For Tammy Rainey, finding a health care provider who understands gender-affirming care has been a challenge in her rural town in northern Mississippi where she lives.
As a trans woman, Rainey needed estrogen, which allowed her to physically transform by developing more feminine characteristics. But when she asked her doctor for an estrogen prescription, he said he couldn’t provide that care.
“He’s usually a nice guy, not biased. He gets my name and pronouns right,” Rainey said. “But when I asked him about hormones, he said, ‘I just don’t think I know enough about it. I don’t want to get involved.'”
So Rainey drives about 170 miles round trip every six months to get estrogen from a clinic in Memphis, Tennessee, and take it home.
Rainey’s overcoming barriers to accessing care illustrates a type of health inequity that trans people living in rural America often face: a widespread lack of information aboutAmong small-town health professionals who may also be reluctant to learn.
“The medical community across the country is clearly seeing a knowledge gap in the delivery of gender-affirming care,” said Dr. Maurice Saladinski, co-director of the Multidisciplinary Gender Group on Youth at the University of Alabama at Birmingham.
Accurately counting the number of transgender people in rural America is hampered by a lack of U.S. Census data and uniform state data. However, the Movement Advancement Project, a nonprofit that advocates for LGBTQ+ issues, estimates using 2014-17 Centers for Disease Control and Prevention data from selected ZIP codes in 35 states that roughly one in six transgender adults in the United States lives in rural areas. When the report was released in 2019, there were an estimated 1.4 million transgender people nationwide aged 13 and over. That number is now at least 1.6 million, according to the Williams Institute, a nonprofit think tank at the UCLA School of Law.
According to an analysis by MAP, one-third of transgender people in rural areas experienced discrimination by a health care provider in the year before the 2015 Transgender in America Survey report. Additionally, based on the data collected, one-third of transgender people reported having to tell their doctor about their healthcare needs to receive appropriate care, and 62 percent feared being Negative reviews of healthcare providers by the Williams Institute and other organizations.
Lack of local rural providers who understand transgender care can mean it takes a long timeClinics in metropolitan areas. Rural transgender people were three times as likely as all transgender adults to travel 25 to 49 miles for routine care.
In Colorado, for example, many trans people outside of Denver struggle to find appropriate care. According to results from the Colorado Transgender Health Survey, released in 2018, those with transgender-inclusive providers are more likely to receive health checks, less likely to be delayed in care due to discrimination, and less likely to attempt suicide.
The lack of care for transgender people is largely related to insufficient education about LGBTQ+ health in medical schools across the country. In 2014, the Association of American Medical Colleges, which represents 170 accredited medical schools in the United States and Canada, released the first curriculum guidelines on caring for LGBTQ+ patients. As of 2018, 76 percent of medical schools included the topic of LGBTQ health in their curriculum, with half of those schools offering three or fewer courses on the topic.
Perhaps because of this, nearly 77 percent of students from 10 New England medical schools felt “incompetent” or “somewhat incompetent” when it came to treating gender minority patients, according to a 2018 pilot study. Another paper published last year found that even clinicians working in transgender-friendly clinics lack knowledge about hormones, gender-affirming surgery options and how to use appropriate pronouns and transgender-inclusive language.
Dr. Justin Bailey, who graduated with a medical degree from UAB in 2021 and is now a resident, said transgender care was only briefly mentioned in endocrinology classes throughout medical school. “I didn’t want to say the wrong thing or use the wrong pronoun, so I was hesitant and a little tepid in interviewing and treating this group of patients,” he said.
In addition to inadequate medical school education, some practicing doctors don’t take the time to educate themselves about trans people, said Kathie Moehlig, founder of TransFamily Support Services, a provider of a range of services for trans people and their families. Non-profit organizations. They were well-intentioned but uneducated when it came to trans care, she said.
Some medical schools, such as UAB’s, have pushed for change. Since 2017, Ladinsky and her colleagues have been working to include trans people in their standardized patient program, which provides medical students with hands-on experience and feedback by interacting with “patients” in simulated clinical settings.
For example, a transgender person playing a patient would fake stomach and chest pains to simulate acid reflux. Then, during the examination, they would reveal that they were transgender.
Elaine Stephens, a trans woman who works on UAB’s standardized patient program, said that early in the program, once a patient’s gender identity was revealed, some students’ bedside attitudes changed. “Sometimes they immediately start asking about sexual activity,” Stephens said.
Since UAB launched the program, student responses have improved dramatically, she said.
The advance is being replicated by other medical schools, Moehlig said. “But it’s been a slow start, and these are large institutions that take a long time to move forward.”
Advocates also work outside of medical schools to improve care in rural areas. In Colorado, the nonprofit Extension for Community Health Outcomes (ECHO Colorado) has been offering monthly virtual sessions on gender-affirming care to rural providers since 2020. The courses are so popular that in 2021 the organization is teaching providers about hormone therapy management, proper terminology, surgical options and supporting patients’ mental health.
Dr. Caroline Kirsch, director of osteopathic education for the Casper Family Medicine Residency Program at the University of Wyoming, said that for years, doctors didn’t appreciate the need to learn about gender-affirming care. In Casper, this has resulted in “a lot of patients going to Colorado for treatment, and it’s a huge financial burden for them,” said Kirsch, who participates in ECHO’s Colorado program.
“I think that something that has not been taught very well historically in medical school is something that a lot of doctors feel anxious about initially,” she said. “The earlier in your career you learn about this kind of care, the better your The more likely you are to see its potential and be less anxious about it.”
Educating more providers about transgender-related care has become increasingly important in recent years as harassment and threats at gender-affirming clinics across the country have increased. For example, the transgender health clinic at Vanderbilt University Medical Center was the target of far-right hate on social media last year. The clinic suspended gender-affirming surgery for patients under the age of 18 after mounting pressure from Republican lawmakers in Tennessee, risking leaving many transgender children without essential care.
Stephens would like to see more medical schools offer courses in transgender healthcare. She also wants doctors to treat transgender people like other patients.
“Just provide quality health care,” she told UAB’s medical students. “We need health care like everyone else.”
KHN (Kaiser Health News) is a national newsroom that produces in-depth coverage of health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating projects of KFF (Kaiser Family Foundation). KFF is a funded nonprofit organization that provides information on health issues to the nation.