must be aware of the risk of tokenism and be transparent in how transgender people are engaged in the consultation, development and implementation process. In our review, only a small number of articles have specified that transgender people were involved directly in the development of the interventions. Another pertinent point to consider is maintaining humanistic interactions in ICT-based interactions. For example, compared to email and online portals, phone contacts were considered the more favourable means for staff to deliver emotional support to users who prefer instant response and a real person to listen [63]. In addition to professionally trained practitioners such as doctors and nurses, peer workers with lived experience of similar issues add significant value to ICT-based interventions, especially for interventions that target the community of colour [72]. More importantly, the success of an intervention depends not only on the intervention itself, but also on the broader socio-political context such as how transgender people are supported by the legal and health systems. Systematic adjustments and health advocacy, such as, establishing a payment policy for telemedicine and allowing longer supplies of medication [48], changing one's gender marker or name on identity documents [82,94], and adjusting licensure requirements for cross-border telehealth programs [95], are necessary for ICT-based interventions to scale up and better link with other components of the healthcare system.

Limitations
Similar to most scoping reviews, while our use of comprehensive search terms and the practice of citation mining allowed us to capture a wide range of relevant publications, it was not possible to identify all literatures in the field. It is important to note that the ways and terms by which transgender people identify themselves are rooted in specific sociocultural contexts [96], making it difficult to capture all transgender people. Our search strategy also limited the review to literatures that are accessed through three databases, and the databases we used had their strengths and limitations (e.g., the use of MeSH terms did not cover ahead-of-print articles that have not been indexed, and Google scholars tended to pick up irrelevant articles). The search potentially favored articles published from resource-privileged and English-speaking countries, although a trial search was also conducted in a Chinese-language database which yielded no relevant articles. Including only peer-reviewed articles in this scoping review was another limitation. The literature varied in designs, sample size, and rigour, and some of the articles reviewed were research protocols, and therefore the degree to which their results could be compared to each other, and the transferability of their conclusions was unclear. Despite these shortcomings, we believe that our efforts help summarise and identify knowledge gaps on the types of work that have been done on this topic, thereby informing further work in this area.

Conclusions
While there is a rapidly growing literature on the use of information and communication technology to deliver healthcare to sexual minorities, transgender people are often still regarded as a sub-sample in most ICT-based programs and research. Future interventions, in addition to HIV and sexual health, should also focus on other unique health needs/issues that transgender people experience such as mental health and gender affirming care. It can also be of great importance to explore how ICT can be used to improve the health of transgender people from diverse sociocultural backgrounds. Crucially, the success of an ICT-based intervention depends not only on the intervention itself, but also on how transgender people are supported in the broader socio-political context. Health researchers have a responsibility to adopt a more inclusive approach in the design and delivery of interventions that are safe, accessible and effective, while continuing to advocate for the rights and health of transgender people from different policy perspectives. 15. United Nations. The struggle of trans and gender-diverse persons. Available form: https://www.ohchr. org/en/special-procedures/ie-sexual-orientation-and-gender-identity/struggle-trans-and-genderdiverse-persons

Human Rights
Campaign. An epidemic of violence: Fatal violence against transgender and gender nonconforming people in the United States in 2020. Available from: https://www.hrc.org/resources/anepidemic-of-violence-fatal-violence-against-transgender-and-gender-non-conforming-people-in-the-us-in-2020.