Facilitators and Barriers to Providing Affirming Care for Transgender Patients in Primary Care Practices in Arkansas

Abstract

Purpose:

This study assessed factors affecting the provision of affirming-care best practices (ACBPs) for transgender individuals by primary care providers (PCPs) in a rural, southern state.

Methods:

We conducted a sequential explanatory mixed-methods study in 2020 including a statewide survey (phase 1) and interviews (phase 2). Surveyed PCPs (phase 1) included MDs/DOs, nurse practitioners, and 1 physician assistant. Interview participants (phase 2) included providers and staff in 6 practices throughout the state. We used an exploratory approach to data collection and performed content analysis to classify interview data into categories representing overarching themes.

Results:

Among surveyed PCPs who reported they had provided care to transgender patients (n=35), the most common reason for providing gender-affirming medical services was “because of my ethical obligation to treat patients equally” (n=27, 77%). The most common reason for not providing such services was because the PCPs “have not been trained/don’t feel competent to provide these services” (n=12, 34%). Interviews revealed the following themes: 1) willingness to provide “culturally competent care”; 2) continuum of accepting to affirming attitudes toward transgender individuals; 3) basic understanding of stigma and an awareness of its impact; 4) changes needed to provide “culturally competent care”; and 5) preferred clinical support strategies.

Conclusion:

Training and education to provide ACBPs are warranted and would meet the needs of patients and providers. Facilitating telemedicine visits for transgender patients with gender-affirming care experts was a favorable implementation strategy for clinical support and is recommended to address access to affirming care.

INTRODUCTION

Transgender individuals constitute a minority group in the US that experiences significant barriers to accessing healthcare.¹ In a 2015 national survey, 27,715 transgender-identifying respondents reported barriers to healthcare access, including cost and lack of coverage for gender-affirming medical care, fear of healthcare discrimination, and distance to gender-affirming care facility; a large proportion traveled more than 50 miles to access hormone-replacement therapy.¹ Seelman et al.² showed that transgender survey respondents who reported delays in care due to fear of discrimination had worse general health and mental health outcomes. Unfortunately, transgender people in southern US states and rural areas are less likely to receive affirming healthcare than those in other environments³ and experience high rates of psychological distress.⁴ Transgender Arkansans identified availability of gender-affirming medical services and access to culturally competent providers among their top 3 priorities for health-related research.^5,6 Further, data from a transgender clinic at Arkansas’s only academic health center revealed that more than half of its patients travel from rural parts of the state to receive care.⁷

Transgender healthcare disparities do not reflect a lack of best practices for quality care for transgender patients.^8–13 Best practices include affirming transgender patients by providing culturally competent primary care and gender-affirming medical services. Nevertheless, one of the greatest established barriers to primary care providers (PCPs) offering affirming care is a lack of knowledge and education about caring for the unique needs of this population.¹⁴ To address this issue, implementation strategies (i.e., SCAN ECHO training and teleconsultation,^15,16 e-consultation,¹⁷ and Trans ECHO¹⁸) are available for PCPs to obtain education and resources for providing gender-affirming healthcare, particularly for providers within the Veterans Health Administration or in Federally Qualified Health Centers (FQHCs).^15–19

However, little is known about facilitators and barriers to adopting ACBPs and what implementation strategies are needed to support adoption by PCPs in rural, underserved and culturally challenging environments, such as the southern US. We present results of an exploratory study with PCPs and staff on barriers and facilitators and make recommendations for implementing ACBPs in Arkansas, a rural southern state with limited access to affirming care for transgender individuals.

METHODS

This study used a 2-phase, sequential explanatory mixed-methods design combining complementary strengths of quantitative and qualitative methods.²⁰ The study was approved by the institutional review board at the University of Arkansas for Medical Sciences and conducted in 2020.

