Transgender individuals experience a number of barriers to access to care including lack of availability of competent healthcare providers and stigma in healthcare settings. This is especially true in rural South Central Appalachia, where access to care for the general population is already limited. However, to date, little research has been done assessing the extent to which and reasons for lack of physical and mental healthcare access for transgender and other gender minority populations in this region. In this mixed-methods study we surveyed 155 healthcare providers and conducted focus groups and interviews with 18 patients in order to gain a better understanding of the obstacles to care that local gender minority patients experience. Results indicate that providers have a lack of training and a general lack of knowledge about these populations and their health needs and that many patients have difficulty identifying friendly and competent providers, have experienced stigma in healthcare settings, and often find themselves educating their own providers about their basic health needs. There is a clear need for training of currently-practicing primary care providers in South Central Appalachia on basic gender minority health needs and a need to train providers-in-training about the needs of LGBT patients.

One-third of transgender individuals report having at least one negative health care experience related to being transgender and nearly a quarter report that they have delayed seeking health care due to fear of being mistreated. Objective: To assess medical providers’ experiences with, attitudes towards, and knowledge of transgender health care in the Northeast Tennessee region. Study Design: Cross-sectional survey. Setting: Academic and community health care clinics in Northeast Tennessee. Participants: Physicians, nurse practitioners, and physician assistants practicing emergency medicine, family medicine, internal medicine, obstetrics & gynecology, or pediatrics (n=154). Main and Secondary Outcome Measures: Descriptive statistics and multiple regression models were used to determine relationships between provider characteristics and three sets of dependent variables (practices, attitudes, and knowledge). Results: The majority of providers (65%) had not received training in transgender healthcare. Over 90% perceived they had treated fewer than five trans-identified patients in the last year. The majority of respondents (69.3%) felt comfortable providing health care to transgender patients, yet only 38% felt competent treating this population. Providers indicated it was important to know their patients’ sexual practices, gender identity and sexual orientation; however, the majority of providers never or rarely asked patients their gender identity (75.4%), sexuality (57.2%), or desired pronouns (84.4%). Having formal training in transgender health was the only significant predictor of knowledge, sexual orientation and gender history taking, and competence/comfort with transgender patient care. Conclusions: Results demonstrate a contradiction between ideology and practice. Most participants responded they felt comfortable providing care to the transgender population, yet their responses indicated a lack of training and absence of inclusivity in their health care practices. As formal training was the only significant predictor of outcomes, this suggests that additional medical education and training is needed on transgender health care.