Clinicians_Experiences_in_Transgender_Healthcare_ by Oras Abd

Gender Issues (2025) 42:4

https://doi.org/10.1007/s12147-024-09347-3

ORIGINAL ARTICLE

Clinicians’ Experiences in Transgender Healthcare: The Impact of Sexology Training on Roles, Challenges, and Solutions

Sérgio A. Carvalho1,2 · Teresa Forte1 · Andreia A. Manão2,3 · Patrícia M. Pascoal2,3,4,5

Accepted: 26 November 2024

Abstract

Despite the critical role of clinicians in facilitating access to healthcare by transgender and gender diverse (TGD) people, their insight and practice-based knowledge have been underresearched. Also, they may complement TGD people’s experiences by giving an insider perspective. This exploratory qualitative study, conducted online in a sample of 25 clinicians who work with TGD people (n = 11 clinical sexologists), explores how clinicians working with TGD people in Portugal perceive healthcare provision to TGD people, using a summative content analysis. Results showed that clinicians perceive their role to be all-encompassing, ranging from helping to cope with individual and interpersonal issues, and to cope with other health services. Participants highlighted the increase of TGD people’s visibility, awareness, and scientifc knowledge, albeit more is needed as evidenced by several challenges derived from clinicians (e.g., lack of national guidelines, lack of training for standardized care, and lack of professional skills) and from the TGD clients (e.g., unrealistic expectations and lack of compliance). The proposed solutions include increasing the investment in specialized training and human resources, raising awareness within the healthcare system, and increasing interdisciplinary specialized care. Clinicians specialized in clinical sexology highlighted changes in scientifc knowledge, more available evidence, and a need for socio-political changes and awareness raising. This study reveals that healthcare providers are self-critical but also refect upon the difculties of navigating between organizational, human, and personal constraints, claiming that to provide better healthcare there, policymakers must take concerted measures that can have a social impact.

Keywords Transgender healthcare · Healthcare equity · Clinicians’ perspectives · Qualitative study

Extended author information available on the last page of the article

Introduction

The World Professional Association for Transgender Health (WPATH), an international multidisciplinary group of professionals that focuses on the evidencebased healthcare provision of transgender and gender diverse (TGD) individuals, provides clinical guidelines for conducting healthcare services for TGD clients (standards of care—SOC-8; Coleman et al., 2022). These guidelines include, for example, updated statistics on population estimates of TGD individuals, suggest recommendations to improve TGD-specialized professional education, provide guidance for the clinical assessment of and intervention with TGD clients throughout the lifespan (e.g., best practices guidelines to conduct developmentally appropriate psychosocial approaches to gender diverse children and adolescents), including mental health assessment and interventions, and discuss biopsychosocial, cultural and intersectional specifcities of providing healthcare to gender nonbinary clients. However, studies consistently show that clinicians working with TGD clients report a lack of knowledge, training, and perceived competence in TGD-specialized healthcare (e.g., Korpaisarn & Safer, 2018), which is echoed by the experience of TGD individuals regarding their healthcare providers (e.g., Ross et al., 2023) and is associated with TGD individuals′ poorer health (e.g., Miller et al., 2023). This calls for an in-depth exploration of clinicians´ perspectives on the barriers and specifcities of providing healthcare to TGD clients, particularly in contexts other than the anglosphere. The diverse legal frameworks of TGD rights across countries, and especially of access to afrmative healthcare, suggest the need to study further contexts of healthcare provision where, beyond the structural, management, and human resources shortages, a gap between the law and cultural values may contribute to experiencing challenges in healthcare by TGD individuals (e.g., a mismatch between a progressive gender recognition law that considers gender identity an inherently individual and self-determined experience, and a medical gatekeeping praxis that requires a set of clinical assessments—e.g., mental health screenings—and that spouses assumptions regarding TGD experience that are not evidence-based—e.g., binary narratives of gender that are viewed as sine qua non conditions to attest a “true” transgender identity) (Moleiro & Pinto, 2009; Snelgrove et al., 2012).

This study explores the perspectives of 25 Portuguese clinicians who provide healthcare to TGD clients in the context of clinical sexology services. Specifcally, we aim to qualitatively explore their perspectives on the role of clinical sexology in TGD healthcare, the challenges they experience in providing healthcare to TGD clients, the perceived changes in providing healthcare to TGD clients throughout their professional careers, and their proposed solutions to mitigate the challenges and improve the quality of TGD healthcare. By expanding the knowledge on clinicians’ perspectives on providing TGD healthcare that considers the developments in the feld and by comparing those who had with those who did not have specifc training in sexology, we aim to create social impact by contributing to tracing the development of transgender care in Portugal, identifying current challenges in gender-afrming care, as well as mapping out possible

solutions for more competent and safer healthcare environments (Veale et al., 2022). Also, by doing so, we intend to contribute to the Sustainable Development Goals of the United Nations (UN, 2015), namely to promote good health and well-being for all (G3, targets 3.4 and 3.7) and to promote inclusive societies with non-discriminatory policies (G16, target 16.b).