Phase 1 - Survey: Quantitative Data Collection, Measures, and Analysis

Data were collected from PCPs (i.e., physicians and nurse practitioners) with an online, cross-sectional, statewide survey using an instrument created by our team. (Appendix 1.) Surveys were distributed by email through the researchers’ networks and by PCP leaders in statewide professional organizations. Quantitative analysis included descriptive statistics of facilitators and barriers to providing affirming care and practice/provider characteristics. Relationships between variables were explored with regression analysis to examine variation by characteristics.

Phase 2 - Interview: Qualitative Data Collection, Measures, and Analysis

Drawing on previous work^21–25and results of the quantitative analysis (phase 1), we interviewed key informants (n=20) (e.g., physicians, nurse practitioners, clinic staff) to conduct a developmental formative evaluation.²⁶ Using our networks and targeted efforts, we recruited 6 PCPs representing different practice models and located in different geographic regions in Arkansas (Figure 1). We intentionally focused on practices that appeared open to implementing ACBPs because they would allow the efficacy of implementation strategies to be explored and pilot tested in future studies. Four practices, all in rural communities in different areas of the state, included private practitioners operating outside of the context of large systems of care. The remaining 2 practices were FQHCs in which the physicians delivered care at multiple rural clinics. Notably, FQHCs are mandated to collect sexual orientation and gender identity (SOGI) data.

Figure 1.

Locations of Participating Practices.

Interview Guide

An interview guide for assessing barriers and facilitators related to ACBPs was developed according to the Consolidated Framework for Implementation Research (CFIR)²⁷; to assess the clinical environment, the guide was also informed by Fenway’s Readiness Assessment.²⁸ Questions asked participants about issues with patient flow; whether relevant information was captured by the electronic health record system (e.g., chosen name and correct pronouns); receptivity for quality improvement; access to gender-neutral bathrooms; and availability of inclusive signage, educational materials, and referral resources.

Interview questions also covered knowledge of stigma and its impact, stigmatizing attitudes and beliefs, attitudes and knowledge of ACBPs, knowledge about the needs of transgender patients, referral networks, structural changes that may be required, and how changes will work with/within existing practices. Feedback was elicited on specific implementation strategies (e.g., ECHO-type training and support, e-consultation, and telemedicine with transgender healthcare experts) and corresponding barriers and facilitators. Additional data were collected with the Transgender Attitudes and Beliefs Scale (TABS)²⁹ to identify beliefs and attitudes requiring strategies to reduce trans-sensitive stigma and bias.

Interviews

Phone interviews (scheduled for 60 minutes each) were conducted with 20 participants, with diverse roles and perspectives within each practice. Before the interview, the participant reviewed a bulleted list of the ACBPs and implementation strategies (Appendix 2). After the interview, the TABS²⁹ was sent to the participant by email. All interviews were audio recorded (with consent) and transcribed by a professional service, using anonymous ID codes to ensure confidentiality.

Analysis

Content analysis was used to interpret interview data,³⁰ allowing classification of interview passages into categories representing overarching themes.³¹ Interview responses were assigned to the coding schema using specific categories of CFIR as initial codes (e.g., inner setting). Emergent codes also were documented. Two authors coded each transcript (to enhance rigor³²) using MAXQDA, compared results, and resolved discrepancies. Final codes were assigned by consensus. Thematic saturation was reached with 20 interviews. TABS data were statistically analyzed by another author who created three factor scores (interpersonal comfort, human value, and sex/gender beliefs) by summing their respective items. Higher scores indicate more favorable attitudes toward transgender individuals. Summary statistics were stratified by role (i.e., provider vs. staff). Each factor summary score was compared with a Wilcoxon rank-sum test.

RESULTS

Phase 1: Statewide Survey of Providers

Providers who completed the survey for phase 1 (N=53) included MDs or DOs (n=14), nurse practitioners (NPs) (n=38), and 1 physician assistant (PA). Regarding the type of population served by their practice (rural vs urban), 50% indicated they served a “mostly rural population.” Additionally, 20% indicated they worked in a private group practice; 19% worked in an “other” type of clinic; 13% worked in a public hospital outpatient clinic; 11% worked in a FQHC; 11% worked in an academic health center clinic; and 11% worked in a rural health clinic while the remaining respondents worked in either a private solo practice or in a private hospital outpatient clinic, and none of the respondents indicated they worked in a local public health clinic.

