In addition, traditional challenges of rural life today, such as the opioid epidemic and unemployment, can be harder on LGBTQ people because they can be legally turned away from services or fired for their identity in most states. Thirty states, most of them “majority rural,” don’t explicitly protect LGBTQ people from discrimination in housing, employment and public services.

The smaller populations of rural areas can also complicate matters for LGBTQ people, because they are more likely to stand out. This can make them more vulnerable to discrimination but also keep problems they face under the radar.

For instance, LGBTQ youth homelessness in rural and urban areas is roughly equal, though LGBTQ people still face much higher homelessness rates than their straight counterparts. However, the report cautions that rates could be higher for rural LGBTQ youth, who often sleep in cars or outside, rather than their urban peers who sleep in shelters where their presence is recorded in data.

One of the biggest challenges the report identifies is health care. Fifty six percent of gay, lesbian and bisexual people across the country reported at least one instance of discrimination or patient profiling in a health care setting. According to statistics cited in the report, more than 40 percent of nonmetropolitan LGBTQ people said if they were turned away by their local hospital, it would be “very difficult” or “not possible” for them to find an alternative, compared to 18 percent of the general LGBTQ population, according to a statistic cited in the report.

Trans people often struggle to find health care providers knowledgeable about gender-affirming care and are more likely to have such care denied by their insurance provider. Trans people of color often face the added burden of providers with a lack of cultural competency for their community.

Trans people are also 15 percent more likely to have transition-related surgery denied by their insurance if they live in a rural area.

For many trans people, especially of color, the burdens of rural life force them to move away from home.

Malaysia Walker, 40, a black trans woman, began her transition in her hometown of Jackson, Mississippi. For eight years, she struggled with doctors who she said would only prescribe the lowest dose of hormones, didn’t test her hormone levels and shuffled her around to different doctors.

“There was not a provider that specializes in working with the trans community,” Walker said. “Getting access to hormones was horrible.”

Walker also said she was denied a promotion at her retail job because she is trans and that she often felt unsafe. But she didn’t decide to leave until a year ago, when her insurance denied a gender-confirmation procedure.

She moved to New Orleans and now works as a retention specialist at a clinic that offers care to transgender people. The move created a “new life” for her, and she’s generally happy living in New Orleans. But she does miss the food, family and familiarity of home.

"The crawfish in New Orleans isn't like Jackson," Walker said. "Thirty-nine years of building a life in Jackson. I miss the comfort of home."

‘SETTLING INTO RURAL LIFE’

While challenges for LGBTQ people can be “amplified” in rural areas, the report also found bright spots for lesbian, gay, bisexual, transgender and queer people living in nonmetropolitan communities.

Same-sex couples and LGBTQ individuals are raising children in rural areas at higher rates than urban areas. Rural residents support a variety of LGBTQ rights at high numbers, especially among women and youth, even if lower than urban residents. Sixty two percent of rural residents support nondiscrimination protections for LGBTQ people; among rural residents 18-29, it’s 75 percent, and among women, it’s 67 percent. In urban areas, 72 percent of residents support such protections.

Michael Patterson, left, and his husband, Bryan Timm. Courtesy of Michael Patterson and Bryan Timm

Some LGBTQ people feel safer in rural areas than urban areas. Michael Patterson, 35, grew up on a dairy farm in Pennsylvania. He moved to Philadelphia when he was 18 in part to be closer to gay life. Yet he moved back in 2013, to a small town outside Erie to start his own business.

He said that while he felt safe in Philly’s “gayborhood,” he was often verbally harassed in other areas of the city and knew of violent attacks on gay men.

He was nervous to move back to rural Pennsylvania, fearing social isolation and repression. But he was pleasantly surprised.

“I thought I was moving back to die alone,” he said with a slight chuckle. “But I wound up meeting my husband here and settling into rural life.”

His husband, Bryan Timm, 39, grew up in the area but never left for a big city.

“I don’t feel like I have to go anywhere, this is my home,” Timm said. “Times are changing here. The guys who bullied me as a kid for being gay, they’re my friends now. I’m not shy to hold hands with Michael in public.”

While social conditions in the area are changing, there are still legal and policy hurdles. Pennsylvania is the only Northeastern state that doesn’t have protections for LGBTQ people against discrimination.

While the MAP report makes several recommendations for improving support systems for LGBTQ people as well as policy and social changes, it appears focused on one in particular: passage of the federal Equality Act. The measure would make it illegal nationwide to discriminate against someone based on their sexual orientation or gender identity. The bill was recently reintroduced in Congress.

“LGBT people in rural areas are disproportionately harmed by the lack of protections and the presence of discriminatory laws,” the report states. “The current policy landscape demonstrates the clear and urgent need for federal and state nondiscrimination protections for LGBT people.”

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