The State of Transgender Health Rights

The term Transgender and Gender Diverse (TGD) is an umbrella term that broadly includes individuals whose gender identities and/or expressions difer from the gender often associated with their sex assigned at birth (Coleman et al., 2022). TGD individuals exist globally, although they may be referred to in culturally specifc terms (e.g., hijra in India, muxé in Mexico, two-spirit in Indigenous North America). TGD individuals go through more instances of minority stressors than cisgender sexual minority individuals (e.g., Borgogna et al., 2019; Lefevor et al., 2019), which contributes to their higher rates of mental health struggles (e.g., Hendricks & Testa, 2012; Su et al., 2016). These sources of minority stress not only pertain to signifcant instances of discrimination and prejudice (e.g., harassment and violence) but also include daily microaggressions (e.g., misgendering). Additionally, minority stress can result from stress cycles reinforced by vicarious learning of oppressive experiences impacting other TGD people due to the overall cisheterosexist (overvaluing heterosexual and gender binary while marginalizing and oppressing sexual and gender minoritized identities and/or expressions) social context (Puckett et al., 2023), including when seeking health services and interacting with healthcare professionals (James et al., 2016).

According to Equaldex (2024) (an equality index that explores and ranks the human rights of sexual and gender-minoritized people globally), changing gender is legal in 66 countries. However, legal requirements in each country suggest a somewhat legality of gender change in 89 countries. Currently, there are 33 countries/ regions in which changing gender is legal without restrictions (e.g., Finland, Portugal, Pakistan, Brazil), 23 in which it is legal but requires a medical diagnosis (e.g., gender dysphoria) (e.g., Italy, Peru, Sweden, Angola), 33 in which it is legal but require surgical procedures (e.g., India, Turkey, Egypt), and 15 countries in which it is unclear (e.g., Monaco, Kenya) or depending on regions (e.g., United States of America, Australia). There are 93 countries (e.g., Hungary, Senegal, Saudi Arabia) where changing gender is illegal. Also, there are diferences in legal frameworks in regard to access to gender-afrming care (see Wright et al., 2024) according to age, with countries where it is legal but restricted (e.g., Finland) or banned (e.g., United Kingdom) for minors. According to the Trans Rights Indicator Project (TRIP; Williamson, 2024), from 2000 to 2021, the majority of countries with the most progressive gender recognition laws were in Western Europe (and New Zealand), although considerable advances occurred in (trans)gender recognition in Latin America, Asia, and Africa. Expressly regarding countries part of the European Union (EU), the Trans Rights Index & Map (TGEU, 2023) report that Malta is the only country that efectively depathologized transgender identities, and fve countries prohibit

so-called conversion therapy on the grounds of gender identity (Malta, Germany, France, Greece, and Spain). The vast diference in transgender legal protections and access to human rights globally, including in access to afrmative evidence-based healthcare, calls for a better understanding of the impact of trans-exclusionary experiences when TGD people navigate healthcare services. There are gaps in reporting and understanding of social and legal drivers of TGD ill health (Thomas et al., 2017). For instance, although Portugal has the 11th most pro-TGD legal framework among the EU countries (Ilga Europe, 2023), 68% of the Portuguese population perceive TGD discrimination as common (Eurobarometer, 2023). In Portugal, a recent study found that acceptance of (trans)gender diversity and tolerance towards TGD people was related to sociopolitical factors. Specifcally, those who identifed as religious, who spoused center-right and far-right political ideology, who had less contact with TGD people, and who identifed as heterosexual had lower acceptance of (trans)gender diversity and lower tolerance towards TGD than those who identifed as atheist/agnostic, who spoused center-left and far-left political ideology, who had contact with TGD individuals, and who identifed as LGBTQI+ (Carvalho et al., 2024).

Transgender Experiences and Perspectives About Healthcare Services

Although the WPATH provides guidance on conducting trans-afrmative and culturally sensitive healthcare (i.e., the diferent versions of the WPATH standards of care through the years; Coleman et al., 2022), studies on TGD individuals’ experiences with healthcare suggest a lack of both technical profciency and interpersonal sensitivity from healthcare professionals (Heng et al., 2018).

