“In the work that we did, we found, not
surprisingly, that some of the poorest health outcomes
and greatest barriers to healthcare access existed at the
intersection between living in a rural area and being
part of the LGBTQ+ community,” Henning-Smith
September 2022 policy brief, the University of
Minnesota RHRC interviewed 14 national LGBTQ+
organizations. These informants shared that the two most
common challenges for rural LGBTQ+ people were a lack of
resources and understanding among healthcare staff. There
were also concerns around stigma and fear of — or past
experiences with — discrimination. Discrimination can
happen in communities of any size, but rural residents
who experience discrimination tend to have fewer
alternatives for care.
Mariana Tuttle, MPH, is a research fellow at the
University of Minnesota RHRC. She explained that there is
a “mental burden” that comes with
LGBTQ+ people not knowing if the healthcare staff might
be unwelcoming or simply uneducated about LGBTQ+ care.
“Not everyone may be hostile, but they may just
not have any idea of 'How do I interact with this person?
Or what do they need? Or what does that identity actually
mean?'” Tuttle said.
Another concern is privacy, as Beth O'Connor, Executive
Director of the Virginia
Rural Health Association, explained: “In
rural communities, HIPAA only does so much when your
doctor is also your neighbor or your aunt or your Sunday
school teacher or — let's face it — your neighbor who is
also your aunt who is also your Sunday school teacher.
And what does that mean to be out in a rural community
and receiving healthcare?”
Tuttle added that another “piece of
exacerbating mental health challenges for LGBTQ+ folks in
rural communities” is a sense of loneliness.
While isolation may be a concern for rural residents in
general, LGBTQ+ people may not know of any other
individuals in town who share their identity.
“Even if they've got a pretty accepting
community, it can be pretty isolating and lonely to not
know any other gay or bisexual or transgender people
nearby,” Tuttle said.
“I think a lot of urban folks would say, 'Well,
just move to the city if you're alone there,' but that
rurality piece is a huge part of your identity
too,” Tuttle said. “And a lot of
people don't want to move. They want to live in their
homes. They just want to do that with resources or access
to care and with other friends.”
To receive good healthcare and have good health outcomes,
it's important to have a provider who knows and
understands you and your lived experience.
Henning-Smith said, “To receive good healthcare
and have good health outcomes, it's important to have a
provider who knows and understands you and your lived
experience.” But rural areas have fewer
providers in general, much less providers trained in
LGBTQ+ care, so “that might mean that people
are going without the really essential and life-saving
care that they need,” she added.
Awareness and Training Programs
O'Connor is part of the Pride of Rural Virginia
program, which started when the Virginia Rural Health
Association hosted a board retreat in 2018 and posed the
questions: “Who are we not serving? Whose voice
is not at the table?” O'Connor said.
“One of the answers we came up with was the
LGBTQ population in our rural communities and the need
for them to be able to access healthcare in an equitable
manner.” According to a
2021 Pride of Rural Virginia presentation, about
426,000 Virginians are LGBTQ+, and 22% of them
— 93,720 — live in rural communities.
Pride of Rural Virginia provides training and resources
to healthcare staff on ways to provide LGBTQ+ care and
make their healthcare facilities more welcoming and
affirming. This program also hosted “Community
Conversations” in rural communities to bring
together providers, LGBTQ+ folks, and allies to discuss
J Gallienne manages a gender-affirming healthcare program
at multiple clinics in Virginia. For Pride of Rural
Virginia, Gallienne and their co-facilitators
Melissa-Irene Jackson and Afton Bradley create,
implement, and facilitate LGBTQ+ affirmative training for
healthcare and mental health providers. “We
have extensive history in training and offering technical
assistance to service providers on LGBTQ healthcare with
a focus on trans healthcare and equity,” they
Pride of Rural Virginia training covers topics like
LGBTQ+ definitions and terminology, trauma-informed care,
historical treatment of LGBTQ+ patients, and current
challenges facing LGBTQ+ people. The training also shows
providers how to collect patient information regarding
gender identity and sexual orientation and how to make a
healthcare facility and patient registration process more
welcoming. Ongoing technical assistance is also available
for participants. Bradley, a family nurse practitioner,
discusses medical care and considerations for LGBTQ+
PiICN connects C-WHO, Valor Health, a statewide medical
residency program, and other regional entities. It
provides training, resources, and virtual consultations
to rural providers in Idaho working with LGBTQ+ patients.
