This article originally appeared on KHN.
For Tammy Rainey, finding a health care provider knowledgeable about gender affirming care in the rural north Mississippi town where she lives was a challenge.
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 he couldn’t provide that kind of care.
“He’s generally a good guy and doesn’t do any harm. He gets my name and pronouns right,” Rainey said. “But when I asked him about hormones, he said, ‘I don’t think I know enough about that. I don’t want to be part of it.”
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 with her.
The obstacles Rainey overcomes to access care reflect the type of medical inequity often faced by transgender people living in the rural US: a general lack of education about trans care among health professionals in small towns who may they are also 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-directs the Multidisciplinary Youth Gender Team at the University of Alabama-Birmingham.
The lack of US census data and uniform state data prevents an accurate count of the number of transgender people in rural America. However, the Movement Advancement Project, a non-profit organization that advocates for LGBTQ+ issues, used 2014-17 Disease Control and Prevention data from select ZIP codes in 35 states to estimate that about 1 in 6 adults in the US is transgender living in the countryside. area. When that report was released in 2019, there were an estimated 1.4 million transgender people aged 13 and over across the country. 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 three transgender people in rural areas experienced discrimination by a health care provider in the year before the 2015 US Transgender Survey Report, according to an analysis by MAP. Additionally, a third of all transgender people report that they have to teach their doctor about their health care needs in order to receive appropriate care, and 62% worry about receiving negative judgment from a health care provider because of their sexual orientation or their gender identity, according to data collected. at the Williams Institute and other organizations.
A lack of local rural providers familiar with trans care may mean a long drive to gender affirming clinics in urban areas. Transgender people are three times more likely to travel 25 to 49 miles for routine care.
In Colorado, for example, many transgender people outside of Denver struggle to get proper care. Those with a trans-inclusive provider are more likely to receive wellness exams, less likely to experience delays in care due to discrimination, and less likely to attempt suicide, according to Survey findings Transgender Health Colorado published in 2018.
Much of the lack of care transgender people experience is linked to inadequate 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, released its first curricular guidelines for caring for LGBTQ+ patients. As of 2018, 76% of medical schools included LGBTQ health themes in their curriculum, and half offered three or fewer classes on this topic.
Perhaps because of this, nearly 77% of students from 10 New England medical schools rated themselves as “not competent” or “somewhat incompetent” in treating gender minority patients, according to a 2018 pilot study. A paper found another, published last year, that even clinicians 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 mentioned only briefly 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 tepid in my approach to interviewing and treating this patient population,” he said.
In addition to inadequate medical school education, some practicing doctors don’t take the time to educate themselves about transgender people, said Kathie Moehlig, founder of TransFamily Support Services, a nonprofit organization that offers a range of services to transgender people and their families. They are well-intentioned but not educated about transgender care, she said.
Some medical schools, like the one at UAB, are trying to change. Since 2017, Ladinsky and her colleagues have been working to include transgender people in their standardized patient program, which gives medical students hands-on experience and feedback by interacting with “patients” in simulated clinical environments.
For example, simulate a trans person acting as an acid reflux patient by pretending to have stomach and chest pain. Then, during the exam, they will reveal that they are transgender.
In the early years of this program, some students’ bedside manner would change once the patient’s gender identity was revealed, said Elaine Stephens, a trans woman who participates in UAB’s patient standardization program. “Sometimes they would immediately start asking about sexual activity,” Stephens said.
Since UAB launched its program, student reactions have improved significantly, she said.
Other medical schools are replicating this progress, Moehlig said. “But it’s a slow start, and these are big institutions that take a long time to get going.”
Advocates are also working outside medical schools to improve care in rural areas. In Colorado, the nonprofit Extension for Community Health Outcomes, or ECHO Colorado, is offering monthly virtual classes on gender-affirming care to rural providers starting in 2020. The classes proved so popular that the organization created a four-week boot camp in 2021 for providers to learn about hormone therapy management, correct terms, surgical options, and supporting patients’ mental health.
For decades, doctors have failed to 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 resulted in “some patients traveling to Colorado to access care, which is a huge financial burden for them,” said Kirsch, who participated in the ECHO Colorado program.
“I think a lot of physicians are concerned about things that have historically not been taught as well in medical school,” she said. “The earlier you learn about this type of care in your career, the more likely you are to see its potential and be less anxious about it.”
Educating more providers about trans care has become increasingly important in recent years as harassment and threats increase in gender affirming clinics across the country. For example, Vanderbilt University Medical Center’s Transgender Health Clinic became the target of far-right hate on social media last year. After mounting pressure from Tennessee’s Republican lawmakers, the clinic performed gender-affirming surgeries on patients younger than 18, potentially leaving many trans children without essential care.
Stephens hopes that more medical schools will include coursework on trans health care. She also wants doctors to treat transgender people like any other patient.
“Provide quality health care,” she tells the medical students at UAB. “We need health care like everyone else.”
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Along with Policy Analysis and Polling, KHN is one of the three major operating programs of the KFF (Kaiser Family Foundation). KFF is a not-for-profit endowment organization that provides information on health issues to the nation.