TGD individuals seeking emergency healthcare report witnessing medical staf gossiping and joking about TGD patients, refusing to use the patient’s preferred pronouns (Chisolm-Straker et al., 2017), and having negative experiences with clinicians can generate distrust in healthcare providers (Newsom et al., 2022). These personal experiences of discrimination constitute a multifactorial equation that includes a perceived lack of knowledge of clinicians on the specifcities of TGD health, which can, as a result, contribute to the TGD experience of barriers in seeking healthcare. In fact, the eligibility to access trans-appropriate healthcare seems to depend on clinicians′ assessment of transgender-related clinical diagnoses (e.g., gender dysphoria), which may impede access to healthcare when the client´s personal experience with gender does not ft into a nosological interpretation and clinical professional narrative of the TGD experience (Snelgrove et al., 2012). For example, in one multi-center European study, many TGD participants reported having to convince health professionals they needed healthcare and/or had to express it in such a way that would likely increase their access to healthcare (Ross et al., 2023). When it comes specifcally to mental healthcare, TGD people report three major barriers to seeking mental health services: (1) fear of being stereotyped, pathologized, and/ or subject to disliked treatment practices, (2) fnding incompetent mental healthcare professionals (i.e., unknowledgeable, unnuanced, unsupportive), and (3) fnancial burden resulting from mental healthcare costs (Snow et al., 2019). These results

echo a call from transgender and non-binary expert researchers who emphasize the importance of conducting research on assessing and improving the safety and transinclusiveness of healthcare settings (Veale et al., 2022).

Clinicians’ Perspectives on Providing Healthcare to TGD Clients

TGD individuals’ perceptions of lack of knowledge on transgender issues by healthcare providers are reiterated by clinicians themselves, who consistently report a lack of trans-specifc knowledge throughout diferent levels of medical education (from medical students to specialists) (Korpaisarn & Safer, 2018; Snelgrove et al., 2012). In addition, clinicians providing healthcare to TGD clients do not feel sufciently knowledgeable on TGD issues or on teaching methods to train other health professionals (Treharne et al., 2022). In fact, interest in TGD health seems to stem from frst clinical encounters with TGD clients, after which clinicians seek education through scientifc conferences on gender-afrming care and mentorship (Stryker et al., 2020). Lack of appropriate training seems to be especially the case when it comes to providing care to TGD youth (Vance et al., 2015) and gender non-binary individuals (Linander et al., 2019).

Although both TGD patients and clinicians consistently report a lack of training and knowledge, incompetence in providing healthcare to TGD clients is better predicted by clinicians’ transphobic attitudes rather than by lack of technical knowledge (Stroumsa et al., 2019), with male clinicians reported to hold more transphobic attitudes (Fisher et al., 2017). Specifcally, in mental healthcare providers, transphobia negatively predicts knowledge of TGD mental health and positively predicts incompetent decision-making regarding mental healthcare provision (Powell & Cochran, 2021). Nonetheless, studies show that mental health professionals generally report positive attitudes toward TGD clients (Brown et al., 2018). In fact, TGD clients seem to appreciate supportive and helpful person-centered clinicians, which seem to align with tentative mental health directives (e.g., Boardman & Dave, 2020; Wong & Cloninger, 2010), even when clinicians may not be highly knowledgeable about TGD people or their health specifcities (Heng et al., 2019).

When it comes to clinicians working in the feld of transgender care in a sexology context, few studies have explored their perspectives on TGD healthcare. Studies found that TGD people report a lack of sufcient information regarding sexual and reproductive health (Saadat et al., 2024), even though gender-afrming clinicians providing education on sexual health are positively viewed by TGD individuals (Warwick et al., 2022). Nevertheless, few studies have explored healthcare providers’ attitudes in clinical sexology (Nimbi et al., 2021). To our knowledge, only one recent study examined the attitudes towards TGD healthcare by clinicians working in clinical sexology (Gieles et al., 2024). However, the study focused specifcally on the role of clinicians in promoting the sexual well-being of TGD clients when the scope of clinical sexology is broader than sexual and reproductive health (WHO, 2006).

