This study used a convenience sample of transgender individuals and compared mental health factors between trans people living in rural and non-rural areas in the United States.

Why would health and health care differ between rural and suburban or urban trans people? A number of possible factors, including…

Transportation issues.

Overall difficulty accessing health care. Fewer physicians, fewer hospitals. Few big research or teaching hospitals.

Possibly less social support for healthy lifestyles. Depending on the community, support of a healthy lifestyle may be less. Rates of tobacco use, alcohol drinking may be high and access to exercise and a fruit/vegetable-focused diet may be low

Less accepting physicians. Rural areas are traditionally more socially conservative, possibly resulting in higher rates of transphobia. Open-minded physicians may not have the resources to learn about transgender health care, and access to specialists is limited in rural areas

Smaller minority communities. With a smaller population, and transportation time, it’s much harder to form a supportive LGBT or trans community. Social support and information sharing may be very limited.

The vast majority of transgender health centers are in urban areas including San Francisco, Los Angeles, New York City, Seattle, Boston, Washington DC, and Philadelphia. Resources in places like the middle of rural New Mexico are few. But that doesn’t mean people in such rural places don’t need care too.

This research used the internet, advertising on mailing lists, journals, and forums, to recruit and survey trans people in all areas. They ended up with a very large sample for a trans study: 1,229 people! What determined whether a person lived in a rural or non-rural area? The participants self-selected an option – and if they selected “rural” or “small town” for their location they were classified into “rural”. Other options (suburban and urban) were classified “non-rural”.

What did they measure? Basic demographics, substance use, mental health (including anxiety, depression, somatization, and self-esteem), and sexual risk behaviors. That last one – sexual risk behaviors – was specifically narrow, focusing only on protected vs unprotected penetration with a penis.

The results were fairly clear.

For trans women, there was no different in mental health between rural women and non-rural women. But trans men were statistically significantly more likely to have depressive or anxiety symptoms, low self-esteem, and other similar mental health problems if they were rural than if they weren’t rural.

There were no significant differences in substance use for either trans men or trans women. There were no differences in sexual risk behavior either.

Some interesting, and some disturbing, statistics that came out of this:

25-27% of trans women reported a previous suicide attempt vs 38-40% of trans men.

7-10% of all trans people in the study reported binge drinking alcohol in the past 3 months. 7-13% used an illicit substance other than marijuana in that same time frame.

42-45% of trans women reported unprotected penile sex with either a primary or non-primary partner, vs 16-21% of trans men (in the past 3 months)

This study isn’t perfect. It was internet-based and used a convenience sample, so it may not reflect the larger trans population. It also used a broad definition for transgender at times, including those who cross dress for reasons other than gender identity. The fact that it was internet-based means that people who do not use computers or have access to the internet weren’t included. Still, it was the first of its time and its methods were fairly sound given these restrictions.

So what can we conclude?

First, something that we knew before: Trans people are in need of compassionate, open-minded mental health care and medical care no matter where they live.

Second: That trans men living in rural ares may be faring worse than their urban and suburban brothers.

Third: That rates of suicide are still unacceptably high for all trans people

Fourth: That trans people, especially trans women, are still at unacceptably high risk for HIV and other STDs via unprotected sexual contact.

What can we do about all of this?

Rural health care is a challenge for both physical and mental health. Telemedicine options continue to be in development. Education and outreach efforts must continue within trans communities. Those who work in physical and mental health, whether rural or urban, must understand that transgender populations face specific stressors and have specific health needs. Efforts to educate all providers, such as WPATH’s mailing list and Trans Line, must continue to be available and probably should expand.

This paper was published in the Journal of Homosexuality and is publicly available.

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