Evans said, “A focus of mine has been expanding
care and creating a safe environment for the LGBTQ
population. That's something I've been working on quite a
bit over the last three to four years.” As a
parent, Evans has made her home a safe space for LGBTQ+
kids, both her own and friends. She wanted healthcare to
be a similar space.
When Evans first started talking to local physicians
about LGBTQ+ inclusive care, some of them told her that
this type of care didn't apply to them because they
didn't have any LGBTQ+ patients. “My argument
was, 'You are not creating a safe space and you're not
asking the right questions,'” she said. Once
providers started doing this, they found that they did
have LGBTQ+ patients, Evans said.
So we said, okay, we need to run this through the filter
of the experience of rural healthcare.
Blanton and her C-WHO team looked for checklists,
toolkits, or roadmaps to improve their care but found
they were written for urban healthcare facilities.
“They're not for Critical Access Hospitals.
They're not for rural primary care provider
offices,” Blanton said. “So we said,
okay, we need to run this through the filter of the
experience of rural healthcare.”
At the local level, Blanton's team talked to patients and
providers who identified as LGBTQ+ or were allies. Then
they worked with existing state networks for integrated
behavioral health and rural primary care to find
providers with a teaching background and expertise in
providing hormone therapy and
pre-exposure prophylaxis (PrEP), medication to
prevent HIV infection.
After finding experts, the PiICN team developed a
consultation model so that primary care providers at
Valor Health could receive guidance in providing hormone
therapy and PrEP to their patients without referring them
outside their rural community. The PiICN team also
connected with urban programs for more regional support.
“At the local, state, and regional level, we
had different strategies [of building partnerships], but
it all comes down to building those relationships of
trust,” Blanton said.
Ways to Improve Care for LGBTQ+ Patients
Henning-Smith in Minnesota said an important first step
to improving care for LGBTQ+ patients is to
“assume that you have LGBTQ+ patients in your
healthcare facility.” She said, “I
have heard people say, 'Oh, no, we don't have anyone like
that here in this community.' That's just simply not
Start with the folks who are experiencing the disparities
and ask them what support they need.
O'Connor in Virginia recommended starting with local
pride organizations: “People tend to think,
'Oh, this is a healthcare issue. I'm going to start with
healthcare providers.' Start with the folks who are
experiencing the disparities and ask them what support
Henning-Smith also advised learning what community-based
resources are available, including libraries, schools,
and senior centers. She then recommended “doing
everything you can to educate yourself,”
whether that's attending webinars and trainings or
Henning-Smith said it's important for all staff members,
not just providers, to receive training:
“Everyone in that setting needs to be on board
to ensure that it's a welcoming and inclusive place
because it only takes one person to misgender someone…or
say something harmful or hurtful for that place to not
feel safe and not feel welcoming and
Train all staff members — not just
doctors — on inclusive care and respectful
language so that patients feel safe from the moment
they walk into the facility.
Build relationships with providers outside your
facility in case you need a consultation or refer a
patient with more complex health needs.
Primary Care Toolkit offers some rural-specific
information as well as ways to use more gender-neutral
language on patient forms and during exams.
Tuttle in Minnesota said that having a rainbow flag or
pin can quickly put an LGBTQ+ patient at ease. Blanton in
Idaho suggested that healthcare staff adjust their
medical records so that all patients can list their
preferred name and pronouns. Staff can also list their
pronouns on their name badges or announce their pronouns
when they meet with patients.