Few studies have paid attention to the specifc difculties (stemming from lack of training) experienced by clinicians when providing TGD clients, for example, in

conducting mental health assessment and intervention (Stroumsa et al., 2022), as well as to the specifc difculties in providing patient-centered care (e.g., clinicians′ assumptions regarding patients′ gender identities and sexual orientations; providing specialized care in a one-size-fts-all manner) (Pulice-Farrow et al., 2021). Indeed, given the absence of biomarkers and solid instruments to conduct a diagnosis of gender dysphoria, and even less so to verify the expression of trans identities (Shuster, 2016), healthcare mental and physical assessments are potentially biased by the clinician’s personal beliefs (Hilário, 2019, 2020). Also, the evolving nature of human rights and increased recognition of diverse gender non-binary identities may pose changes in gender afrmative healthcare provision (e.g., legal requirements to access afrming gender healthcare; recognition of health specifcities of diverse gender identities and/or expressions), which calls for a comprehensive exploration of the healthcare providers´ perspectives on an ever-evolving feld that intersects with changes in the law (Motmans et al., 2019).

The Portuguese Context: From Healthcare Gatekeeping to Legal Progressivism

During the twentieth century, Portugal was under a 48-year fascist dictatorship emboldened by the catholic church, which ended in 1974 with the Carnation Revolution (e.g., Rosas, 2022). The LGBTQI+ (lesbian, gay, bisexual, transgender, queer, intersex) rights movement gained momentum only in the 1990s (see Santos, 2016 for an overview). Only after 2006, the Portuguese transgender rights movement was propelled after the tragic death of Gisberta, a transgender woman assassinated by a group of male adolescents (Santos, 2013). The frst gender identity law was passed in 2011 (Law 7/2011), allowing a person to change their legal name and gender on their birth certifcate if accompanied by a medical document attesting the presence of “Gender Identity Disorder”. Although this was a step towards self-determination, in comparison to the legal dispute in courts previously required to change gender legally, it left TGD individuals′ access to legal gender recognition at the hands of a morose medical assessment (see Saleiro, 2021). The medical gatekeeping of TGD legal identities was overcome in 2018 (Law 38/2018), and the current legal framework does not require a medical document to change name and gender legally (see Moleiro & Pinto, 2020). The rapid changes in TGD rights in the last 15 years, especially in terms of the healthcare professionals’ involvement in the legal recognition and afrmation of TGD identities, calls for an in-depth examination of clinicians’ perspectives on these changes, their role in healthcare provision, as well as barriers and solutions they present, with their unique insider perspective to TGD healthcare provision.

Seminal research developed before the recent legal changes suggests that Portuguese clinicians seemed to hold stereotypical views of gender (Moleiro & Pinto, 2009), which potentially impacted their medical assessment of treatment adequacy (e.g., the desire not to have gender-afrming surgeries as an indication of not being truly transgender) (Pinto & Moleiro, 2012). However, to our knowledge, no study has been conducted on clinicians’ perspectives on TGD healthcare provision after the end of the legal medical gatekeeping. Currently, TGD healthcare in Portugal

may be developed in diferent sexological health contexts (e.g., private or public healthcare settings), and clinicians who act in TGD healthcare may have received, or not, training in clinical sexology and therefore be, or not, licensed clinical sexologists (recognized by the Medical or Psychological National Associations) (Raposo et al., 2024).

Overall, Portuguese TGD individuals continue to report a lack of healthcare providers’ appropriate training and use of incorrect pronouns (Marinho et al., 2021), disregard for the diversity of TGD bodies (Rodrigues et al., 2021), and overall institutional and interpersonal cisheteronormativity (Pieri & Brilhante, 2022). However, clinicians’ perspectives that consider the evolving changes in the feld is lacking and may contribute to a comprehensive approach to current TGD healthcare, helping to identify future venues for improvement.

Aims and Contributions of the Study

Previous studies have contributed to the scientifc knowledge about clinicians’ perspectives on providing healthcare to TGD clients. Studies suggest (1) clinicians experience barriers to providing care to TGD clients, such as educational barriers (e.g., lack of knowledge and training in TGD-specifc health and treatments), organizational barriers (e.g., difculties in fnding “trans-friendly” colleagues, and colleagues with expertise in TGD afrmative medical care), systemic barriers (e.g., the “two-gender” approach in medicine), and personal barriers (e.g., stigma, prejudice and negative stereotypes of TGD individuals) (e.g., Grant et al., 2021; Snelgrove et al., 2012; Soled et al., 2022); (2) clinicians fnd mental healthcare professionals to have a crucial role in afrmative TGD medical care (e.g., ascertaining gender dysphoria or incongruence, attesting the client´s ability to provide informed consent, and screening for mental illness that could impact and/or be impacted by medical treatments) (Snelgrove et al., 2012; Stroumsa et al., 2019); (3) clinicians experience concern regarding the consequences of hormone and surgical procedures (e.g., fear of client´s regret) (Madera et al., 2019; Snelgrove et al., 2012); (4) clinicians suggest some ways in which lack of knowledge and training can be ameliorated (e.g., support networks, development of clinical guidelines) (Snelgrove et al., 2012); (5) clinicians provide critical refections on providing sexological healthcare to TGD clients (e.g., refection on positionality, addressing societal narratives of TGD sexualities, encouragement of positive sexual experiences) (Gieles et al., 2024). However, these studies, although they present the richness of qualitative data collection via interviews, present some limitations, namely: (a) most studies were conducted in North America (U.S.A, Canada) or in the Anglosphere (e.g., U.K., Australia), thus not refecting other cultural and legal contexts of healthcare provision; (b) they lack professional diversity (their focus is either exclusively mental health providers or exclusively physicians, with a signifcant proportion of general practitioners), thus not providing the wide range of scientifc areas involved in afrmative gender care; (c) studies have lacked a chronological approach, thus not providing a picture on perceived changes of TGD healthcare

