This article originally appeared on KHN.
For Tammy Rainey, finding a healthcare provider who knows about gender-affirming care has been a challenge in the rural northern Mississippi town where she lives.
As a transgender woman, Rainey needs the hormone estrogen, which allows her to physically transition by developing more feminine features. But when she asked her doctor for an estrogen prescription, he said she couldn’t provide that kind of care.
“He’s generally a nice guy and doesn’t act prejudiced. 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 get a supply of estrogen from a clinic in Memphis, Tennessee, to take home.
The obstacles Rainey overcomes to access care illustrate a type of medical inequity that transgender people living in rural America often face: a general lack of education about trans-related care among health professionals from small towns who may also be reluctant to learn.
“Medical communities across the country are clearly seeing that there is a knowledge gap in the provision of gender-affirming care,” said Dr. Morissa Ladinsky, a pediatrician who co-leads the Youth Gender Multidisciplinary 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 uniform state data. However, the Movement Advancement Project, a nonprofit organization that advocates for LGBTQ+ issues, used 2014-17 Centers for Disease Control and Prevention data from select ZIP codes in 35 states to estimate that approximately 1 in 6 transgender adults in the US lives in a rural area. area. When that report was released in 2019, there were an estimated 1.4 million transgender people ages 13 and older 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.
One in 3 transgender people in rural areas experienced discrimination by a health care provider in the year prior to the 2015 US Transgender Survey Report, according to an analysis by MAP. Additionally, one-third of all transgender people report that they need to teach their doctor about their health care needs in order to receive appropriate care, and 62% worry about being negatively judged by a health care provider because of their sexual orientation or gender identity, according to the data collected. by the Williams Institute and other organizations.
The lack of local rural providers with knowledge of trans care can mean long trips to gender affirming clinics in metropolitan areas. Rural trans people are three times more likely than all transgender adults to travel 25 to 49 miles for routine care.
In Colorado, for example, many transgender people outside of Denver struggle to find the right care. Those who have a trans-inclusive provider are more likely to receive well exams, less likely to delay care due to discrimination, and less likely to attempt suicide, according to results from the Colorado Transgender Health Survey published in 2018.
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 in the United States and Canada, published its first curriculum guidelines on caring for LGBTQ+ patients. As of 2018, 76% of medical schools included LGBTQ health topics in their curriculum, with half providing three or fewer classes on this topic.
Perhaps because of this, nearly 77% of students at 10 New England medical schools felt “not competent” or “somewhat not competent” in treating gender minority patients, according to a 2018 pilot study. article, published last year, found that even doctors working in trans-friendly clinics lack knowledge about hormones, gender-affirming surgical options, and how to use appropriate pronouns and trans-inclusive language.
Throughout medical school, trans care was only briefly mentioned in endocrinology class, said Dr. Justin Bailey, who received his medical degree from UAB in 2021 and is now a resident there. “I don’t want to say the wrong thing or use the wrong pronouns, so I was hesitant and a little lukewarm in my approach to interviewing and treating this patient population,” he said.
In addition to insufficient medical school education, some practicing doctors don’t take the time to learn about trans people, said Kathie Moehlig, founder of TransFamily Support Services, a nonprofit organization that offers a variety of services to trans people. transgender people and their families. They mean very well but are uneducated when it comes to caring for transgender people, she said.
Some medical schools, such as the UAB, have opted for change. Since 2017, Ladinsky and her colleagues have worked to include trans people in their standardized patient program, giving medical students hands-on experience and feedback interacting with “patients” in simulated clinical settings.
For example, a trans person acting as a patient will simulate acid reflux by pretending to have stomach and chest pain. Then, in the course of the exam, they will reveal that they are transgender.
In the early years of this program, some students’ bedside attitudes would change once the patient’s gender identity was revealed, said Elaine Stephens, a trans woman who participates in UAB’s standardized patient program. “Sometimes they would immediately start asking about sexual activity,” Stephens said.
Since the UAB launched its program, student reactions have improved significantly, he said.
This progress is being replicated by other medical schools, Moehlig said. “But it’s a slow start, and these are large institutions that take a long time to get going.”
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 on gender-affirming care to rural providers since 2020. The classes became so popular that the organization created a field of 2021 four-week training for providers to learn hormone therapy management, proper terminology, surgical options, and mental health support for patients.
For many years, doctors did not recognize the need to learn about gender-affirming care, said Dr. Caroline Kirsch, director of osteopathic education at the University of Wyoming-Casper Family Medicine Residency Program. In Casper, this led to “a number of patients traveling to Colorado to access care, which is a huge financial burden for them,” said Kirsch, who participated in the ECHO Colorado program.
“Things that historically haven’t been taught that well in medical school are things that I think a lot of doctors feel anxious about at first,” he said. “The earlier you learn about this type of care in your career, the more likely you are to see its potential and feel less anxious about it.”
Educating more providers about trans-related care has become increasingly vital in recent years, as gender-affirming clinics across the country experience an increase 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 mounting pressure from Tennessee Republican lawmakers, the clinic halted gender-affirming surgeries on patients under the age of 18, which could leave many trans children without needed care.
Stephens hopes to see more medical schools include courses on trans healthcare. He also wants doctors to treat trans people like they would any other patient.
“Just provide quality healthcare,” he tells UAB medical students. “We need healthcare just like everyone else.”
KHN (Kaiser Health News) is a national newsroom that produces detailed journalism on health issues. Along with Policy Analysis and Polling, KHN is one of the three main operating programs of the KFF (Kaiser Family Foundation). KFF is an endowed non-profit organization that provides information on health issues to the nation.