For Tammy Rainey in the rural north Mississippi area where she lives, finding a health care provider knowledgeable about gender-affirming care has been a challenge.

As a transsexual woman, Rainey needs the hormone estrogen to allow her to physically change, developing more feminine features. But when she asked her doctor to prescribe her estrogen, he said he could not provide such help.

“Overall, he’s a nice guy and doesn’t act prejudicial. He gets my name and pronouns right,” Rainey said. “But when I asked him about hormones, he said, ‘I just don’t feel like I 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, and take it home with her.

The obstacles Rainey overcomes to access health care illustrate the type of health disparity often faced by transgender people living in rural America: a general lack of education about care related to trans among health workers from small towns who may also be reluctant to learn.

“Medical communities across the country clearly see that there is a knowledge gap in providing gender-affirming care,” said Dr. Marissa Ladzinski, a pediatrician who leads the Youth Interdisciplinary Group on Gender at the University of Alabama-Birmingham.

An accurate count of the number of transgender people in rural America is hampered by the lack of US Census data and single state data. However, the Movement Advancement Project, a non-profit organization that advocates for LGBTQ+ issues, used data from the Centers for Disease Control and Prevention from 2014-2017. from select zip codes in 35 states estimate that approximately 1 in 6 adults are transgender in the US live in rural areas. When this report was published in 2019, there were approximately 1.4 million transgender people aged 13 and over across the country. Now that number is at least 1.6 million, according to the Williams Institutea nonprofit think tank at the UCLA School of Law.

One in three trans people in rural areas felt discriminated against by medical professionals in the year preceding the 2015 US Transgender Survey Report, according to MAP’s analysis. In addition, a third of all trans individuals report that they need to tell their doctor about their trans health care needs receive appropriate care, and 62% worry about being negatively evaluated by medical professionals because of their sexual orientation or gender identityaccording to data compiled by the Williams Institute and other organizations.

Lack of local rural providers knowledgeable in transgender care can mean long commutes gender affirming clinics in metropolitan areas. Rural transgender people are three times more likely than all transsexual adults drive 25 to 49 miles for routine care.

Colorado, for example, has many trans people outside of Denver it’s hard to find proper care. Those with a trans-inclusive service provider are more likely to receive health screenings, are less likely to delay seeking care because of discrimination and are less likely to attempt suicide, findings show Colorado Transgender Health Study published in 2018.

Much of the lack of care for trans people is due to a lack of 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 educational guidelines for the care of LGBTQ+ patients. As of 2018, 76% of medical schools are included LGBTQ health topics in their curriculumwith half providing three or fewer sessions on the topic.

Maybe because of that, almost 77% of students from 10 medical universities in New England felt “incompetent” or “somewhat incompetent” in 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 them. appropriate pronouns and trans-inclusive language.

Throughout medical school, trans care was only briefly mentioned in endocrinology classes, said Dr. Justin Bailey, who received his medical degree from UAB in 2021 and is currently a resident there. “I don’t want to say the wrong thing or use the wrong pronouns, so I was hesitant and a little cool in my approach to interviewing and treating this group of patients,” he said.

In addition to a lack of medical education, some medical practitioners don’t take the time to educate themselves about trans people, said Kathy Mollig, founder of TransFamily Support Services, a nonprofit that offers a wide range of services to transgender people and their families. They are very well-intentioned but uneducated when it comes to transgender people, she said.

Some medical schools, such as UAB, have pushed for change. Since 2017, Lodzinski and her colleagues have been working to include trans people in a standardized patient program that gives medical students hands-on experience and feedback by interacting with “patients” in simulated clinical settings.

For example, a trans person acting as a patient will simulate acid reflux by pretending to have abdominal and chest pain. Then, during the examination, they will show that they are transgender.

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

Since UAB launched its program, student response has improved significantly, she said.

Elaine Stevens passes her medical student exam
Elaine Stevens is being examined by a medical student in the University of Alabama at Birmingham’s standardized patient program. In the program’s early years, Stevens says, some students’ behavior changed once she came out as transgender.

UAB Office of Standardized Patient Education

That progress is being replicated by other medical schools, Mollig said. “But it’s a slow start, and these are large institutions that take a long time to move forward.”

Advocates are also working outside medical schools to improve care in rural areas. In Colorado, the nonprofit organization Extension for Community Health Outcomes, OR ECHO Coloradostarting in 2020, offers monthly virtual classes on gender-affirming care to rural providers. The classes became so popular that the organization created a four-week boot camp in 2021 for providers to learn about hormone therapy management, correct terminology, surgical options, and patient mental health support.

For years, doctors didn’t realize the need to learn about gender-affirming care, said Dr. Caroline Kirsch, director of osteopathic education at the University of Wyoming Family Medicine Residency Program-Casper. In Casper, this has resulted in “several patients traveling to Colorado to access care, which is a huge financial burden for them,” said Kirsch, who was involved with ECHO Colorado.

“Things that weren’t taught very well in medical school are things that I think a lot of doctors are initially nervous about,” she said. “The earlier you learn about this type of help in your career, the more likely you are to see its potential and worry less about it.”

Training more providers in transgender health care has become increasingly important in recent years as gender-affirming clinics open up across the country feel increased persecution and threats. For example, the Transgender Health Clinic at Vanderbilt University Medical Center became the target of far-right hate speech on social media last year. After mounting pressure from Republican lawmakers in Tennessee, the clinic suspended gender confirmation surgeries on patients younger than 18, potentially leaving many trans children without the care they need.

Stevens hopes more medical schools will include coursework on transgender health. She also wants doctors to treat trans people like other patients.

“Just provide quality health care,” she tells UAB medical students. “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 surveying, KHN is one of the three main operating programs in the KFF (Kaiser Family Foundation). KFF is a non-profit organization that provides health information to the nation.

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