Abstract
Purpose:
Pediatric primary-care providers (PPCPs) often care for gender diverse youth (GDY), particularly in rural areas, but little is known about their relevant knowledge, attitudes, or educational experiences regarding caring for this population.
Methods:
This study surveyed PPCPs throughout the rural state of West Virginia using an online survey assessing 1) demographics, 2) knowledge, 3) attitudes, and 4) educational experiences. Knowledge and attitude scores were calculated and proportion-tests and t-tests were used to compare these scores by PPCP characteristics including age, time in practice, and training background.
Results:
In total, 51 PPCPs from throughout the state completed the survey and 82% had cared for GDY in the prior year. Younger providers (<age 40) and those who had less time in practice (<10 years) had significantly higher knowledge (p=0.02, p<0.01) and attitude scores (p=0.01, p<0.01) than older providers and those who had been in practice longer. Most (84%) PPCPs reported having received some form of education related to caring for GDY. Those who reported no education had significantly lower knowledge (p<0.01) and attitude scores (p<0.01).
Conclusions:
PPCPs in a rural state reported caring for GDY, but knowledge and attitudes related to this care varied by age, time in practice, and relevant educational experiences. More research is needed to determine best strategies for providing education to PPCPs, particularly those who are older and have been in practice longer, and to better understand the impacts of legislation limiting evidence-based gender-affirming care on PPCP knowledge, attitudes, and access to educational experiences.
Keywords: LGBTQ, Primary Care, Pediatrics, Rural Health
Gender-affirming care for gender diverse people often includes the provision of medical and surgical interventions, but is also more broadly considered to include support with legal document updates, creating affirming environments at school and in other social situations, and support for patients and their families [1]. For gender diverse youth (GDY) under the age of 18, emphasis is often initially focused on social transition, which could include using an affirming name and pronouns and wearing affirming clothing [1-2]. When a GDY has begun puberty, this care could also include the use of medication to pause pubertal progression to allow for more time to explore gender identity and decide if hormonal therapy should be considered [1]. Access to gender-affirming care is associated with improved mental health outcomes for GDY, a group who otherwise face marked mental health inequity including higher rates of anxiety, depression, and suicidality [3-7].
Despite being recommended by every major medical organization, including the American Academy of Pediatrics (AAP) [8] and the American Academy of Family Physicians (AAFP) [9], and there being evidence-based guidelines supporting this care [10-11], gender-affirming care has been under legislative attack since 2020 with nearly a third of US states banning or significantly restricting this care in 2023 [12-13]. Many of these states are in the predominantly rural Appalachian and southern regions of the United States (US), further limiting access for GDY who already experience significant geographic barriers to care [12]. The Appalachian state of West Virginia passed a law limiting access to gender-affirming care for minors in 2023.
Pediatric primary care providers (PPCPs) play an important role in caring for GDY and their families, as the long-standing relationships PPCPs have with their patients may lead families to seek guidance in understanding their child’s gender diverse identity [14]. The role of PPCPs is likely even more important in rural areas where subspecialists in gender-affirming care for minors are few and separated by large geographic distances [15-17].
Little is known about the knowledge, attitudes, and educational experiences that PPCPs have related to gender-affirming care provision for GDY, especially those practicing in rural areas [18-19]. This study aimed to better understand the knowledge, attitudes, and experiences of PPCPs in the Appalachian state of West Virginia (WV) with regard to caring for GDY.
Methods
A 76-item anonymous mixed methods online survey was developed by the research team in concert with the Gender Research Stakeholder Program (GRSP) [20], a group of gender diverse people and parents of GDY. Once developed, the survey was beta tested by PPCPs and pediatric gender specialists, which led to several, primarily language-related, updates. This study reports on the following question domains included in the survey: 1) PPCP demographic characteristics, 2) knowledge about gender identity, sexual orientation, and gender-affirming interventions, 3) attitudes towards caring for GDY, and 4) education experiences related to caring for GDY.
