Transgender people in rural America struggle to find doctors willing or able to help.

For Tammy Rainey, finding a health care 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, developing more feminine traits. But when she asked her doctor for a prescription for estrogen, he said he couldn’t provide that kind of care.

“In general, he is a good guy and does not behave in a biased way. He understands my name and pronouns correctly,” 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 this.”

So Rainey drives about 170 miles back and forth every six months to get a supply of estrogen from a clinic in Memphis, Tennessee, and take it home.

The hurdles Rainey overcomes to access healthcare exemplify the type of medical disparity that transgender people living in rural U.S. often face: a general lack of knowledge about trans-kinship care among small-town healthcare professionals, who may also be reluctant to to study.

“The medical community across the country is clearly seeing that there is a gap in knowledge about providing gender-affirming care,” said Dr. Morissa Ladinsky, a pediatrician who leads the Youth Interdisciplinary Gender Group at the University of Alabama at Birmingham.

An accurate count of the number of transgender people in rural America is hampered by the lack of US Census data and unified state data. However, the Movement Advancement Project, a non-profit advocating for LGBTQ+ issues, used data from the Centers for Disease Control and Prevention 2014-2017 for selected zip codes in 35 states to estimate that about one in six U.S. transgender adults lives in the countryside. region. When this report was published in 2019, there were approximately 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 for the UCLA School of Law.

According to an analysis by MAP, one in three transgender people in rural areas experienced discrimination from a healthcare provider in the year leading up to the 2015 US Transgender Study report. In addition, according to the collected data, one third of all transgender people report having to inform their doctor about what they need to get proper health care, and 62% worry that their health care provider will negatively judge them because of their sexual orientation or gender identity. Williams Institute and other organizations.

The lack of local health care providers in rural areas with expertise in caring for transgender people can lead to long trips to gender-affirming clinics in metropolitan areas. Rural transgender people are three times more likely than all adult transgender people to travel 25 to 49 miles for routine grooming.

In Colorado, for example, many trans people outside of Denver struggle to find proper care. Those with a trans-inclusive provider are more likely to have health screenings, less likely to delay treatment due to discrimination, and less likely to attempt suicide, according to the results of the Colorado Transgender Health Study published in 2018.

The lack of care that transgender people face is largely due to the 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 US and Canada, released its first LGBTQ+ Patient Care Curriculum Guidelines. As of 2018, 76% of medical schools included LGBTQ health topics in their curricula, with half of them having three or fewer classes on the topic.

Perhaps because of this, nearly 77% of students in 10 New England medical schools felt “incompetent” or “somewhat incompetent” in treating patients from gender minorities, according to a 2018 pilot study. Another paper published last year found that even clinicians working in trans-friendly clinics lack knowledge about hormones, surgical options for gender confirmation, and how to use appropriate pronouns and trans-inclusive language.

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

In addition to insufficient medical education, some medical practitioners don’t take the time to study transgender people, says Cathy Möhlig, founder of TransFamily Support Services, a non-profit organization that offers a range of services to transgender people and their families. They have very good intentions, she said, but are uneducated when it comes to caring for transgender people.

Some medical schools, such as UAB, pushed for change. Since 2017, Ladinski 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 a simulated clinical setting.

For example, a trans person acting as a patient will mimic acid reflux by pretending to have stomach and chest pain. Then, during the examination, it turns out that they are transgender.

In the early years of the program, some students’ bedside behavior changed after a patient’s gender identity was revealed, says Elaine Stevens, a transgender woman who participates in UAB’s standardized patient program. “Sometimes they immediately started asking about sexual activity,” Stevens said.

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

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

Lawyers are also working outside of medical schools to improve patient care in rural areas. In Colorado, the nonprofit Extension for Community Health Outcomes, or ECHO Colorado, has been offering monthly virtual sessions on gender-affirming care to rural health care providers since 2020. These classes have become so popular that the organization created a four-week provider boot camp in 2021 to learn about hormone therapy, proper terminology, surgical options, and patient mental health support.

According to Dr. Caroline Kirsch, director of osteopathic training at the University of Wyoming Family Medicine Residency Program, Dr. Kasper, for many years physicians did not recognize the need to explore gender-affirming care. In Casper, this resulted in “several patients going to Colorado for care, which was a big financial burden for them,” said Kirsch, who participated in Colorado’s ECHO program.

“Things that have historically not been taught as well in medical schools are things that I think a lot of doctors are worried about at first,” she said. “The earlier you learn about this type of care in your career, the more likely you are to see its potential and worry less about it.”

In recent years, it has become increasingly important to inform more trans related care providers as gender-affirming clinics across the country face increased 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. Following mounting pressure from Republican Tennessee lawmakers, the clinic has suspended gender confirmation surgeries on patients under the age of 18, potentially leaving many transgender children without the care they need.

Stevens hopes more medical schools will include courses in trans-medical care. She also wants doctors to treat transgender people the same way they treat any other patient.

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