provision, which changes in the political climate can highly impact; (d) only one study has focused on clinicians specialized in clinical sexology, although not exploring diferences in perceptions between specialized versus not specialized in clinical sexology.

The current study aimed to qualitatively examine the perspectives of Portuguese clinicians working in the feld of clinical sexology/sexual medicine, currently providing healthcare to TGD clients, on (a) the role of professionals acting in clinical sexology in TGD healthcare; (b) diferences in healthcare provision to TGD clients (when they started versus currently); (c) challenges faced when providing healthcare to TGD clients; (d) proposed solutions/measures to tackle these challenges. Also, this study aimed to (e) explore if these perspectives difer in function of the presence or absence of specialized training in clinical sexology. This study’s contributions include (a) expanding the literature on clinicians’ perspectives on TGD healthcare to other cultural contexts beyond the Anglosphere; (b) comparing perspectives of clinicians specialized versus not specialized in clinical sexology on their role on clinical sexology contexts related to TGD health; (c) mapping out perceived changes in transgender healthcare provision in Portugal, which has witnessed a rapidly evolving legal framework towards gender self-determination; (d) gather measures/solutions proposed by clinicians on how to improve TGD healthcare.

Materials and Methods

Participants

Our fnal sample comprised 25 health professionals who practice in the feld of clinical sexology and provide healthcare to TGD clients. Gender identity was asked via an open-ended question. Among participants, 9 self-identifed as men (36%; two specifed “cisgender man”), 15 as women (60%; one specifed “cisgender woman”), and 1 (4%) reported being a “queer man”. On average, participants were 45.54 years (SD = 12.3) and had acted in the sexology feld on average for 12.84 years (SD = 11.25 years). Participants had, on average, 10.95 years (SD = 10.38) of specifc experience with transgender people. There were 7 clinical or health psychologists (28%) and 18 (72%) medical doctors whose specialties were: 1 anaesthesiologist (4%); 1 child and adolescence psychiatrist (4%); 1 endocrinologist (4%); 2 gynecologists (8%); 3 urologists (12%); 3 family physicians (12%) and 7 psychiatrists (28%). Among these practitioners, 56% reported not having a recognized specifc specialty or competence as clinical sexologists recognized by the Portuguese Psychologists Association (Ordem dos Psicólogos) nor the Portuguese Medical Association (Ordem dos Médicos) (n = 14). Most participants were practicing in transgender healthcare simultaneously in both the public and private sector (n = 11; 44%), while some practiced exclusively in the public healthcare service (n = 4; 16%), exclusively in private practice (n = 5, 20%), and in other contexts, such as community services (n = 5; 20%).

Procedure

We followed the ethical and deontological guidelines and principles presented in the Helsinki Declaration and those presented in the European Textbook on Ethics in Research. Also, the study was approved by the Ethical and Deontological Committee for Scientifc Research of the the School of Psychology and Life Sciences (CEDIC) of Lusófona University (Lisbon, Portugal) (Ref. CEDIC-2022-13-07).

This study design follows a participatory research approach (Cornwall & Jewkes, 1995). Therefore, the survey was developed in collaboration with some elements of the Portuguese Society of Clinical Sexology board of directors, who were invited to review the survey and comment and elaborate on its adequacy and relevance. After being presented with the primary goal of the study and considering the difculties in concealing agendas to develop face-to-face interviews as well as previous experience with data collected among clinical sexologists (e.g., Costa et al., 2023), it was agreed upon that online data collection would be the most efective means to gather relevant and geodiverse contributions and make the study feasible. Furthermore, all people involved highlighted that the survey needed only a few sociodemographic and work-related data to prevent the identifcation of professionals based on sociodemographic data and that the number of open questions should be very low and distinct to avoid redundancy, boredom, and lack of involvement.