Nine of the MDs or DOs (64.3%) and 26 of the NPs (68.4%) reported they had provided primary care for transgender patients (n=35). The most common reasons for providing care were “because of my ethical obligation to treat patients equally” (n=27, 77%) and “because of transgender patients’ need/demand for care” (n=22, 63%). Most providers indicated they “[did] not provide gender transition services” (n=21, 60%), the most common reasons being they “have not been trained/don’t feel competent to provide these services” (n=12, 34%) and “my patients have not asked me to provide these services” (n=9, 26%). We found no statistically significant differences in facilitators and barriers according to practice and provider characteristics.

Phase 2: Transgender Attitudes and Beliefs Scale

Phone interviews were completed with providers or staff (N=20), and all but 2 interviewees completed the TABS (n=18),²⁹ which asks about the level of agreement with statements using a 7-point scale from “strongly disagree” to “strongly agree” (Table 1). Differences between providers and staff in scores for factor 1, “interpersonal comfort” (p=0.207), and factor 3, “human value” (p=1), were not statistically significant; although, there was a significant difference (p=0.036) for factor 2, “sex/gender beliefs.”

Table 1.

Summary Statistics of the Transgender Attitudes and Beliefs Scale Among Interviewed Participants.

Measure	Mean ± SD			p-value
	Overall (N=18)	Provider (N=6)	Staff (N=11)
Factor 1 (interpersonal comfort)	58.17 ± 5.15	60.17 ± 6.71	56.82 ± 4.17	0.207
Factor 2 (sex/gender beliefs)	41.83 ± 4.63	45.17 ± 1.83	40.00 ± 4.94	0.036
Factor 3 (human value)	5.89 ± 2.05	6.00 ± 2.45	5.91 ± 2.02	1

SD = Standard Deviation

Phase 2: Interview Findings

Initial content analysis generated the following themes below. Note: examination of the construct labeled “culturally competent care” allowed the interviewer to ask about a participant’s willingness to adopt and readiness to implement ACBPs as a whole within their clinics. See Table 2 for interview participant characteristics. (Additional illustrative quotes, See Table 3.)

Table 2.

Interview Participant Characteristics.

Participant Number	Professional Category	Professional Role	Sex/Gender	Race	Age	Clinic Type	Clinic in a Rural or Non-rural County1	Previously Served at Least 1 Transgender Patient (*provided HRT routinely)
1	Provider	Nurse Practitioner	Female	White	60	Private	Rural	Yes
2	Provider	Physician	Male	White	69	Private	Rural	Yes once
3	Provider	Physician	Male	White	54	FQHC	Rural	Yes
4	Provider	Physician	Male	White	50	FQHC	Rural	Yes *
5	Provider	Physician	Male	White	60	Private	Non	Yes *
6	Provider	Physician	Female	White	40	Private	Rural	Yes
7	Staff	Nurse	Female	White	31	Private	Rural	Yes
8	Staff	Clinic Manager	Male	White	43	FQHC	Non	Likely
9	Staff	HIV Case Manager	Female	Black	39	FQHC	Rural	Yes
10	Staff	Clinic Manager	Female	White	46	FQHC	Rural	Yes
11	Staff	Scheduler	Female	White	64	Private	Rural	Unknown
12	Staff	Receptionist	Female	White	25	Private	Rural	Likely
13	Staff	Director of Operations	Female	White	46	FQHC	Rural	Likely
14	Staff	Receptionist	Male	White	60	Private	Non	Yes
15	Staff	Nurse	Female	White	35	Private	Rural	Yes
16	Staff	Medical Assistant	Female	White	36	FQHC	Rural	Yes
17	Staff	Receptionist	Female	White	42	FQHC	Rural	Yes
18	Staff	Nurse/ Clinical Supervisor	Female	White	63	Private	Rural	Likely once
19	Staff	Nurse	Female	White	47	FQHC	Rural	Likely
20	Staff	Nurse	Female	White	46	FQHC	Rural	Likely

HRT = Hormone Replacement Therapy

FQHC = Federally Qualified Health Center

¹Rural or non-rural county determination based on the results of the Rural Health Grants Eligibility Analyzer tool found at data.HRSA.gov.