Measures
Demographic characteristics
PPCPs were asked about their age, gender identity, sex assigned at birth, sexual orientation, ethnicity, race, training background, role, time in practice, practice type, and how many GDY they cared for in the past year. For statistical analyses, categorical variables were created for provider age (<40 years, ≥40 years) and time in practice (<10 years, ≥10 years) based on the sample distribution.
Knowledge
Knowledge assessment questions were created by the research team and were derived from assessment items used to evaluate medical students at the lead authors’ institutions following the delivery of transgender health-focused curricula. Similar assessment items are represented in medical school exams and pediatric and family medicine board preparation materials [21-22]. A full list of knowledge questions is available in Table 1. Respondents received one point for each correct answer, and item scores were summed to create a total knowledge score (range: 0-9). PPCPs were also asked if they were familiar with the World Professional Association for Transgender Health (WPATH) Standard of Care (SOC) guidelines for the care of transgender and gender diverse patients [10] and were able to respond on a 5-point Likert scale ranging from strongly disagree (1) to strongly agree (5).
Table 1.
Knowledge & Attitude Survey Items
| Knowledge Itemsa | Answer Options |
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| Attitude Itemsb | Answer Options |
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Correct answers on knowledge questions are bolded above. Correct responses =1 point while incorrect responses =0 points towards the knowledge score so that higher knowledge scores were reflective of more correct responses.
Attitude items 1-3 and 5 were reverse coded (1=strongly agree, 5= strongly disagree) so that higher attitude scores were in-line with current standard of care practices.
Attitudes
Attitude questions were developed as statements that participants could note their level of agreement or disagreement with using a 5-point Likert scale from strongly disagree (1) to strongly agree (5). All statements referenced standard of care practices [14,23] (Table 1). Attitude scores were created by reverse coding items 1-3 and 5 (1=strongly agree, 5=strongly disagree) to align higher attitude scores with current best practice guidelines around the care of transgender and gender diverse patients. Scores were summed to create a total attitude score (range: 5-25).
Education Experiences
Participants were asked to select the education experiences related to caring for GDY that they had over the previous five years and were able to select all that applied from the following options: National AAP Conference Session/Workshop, State Chapter of the AAP Conference Session/Workshop, National AAFP Conference Session/Workshop, State Chapter of the AAFP Conference Session/Workshop, Other Conference Session/Workshop, Grand Rounds or Other Institution-Specific Training, Self-Guided Literature Review, Online Training, Other, or None.
Recruitment
During the winter and spring of 2021-2022, PPCPs from across West Virginia were recruited through professional organizations, including the State Chapters of the AAP and AAFP, pediatric and family medicine departments at large medical systems within the state, and via phone calls, emails, and faxes directly to community-based PPCP practices.
Analysis
Demographic information was summarized using frequencies and percentages for categorical items and means and standard deviations for continuous items. Proportion tests were used to compare correct answers to each knowledge item, and t-tests were used to compare total knowledge scores by provider characteristics (i.e., age, time in practice, training background). Similarly, t-tests were used to compare attitude items and total scores by provider characteristics. Linear regression was then used to test for an association between total knowledge and attitude scores. Finally, we used t-tests to compare knowledge and attitude scores between those who did and did not report each education experience. All study procedures were reviewed and deemed exempt by the West Virginia University IRB (Protocol #2110449675).
Results
A total of 51 PPCPs completed the survey (Table 2). The mean age was 40 years (SD=11.9) and the mean number of years providing pediatric primary care was 11.1 (SD=9.3). Of physicians, 60% (n=28) were trained in pediatrics or internal medicine and pediatrics (med-peds), while 40% (n=19) were trained in family medicine. PPCPs represented in the study reported providing care to more than half of WV counties. Most (82%) endorsed caring for one or more GDY in the prior year (median 3 patients, range 0-50 patients). Ten PPCPs (19.6%) indicated that they were familiar with the WPATH SOC guidelines. Notably, while age and time in practice were highly correlated (r=0.89), we report them separately as there were some differences between these classifications.
Table 2.
