Rural LGBTQ+ Populations Continue to Face Health Care Disparities
As part of its mission to aid Kansas’ rural and medically underserved communities in building sustainable access to quality primary care, the Kansas Department of Health and Environment Office of Primary Care & Rural Health hosted a webinar entitled “Caring for LGBTQ+ Populations in Rural Kansas” in conjunction with its Navigating Rural Health Resources webinar series.
Who are LGBTQ in Kansas?
Presenter Tori Gleason, DC, a clinical analyst at LMH Health in Lawrence, Kansas, shared statistics compiled by the UCLA Williams Institute estimating 92,000 total LGBTQ+ individuals (age 13 and older) in Kansas, comprising 3.3% of the state’s population. Over half (57%) are ages 18-34. One-third of LGBTQ adults age 25 and older are raising children. Regarding work and education, there are 56,000 LGBTQ+ workers (4% of the workforce), though 30% have an income less than $24,000; 43% have a high school education. Other socioeconomic indicators reveal that 33% are food insecure and 20% are uninsured.
The misconception is that all LGBTQ+ Kansans live in the state’s most populous urban areas, but that is not true. According to a 2019 report, “Where We Call Home: LGBT People in Rural America,” U.S. Census and Centers for Disease Control and Prevention (CDC) data suggest that 15% to 20% of the total U.S. LGBT population live in rural areas around the country.
Understanding Gender Identity Terms
An NPR article, “A Guide to Gender Identity Terms,” provides a simple glossary to help people understand and communicate respectfully and accurately with one another.
Gender identity is one’s internal sense of self and gender, whether male, female, a combination of both, or neither. Gender identity, unlike gender expression, is not outwardly visible to others.
Cisgender (often shortened to cis, pronounced ‘sis’) describes a person whose gender identity aligns with the sex they were assigned at birth. If the birth attendant’s pronouncement that your parents heard — It’s a girl! or It’s a boy! — still feels accurate to you, then you’re cisgender.
Transgender, or simply trans, describes someone whose gender identity differs from the sex assigned at birth. Gleason, a transgender female, was listed as male at birth but her gender identity is female.
Mental Health in the Transgender Community
According to a study, “Demographic Characteristics and Health Status of Transgender Adults in Select U.S. Regions,” transgender people see more days per month of poor physical and mental with a higher prevalence of poor general health, lack of health insurance, and lack of health care providers.
One nationwide study of mental health differences between transgender and cisgender patients age 12-29 found transgender youth were two to three times more likely to have depression, anxiety, self-harm without lethal intent, as well as suicidal ideation and attempt. Another study, “Suicide Thoughts and Attempts Among Transgender Adults,” revealed the prevalence of suicide attempts was highest among those age 18 to 24 (45%); multiracial (54%); American Indian or Alaska Native (56%); lower educational attainment, high school or less (48 to 49%); and have a lower annual household, less than $10,000 (54%).
Respondents who experienced rejection by family and friends, discrimination, victimization, or violence had more suicide attempts. Contributing factors included their family choosing not to speak to or spend time with them (57%); being bullied at school (50%-54%); being discriminated against or harassed at work (50% to 59%), being disrespected or harassed by law enforcement (57% to 61%); being refused treatment by health care providers (60%); experiencing physical or sexual violence (64% to 65% at work; 63% to 78% at any level of school; 60% to 70% by law enforcement); and experiencing homelessness (69%).
“As someone that has attempted suicide when I was in the 6th grade, when I was 12, I have struggled with suicidal ideation my entire life. It did get better with gender-affirming care. Don’t believe everything you read on social media. It actually makes a significant difference. Gender-affirming care is health care, and it’s real care.” Gleason notes.
Health Disparities and Barriers for LGBTQ+
According to Gleason, health inequities experienced by LGBTQ+ include poor self-rated general health, HIV infection and sexually transmitted infections, mental health conditions, substance abuse, violence, disordered eating, homelessness, incarceration, and lack of access to culturally competent care and preventative screening.
“I want to address implicit bias for just a second,” Gleason stated. “As you read through these, pay attention to what emotions you have. Does it take your brain somewhere else when it comes to my population, when it comes to me, when it comes to people that are in my community? Pay attention to that.”
According to the Merriam-Webster dictionary, implicit bias is a bias or prejudice that is present but not consciously held or recognized. A 2009 article notes, “… studies reveal that students, nurses, doctors, police officers, employment recruiters, and many others exhibit implicit biases with respect to race, ethnicity, nationality, gender, social status, and other distinctions.”
Additionally, LGBTQ+ individuals in rural areas face barriers to care due to the unavailability of resources, a lack of cultural humility, and insufficient training for medical providers and healthcare staff.
Concern that a doctor or health care provider will refuse to treat them is a common occurrence in the trans and LGBTQ communities, according to Gleason. A 2022 ACLU of Kansas informal online survey of 100 Kansans from a rural/urban mix of 13 Kansas counties found that of the LGBTQ+ Kansans completing the survey, 28.7% had experienced discrimination in health care, including denial of services or care. Denial of care is much more amplified in rural communities with only one or two providers, limiting patient resources and options. Because of this and the fear of not being in an inclusive environment, many in the LGBTQ community avoid seeking general preventative care.