Table 3.

Illustrative Interview Quotes from Participating Providers and Staff.

Themes and Coding (including CFIR construct/coding domain, primary codes and some sub-codes)	Quote
Theme 1: Participants have a willingness to provide “culturally competent care” to transgender patients.
CFIR construct: Inner setting  Code: Organizational culture	“We’re willing to do whatever to help.” (receptionist/scheduler at an FQHC that routinely provides HRT)
	“…I think I’ve got a wonderful staff that would be very open.” (private practice[ physician who had knowingly cared for only one transgender patient in their career)
CFIR construct: Intervention characteristics  Code: Culturally competent care  Sub-code: Opinions/reactions	“…I definitely do not think it’s asking too much. I think it’s a good list and makes someone feel comfortable.” (nurse)
	“…we will address people by their preferred name… If we can’t pronounce it, we’ll move to the last name, but just use the name; we usually don’t use any honorifics or anything like that.” (clinic manager/administrator of FQHCs)
CFIR construct: Inner setting  Code: Organizational culture  Sub-code: Receptivity	“We are all about our patients and whatever [we need] to do to make them feel better, to make them comfortable, listen to them, whatever they need, that’s what we’re here for.” (nurse in a private practice clinic)
Theme 2: Attitudes toward transgender individuals were on a continuum from acceptance to affirmation.
CFIR construct: Characteristics of individuals  Code: Attitudes toward trans individuals	“I personally believe that in the human, as in nature, there are all forms of sexual behavior and set of identifications. Why would it be any different for us? So we should support individuals in the best life they can have. And do all that we can for them. Right?” (private practice physician who had knowingly cared for only one transgender patient in their career)
	“I believe that everyone should be able to be who they are. I don’t have anything against it at all. I just believe that anyone should be able to be who they want to be and no judgment.” (receptionist in a private practice setting)
	“They’re still a person. They still have needs. They still have health issues. They still have things that we need to figure out what’s going on with them and treat it appropriately, regardless of any of it.” (nurse with a group of FQHCs)
	“A person is a person to me and I’m going to treat everyone as I would treat anyone else. … I mean, they’re who they want to be and I think that’s great.” (nurse in a private clinic)
CFIR construct: Characteristics of individuals  Code: Attitudes toward trans individuals  Sub-code: Concerns about attitudes of others	“If someone that was transgender walked into a [small town] clinic, very rural, I think that would be a shock and definitely an adjustment for [the clinic staff].” (administrator overseeing group of FQHCs)
	“I do have some that I worry about being judgmental, but usually [we practice] open communication, where we can say, ‘Hey. That’s not how we should act, and we need to respect them for their personal choices and treat them as a patient instead of judging them.’” (administrative nurse in a private practice setting)
	“There’s still stigma, unfortunately, and so he [or] she will come into the waiting room and they’d get looked at or whatever. I always worry about my front office staff, that they may not be as keen on this. My clinic staff in the back…, we’re doing okay, but I always worry about the front desk, how they’re going to react or use the right pronouns and things like that. That’s probably the biggest thing in the office, is the staff that’s unaware or would make snide remarks about them.” (physician in a group of FQHCs)
Theme 3: Many participants have a basic understanding of stigma and an awareness of its potential impact.
CFIR construct: Characteristics of individuals  Code: Stigma	“Anybody who is suffering from a stigma coming from society at large has a harder path to walk, okay? If you’re stigmatized, then that means that you are seen as something different or less than your fellow persons, fellow human beings, and that just makes every interaction more difficult.” (receptionist in a private practice clinic)
	“[The] community is probably quite polarized, either very accepting or very unaccepting. The majority would be unaccepting. The children get teased, saying that they’re doing this for attention, not much support from teachers, classmates, and just the psychological burden of feeling this and not being able to express it because of all those fears. Young kids have been beaten up because of it, physically abused, psychologically abused. My heart just breaks for them.” (physician in a private practice clinic affiliated with a rural hospital)
	“I’ve already had a few people come in that had expressed a desire to transition and then backed out just because of stigma, so I now realize it’s a big deal. And I hate that, but I think… when you were asking if I was worried about the clinic becoming known for [gender-affirming care], I think one way to combat the stigma is to get it out there and make people more comfortable with it.” (private practice physician)