Demographics of survey participants (n=51)
| % (n) | |
|---|---|
| Gender identity | |
| Female | 62.7% (32) |
| Male | 33.3% (17) |
| Prefer not to say | 3.9% (2) |
| Sex at birth | |
| Female | 62.7% (32) |
| Male | 33.3% (17) |
| Prefer not to say | 3.9% (2) |
| Sexual orientation | |
| Heterosexual | 84.3% (43) |
| Not heterosexual | 5.9% (3) |
| Not sure/Prefer not to say | 9.8% (5) |
| Ethnicity | |
| Hispanic/Latino/a/x/e | 0% (0) |
| Not Hispanic/Latino/a/x/e | 92.2% (47) |
| Prefer not to say | 7.8% (4) |
| Race | |
| Asian | 5.9% (3) |
| Black | 2.0% (1) |
| White | 84.3% (43) |
| Other | 3.9% (2) |
| Prefer not to say | 3.9% (2) |
| Training background | |
| Pediatricsa | 54.9% (28) |
| Family Medicine | 37.3% (19) |
| N/A | 7.8% (4) |
| Role | |
| MD | 68.6% (35) |
| Resident | 23.5% (12) |
| Other | 7.8% (4) |
| Practice type | |
| Private (solo or group) | 9.8% (5) |
| Academic/hospital-based | 66.7% (34) |
| Community/Federally Qualified Health Center | 15.7% (8) |
| Multiple | 3.9% (2) |
| Age (years; mean [SD], range: 18-75) | 40.0 (11.9) |
| Time in practice (years; mean [SD], range: 0-46) | 11.1 (9.3) |
| GDY seen in past year (mean [SD], range: 0-50) | 5.3 (8.2) |
Notes: aincludes Internal Medicine/Pediatrics
Knowledge
Knowledge scores by item and total score are provided in Table 3. The mean knowledge score for the overall sample was 4.75 (SD=2.06). Correct answers were most common for the gender identity item (Item K2; n=45, 88.2%) and least common for the testosterone effects item (Item K8; n=8, 15.7%). Results of proportion tests comparing correct answers by provider age, years in practice, and training background are also shown in Table 2. Younger providers (<40 years) were significantly more likely to answer the sexual orientation (Item K1; 92.6% vs. 54.2%, p<0.01) and mental health (Item K5; 74.1% vs. 58.3%, p=0.02) items correctly compared to older providers (≥40 years). Similarly, providers who had less time in practice (<10 years) were significantly more likely to answer the sexual orientation (95.8% vs.55.6%, p<0.01) and mental health (79.2% vs. 44.4%, p<0.01) items correctly compared to providers who had more time in practice (≥10 years). Regarding training background, those trained in pediatrics were significantly more likely to answer the Tanner stage item correctly than those trained in family medicine (Item K6; 32.1% vs. 10.5%, p=0.04). No other significant differences emerged for individual items. T-tests indicated that younger providers and those who had less time in practice had significantly higher knowledge scores compared to older providers (5.30 vs. 4.13; t=2.08, p=0.02) and those who had been in practice longer (5.54 vs. 4.04; t=2.83, p<0.01), respectively. No such differences emerged when comparing physician training backgrounds (5.07 vs. 4.74; t=0.56, p=0.29).
Table 3.