All people were presented with a preliminary survey version to comment upon. A tentative fnal version was presented to two representatives of two LGBTQI+ associations, who had the opportunity to give their suggestions for improving the survey. The fnal version of the manuscript refects the consensus between the authors and the members involved in the SPSC and integrates suggestions from the representatives of the LGBTQI+ associations.

After implementation in a secure server and testing for formatting and presentation (e.g., font size), the study URL was disseminated through the newsletters of associations that act in clinical sexology/sexual medicine (e.g., Sociedade Portuguesa de Sexologia Clínica, Sociedade Portuguesa de Andrologia). The sample was collected using a snowball-like method as putative participants were invited to disseminate the URL among eligible people. Therefore, we cannot establish or estimate how many were reached by the study. The advertising message clearly stated that the inclusion criteria were to (a) master the Portuguese language, (b) be a health professional carrying out their practice in Portugal, (c) currently working in clinical sexology, (d) currently in contact with transgender people in a clinical context due to issues linked to gender identity; and contained the URL that gave access to the informed consent page. The informed consent clearly stated that the IP and geolocation information would be deleted and that only the researchers involved in the data analysis would have access to the database that was protected with a password.

The following open questions were analyzed: 1. What is the role of people working in clinical sexology in providing healthcare to transgender people?; 2. What differences do you fnd in providing healthcare to transgender people between when you started practicing your profession and today?; 3.What challenges have you encountered, as a health professional, in the clinical monitoring of transgender

people?; 4. What proposals/solutions/measures do you suggest to overcome the challenges you have encountered in the clinical monitoring of transgender people?

The data was collected between February 28th and April 8th, 2023. A total of 50 people agreed to participate in the study, of which 25 (50%) completed the survey.

Data Analysis

We used SPSS 26 (IBM SPSS, Armonk, NY, USA) for descriptive statistics and NVIVO v.12 for the summative content analysis (Hsieh & Shannon, 2005) combined with the procedures for qualitative coding proposed by Zhang and Wildemuth (2009). We defned each participant’s answer to each question as a unit of analysis and inductively derived from the data a coding frame composed of mutually exclusive and exhaustive categories and sub-categories.

The coding frame was independently created by three authors (TF, AAM, and PMP) and compared throughout the process. The raters mainly agreed with each other’s coding frames, only diverging in the phrasing of some categories’ and subcategories’ names, which were debated until a collaborative agreement was reached. Then, all coders revisited the whole text corpus independently to confrm the consistency and respective count of references coded. As depicted in Table 1, four questions with the respective categories and subcategories were inductively derived from the analysis (see Table 1). To understand the potential role of specialized training in sexology on participants’ views, we compared the responses of those with (n = 14) and without this background (n = 11) for the four main themes.

Collaboratively, all authors explored inferences, made meaning of the data, and drafted the main conclusions.

The results for each open question will be presented separately, i.e., there will be one subsection for each question. Within each subsection, contents in bold refect a category’s name, and italicized contents represent a subcategory’s name within a category. Within each subsection and for each question, we present the rationale behind each category, enumerate its subcategories, and present a detailed table where we systematize the categories’ names, and their subcategories. For each subcategory, between quotation marks, we present examples of answers with information revealing the participant’s ID, profession, and whether the participant had sexology training (marked with an "[S]") or not (marked with an "[NS]"). After each table, we give a comprehensive overview of the results.

Table 1 Questions, categories and sub-categories in the analysis Questions

Because we take a quantitative approach to our data, our categories will be presented in crescent order, i.e., frst, we present the more prevalent categories. The frequency of answers for each category and sub-category is presented in the table. In the text, within each category, the enumeration of each subcategory follows logical reasoning instead of preestablished numeric/metric criteria that could compromise the natural fow of the text.

Results

Across the diferent questions, participants’ answers vary between short answers (e.g., “[The role of professionals is to] Publicise and facilitate access to NHS sexuality consultations”; ID9, Physician, Endocrinology-Nutrition, NS) and long answers. In this last case, they may integrate more than one subcategory refecting the complex nature of some of the respondents’ refections, experiences, and perceptions, and the interrelation across subcategories (e.g., “[to overcome the challenges in the clinical monitoring of transgender people] Massive training of all primary health care professionals (administration, nursing, medicine) to enable them to approach and orientate transgender people within the national health service. Expanding not only the locations but also the number of professionals capable of providing specialized care to trans people (e.g., training in the area of sexual and gender diversity in the medical and nursing curricula, post-graduate training, sexology consultations in primary healthcare). Policy measures to promote greater interest in and response to the needs of trans people (e.g., portfolios of services in PHC, incentives for postgraduate training for professionals; ID20, Physician, General Practice, NS).