Evans in Idaho said, “With Cornerstone, what we
are working on is just really helping other clinics to be
able to start providing more inclusive care and making
small changes like adding sexual orientation and gender
identity to their intake forms and making sure that the
electronic medical record has a way of identifying
O'Connor in Virginia also advised that healthcare
providers learn what they can before they meet with a
patient and avoid blanket statements like, “Oh,
well, this is new for me. Let's learn
together.” She said, “That is not
reassuring for the patient. I would very much encourage
people to be proactive and learn what you can before you
get a patient in your waiting room that identifies as
LGBTQ+. You certainly wouldn't want to have your doctor
say, 'Oh, well, I've never treated breast cancer before.
Let's learn together.'”
Blanton stressed that the goal is for providers to gain
enough knowledge and understanding so that patients will
“feel comfortable coming back to you and
seeking care, because right now the data shows us that a
lot of those patients don't.”
But she added that it's okay for providers to ask what a
particular identity means to an individual patient and
what kind of care they are looking for. For example, some
patients who are asexual — people who do not
experience sexual attraction — have never been
sexually active, while other asexual patients have.
“Having some humility about what you do and you
don't know about a person is really important,”
“We know that rural healthcare providers have
so much on their plate,” Henning-Smith in
Minnesota said. “It's a lot to ask that they be
well-versed in every population and in every issue. But
the lack of understanding or lack of training…means that
it can be much harder for people who live in rural areas
and are LGBTQ+ to find providers or healthcare settings
that feel welcoming and comfortable and
So far, PiICN in Idaho has trained 52 healthcare staff
— completing a total of 700 hours of training
— and has directly served 104 patients. PiICN
has been invited to provide a rural perspective on
different national panels and organizations.
“We're excited that rural now has a voice in
LGBTQ+ care at the national level,” Blanton
Blanton also said that healthcare students, especially
leadership groups, “are reaching out to us to
do more presentations and to do more patient panels and
to get on the curriculum for certain education
Evans remembered an LGBTQ+ patient who had anxiety and
difficulty in regulating emotions. Through therapy and
LGBTQ+-specific care, this patient is doing much better.
In Virginia, over 50 healthcare staff from three Rural
Health Clinics have completed the Pride of Rural Virginia
training. This fall, the program will provide in-person
and virtual training to over 600 employees at a large
“We have been very successful and have received
positive feedback from providers on our
training,” Gallienne said. Pre- and
post-training surveys show that providers who complete
the training feel better prepared to serve LGBTQ+
Participants have also shared with us how important this
training was for them.
“Participants have also shared with us how
important this training was for them and were glad we
offered the training,” Gallienne added.
“They also felt like we are approachable
trainers and engage in the content in an accessible
Evans in Idaho explained that there are changes rural
healthcare facilities can make right away and other
changes that might take time. For example, many LGBTQ+
inclusive care checklists made for urban facilities
suggest having LGBTQ+ patients on the facility's board.
“When you're in a small community and the
LGBTQ+ population just doesn't really feel safe and
they're invisible, that's probably not something that's
going to happen right away,” she said.
“Strong leadership support is
crucial,” Evans added. In cases of community
pushback or provider hesitation, she added, “Do
what you can. It gets frustrating that there's things
that you want to do that the organization's not ready
for, but we have to find the areas where we can start
slowly turning that ship and know that it's going to be a
But change is possible. “I've seen such a shift
in just so much more openness to talk about that part of
who some of our patients are and how they identify and
what their needs might be,” Evans said.
“I've got a couple of physicians that are
Evans added that it's important to “build a
support system for yourself, especially in a rural
community. What I have found is that it can be pretty
isolating, because there tends to not be a whole lot of
other people.” Connecting to other
organizations helps reduce the isolation and helps
providers and patients find needed resources.
“There are a lot of really wonderful and
thoughtful providers out there who are doing amazing work
in this area,” Henning-Smith said.
Allee Mead is a web writer for the Rural Health Information Hub. She has written on important rural issues, including maternal mortality and farmers' mental health, and has presented nationally on RHIhub's opioid resources. Originally from rural North Dakota, she has a master's degree in English. Full Biography