Comparing proportions responding correctly to knowledge items and total scores by provider characteristics
| Knowledge Item |
Overall (n=51) |
Age (years) | Time in Practice (years) | Training Background | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Correct % (n) |
<40 (n=27) |
≥40 (n=24) |
Sig. | <10 (n=24) |
≥10 (n=27) | Sig. | Pediatrics (n=28) |
Family Medicine (n=19) |
Sig. | |
| K1 | 74.5% (38) | 92.6% | 54.2% | z=3.14 p<0.01* |
95.8% | 55.6% | z=3.29 p<0.01* |
78.6% | 78.9% | z=−0.03 p=0.51 |
| K2 | 88.2% (45) | 92.6% | 83.3% | z=1.02 p=0.15 |
95.8% | 81.5% | z=1.59 p=0.06 |
89.3% | 89.5% | z=−0.02 p=0.51 |
| K3 | 82.4% (42) | 88.9% | 75.0% | z=1.30 p=0.10 |
91.7% | 74.1% | z=1.65 p=0.05 |
85.7% | 84.2% | z=0.14 p=0.44 |
| K4 | 66.7% (34) | 74.1% | 58.3% | z=1.19 p=0.12 |
75.0% | 59.3% | z=1.19 p=0.12 |
71.4% | 68.4% | z=0.22 p=0.41 |
| K5 | 60.8% (31) | 74.1% | 45.8% | z=2.06 p=0.02* |
79.2% | 44.4% | z=2.54 p<0.01* |
60.7% | 68.4% | z=−0.54 p=0.71 |
| K6 | 21.6% (11) | 25.9% | 16.7% | z=0.80 p=0.21 |
25.0% | 18.5% | z=0.56 p=0.29 |
32.1% | 10.5% | z=1.72 p=0.04* |
| K7 | 23.5% (12) | 22.2% | 25.0% | z=−0.23 p=0.59 |
25.0% | 22.2% | z=0.23 p=0.41 |
28.6% | 15.8% | z=1.02 p=0.15 |
| K8 | 15.7% (8) | 18.5% | 12.5% | z=0.59 p=0.28 |
20.8% | 11.1% | z=0.95 p=0.17 |
14.3% | 21.1% | z=−0.61 p=0.73 |
| K9 | 41.2% (21) | 40.7% | 41.7% | z=−0.07 p=0.53 |
45.8% | 37.0% | z=0.64 p=0.26 |
46.4% | 36.8% | z=0.65 p=0.26 |
| Total (mean) Range: 0-9 | 4.75 (2.06) | 5.30(1.84) | 4.13(2.15) | t=2.08 p=0.02* |
5.54 (1.56) | 4.04 (2.21) | t=2.83 p<0.01* |
5.07 (2.12) | 4.74(1.91) | t=0.56 p=0.29 |
Attitude
Attitude scores by item and total score are provided in Table 4. The mean attitude score (scores ranged from 5-25 with higher scores indicating more alignment with current clinical guidelines) for the overall sample was 18.80 (SD=4.60). Providers reported the most positive attitudes towards social affirmation (Item A5; mean=4.45, SD=0.98) and least positive attitudes towards gender-affirming surgery before age 18 (Item A3; mean=2.86, SD=1.27). Results of t-tests comparing mean item and total attitude scores by provider age, years in practice, and training background are also shown in Table 4. Younger providers (4.15 vs. 3.29; t=2.39, p=0.01), providers who had less time in practice (4.21 vs. 3.33; t=2.60, p<0.01), and providers trained in pediatrics (4.18 vs. 3.47; t=1.89, p=0.03) had significantly more positive attitudes towards the provision of gonadotropin-releasing hormone agonists (GnRHa) before age 18 compared to their respective counterparts (Item A1). The same pattern emerged for the provision of hormones before age 18 (Item A2). Younger providers (3.41 vs. 2.25; t=3.67, p<0.01) and providers who had less time in practice (3.50 vs. 2.30; t=3.83, p<0.01) also had significantly more positive attitudes towards gender-affirming surgery before age 18 (Item A3), though no difference emerged by training background. Although there were no differences in attitudes towards social affirmation (Item A5) by provider age, providers with less time in practice (4.71 vs. 4.19; t=1.99, p=0.03) and providers trained in pediatrics (4.75 vs. 4.16; t=1.94, p=0.03) had more positive attitudes towards social affirmation compared to providers who had been in practice for longer and were trained in family medicine, respectively. Finally, total attitude scores were significantly higher among younger providers (20.26 vs. 17.17; t=2.46, p<0.01), providers with less time in practice (20.62 vs. 17.19; t=2.93, p<0.01), and providers trained in pediatrics (20.43 vs. 17.79; t=2.02, p=0.02) compared to their respective peers. Linear regression indicated a positive association between total knowledge and attitude scores, such that each additional point on the knowledge test was associated with a 1.19-point increase in attitude scores.
