Understanding the health care needs of transgender and gender diverse people engaging with rural Australian sexual health centres: a qualitative interview study

Introduction

Transgender and gender diverse (henceforth referred to as ‘trans’) people face a variety of barriers to accessing health care including discrimination, mental health challenges and challenges accessing healthcare providers willing and able to provide appropriate forms of gender affirming care.^1,2 These specific barriers could be compounded for trans people living in rural communities, wherein access to health across a range of indicators are recognised as a challenge.³ Currently, there is little to no research into the trans experience in rural Australia.^4,5 This paper aims to address the trans experience in rural New South Wales to gain a better understanding of their specific health and wellbeing needs.

Trans people face increased stigma and discrimination that often leads to increased rates of self-harm, suicide and risk-taking behaviour compared to the general population. The need for increased support is particularly relevant during a trans individual’s ‘coming out’ process. A study of trans youth mental health and abuse in Australia found 79.7% have self-harmed, 82.4% have considered suicide and 48.1% have attempted suicide, with 74.6% diagnosed with depression, and 72.2% diagnosed with anxiety (data was not collected about geographical location within states or territories).⁶ Lack of early education, workplace discrimination and consequent under- or unemployment can make trans individuals more susceptible to situations and behaviours where their health and wellbeing may be compromised, such as sex work, substance abuse and deliberate self-harm.^7,8

Specific research looking at trans experiences of stigma and discrimination in rural areas is lacking. Studies in metropolitan areas showed that when compared to cisgender lesbian, gay and bisexual (LGB) identifying individuals, trans individuals reported more discrimination and lower levels of acceptance in the community and environments such as workplaces, and higher rates of homelessness.⁹ This demonstrates the increased discrimination that trans peoples can face when compared to other members of LGBTQ+ communities⁹ and the persistent negative impact this discrimination has on mental health and wellbeing.¹⁰

One study demonstrated that LGB individuals living in rural areas report being stigmatised and discriminated against substantially more than their metropolitan counterparts.² However in the majority of studies addressing rural populations, which are already low in number, trans participants are often grouped under the same umbrella as LGB individuals, making issues specific to trans populations difficult to separate from issues related to sexuality or sexual orientation.⁹

At a population level, LGBTQI+ in Australia report poorer health outcomes compared to the general population. These health disparities can be exacerbated by living in a rural area, leading to a cycle of poor health outcomes within this community.^5,8,9,11 ‘Private Lives 3’, the largest national survey of LGBTQI+ individuals living in Australia, showed that LGBTQI+ populations within Australia generally report lower self-rated health and a higher burden of disease than the general population.⁹ Other studies have demonstrated a bi-directional link between physical and mental health and wellbeing,¹² such that poor health in either domain can lead to a self-perpetuating cycle of negative outcomes in both. Rural communities often have poorer health outcomes compared with their metropolitan counterparts.⁵ A 2014 survey of 1032 ‘gender variant and sexually diverse’ Australian youth between the ages of 16–27 years concluded that stigma and discrimination was a systemic societal issue for these young people.⁸ Living in a rural area was found to have exacerbated these issues, as individuals had access to fewer support options, which may lead to social isolation and loneliness.^8,11 Of the young people surveyed (who were from both rural and urban backgrounds), 41% considered self-harm or suicide, 33% had harmed themselves and 16% had attempted suicide.⁸

The theory of minority stress provides an explanation of why a minority group (trans people) within a minority population (LGBTIQ+ populations) may experience health disparities. ‘Minority stress’⁷ is the theory that a minority group’s health disparities can be explained by the stressors they experience, such as a hostile culture, victimisation, abuse and heteronormative and cisnormative assumptions.^1,13 In the context of the healthcare system, these stressors often present as cumulative experiences of maltreatment, harassment, stigma, and discrimnation, which ultimately leads to decreased willingness among many trans people to access healthcare services, and poorer experiences when they do.^1,7 With both rural and LGBT+ communities already facing poorer health outcomes compared to metropolitan and non-LGBT+ populations⁹ it does bring into question whether the culmination of minority status in the rural trans population will impact further on health status. This paper draws on qualitative interviews with trans people living in rural NSW who engage with sexual health centres (SHCs) to provide insight into the needs of this community and the impact rural living has upon trans populations.

Materials and methods

Recruitment and interview process

Adults identifying as transgender and/or gender diverse attending Western NSW SHCs were recruited for this study. Prospective participants were identified and invited to participate by Nurse Unit Managers from SHCs. SHCs in NSW are publicly funded sexual health services providing access to sexually transmissible infection and blood-borne virus prevention and management for identified priority populations.¹⁴ This study utilised convenience sampling as there was only a short period of time available for data collection. Participants were contacted via phone and email and if they consented to the study their details were passed on to the research team. Inclusion and exclusion criteria for these individuals as well as the recruitment process is included in Fig. 1. Nineteen of the interviews were face-to-face; however, due to coronavirus disease lockdowns in Sydney in June/July 2021, the final two interviews were conducted via Zoom. A copy of the interview guide is included in the Appendix. Interviews were conducted in person over 2 weeks in June 2021, the interview guide was developed in consultation with the authorship group and ACON, and explored experiences of living rurally, access to health care, and perspectives about health and wellbeing. Demographic questions included sex at birth, gender, sexuality, age, and highest level of education. Interviews lasted from 20 min to 2 h with the average interview time being 1 h.