1. Results related to Question 1: “What is the role of people working in clinical sexology in providing healthcare to transgender people?”

The categories created for this question are: enablement of other adequate therapeutical support, help in specifc challenges, provision of integrated and longitudinal support and specialized care (Table 2).

Most of the references to the role of clinical sexologists pertain, however, to the enablement of adequate therapeutic support, which focuses on the role of professionals as facilitators of other professionals’ work. Within this category, afrmative therapy is mentioned explicitly only once. Particular importance is given to providing unbiased information and psychoeducation, which is also extensible to relatives. Referral to mental health evaluation is another crucial element alongside enabling access to other healthcare services.

The role of clinical sexologist professionals in providing help in specifc challenges faced by transgender people specifes the tasks that these professionals may provide. It comes down to identifying support groups, assisting in intrapersonal or interpersonal issues, and supporting them to counter stigma and discrimination.

The third role our participants attribute to clinical sexologists is the provision of integrated and longitudinal support. This category stresses the fundamental role of clinical sexologists as professionals who can continuously develop a comprehensive view of each case.

Table 2 Final coding schema for question 1: “What is the role of people working in clinical sexology in providing healthcare to transgender people?”

Examples

(n = 12) Provide psychoeducation to explain concepts, answer questions they may have about their identity, share information based on current scientifc evidence, free from political or activist polarisation (ID25, Physician, Pedo-psychiatrist, S)

Assessment of the person as a whole, assessment of the possible presence of symptoms related to gender incongruence/dysphoria or other mental health issues (ID16, Physician, Psychiatry, NS)

Referral to appropriate services if they require sexual reassignment surgery and medical treatment (ID14, Physician, Gynecologist, Obstetrician, S)

If necessary, provide psychoeducation for family members (ID10, Psychologist, Clinical and Health, NS)

Supportive afrmative psychotherapy (ID22, Physician, Psychiatrist, NS)

Sub-categories (n)

Provision of unbiased information and psychoeducation

Referral to mental health evaluation (n = 7)

Enabling access to other healthcare services (n = 5)

Category (n)

Enablement of other adequate therapeutical support (n = 27)

Relatives (n = 2)

Afrmative therapy (n = 1)

Help in specifc challenges (n = 12) Assist in intrapersonal or interpersonal issues (n = 7) […] other times it’s about working out internal difculties or diffculties in relationships with others (ID1, Psychologist, Clinical and Health, NS)

Sexology health professionals are instrumental in providing psychosocial and therapeutic support in mental health, particularly in light of the discrimination and stigma (ID7, Psychologist, Health and Sexology, S)

Sometimes, it can make a big diference to help with simple things like fnding support groups, associations or services […] (ID1, Psychologist, Clinical and Health, NS)

Stigma and discrimination (n = 4)

Identifying support groups (n = 1)

Table 2 (continued)

Examples

Sexual health professionals play a key role in understanding diversity and psychoeducation (ID7, Psychologist, Health and Sexology, S)

Clinical sexology aims to address sexual concerns related to sexual functioning and sexual problems, and to promote sexual health and well-being for all (ID9, Physician, EndocrinologyNutrition, NS)

[…] in the area of sexual health, particularly strategies to prevent sexually transmitted infections (ID3, Psychologist, Sexology and Community Intervention, S)

[…] It was not an option, but an option of the service in which I work (ID23, Physician, Anesthesiologist, NS)

“early-stage detection and therapeutical intervention in issues, problems or even sexual dysfunctions that may appear in the transgender persons’ life cycle, often intertwined with biomedical transition (hormonal or chirurgic interventions)” (ID25, Physician, Pedo-psychiatrist, S)

Sub-categories (n)

Assessment of its importance (n = 5)

Promotion of sexual health and physical and mental wellbeing (n = 3)

Prevention of sexually transmitted infections (STIs) (n = 1)

Something part of the surgery service (n = 1)

Category (n)

(n = 10)

Specialized care

Provision of integrated and longitudinal support (n = 10) –

Specialized care stresses that clinical sexologists have unique knowledge to beneft trans healthcare as it encompasses an assessment of its importance, the promotion of sexual health and physical and mental wellbeing, also the prevention of sexually transmitted infections (STIs), and merely something part of the chirurgic service.