Table 4.
Comparing attitude item and total scores by provider characteristics
| Attitude Item | Overall (n=51) | Age | Time in Practice | Training Background | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| <40 (n=27) |
40+ (n=24) |
Sig. | <10 (n=24) |
10+ (n=27) |
Sig. | Pediatrics (n=28) |
Family Medicine (n=19) |
Sig. | ||
| A1 | 3.75 (1.31) | 4.15 (0.99) | 3.29 (1.49) | t=2.39 p=0.01* |
4.21 (0.78) | 3.33 (1.54) | t=2.60 p<0.01* |
4.18 (1.02) | 3.47 (1.39) | t=1.89 p=0.03* |
| A2 | 3.67 (1.29) | 4.11 (0.93) | 3.17 (1.46) | t=2.71 p<0.01* |
4.17 (0.70) | 3.22 (1.53) | t=2.89 p<0.01* |
4.18 (0.98) | 3.26 (1.33) | t=2.57 p<0.01* |
| A3 | 2.86 (1.27) | 3.41 (1.22) | 2.25 (1.03) | t=3.67 p<0.01* |
3.50 (1.10) | 2.30 (1.14) | t=3.83 p<0.01* |
3.11 (1.23) | 2.68 (1.29) | t=1.12 p=0.13 |
| A4 | 4.10 (1.40) | 4.07 (1.54) | 4.13 (1.26) | t=−0.13 p=0.55 |
4.04 (1.60) | 4.15 (1.23) | t=−0.26 p=0.60 |
4.21 (1.47) | 4.21 (1.32) | t=0.01 p=0.50 |
| A5 | 4.43 (0.98) | 4.52 (1.09) | 4.33 (0.87) | t=0.68 p=0.25 |
4.71 (0.81) | 4.19 (1.08) | t=1.99 p=0.03* |
4.75 (0.65) | 4.16 (1.21) | t=1.94 p=0.03* |
| Total (mean), range: 0-25 | 18.80 (4.61) | 20.26 (5.53) | 17.17 (5.18) | t=2.46 p<0.01* |
20.62 (2.87) | 17.19 (5.27) | t=2.93 p<0.01* |
20.43 (3.41) | 17.79 (1.13) | t=2.02 p=0.03* |
Education Experiences
Results regarding educational experiences are shown in Table 5. Providers most commonly endorsed receiving education about caring for GDY via grand rounds (n=24, 47.1%) and self-guided education (n=21, 41.2%). A total of eight providers (15.7%) indicated that they had not received education about caring for GDY. For total knowledge scores, t-tests showed that those who endorsed education via grand rounds had significantly higher scores (5.58 vs. 4.00; t=3.01, p<0.01), and those who indicated that they had not received education about caring for GDY had significantly lower knowledge scores (2.13 vs. 5.23; t=−5.99, p<0.01). Regarding attitudes, those who received education from the national AAP (21.40 vs. 18.52; t=3.56, p<0.01), state AAP (21.67 vs. 18.63; t=4.03, p<0.01), and grand rounds (20.46 vs. 17.33; t=2.64, p<0.01) had significantly higher scores, while those who indicated that they did not receive education had significantly lower attitude scores (13.88 vs. 19.72; t=−3.30, p<0.01).
Table 5.
