This story was originally produced by the Keene Sentinel. NHPR is republishing it in partnership with the Granite State News Collaborative.
Editor’s note: The term “transgender” is used in this article as an umbrella term to describe someone whose gender identity and/or gender expression differs from the sex they were assigned at birth.
Kee Dwane was sent home from their job at Walker Farm in East Dummerston, Vermont, this past Monday due to symptoms of heat exhaustion.
The Chesterfield resident felt better after some rest, but visited Cheshire Medical Center’s urgent care clinic the next day out of caution.
“I just went to get labs and to get checked out, ya know — make sure it wasn’t a bigger issue,” Dwane, 28, said after leaving the clinic Tuesday afternoon.
They said they’d waited five hours to be seen at urgent care, but even so, it was the best option for them. As a transmasculine person, they feel uncomfortable seeing their primary care provider.
“The thing about growing up in a rural area is a lot of the doctors know you outside of their work,” said Dwane, who was raised in Swanzey. “They know you on a non-professional level, and some of them feel like they can give their opinion on parts of your life that are completely irrelevant.”
But with no knowledge of local providers who would be more affirming, Dwane — like other gender-diverse people in the Monadnock Region — is unsure where else to turn for routine health care.
“There is a big problem with [health care] access in general,” Dwane said. “But then you add gender-specific care to that, and it’s so much worse, trying to access it. There’s so little here.”
Though the number of gender-affirming care providers in the Granite State is limited, a few New Hampshire mental health professionals have launched a coalition to help people find these resources.
Barriers to care
For transgender people, receiving gender-affirming health care is a necessary step for both mental and physical wellness. Some are seeking transition-related medical care, such as hormone therapy or surgery. Others just need access to an affirming primary care provider. Regardless of whether they seek transition-related care, transgender people need access to routine health care throughout their lives — just like anyone else.
Gender-affirming health care is treatment that supports and affirms someone’s gender identity through social, psychological, behavioral and medical interventions, according to the World Health Organization.
Many major medical associations — including the American Medical Association, the American Academy of Pediatrics and the American Psychological Association — support access to this care.
But, providers in rural areas, including in New Hampshire, are less likely to have the knowledge or be supportive of transgender people and their medical needs, according to a 2019 report from the Movement Advancement Project, a nonprofit organization that researches issues such as health care, voting and criminal justice.
In a 2018 study of students from 10 medical schools in New England, the majority of them felt “not competent” or “somewhat not competent” in their ability to treat transgender or gender non-conforming patients.
For some providers, this stems from how they were trained. In a 2018 study of students from 10 medical schools in New England, the majority of them felt “not competent” or “somewhat not competent” in their ability to treat transgender or gender non-conforming patients. That same study found that at seven of the schools, more than half of the students felt the curriculum didn’t adequately cover specific topics affecting trans patients nor did it adequately prepare students to treat them.
In 2014, one in three rural transgender people said they were mistreated by a health care provider in one or more ways, according to an analysis of the 2015 U.S. Transgender Survey Report by the Movement Advancement Project. Respondents included those who reported having to teach their provider about transgender people in order to get the care they needed and those who said their provider asked questions about their gender identity that were unrelated to the reason for their visit. Asking why a patient started hormone therapy, for example, is unrelated to seeking treatment for a rash on their leg.
Regardless of a patient’s identity, approximately one in two trips for medical care in rural areas will take more than 30 minutes, according to a study from the Southwest Rural Health Research Center. Compared to those living in urban areas — who traveled approximately 8 miles for routine care on average — people in rural areas had to travel almost twice as far.
Based in the School of Public Health at Texas A&M, the research center addresses the health needs of rural and underserved populations across the nation and is funded by the Health Resources and Services Administration’s Federal Office of Rural Health Policy.
For trans people of color, the distance between their home and their doctor is often even greater.
The 2019 report from the Movement Advancement Project found that rural transgender people of color were nearly five times more likely than all transgender adults to have to travel 25 to 49 miles for routine health care.
Transgender residents of rural areas often face even longer drives to get to either a gender-affirming clinic or a specialist. As of the 2019 report, more than one in four rural transgender people would have to travel 75 miles or more to see a transgender-care provider. Rural transgender people of color have to travel even farther, with more than one in five having to travel 100 miles or more.
Telehealth has been a silver lining in terms of access issues, but the end of the public health emergency in the U.S. on May 11 could see the return of some pre-pandemic restrictions. The Drug Enforcement Administration (DEA) provided a waiver at the beginning of the pandemic that allowed doctors to prescribe testosterone without meeting in person. And while the DEA announced in early May it would extend these waivers, it’s unclear if or when this extension will end.