Fig. 1.

Inclusion and exclusion criteria for participants.

Results

Personal demographic information for participants is in Table 1. Participants were transgender or gender diverse peoples who resided predominantly in Western or Far Western NSW LHDs. Twenty-one participants took part in interviews and together shared a range of experiences involving health care and their rural community. Individuals ranged in age from 18 to 60 years and there was a mix of non-binary and binary gender identities. Most participants were of Anglo-Australian descent and non-Indigenous. The following themes describe key issues related to the trans experience in rural NSW. The overarching theme was navigating gender affirmation, with the subsequent five themes reflecting key aspects of this experience: (1) lack of respectful holistic care; (2) accessibility of healthcare services; (3) safety and belonging; (4) isolation and loneliness; and (5) employment issues.

Implicit across all themes was the complexity of navigating gender affirmation. The following quote by P-3 exemplifies some of the complex range of emotions participants discussed feeling in relation to their health and body.

Well, the fact that I care about my body now and the fact that I’m not just a flesh construct, this isn’t just a vessel. I quit smoking and I’ve been smoking for 14 years, and I quit to better myself… You get depressed when certain things stop working and you get elated when certain things start growing... It [transitioning] is a wavy cycle. But you want to take care of your body, you turn from not caring to oh let’s give this a go that looks alright. (P-3, aged 26–35 years).

For trans peoples in this study, health and wellbeing meant being able to affirm their gender either socially or medically, coupled with a subsequent acceptance by society, those closest to them, and in relation to self-acceptance and affirmation.

Discussion

This study sought to understand trans peoples’ experiences of health and wellbeing in rural communities. While there appeared to be some advantages to living in a rural setting, participants also reported discrimination and stigma that impacted on their health and wellbeing. Our findings regarding feelings of loneliness and the impacts of stigma align to some extent with previous studies that have found that transgender identity was associated with higher odds of discrimination and depressive symptoms such as loneliness.¹⁸ In accessing health services, our findings suggest that it is vital for trans people to see evidence that they are being treated in an affirming manner by those providing healthcare services. However, such support and affirmation might not always be readily available in rural and remote settings. Many participants spoke about the need for support services and easier access to allied health services, as well as a lack of access to mental health services with staff that had training in transgender health care.

Gender-affirming and supportive health care and environments can offset the negative psychological effects of ‘minority stress’ and associated poor health outcomes.^1,7,19,20 For example, Glynn et al. found that in populations of transgender women, medical, psychological and social gender affirmation was linked to lower rates of depression and higher levels of self-esteem.²⁰ These studies, although based outside of Australia, further support the findings of our analysis. In Australia however, accessing specialist services, which includes access to gender affirming care, becomes more difficult as remoteness increases. In 2017, it was found that the proportion of allied health professionals and pharmacists was lower in regional areas and lowest in remote and very remote areas compared to major cities, and that the number of healthcare professionals as a percentage of the population decreases as remoteness increases.⁵ This provides a barrier to accessing gender affirming treatment, which as P-6 explained, was having a particularly detrimental impact on rural-based trans communities.

However, some participants in our study reported that smaller communities allow patients to forge a stronger relationship with service providers, which they said is unlikely to occur in metropolitan clinics. This confirmed pre-existing conclusions that although there can be poorer health outcomes for some, there can be increased comfort in social settings for others in non-urban areas when compared to metropolitan cities.^21,22 Another positive impact on the community is the readily accessible care through SHCs as previously mentioned, when compared with accessing other specialist pathways, and the positive impact this is having on the community, as seen in P-20’s quote. Unfortunately, there are few studies around positive health outcomes in rural communities as published research often demonstrates a bias towards investigating and reporting negative health outcomes.^21,23

A lack of acceptance of the LGBTQI+ community in rural areas was also found in a Beyond Blue study, which reported that 43% of transgender individuals did not feel safe on the street.²⁴ During our study, we often noticed these threats of violence were due to homophobia, rather than transphobia, and the assumption that interviewees were ‘gay’. Lack of education and exposure to LGBTQ+ communities may have led to negative perceptions of transgender individuals in rural communities, providing further evidence of the need for increased awareness and education on inclusion of people of both diverse genders and sexualities. These findings contrasted with quotes by P-11 and P-21 about the positive aspect of living in a rural area; that people ‘mind their own business’ and how this promotes safety. There appears to be tension within the community regarding the narrative of trans acceptance in rural NSW. P-14 and P-9 discuss a lack of safety in their community, a direct contrast to prior quotes. Further research should explore trans people’s experiences of safety and community belonging in rural communities.