Theme 4: Several changes are needed to provide “culturally competent care.”
CFIR construct: Inner setting  Code: Infrastructure  Sub-code: Infrastructure changes needed	“Ours only asks for male, female, or other. It doesn’t give any way to give any elaboration on that. It also does not, except in one section, have sexual orientation.” (physician in a private practice clinic affiliated with a rural hospital)
	“I think we would have to do some updating to our EMR. I know for a fact that you can’t... We have a patient that when they filled out their paperwork, they filled out as male, but they have since started to transition to female and we can’t change that. And we can’t reflect that in the computer right now, so just updates to our system would need to happen.” (medical assistant with a group of FQHCs)
	“The demographics on the chart has to agree with the demographics on the insurance or else the claim fails………But frankly, like I said, the pronouns, that’s an interesting thing, there’s nothing in the EMR that has a place that I’ve found anyway, that has a place for preferred pronouns.” (receptionist in a private practice clinic)
	“I think there’s probably going to have to be a lot of education in our particular group for nurse practitioners. [Doctor’s name] has done well educating our immediate staff, but we work with lots of family practice nurse practitioners, too.” (nurse with a group of FQHCs)
CFIR construct: Intervention characteristics  Code: Culturally competent care  Sub-code: changes needed	“I think that there’s probably not that many medical facilities doing this. There’s probably not staff that understand all the terminology. I myself don’t understand all the terminology. I know that people don’t know the pronouns. I know that we don’t have information or posters about serving this demographic. We ourselves have to enter their gender identity and assigned [sex] at birth. We have to enter those into our EMR, so we’re used to answering that question, but based on the patient’s answer; we don’t choose for them. We ask those questions so they can identify with that. I don’t really know if our staff understand what they mean.” (clinic manager with a group of FQHCs)
	“Probably the simple answer is education…I think if providers, maybe there’s a fear because they aren’t educated… I think some of it is just their belief system that they’ve grown up with in rural Arkansas. I mean you can educate but sometimes it’s even more than the education to help them understand we’re not all alike but we still have to care for individuals. I think that’s a hard thing and a big barrier…to overcome in a lot of areas.” (administrator overseeing a group of FQHCs)
	“I think it’s more just changing the staff’s point of view.” (nurse in a private practice clinic)
	“My personal and practical experience with transgender is very limited…I’ve had no real exposure.” (private practice physician who had knowingly cared for only one transgender patient in their career)
CFIR construct: Characteristics of individuals  Code: Training	“I always really like to be educated on the different pronouns and just some of the terminology. I don’t understand gender fluidity or some of these other terms that are out there. I don’t understand them all. I just would like to be aware so I can be more helpful for these clients. It’s one thing to say that, hey I care about you, but it’s another thing to be able to speak to what their issues are.” (clinic manager at an FQHC)
	“Would be great to have someone who is actually transgender to be able to share. It’s one thing for me just standing up there, giving a presentation or a PowerPoint, but it’s something that someone who’s gone through that feelings and the stigma side of it, I think having someone that actually is a transgender individual speaks to them or share, would make more of an impact than anything.” (administrator overseeing a group of FQHCs)
CFIR construct: Outer setting  Code: Referral/resource network	“…trying to figure out where these patients would need to go for help, or even beginning [that] process is kind of hard.” (nurse in a rural private practice setting)
	“…if I have [a transgender patient] …then I’ll have them see [doctor’s name]. That’s my referral network right there. Outside of that, I don’t have anybody in particular.” (physician with a group of FQHCs)
Theme 5: Participants identified preferred implementation strategies for clinical support.
CFIR construct: Intervention characteristics  Code: Support strategies	“I don’t have any problems with any three of those. We’ve been doing telemedicine for over two years for all of our patients and because of the COVID, we’re doing it more, but we’ve always been doing telemedicine, so [that’s] not a problem for setting that up for one to come to our office and do a telemedicine [visit] with an expert on the outside. That shouldn’t be a problem. I like the e-consultation, because that way, being a provider starting out doing this, I can run it by somebody and say, you know, ‘hey, can you give me some advice’ or ‘Am I in the right direction on this?’ Or whatever, so I think that’s also good. Of course presentations and discussions ongoing, those are also good.” (physician with a group of FQHCs)

