Barriers to Accessing Health Care in Rural Regions by Transgender, Non-Binary, and Gender Diverse People: A Case-Based Scoping Review

Abstract

Research shows an overrepresentation of trans people in vulnerable socioeconomic situations, primarily due to experiences of discrimination. At the same time, rural or suburban living areas often lack specialized trans-related health care, which a majority of trans people rely on to some extent. Taken together, the lack of both socioeconomic resources and access to trans-related health care can exacerbate health-related distress and impairment for trans people. We illustrate this problem using case vignettes of trans people from rural and suburban areas in (Northern) Germany. They are currently participating in an e-health intervention and randomized controlled trial (RCT) called i2TransHealth, whose case vignettes provided the impetus for the scoping review. The scoping review analyzes the impact of place of residence and its intersection with barriers to accessing trans-related health care. PubMed and Web of Science Data bases were searched for relevant studies using a search strategy related to trans people and remote, rural, or suburban residences. 33 studies were selected after full-text screening and supplemented via reference list checks and study team expertise by 12 articles addressing the living conditions of remotely living trans people and describing requirements for trans-related health care. The literature on trans people living remotely reveals intersections of trans mental health with age, race, gender expression, geographic location, community size, socioeconomic status, discrimination experiences, and attitudes towards health care providers. Several structural health care barriers are identified. The role of health care professionals (HCPs) for remotely living trans people is discussed. There is no need assuming that rural life for trans people is inevitably worse for health and well-being than urban life. Nevertheless, some clear barriers and health disparities exist for trans people in remote settings. Empowering trans groups and diversity-sensitive education of remote communities in private and institutional settings are needed for respectful inclusion of trans people. Facilitating access to trans-related health care, such as through video-based e-health programs with HCPs, can improve both the health and socioeconomic situation of trans people.

Restriction of Access to Healthcare and Discrimination of Individuals of Sexual and Gender Minority: An Analysis of Judgments of the European Court of Human Rights from an Ethical Perspective

“…Furthermore, SGM individuals are at a greater risk to experience emotional distress as a consequence of experiencing bullying [ 39 ]. Thus, any form of discrimination can have a negative impact on the physical and mental health status of SGM individuals [ 16 , 17 , 18 ]. This might contribute to the persistent health disparities seen amongst the SGM population [ 40 , 41 ].…”

“…Some areas, such as rural regions, seem to be prone to more frequent acts of discrimination. This can occur through the development of a specific atmosphere of discrimination and results in a phenomenon of ‘health migration’, e.g., transsexual individuals changing their place of residence in order to get better access to trans-specific healthcare [ 17 , 18 , 19 , 20 , 21 ].…”

Interdisciplinary, internet-based trans health care (i²TransHealth): study protocol for a randomised controlled trial

“…Modern technologies are now strongly recommended in order to offer rural LGBTQIA+ people gender-reflective health care regardless of where they live, but still need to be adequately tested for their effectiveness. E-health is a promising tool,60 61 with research on rural and non-rural residing trans people arguing for it 23 24…”

“…Researchers have already indicated the use of e-health approaches for trans people living in rural villages and small towns 22 23. Specifically, it is hypothesised that e-health approaches can help trans people with increased mental stress living in rural areas to receive support from mental and physical health services 24. Based on our clinical experience and previous research10 24 25 we expect e-health services offered by trans-informed HCPs supporting both less-specialised HCPs and trans individuals living outside a metropolis may be helpful in reducing trans people’s reservations about rural HCPs 26 27.…”

“…Specifically, it is hypothesised that e-health approaches can help trans people with increased mental stress living in rural areas to receive support from mental and physical health services 24. Based on our clinical experience and previous research10 24 25 we expect e-health services offered by trans-informed HCPs supporting both less-specialised HCPs and trans individuals living outside a metropolis may be helpful in reducing trans people’s reservations about rural HCPs 26 27. For Germany, both quantitative survey research and qualitative studies revealed minority stress and health disparities for trans people 28–30.…”