A new study out of Michigan shows that transphobia – an aversion to accepting transgender people – may play a bigger role than the amount of education a medical professional has when it comes to transgender people receiving competent health care.

Using an online survey, researchers asked the primary care providers in an integrated health care system in the Midwestern United States about their exposure to materials about caring for transgender and gender non-conforming patients, as well as their knowledge of health care for same. In total, researchers heard from 389 attending physicians, advanced practitioners, and residents.

48.8% of those who responded claimed to have had no formal education on health care for transgender or gender non-conforming patients. However, 49.7% said that they had cared for at least one transgender or gender non-conforming patient.

What’s more, researchers found no link between more hours of education on transgender care and improvements in the knowledge of a health care provider.

What they discovered was that it wasn’t education, but a care provider’s attitudes towards transgender people that played the biggest role in determining how knowledgeable a medical professional is on the needs of transgender or gender non-conforming patients.

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“We were surprised to find that more hours of education about transgender health didn’t correlate with a higher level of knowledge about this topic among providers,” says the study’s lead author Daphna Stroumsa, M.D., MPH, via an article on the Michigan Medicine’s blog.

Researchers feel that it is not more education that will solve the issues for transgender and gender non-conforming healthcare, but that, “broader efforts to address transphobia in society in general, and in medical education in particular, may be required.”

“Transgender and gender diverse individuals often face discrimination in health-care settings, and many are unable to find competent, knowledgeable and culturally appropriate health care,” said Stroumsa. “Lack of provider knowledge is a significant barrier, but our findings suggest that simply increasing training may not be the solution.

A third of transgender people who responded to the U.S. Transgender Survey (USTS) in 2015 reported having had a negative experience — such as verbal harassment or a refusal of care — with a health care provider due to their gender identity or expression.

Nearly a quarter of those surveyed said that they had to teach their provider about appropriate treatment in order to get the care they needed. Additionally, 23% of those who responded avoided medical care entirely over fears of being mistreated.