CFIR = The Consolidated Framework for Implementation Research

HRT = Hormone Replacement Therapy

FQHC = Federally Qualified Health Center

EMR = Electronic Medical Record

Theme 1: Participants were willing to provide “culturally competent care” to transgender patients

Most participants expressed willingness and ability to provide the best care no matter what, saying “We’re willing to do whatever to help.” When asked to react to the list of ACBPs in the context of culturally competent care, most participants indicated they were appropriate and that implementing ACBPs was warranted and feasible. Some indicated they were already implementing some ACBPs—all participants said that patients could easily access a gender-neutral restroom, and some clinics addressed patients by their preferred name or last name without honorifics. Most participants believed their clinic would be receptive to providing gender-affirming care and/or implementing any changes needed to provide ACBPs.

Theme 2: Attitudes toward transgender individuals spanned a continuum from acceptance to affirmation

One provider with a group of FQHCs said, “I believe everybody should live their life to the fullest in whatever way they can, so I’m very affirming of that.” Many participants indicated their attitudes towards transgender individuals by describing their sense of professional duty to treat transgender patients. For example, a receptionist said, “They should just be treated like any other patient.” A nurse with a second group of FQHCs stated, “I accept them. I don’t understand everything; personally, there’s a lot I don’t understand. I respect that’s how they feel… And I just want to help.”

A few participants were concerned about coworkers’ negative attitudes about transgender individuals, but they were more concerned about the attitudes of people in other clinical care settings or the community. If participants expressed concern about coworkers, it was because they did not want coworkers to be offensive to transgender patients (e.g., accidentally using the wrong name or pronouns); other participants expressed concern about people gossiping about transgender patients.

Theme 3: Participants had a basic understanding of stigma and its potential impact

More than half of participants indicated they had some basic understanding of stigma experienced by transgender individuals and/or its potential impact on those who experience it. A clinic manager for a group of FQHCs said, “I totally understand stigma. I’ve witnessed it myself in certain areas…” Two providers, from different practice settings and regions, stated they believed stigma came from ignorance and could be mitigated with education.

Some participants acknowledged the presence of stigma towards transgender people in the community. A provider in a private practice affiliated with a rural hospital said, “[The] community is probably quite polarized…The majority would be unaccepting.” Another private provider spoke to their observed effects of stigma and offered a solution: “I’ve already had a few people come in that had expressed a desire to transition and then backed out just because of stigma… I think one way to combat the stigma is to get it out there and make people more comfortable with it.”

Theme 4: Changes are needed to provide “culturally competent care”

Many participants, both providers and staff, mentioned issues with their current electronic medical record (EMR) system, a lack of education/training, and a lack of exposure to transgender people. Many providers, but not necessarily staff, also indicated their need for a referral/resource network for transition-related medical services. These responses were coded as changes needed to provide “culturally competent care” and/or to implement ACBPs.

The most commonly reported change needed was the EMR; some systems did not capture appropriate identifiers, such as chosen name or a name different from the legal name, or gender identity was limited to male or female. Furthermore, some systems used the selected gender to generate a template of questions for the clinical exam, and no other questions appeared. Some systems also did not allow changes after the identifying information was entered at intake.

