RICHMOND, Va. (AP) – For all the primping, powdering and pumping up many transgender men and women will undergo to pass as the opposite sex, there’s one thing health care experts say too many of them can’t stomach: A visit to the doctor.

A health study by the Virginia Health Department and Virginia Commonwealth University is intended to unravel the fears and prejudices hindering transgender people from seeking health care.

The Virginia Transgender Health Initiative Study targets those who feel they were born the wrong biological sex. Some undergo full transitions; others depend on hormone injections to look the part.

Health Department officials estimate 1 percent of Virginians are transgender, concentrated in northern Virginia, Richmond and Norfolk. Though documenting a largely closeted community is difficult, The National Center for Transgender Equality estimates as many as 3 million Americans are transgender.

Some medical experts say doctors are unschooled in how to deal with transgender patients and often are confused on everything from hormone therapy to sex change surgery to the proper personal pronouns. Some are simply uncomfortable with a transgender patient, advocates say.

Transgender men and women face the standard medical issues – high blood pressure, for instance – which many of them let linger because of fear of an awkward doctor’s office visit, explained Zakia McKensey, a transgender woman and outreach specialist at Fan Free Clinic. The Richmond center includes transgender services and is distributing the survey.

They also have more specific concerns, among them the need for hormonal treatment and counseling surrounding gender change surgery, she said.

In those cases, fear of being made uncomfortable may push some transgender people to risky black market hormones, she said. Still others may be put off by difficulties finding doctors qualified to oversee a complicated hormone regimen, said Ted Heck, a transgender man and one of the study’s researchers.

Heck recalled his own difficulties finding a doctor for his transition.

“A friend of mine and I called every endocrinologist we could find in the Richmond area,” said Heck, who eventually had to go to Maryland for treatment. “It was pretty frustrating.”

The three-year outreach effort, to conclude this summer, is spearheaded by researchers at VCU and the state Health Department’s HIV planning group. It is funded by an HIV grant from the Centers for Disease Control and Prevention.

Such grants are used to identify and help high HIV risk populations, said Judith Bradford, director of the community health research initiative at VCU.

“The process of transitioning [to another gender] puts many people at risk for not being able to have a way to earn a living,” Bradford said, explaining job discrimination leads some transgender people to prostitution and other high HIV risk behaviors to make ends meet.

The study includes an 83-question survey asking things like whether the survey-taker has tested for HIV, frequency of condom use and history of rape.

Researchers also ask if a person has been denied medical treatment because they’re transgender or if they’ve ever injected illegally purchased hormones. Those questions target a bigger problem: a high-risk population that feels walled off from doctors, advocates say.

It’s in the way a physician refuses to make eye contact, they say, or calls a female-looking patient “he.”

“When we refer people out to other agencies, a lot of people kind of disrespect the girls,” McKensey said. “They see that they might not be legally changed and they refer to them as ‘sir.’”

Medical schools don’t often educate future doctors on sexual minority issues, explained Dr. Harvey Makadon, an associate professor of medicine at Harvard Medical School and a director at the Fenway Institute.

The institute recently began a program to educate clinicians on those needs.