Comparing knowledge and attitude scores by education type
| Education type |
Overall %(n) |
Knowledge Mean (SD) |
Attitudes Mean (SD) |
|||||
|---|---|---|---|---|---|---|---|---|
| No | Yes | No | Yes | Sig. | No | Yes | Sig. | |
| National AAP | 90.2% (46) | 9.8% (5) | 4.72 (2.12) | 5.00 (1.58) | t=0.37 p=0.36 |
18.52 (4.76) | 21.40 (0.89) | t=3.56 p<0.01* |
| State AAP | 94.1% (48) | 5.9% (3) | 4.73 (2.11) | 5.00 (1.00) | t=0.41 p=0.35 |
18.63 (4.69) | 21.67 (2.58) | t=4.03 p<0.01* |
| National AAFP | 96.1% (49) | 3.9% (2) | 4.84 (1.98) | 2.50 (3.54) | t=−0.92 p=0.74 |
19.06 (4.46) | 12.50 (4.95) | t=−1.84 p=0.14 |
| State AAFP | 98.0% (50) | 2.0 (1) | - | - | - | - | - | - |
| Other conference | 92.2% (47) | 7.8% (4) | 4.72 (2.11) | 5.00 (1.41) | t=0.36 p=0.37 |
18.77 (4.74) | 19.25 (2.99) | t=0.29 p=0.39 |
| Grand rounds | 52.9% (27) | 47.1% (24) | 4.00 (2.20) | 5.58 (1.53) | t=3.01 p<0.01* |
17.33 (5.46) | 20.46 (2.67) | t=2.64 p<0.01* |
| Self-guided | 58.8% (30) | 41.2% (21) | 4.53 (2.11) | 5.04 (1.99) | t=0.89 p=0.19 |
18.00 (4.59) | 19.95 (4.49) | t=1.51 p=0.07 |
| Online training | 94.1% (48) | 5.9% (3) | 4.73 (2.09) | 5.00 (0.70) | t=0.26 p=0.41 |
18.92 (4.60) | 17.00 (5.29) | t=−0.61 p=0.70 |
| Other | 92.2% (47) | 7.8% (4) | 4.64 (2.08) | 6.00 (1.41) | t=1.77 p=0.07 |
18.66 (4.75) | 20.50 (2.08) | t=1.47 p=0.09 |
| None | 84.3% (43) | 15.7% (8) | 5.23 (1.80) | 2.13 (1.25) | t=−5.99 p<0.01* |
19.72 (4.01) | 13.88 (4.70) | t=−3.30 p<0.01* |
Notes: T-tests were not completed for State AAFP due to sample size
Discussion
Prior studies have explored the compounded challenges of being a gender-diverse adolescent living in a rural area, including the limited access to specialists with skills in gender-affirming care for youth seeking medical interventions [10,17,24]. This scarcity of gender-affirming medical care subspecialists often leads to reliance on PPCPs to have the knowledge and willingness to support this population [17-18]. That support is often through provision of routine primary care while fostering a safe space for youth to talk about their gender identity. It may also be through sharing knowledge about resources for GDY and their families, aiding in legal document updates, and providing guidance to local schools and organizations about how to affirm GDY in these settings [1,18]. Though PPCPs may prescribe some medications, such as those to suppress menses, it is uncommon that PPCPs prescribe other gender-affirming medications like puberty blocking or hormonal therapies to adolescents. In West Virginia, the new legislation restricting access to these interventions requires involvement by pediatric gender-affirming medical specialists.
Despite caring for GDY, only one in five PPCPs in our study were familiar with the evidence-based standards of care guidelines from WPATH that have existed for decades [10]. This limitation was further reflected in the number of incorrectly answered knowledge questions, particularly among medical providers who are, by nature of their training, very familiar with medical knowledge testing. One such example was a question asking for the appropriate Tanner stage required to initiate GnRHa therapy where less than a third of pediatricians and only a tenth of family medicine-trained PPCPs selected the correct answer. As PPCPs often refer GDY and families to gender-affirming care specialists to consider initiating a GnRHa, not knowing the appropriate developmental stage for such a referral could unnecessarily delay care.
Younger age and time in practice were associated with higher knowledge and attitude scores, and this most likely reflects a significant increase in the inclusion of LGBTQ health education in medical curricula following evidence that this education was minimally covered nationwide just a decade ago [25]. As LGBTQ health education inclusion is expected to continue, the challenges with accessing a knowledgeable and affirming PPCP may decrease over time, but those living in rural areas may see this change more slowly due to the higher provider-to-prospective patient ratios and aging community PPCPs [26-27].
