When I told my family practitioner that I was having sex with men, he walked out of the consultation room and never treated me again. The medical profession was not, as I had naively hoped, immune to the stigmas that permeated the rest of my life as a gay kid living in rural Virginia (prior post on LGBTQIA+ bullying here).
A few years later, I expressed an interest to my replacement doctor in starting Pre-Exposure Prophylaxis (PrEP), a preventive treatment commonly used by gay and bisexual men, among other at risk populations, which decreases the risk of contracting HIV sexually by 99% according to the Center for Disease Control and Prevention (CDC) (prior post on rural HIV treatment here). My doctor informed me that he had "never heard of that" and was "not comfortable prescribing" it to me.
My experiences with health care providers are far from unique for sexual and gender minority (SGM) populations residing in rural America. In a CBS News article headlined "Transgender people in rural America struggle to find doctors willing or able to provide care," Tammy Rainey, a transgender woman who needs hormone estrogen, details her inability to access gender affirming care near her hometown in rural northern Mississippi. I mention Rainey, specifically, because my own doctor's words echo in her doctor's response to her request for an estrogen prescription:
I just don't feel like I know enough about that. I don't want to get involved in that.
I now drive an additional 35 minutes towards Washington, D.C. for doctor's appointments. Rainey has to drive 170 miles round trip to pick up her estrogen from a provider in Memphis, Tennessee.
It is well documented, including by the CDC, that rural Americans suffer significantly poorer health outcomes relative to urban Americans. These disparities arise from a myriad of social determinants of rural health, many of which have been discussed on this blog, including financial constraints and the intertwined phenomena of rural doctor shortages and hospital closures.
SGMs in rural America, a population estimated to be up to 3.8 million, face the same health disparities as their non-SGM counterparts, but also confront unique challenges as SGMs that are amplified by the rural experience. Specifically, heteronormativity, discrimination, and stigma distinguish the health of SGM groups in ways that demand specific attention from academics, public health professionals, and policymakers.
As Ilan Meyer identifies in an editorial in the American Journal of Public Health, from an institutional perspective heteronormativity contributes to health disparities by disadvantaging SGM people in:
the selection of research priorities, the design of public health prevention and intervention programs, the development of standards of care, access to care, and the provision of culturally sensitive care.
A WVUToday article from last year summarizing Zachary Ramsey's research highlights specific examples of obstacles SGMs face as a result of heteronormativity in health care systems, including insurance plans that fail to cover imperative SGM treatments and a knowledge gap between health care providers' training and SGM health needs. The existence of this knowledge gap is evident in a 2019 study conducted by the Movement Advancement Project (MAP), "Where We Call Home: Transgender People in Rural America," which found 23% of transgender people in rural America had to teach their provider about transgender health care needs in order to receive necessary care.
Zooming in, a 2021 Center for American Progress article, "Protecting and Advancing Health Care for Transgender Adult Communities," details how recurring exposure to discrimination, stigma, and the threat of violence, in conjunction with disadvantageous sociopolitical and economic risk factors, materially contributes to worsened overall health outcomes for SGMs, such as increased rates of chronic health conditions. Notably, mental illness among SGMs resulting from regular psychological stress is of particular concern in rural areas, where specialized SGM mental health resources are almost never available.
Moreover, as I experienced in rural Virginia, the trauma of anti-SGM discrimination and stigma is frequently reenacted by poor clinical care. According to MAP's 2019 analysis, one in three transgender people in rural America experienced discrimination by their health care provider in the past year. Similarly, a 2021 Williams Institute survey found 38.3% of SGM patients expressed concern about being judged negatively when accessing health care due to their SGM status. Experience and fear of stigma in health care settings has significant implications beyond concerns of bedside manner. A 2016 study published in PLOS ONE identified that higher stigma in health care settings directly correlated to lower utilization of primary care services by rural SGM groups, thereby contributing to health disparities.
Refocusing on rural contexts, MAP's 2019 analysis highlights four ways rural life exacerbates negative health consequences experienced by SGMs: (1) increased visibility, (2) ripple effects, (3) fewer alternatives, and (4) fewer support structures. First, increased visibility, arising from decreased population and heightened sense of community, renders non-conforming SGMs more at risk for harassment. Second, the intimate nature of rural communities increases the likelihood that ostracization by a portion of the community, such as a religious body, will have a ripple effect that spreads unlike it would in an urban setting. Third, scarcity of rural health care providers is especially challenging for SGMs because accessible providers often are not informed on their distinct needs and sometimes are religiously affiliated, such that, they can deny service under state religious exemption laws. Finally, geographic isolation means fewer support structures generally, a reality which leaves rural SGMs struggling to find adequate support in virtually every area ranging from social to legal.
While I have painted a bleak picture of the American public health landscape as it pertains to SGM populations in rural areas, there are actionable ways in which we as individuals, local communities, and a nation can improve this state of affairs (prior post on improving transgender health care in rural Colorado here). Critically, adopting an intersectional framework that centers SGMs existing at the axis of multiple marginalized identities, specifically transgender people of color, is necessary for effective mitigation of SGM health disparities.
3 comments:
thank you for sharing your experience and a part of your story in this post! I think so often the conversation about healthcare in rural areas can be divorced from sexual and gender minority healthcare when it shouldn't be. I learned alot from your post!
Echoing Laiba, I learned so much from your post and appreciate you sharing your experience. Reading this, I wondered if there are similar situations in other countries, particularly in countries that have publicly owned health services and a "rural-urban" political, economic, or cultural divide. I am curious to know if public control of health infrastructure - where primary care doctors function as state employees instead of almost like business-people, and thereby have less latitude to make "business decisions" like choosing not to treat someone impacts the quality of care across spatial lines.
As a transgender man, I felt like my doctor relied on my opinion or knowledge when I was seeking to start hormone replacement therapy, asking me how much testosterone I wanted to start at (how was I supposed to know?!). This was in Davis, so I cannot even imagine what it must be like in more rural places, where trans people may have no other physicians available. I think there is an extra layer of horror when thinking about states attempting to outlaw hormone replacement therapy or forms that have more animosity toward transgender people!
It is interesting to consider the unique difficulties of sexual and gender minorities in rural America. I appreciate you sharing your experience, it was very illustrative of this unique phenomenon. I can't imagine how disheartening that must have felt at the time.
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