In a 2018 study, “Primary Care Clinicians’ Willingness to Care for Transgender Patients,” out of 140 respondents, 75% reported ever having met a transgender person, and slightly more than half (53%) had treated a transgender patient in the last five years. Overall, 85.7% of clinicians stated they were willing to provide routine care to transgender patients, and 78.6% were willing to provide Pap tests for transgender females. However, only about 69% reported feeling capable of providing routine care to transgender individuals.
How Healthcare Providers Can Deliver Equitable Care to LGBTQ+ Patients
Gleason offered several suggestions to empower providers to deliver equitable care to the LGBTQ+ community.
1. Enable the electronic health record (EHR) to collect relevant data and use that information to support the needs of LGBTQ+ individuals. According to a 2017 “Emergency Department Query for Patient-Centered Approaches to Sexual Orientation and Gender Identity: The EQUALITY Study,” 78% of clinicians nationally believe patients would refuse to answer sexual orientation questions when in reality, only 10% of patients said they would refuse to provide that information if asked. On the contrary, most believed the questions were essential, per a “Do Ask, Do Tell” study. Gleason stressed it’s okay to ask questions regarding a patient’s sexual orientation and gender identity (SOGI, pronounced so-gee). “When it comes to the SOGI questions, turn on your [EHR] modules, ask your patients. Identify your patients for who they are because if you don’t from a population health perspective, you’re going to miss things from a health outcomes perspective.”
2. Build a culture of awareness and caring to break down barriers of misunderstanding and trust and create an inclusive and welcoming environment. Gleason notes that at her institution, LMH Health, gender markers (which remain in the medical chart) have been removed from patients’ ID wristbands and replaced with pronouns. She also emphasizes the necessity of first impressions. “I learn more about my providers by their waiting room and my interaction with front desk staff about how this experience is going to be than anything else.” How can an institution signal that they are welcoming to LGBTQ+? “One of the things I always appreciate is just seeing an equal sign … the equal sign oftentimes means … that this is a safe place and an inclusive place.” Lanyards and pins worn by staff are other nonverbal cues that an office is inclusive and welcoming to all communities. “Just treat people as people. That’s all any of us want. Seeing the whole person is an important part of care,” Gleason said.
3. Develop services to address the needs of LGBTQ+. Gleason encourages federally qualified health centers (FQHCs) and county health departments to establish a health equity action team responsible for keeping current on federal, state, and local legislation and initiatives and studying data concerning health care disparities affecting underserved populations.
4. Partner with the local community to become a trusted health care provider. “This is where your community advisory boards come in. If you don’t have one, establish one,” Gleason said. Advisory boards make recommendations to clinics and facilities by continually assessing needs, uncovering service gaps, and identifying improvement areas. It’s important to note that in frontier (defined by the National Rural Health Association as an area that is sparsely populated and geographically isolated from population centers and services) and rural areas, some community members will take longer to normalize the narrative, so be mindful and respectful of all viewpoints and realize it will be a series of baby steps toward progress.
5. Understand the unique experiences faced by LGBTQ individuals. Patients should not have to educate their providers. Health care professionals should seek out and complete training and maintain continuing education regarding health care disparities that exist within the LGBTQ communities. This includes completing implicit bias training. “I think [implicit bias training] should be yearly, it should be mandatory, and if you don’t do it yearly, you should not be allowed to be employed at your location. It’s as simple as that,” Gleason stressed.
6. Provide culturally responsive and clinically competent care that meets the needs of LGBTQ patients. This begins with comprehensive training of all staff. According to Gleason, often, front and back office staff do not receive implicit bias or cultural humility training, nor do they receive training on how to work from a trauma-informed care perspective with those who are in historically resilient and marginalized communities. All health care team members should use inclusive language, such as gender-inclusive terms and pronouns, and ask patients the name they prefer to be addressed by.
7. Advocate within policy and insurance systems to improve LGBTQ health outcomes. Providers should advocate for patients accessing LGBTQ-specific care, including gender-affirming care, which includes navigating prior authorization processes and appealing insurance coverage denials. “To make sure we understand gender-affirming care, it’s something that affirms your gender,” explained Gleason. “A person with a penis that takes Viagra for erectile dysfunction – that’s gender affirming care. Gender-affirming care is also a cisgender female that wants to get breast augmentation.“
Providers should also partner with the population impacted to engage in public policy and change systems to improve health outcomes within the LGBTQ community. “Involve them in that process, listen to them, engage with them, see what their barriers are,” said Gleason.
8. Increase accessibility to rural LGBTQ patients via telehealth. According to Gleason, many physicians in the state of Kansas provide telehealth appointments for transgender patients. Providers interested in instituting telehealth capabilities can reach out to clinics successfully utilizing the technology to learn the policies, procedures, and best practices they have learned from their experience. “Telehealth and virtual care is a huge area because especially in the rural side, that’s often your opportunity. If you’re driving three hours for your family physician, telehealth is that opportunity.”
Rural LGBTQ+ Resources
Movement Advancement Project Rural LGBT Resources: Many resources to support LGBT people living in rural areas and get them in touch with the communities, networks, and resources they need to thrive in rural America.