Most participants mentioned a need and/or desire for education/training on providing gender-affirming care, particularly how to interact appropriately with transgender patients. Many wanted to be affirming but were concerned about “messing up” and were insecure with appropriate terminology or pronoun usage. Additionally, an administrator overseeing a group of FQHCs recognized the need to address both knowledge and attitudes. Several participants mentioned a lack of exposure to transgender individuals and/or content related to gender-affirming care.

Interview participants suggested many different approaches for delivering education/training about ACBPs. One provider in private practice wanted materials to read independently. A provider in a system of FQHCs said their annual meeting might incorporate topics like ACBPs; similarly, a provider with a different group of FQHCs noted that staff areas had monitors that scroll educational messages, and these could potentially be used to communicate ACBPs. Several participants said they “used to have regular meetings” and would be open to receiving education/training at a “lunch and learn,” but only 1 provider mentioned having an ongoing monthly meeting.

Seven participants (4 physicians, 1 NP, and 2 nurses) expressed needs surrounding referral/resource networks for gender-affirming care; at least 2 others implied they need a referral network. Six participants believed they had an adequate referral/resource network for mental health even in their rural, non-FQHC systems of care. Some indicated they had contacts for mental health but not for other medical services. Two indicated they had only a single provider to whom they referred patients for transition-related care, and the provider was often far away (e.g., a 3.5-hour drive). The 2 providers providing hormone-replacement therapy (HRT) were the most confident in their referral networks.

Theme 5: Participants identified preferred implementation strategies for clinical support

One provider said their internet access “is horrible, absolutely horrible” indicating a potential barrier to the proposed implementation strategies. A few participants mentioned time as a barrier to deploying any/all strategies; the rest did not see any barriers. Hosting telemedicine visits between patients and transgender-care experts was the most favorable/desired strategy (n=10 mentions) because staff and providers readily saw this would benefit patients. Having monthly case presentations or a learning collaborative (e.g., Trans ECHO) was the second-most preferred strategy (n=5 mentions), with e-consultation a close third (n=4). The latter 2 strategies were favored by providers more than staff, probably because they primarily support the provider. Notably, the 4 mentions of e-consultation came from providers, who recognized the value of a consult when initiating gender-affirming care with transgender patients and were not already providing HRT to transgender patients; while the other 2 providers were already providing HRT and felt comfortable with the services they provided. Finally, while at least 5 participants indicated interest in monthly case presentations, few participants had heard of the ECHO model.

DISCUSSION

From our study, the themes most commonly identified included a willingness to provide “culturally competent care”; relatively favorable attitudes toward transgender individuals; a basic understanding of stigma and its negative impact; changes needed to provide “culturally competent care”; and identifying preferred clinical support strategies. We intentionally recruited interviewees receptive to (or already) providing affirming care to transgender patients to obtain their perspectives on specific implementation strategies. Thus, it is not surprising that the themes are relatively positive. However, these features of our respondents, in addition to potential social-desirability bias, do not undercut the validity of previous studies with transgender individuals documenting their negative experiences within healthcare settings and their desire for better-trained providers and more accepting healthcare settings.^1,5–7,33 Our sample likely represents a “best case”—or at least a “better case”—scenario, despite being located in – or perhaps especially because they are located in – predominantly rural settings where stigma likely exists at multiple levels and is a factor in the health and wellbeing of transgender patients.³⁴ Such settings are ideal for pilot testing implementation strategies that support adoption of ACBPs.

Participants’ willingness to provide “culturally competent care” came from their professional duty. Several participants indicated that receiving education/training to better serve transgender patients would move them from acceptance of transgender patients toward affirmation; and educational efforts to increase transgender cultural competency are often successful. ³⁵ Despite the expressed willingness to “treat everyone equally,” when participants said, “I respect that’s how they feel,” or that they would not judge transgender individuals for their “personal choice,” their language seemingly betrayed their true sentiments. These remarks illustrate an issue observed by the researchers that occurs when some people think they are being affirming but are not because they lack education, understanding, and/or awareness of their biases. In general, clinicians, compared to staff, seemed to have a broader knowledge base of concepts like SOGI, which seemed to influence their beliefs, and they expressed more affirming attitudes.