Studies have shown significant disparities between homophobic attitudes in rural areas versus metropolitan regions. By way of example, a recent poll of rural central south-west Queensland found that 50% of the population considered homosexuality to be ‘immoral’, compared to 14% in inner city Melbourne.⁵ As seen in P-14’s quote, trans people are often assumed to be part of the LGB community. Research shows that these homophobic perspectives were often due to decreased acceptance of non-traditional sexualities and a decrease in the LGB community presence^2,25 but little research has been done into transgender experiences in rural communities.⁵

Peer-oriented networks and support groups can play an important role in decreasing feelings of loneliness and isolation, but they can be difficult to maintain. In 2019, the peer-trans support group based in western NSW stopped running²⁶ due to a lack of external support. This may have contributed to increased feelings of isolation and loneliness among transgender individuals in rural communities. Although data is limited regarding trans individuals, other members of the LGBT+ community such as same sex attracted individuals, have found that one of the most important aspects to counter the experiences of stigma and marginalisation is social support.^27,28 Without a social support network in western NSW the LGBT+ community would be left without an environment where they could interact socially without fear of stigma or discrimination, which is a vital aspect of maintaining mental health and wellbeing.^2,29

In Australia, the unemployment rate in trans people is 19%³ while the current Australia wide unemployment rate is 4.5%.³⁰ Furthermore, 33% of the trans population have reported discrimination due to being out as transgender in the workplace and in interviews.³ A third of the participants in our study were unemployed, confirming this research. Low rural rates of employment could also be attributed to decreased employment opportunities seen more generally throughout rural communities.^21,23 There is a perpetuating cycle in society of discrimination and stigma surrounding being transgender, which is linked in with poor mental health and economic stability, and urgent attention must be paid to investing in community-led strategies to address this.^7,31

This study had multiple strengths: extensive consultation with the trans community through the LGBTQI+ community organisation ACON meant that it was developed with community input and support, positioning it to address community-identified issues. However, there were some limitations to the study. All the participants were associated with western NSW SHCs. Based on participant accounts, these clinics have had a profound positive impact, which may skew our data towards a more positive outlook than if we were to study a region that is not serviced by these two clinics, or participants not linked to these clinics. Also, as mentioned in the reflexive statement the interviewer is not a member of the study population. Furthermore, this is not a generalisable sample and does not mimic the demographics present in rural areas regarding First Nations and migrant populations. A total of 16 out of 21 participants self-identified as non-Indigenous Australians; intersectional minority stress may have impacted those from more diverse backgrounds more significantly than Non-Indigenous Populations. A final limitation was that this study had more people in the 18–25 years age group compared to all other categories. A larger sample of older age groups of trans people in rural communities should be sought in future studies. In our study, most older participants reported having affirmed their gender for longer than younger participants, and these older participants often seemed more comfortable in themselves and more settled in the community.

From the results of this study, there are several implications with relevance to policy and practice change. Implementation of social support and community support groups in these communities would likely improve mental health and wellbeing and reduce the feelings of isolation and loneliness. Increasing LGBTQI+ community visibility and general community education would reduce stigma and discrimination at a societal level and lead to a more welcoming environment. There is also a need for increased education for employers regarding stigma and discrimination of trans employees. Continued support of the delivery of gender affirming health care in rural settings is needed into the foreseeable future to ensure this community continues to have access to the healthcare services they need and a environment they can feel safe and welcomed in. Furthermore, increased training of other healthcare services including the general practice workforce and mental health services could lead to more positive experiences in health care for trans individuals and increased access to appropriate care.

Conclusion

We found that many trans individuals reported stigma and discrimination within rural areas, with many younger participants (under 25 years old) feeling isolated and lonely and reporting difficulty gaining and retaining employment. However, rural communities with access to LGBTQ+ inclusive SHCs can positively benefit mental health and allow easier access to gender affirming therapy than travelling to metropolitan areas. We found that while health and wellbeing can mean different things to different people, it was commonly associated with feeling accepted by both society and self, whether that be socially, emotionally, or physically. Transgender and gender diverse peoples want to live freely and have access to health care and a community that supports them, regardless of where they live. Living rurally cannot be construed as either having a wholly positive or negative impact on the health and wellbeing of trans individuals, and the experiences of living in this environment are complex and diverse.

Supplementary material

Supplementary material is available online.

Data availability

Data from this study cannot be made available as it contains sensitive information that participants did not consent to sharing.

Conflicts of interest

Anna McNulty and Rosalind Foster are staff members of the Sydney Sexual Health Centre and provide medical care quarterly at the Western NSW Sexual Health Centres. Margaret Crowley and Donna Burns are the Nurse Unit Managers of the Dubbo and Orange Sexual Health Centres respectively. Anthony K J Smith (he/him) is an Associate Editor of Sexual Health but was blinded from the peer-review process for this paper. As a member of ACON’s ethics committee, he was not involved in the ethics approval of this research.

Declaration of funding

This research did not receive any specific funding.