The closest gender-affirming clinic to the Monadnock Region is the Equality Health Center in Concord.
Expanding affirming care through education, training
The Gender Diverse Care Coalition of New Hampshire — which launched in the fall of 2021 — is working to expand access to gender-affirming care in the state. The coalition does this through free training opportunities, consultations with providers, resource sharing and advocacy work.
Harvey Feldman, a licensed therapist based in Concord, is one of the coalition’s founders. He, along with New Hampshire-based therapists Deb Horton and Xavier Quinn, worked together to launch a website for the coalition in early 2022.
The website (genderdiversecarecoalitionnh.com) consists of a database of resources for mental, physical and social gender affirmation in New Hampshire and surrounding states. This includes not only primary care options, but transition-related health care and support groups for transgender people and their families.
Feldman said there were two goals when forming the coalition: to expand, through education and training, the number of providers in the state who feel comfortable treating transgender patients, and to provide a way to share trusted resources from the transgender community and gender-affirming providers.
“We were running into gender-diverse clients who were saying that either they couldn’t find a therapist who was able to help them, or they were in a situation where their therapist was attempting to refer them out at the first mention of gender diversity,” he said.
Feldman said he, as well as Horton and Quinn, heard from other providers in New Hampshire who wanted to work with transgender patients but were wary about their own lack of expertise with gender-diverse populations.
The website has a resource library that providers can access at any time. People can also reach out to the coalition directly about in-depth training and consultations.
Especially in rural areas of the state, Feldman emphasized the importance of those in any health care role seeking further education on working with gender-diverse populations, to increase the number of providers who feel confident doing so.
“There are some real gaps, in terms of where people can get care and how far they might have to travel to get good care,” he said. “I don’t think that it’s a question of not enough providers by number. It’s an issue of providers who, out of probably an abundance of too much caution, don’t feel comfortable working with gender-diverse folks.”
The Gender Diverse Care Coalition consists of providers throughout New Hampshire across numerous specialties, and they hold quarterly meetings to share information, receive advice on providing gender-affirming care and discuss recent events.
Those interested in learning more about the coalition or who want to be involved can reach out through the contact form on its website, www.genderdiversecarecoalitionnh.com/contact.
Looking ahead, Feldman is worried about the future when it comes to access to gender-affirming care in this country.
He’s concerned about the rise of legislation, including in New Hampshire, focused on banning gender-affirming care for transgender youth and how it could present challenges for transgender people trying to access any form of care in the future. In the Granite State, House Bill 619 would have prohibited the practice of and access to gender-affirming care for people under 18 and banned the affirmation of and education on LGBTQ+ identities in New Hampshire public schools. It also would have changed the definition of conversion therapy in the state, effectively re-legalizing it. It was retained in committee on March 15.
“There’s a real underlying belief here that [gender-affirming care] is elective, that it’s a choice people are making,” Feldman said. “This is not seen as health care, and I think that’s sort of a fundamental piece of trying to have a conversation here. If you don’t see it as health care, then none of the rest of the conversation makes sense.”
Resources
If you or a loved one is struggling with mental health, there are local and national resources available to help. Monadnock Family Services is a community mental health center with locations in Keene and Peterborough. It offers 24/7 care to Monadnock Region residents at 603-357-4400.
The Brattleboro Retreat has an adult inpatient program for LGBTQ+ people. You can find more information at brattlebororetreat.org/programs/lgbtq-adult-inpatient-program.
The Trevor Project provides help to LGBTQ+ and questioning young people ages 13 to 25. Get help at thetrevorproject.org/get-help. People can use an online chat function, as well as text and phone.
The Trans Lifeline is a nonprofit organization offering direct emotional and financial support to trans people in crisis — for the trans community, by the trans community. Call 1-877-565-8860.
The LGBT National Help Center provides peer counseling, information and local resources. Call 1-888-843-4564. If you need help specifically with coming out, the center has a National Coming Out Support Hotline you can call at 1-888-688-5428.
This part of a series on the lack of gender-affirming care resources in New Hampshire, the people who have been affected and identifying solutions that could help close that gap. Funding for the Monadnock Region Health Reporting Lab comes from several sources, including The Sentinel and several local businesses and private donors. We continue to seek additional support. The newsroom maintains full editorial control over all content produced by the lab.
These articles are being shared by partners in The Granite State News Collaborative. For more information visitcollaborativenh.org.