Differences in attitudes by training background identified in this study may be secondary to the overall comfort and confidence of family medicine clinicians with providing pediatric subspecialty care broadly, particularly given the recent downtrends in the number of children cared for by family physicians [28] or it may be specific to gender-affirming care. Like the AAP, AAFP recommends that family medicine physicians know about gender-affirming medical interventions and include this in residency training [29]. One recent study found that while half of family medicine residency program directors (PDs) provide gender-affirming hormone therapy to their own patients, only a quarter are comfortable teaching this topic to residents [30]. Future research should consider more in-depth exploration of the experiences of family medicine physicians, particularly those practicing in rural areas, and their comfort with providing pediatric gender-affirming care.
Correct answers on the knowledge items were associated with higher attitude scores, suggesting that a more thorough understanding of gender-affirming care is related to greater acceptance. Findings related to educational experiences further support the ways in which education from academic institutions—such as via grand grounds or through national organizations such as the AAP and other groups including the World Professional Association for Transgender Health —may affect knowledge and attitudes. Importantly, these institutional and national level educational opportunities may be more likely to follow current best practice guidelines than they would for materials PPCPs used for self-study or other educational outlets – further suggesting that institutional and organizational support for educational initiatives related to gender-affirming care could help to increase knowledge and better align attitudes with best practices, ultimately helping more PPCPs care for GDY in their practices.
This study is limited by its small sample size and single-state representation. It is possible that providers who chose to take the survey may not reflect all WV PPCPs, and we do not know if any of the participants prescribed gender-affirming medications like GnRHas or hormones. We were not able to assess differences in PPCP knowledge or attitudes by region. While most survey participants saw GDY in their practices in the prior year, we did not assess the reasons for these visits (e.g. well-checks, sick visits, etc.). While legislation restricting pediatric gender-affirming care in the state had been proposed during the survey period, it did not ultimately pass until the following year, 2023. Thus, additional studies will need to be conducted to determine how legislative actions to restrict or ban gender-affirming care may impact PPCP knowledge, attitudes, and access to educational experiences, both in West Virginia and the numerous other states where this legislation has been enacted. Despite these limitations, this is one of few studies to explore the knowledge, attitudes, and educational experiences of PPCPs related to caring for GDY, especially for those living in a predominantly rural area.
Conclusions
We aimed to better understand the knowledge, attitudes, and educational experiences of PPCPs in a rural state. Participants in this study shared a lack of familiarity with current care guidelines and demonstrated low average knowledge and guideline-consistent attitudes relevant to gender-affirming care. The differences by age, time in practice, training background, and source of education suggest a significant need to provide support and education, particularly through academic institutions and medical organizations, to those whose background may not have adequately prepared them to care for GDY. More research is needed to determine best strategies for providing education to PPCPs and to better understand the impacts of legislation limiting evidence-based medical interventions for GDY in West Virginia and across the United States.
Implication & Contribution Statement.
Gender diverse youth face barriers in accessing care, particularly in rural areas and regions impacted by legislative action banning gender-affirming care. This study surveyed pediatric primary care providers in a rural U.S. state and found significant differences in related knowledge and attitudes by age, practice time, and relevant educational exposure.
Acknowledgements
The authors wish to express their gratitude to the primary care providers who participated in this study as well as the Gender Research Stakeholder Program for their support in the development and conduct of this research. We also wish to thank Bronson Herr for editorial support.
Funding
This research was supported by the National Institute of General Medical Sciences of the National Institutes of Health (2U54GM104942-07; PI Hodder, for KMK). This content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The National Institutes of Health was not involved in the study design, conduct, or decision to submit for publication.
Abbreviations
- GDY
gender diverse youth
- PPCP
pediatric primary care provider
- AAP
American Academy of Pediatrics
- AAFP
American Academy of Family Physicians
- WV
West Virginia
- US
United States
Footnotes
Disclosures
GMS has received compensation for consultation provided to Pivotal Ventures and the Fenway Institute. All other authors have no disclosures.
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