All participants recognized the need for education/training, even if they differed in their recommendations for how it could/should be delivered. This confirms previous findings that physicians had insufficient knowledge of transgender healthcare issues and were unsure where to access reliable information.³⁶ Providers’ lack of knowledge of transgender-specific treatments and resources can hinder their ability to gather salient information about patients’ healthcare needs and refer them to specialized care. This further limits patients’ access to needed services.³⁷ In fact, one provider did not know where to refer patients for transition-related care or other services without having an established referral/resource network. Interventions aimed at bettering providers’ medical knowledge about transition-related care have been successful.³⁸ Many of our participants also lacked confidence in the ability of other providers to be affirming upon referral. Indeed, the literature indicates that providers often struggle to identify and make appropriate referrals.^36,39 In our study, the 2 providers already providing HRT were the most confident in their referral networks. This differed from the 4 providers who were interested in providing HRT and who wanted e-consultation.

Additionally, providers and staff were most likely to desire telemedicine or monthly case presentations for clinical support. Hamnvik et al.⁴⁰ made a strong case for telemedicine for transgender patients, particularly in the context of the COVID pandemic, who struggle to access affirming care, especially in rural environments. Overall, we found that providers and staff favored telemedicine visits for transgender patients, indicating this as a strategy to improve access to affirming care.

In addition to education/training, other changes are needed to the “inner setting”²⁷ – most commonly with the EMR systems. Issues such as inappropriate or missing question prompts are common among practices seeking patient-centered, affirming care.^41,42 Notably, FQHCs have been mandated to collect SOGI data for several years; therefore, providers at FQHCs may not have mentioned SOGI data collection as a barrier.

Implications and Recommendations

Education/training emerged as a key strategy to facilitate adoption of ACBPs. Evidence demonstrates that brief educational interventions involving transgender individuals can improve providers’ knowledge and attitudes about transgender healthcare ^34,43,44and act as a stigma-reduction strategy.^{34, 45, 46} Further, while such education/training can benefit current providers, it is also beneficial to future providers and has been shown to improve knowledge and attitudes of students pursuing healthcare professions^{35, 47} In general, participants were receptive to the clinical support strategies presented. Not surprisingly, e-consultation was most attractive to providers who were less experienced with transgender patients. We recommend developing a set of implementation strategies and pilot testing them in favorable contexts, such as those used in our study.^48,49

Limitations

This study provides valuable information, but there are limitations. Only a small number of physicians responded to the survey, raising the possibility of response bias; those serving transgender patients may have been more likely to respond, and the same may be true for NPs. Due to the small sample size, the results are not generalizable. However, the interviews provide rich information on PCPs’ perceptions of culturally competent care and factors needed to support their provision of ACBPs, particularly in rural environments. Additionally, the participating practices were recruited through other professional contacts and were, in some cases, already serving transgender patients and/or were interested in receiving education. Thus, these participating practices likely do not represent the PCP community overall. Indeed, they were selected intentionally to assess barriers/facilitators to ACBPs and gain insight into the proposed implementation strategies because they provided a “best case scenario”; nevertheless, we found that even these settings had barriers to implementing ACBPs. Furthermore, our approach of asking the respondents to review the list of ACBPs before the interview could have increased social-desirability bias. Finally, although some participants reported that they already adhered to most ACBPs, we lack data to validate their actual practices.

Conclusion

Given the willingness to provide culturally competent care for transgender patients and incorporate requisite changes to their practices, implementing education/training strategies would meet the needs of both patients and providers in the state. Telemedicine was the most favorable strategy for supporting affirming medical services, and implementing telemedicine with transgender healthcare experts at local primary care practices, particularly in rural areas, seems feasible. Pilot testing a package of strategies is the appropriate next step to facilitate adoption of ACBPs.