January 27, 2023

Finding a healthcare provider who is knowledgeable about gender-affirming care has been a challenge for Tammy Rainey in the rural northern Mississippi town where she lives.

As a transgender woman, Rainey needs the hormone estrogen, which allows her to change physically by developing more feminine traits. But when she asked her doctor for an estrogen prescription, he said he couldn’t afford that kind of treatment.

“He’s generally a good guy and doesn’t act in a biased manner. He gets my name and pronouns right,” Rainey said. “But when I asked him about hormones, he said, ‘I just feel like I don’t know enough about it. I don’t want to get involved in that.’”

So Rainey drives about 170 miles round trip every six months to bring home a supply of estrogen from a clinic in Memphis, Tennessee.

The barriers Rainey overcomes in accessing care illustrate a type of medical injustice that transgender people living in rural US often face: a general lack of education about transgender care among small-town health workers who may also reluctant to learn.

“Medical communities across the country clearly see that there is a knowledge gap in the delivery of gender-affirming care,” said Dr. Morissa Ladinsky, a pediatrician who co-leads the Youth Multidisciplinary Gender Team at the University of Alabama-Birmingham.

Accurately counting the number of transgender people in rural America is hampered by a lack of US census data and consistent state data. However, the Movement Advancement Project, a nonprofit advocating for LGBTQ+ issues, used 2014-17 data from the Centers for Disease Control and Prevention from select ZIP codes in 35 states to estimate that about 1 in 6 Transgender adults living in the US rural area. At the time this report was published in 2019, there were an estimated 1.4 million transgender people aged 13 and over nationwide. 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, in the year prior to the 2015 US Transgender Survey Report, one in three trans people in rural areas experienced discrimination from a healthcare provider. Additionally, one-third of all trans people say they need to educate their healthcare provider about their healthcare needs in order to receive appropriate care, and 62% fear being negatively judged by a healthcare provider based on their sexual orientation or gender identity, according to data collected as of September 2017 Williams Institute and other organizations.

A lack of local rural providers knowledgeable about transgender care can mean long trips to gender-affirming clinics in metropolitan areas. Rural trans people are three times more likely than all trans adults to travel 25 to 49 miles for routine care.

In Colorado, for example, outside of Denver, many trans people struggle to find appropriate care. According to the results of the 2018 Colorado Transgender Health Survey, those who have a transinclusive provider are more likely to receive wellness assessments, are less likely to delay treatment because of discrimination, and are less likely to attempt suicide.

Much of the lack of care trans people experience is related to insufficient LGBTQ+ health education in medical schools across the country. In 2014, the Association of American Medical Colleges, which represents 170 accredited medical schools across the United States and Canada, released its first curriculum guidelines for the care of LGBTQ+ patients. In 2018, 76% of medical schools included LGBTQ health topics in their curriculum, with half offering three or fewer courses on the topic.

Perhaps for this reason, according to a 2018 pilot study, nearly 77% of students at 10 New England medical schools felt “not competent” or “rather not competent” in treating minority-sex patients. Another study published last year found that even doctors working in trans-friendly clinics lack knowledge about hormones, gender-affirming surgical options, and the use of appropriate pronouns and trans-inclusive language.

Throughout medical school, endocrinology classes made only brief mention of caring for transgender people, said Dr. Justin Bailey, who received his medical degree from UAB in 2021 and is now based there. “I don’t want to say the wrong thing or use the wrong pronouns, so I was hesitant and a bit lazy in my approach to interviewing and treating this patient population,” he said.

Adding to the lack of training in medical schools, some practicing physicians don’t take the time to educate themselves about transgender people, said Kathie Moehlig, founder of TransFamily Support Services, a nonprofit organization that provides a range of services for transgender people and their families offers. They have very good intentions but are uneducated when it comes to transgender nurturing, she said.

Some medical schools, like those at UAB, 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 through interacting with “patients” in simulated clinical settings.

For example, a trans person acting as a patient simulates acid reflux by pretending to have stomach and chest pains. Then, in the course of the investigation, they will reveal that they are transgender.

In the early years of this program, some bedside students’ behavior changed once the patient’s gender identity was revealed, said Elaine Stephens, a trans woman who participates in the UAB’s standardized patient program. “Sometimes they would start asking about sexual activity right away,” Stephens said.

Since the UAB started its program, student responses have improved significantly, she said.

This advance is being replicated by other medical schools, Moehlig said. “But it’s a slow start and these are big institutions that take a long time to move forward.”

Advocates are also working outside of medical schools to improve care in rural areas. In Colorado, the nonprofit Extension for Community Health Outcomes, or ECHO Colorado, has been offering monthly virtual classes in gender-affirming care to rural providers since 2020. The courses became so popular that in 2021 the organization established a four-week boot camp for providers to learn about hormone therapy management, proper terminology, surgical options, and mental health support for patients.

For many years, physicians have missed the need to learn about gender-affirming nursing, said Dr. Caroline Kirsch, Director of Osteopathic Education at the University of Wyoming Family Medicine Residency Program at Casper. In Casper, this resulted in “a number of patients traveling to Colorado to access medical care, which is a major drain on them financially,” said Kirsch, who has participated in the ECHO Colorado program.

“Things that haven’t been taught as well in medical education in the past are things that I think initially worry a lot of doctors,” she said. “The earlier in your career you learn about this type of care, the more likely you are to see its potential and be less concerned about it.”

Educating more providers about trans-related care has become increasingly important in recent years as gender-affirming clinics across the country experience a rise in harassment and threats. For example, the Transgender Health Clinic at Vanderbilt University Medical Center became the target of far-right hate on social media last year. After growing pressure from Republican lawmakers in Tennessee, the clinic paused gender confirmation surgeries on patients under the age of 18, potentially leaving many trans children without the care they need.

Stephens hopes more medical schools will include trans healthcare courses. She also wishes doctors would treat trans people like any other patient.

“Just provide quality healthcare,” she tells UAB medical students. “We need health care like everyone else.”

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