The Maine Public Health Association and the Social Sciences Program at the University of Maine at Augusta have been addressing barriers to health care that people experience through the monthly Zoom panels, Health Equity Dialogues. February focused on challenges that transgender patients face when accessing health care, often more apparent in rural Maine such as Franklin County.

Primary concerns expressed by the Feb. 10 panelists included data collection, transphobic attitudes and the lack of trans-competent providers, doctors and medical professionals who have had training and experience working with people who identify as transgender.

“When I talk about the landscape of health care, the sort of three metrics or buckets that we look at is we think about access – can a trans person get gender-affirming care and can they get other care that they need? And where can they get that? How close in proximity to them is a concern for us in such a rural state, and is that care culturally and financially accessible to them?” Quinn Gormley, executive director of MaineTransNet, said during the panel.

Franklin County has one health care provider, Dr. Karren Seely at Farmington Family Practice, dedicated to LGBTQ patients according to the national organization Health Professionals Advancing LGBTQ Equality which maintains a directory of providers.

With few providers in close proximity, this leads many patients from the Franklin County area to travel as far as Bangor to the Mabel Wadsworth Center, an inclusive clinic committed to sexual and reproductive health care.

“For year years and years we’ve had clients who would travel quite a distance to get to us, but definitely from the Farmington area, honestly even farther away from Southern Maine,” Aspen Ruhlin, Mabel Wadsworth’s community and client advocate, said in a phone interview.

Ruhlin attributes this to a number of factors, explaining that even if a doctor is competent with trans care, the practice’s staff may still harbor biases and transphobic attitudes that make a patient’s visit uncomfortable and at times, traumatizing.

They added that race often adds a heightened level of discrimination from health care providers. Ruhlin said that if a patient who is a person of color doesn’t follow what society deems as an appropriate presentation of a woman, they may even be rejected gender-affirming care.

“A lot of the gender rules that we have are within a cis-centric society, that we then put on trans people to harm them, are also very much based in race,” Ruhlin said. “And how we really see that both in the fact that trans women of color are the most heavily policed when it comes to gender, but also even cisgender women of color face really significant gender policing.”

Brandy Brown, the program manager at Maine Medical Partners and the Barbara Bush Children’s Hospital Gender Clinic in Portland, also sees patients traveling long distances for competent and nondiscriminatory health care. The Gender Clinic sees people across the state and even the New England region for pediatric gender-affirming care and offers services to patients until the age of 25.

The clinic is constantly at capacity Brown said, who sees 20 to 30 referrals a month and these numbers have been increasing during the pandemic.

Patients seek out specific providers based on their approach to trans care and may use grassroots directories such as the Maine Queer Health Community Database offered through the MaineTransNet. The directory allows patients and providers to submit practices that offer competent care for the LGBTQ community.

There are no specific doctors listed for Western Maine on this directory and there are only eight recommended primary care doctors for LGBTQ patients in the state.

“I think we really need to imbed competencies and provide more communities for providers who are in practice to be vulnerable and learn about what their biases are and what their concerns are and understand how to do the work,” Brown said at the panel, addressing that most medical doctors receive no more than four hours of health care training related to LGBTQ patients in a four-year program.

It is also difficult to assess the inequities transgender patients face in Franklin County when government data often excludes this demographic or maintains cis-centric analytics, a system that privileges binary genders.

The Franklin County’s 2019 Maine Shared Community Health Needs Assessment Report reviews specific groups of people encountering health inequities. Although the report recognizes that the transgender community experiences heightened health care disparities, the data is relatively nonexistent.

The report reads, “barriers to accessing care also include the availability and affordability of care. Low-income individuals, people of color, those with less than a high school diploma, rural residents, and lesbian, gay, bisexual, transgender, and queer/questioning  populations face even greater disparities in health insurance coverage compared to those who are heterosexual, white, and well-educated.”

The report’s data comes from the state’s DHHS which collaborates with health care systems and the Maine Center for Disease Control. The interactive data on the DHHS website includes a health equity section with only two genders listed and does not show the disparities that people of color who also identify as trans face.

Brown said there are efforts within Maine Medical Partners to implement new data policies that would respectfully gather a patient’s gender identity. She hopes this system could act as a template for other health care organizations so “all rise together,” with more inclusive statewide data revealing areas for care to improve.

During the pandemic, telehealth has become more common, potentially decreasing some of the geographical barriers that patients in rural counties have faced in the past. Ruhlin works with patients virtually to navigate the insurance system and locate services and providers. They said the Mabel Wadsworth Center is offering telehealth doctor appointments when possible.

Ruhlin can be reached at ruhlin@mabelwadsworth.org and more information about the center can be found at https://www.mabelwadsworth.org or by calling (207) 947-5337.

Brown offers virtual preliminary interviews for the Gender Clinic. For more information visit https://www.mainehealth.org/barbara-bush-childrens-hospital/services/the-gender-clinic or call (207) 662-5522.

MaineTransNet has moved its more than 30 peer support groups to online meetings. Visit www.mainetrans.net for more information.

UMA’s next dialogue will take place this month, focusing on inequities in oral health. Visit uma.edu for the upcoming date listing.