Even though only four participants—3 psychologists and 1 physician—explicitly acknowledged the importance of clinical sexology professionals in meeting transgender population’s specifc needs, they refer to diferent care modalities, ranging from specialized to integrated.

Taken together, the results refect that, according to our participants, the role of clinical sexology is fundamental for the transgender population, and they specify that this importance is linked to comprehensive care that integrates specifc interventions.

2. Results related to Question 2: “What diferences do you fnd in providing healthcare to transgender people between when you started practicing your profession and today?”

Participants mentioned changes in areas that appear to be co-evolving and are fundamental for adequate healthcare provision to the transgender population: more knowledge and services, changes in scientifc knowledge, higher visibility and awareness, shortcomings in human resources, demand for healthcare, and changes in the law (Table 3).

The category More knowledge and services emphasizes the crescent implications of having more information available. It includes reference to more clinical services available, which translates into a more specialized response and more medical responses for young people More available evidence and public awareness are extensible to trans persons who, as patients, are more informed

Changes in scientifc knowledge is a standalone category (i.e., without subcategories) that recognizes changes in the content of scientifc knowledge, not the amount of knowledge. It integrates references to specifc advances.

Changes in the law include generic references and lengthy informed descriptions, such as replacing Law nº7/2011 with Law nº38/2018 concerning the right to self-determination of gender identity and expression. There is also mention of the changes in Directorate-General Health normative directives and the apparent mismatch between these changes in the law and the lack of specifc provisions regarding trans people’s health.

Higher visibility and awareness acknowledge that trans healthcare has moved beyond the margins to gain the spotlight in the public domain and that knowledge is being disseminated. This category integrates the perception that the activity of social movements pushed knowledge dissemination forward and relates mainly to health professionals’ views on their own experience or colleagues’ experiences.

There is also a reference to shortcomings in human resources, a category that focuses on more situated changes as the availability of specialized professionals has shortened over time.

Finally, participants identify changes in terms of the demand for healthcare from transgender people, highlighting that there has been a growing complexity and number of requests in this feld, with a particular emphasis on the increase in

Table 3 Final coding schema for question 2: “What diferences do you fnd in providing healthcare to transgender people between when you started practicing your profes -

sion and today?”

Examples

I am noticing more information [from the patients] and less repetition of the gender paths (ID7, Psychologist, Health and Sexology, S)

There is now a greater hospital response to these situations (ID23, Physician, Anaesthesiology, NS)

More visibility of trans people that causes health professionals to care more about this population (ID14, Physician, Gynecologist, Obstetrician, S)

[…] the provision of non-surgical care is higher (ID10, Psychologist, Clinical and Health, NS)

Sub-categories (n)

Category (n)

More knowledge and services (n = 16) As patients, are more informed (n = 6)

More clinical services available (n = 4)

More available evidence and public awareness (n = 4)

More specialized response (n = 1)

More medical responses for young people (n = 1) comparing with six years ago, the main diference lies in the more specialized endocrinological intervention with children and adolescents (ID25, Physician, Pedo-psychiatrist, S)

Table 3 (continued)

Examples

Sub-categories (n)

Increase in healthcare requests from younger people (n = 4) […] Nowadays I get requests for help from younger people, from families with children and young people […] (ID8, Physician, Urologist, S)

When I frst started, requests for support tended to come from young adults and adults who wanted a more binary gender transition, from male to female and vice versa, including surgery. Nowadays I get requests for support from […] [people] who are also exploring non-binarism, gender fuidity and even other diversities such as asexuality (ID8, Physician, Urologist, S)

Increased proportion of young people with biological female sex (female gender assigned at birth) (ID25, Physician, Pedopsychiatrist, S)

I have the perception that neurodiversity and neurodevelopmental disorders (including autism spectrum disorder) in referred young people, the majority of whom without a formal previous diagnosis (ID25, Physician, Pedo-psychiatrist, S)

There is much more scientifc information available. In 2018, there were few studies on issues such as contraception, preconception care and hormone therapy in general (ID13, Physician, Gynaecology-obstetrics, S)

It seems that the health care that should be available through the NHS is not being provided in an informed and timely manner to transgender people (ID6, Psychologist, Clinical Sexology and Psychology of Justice, S)

Much easier when comparing with the process of changing name/identity. Not so long ago it was necessary to sue the State (ID10, Psychologist, Clinical and Health, NS)

Category (n)

Demand for healthcare (n = 8)

Higher demand for non-surgical care (n = 2)

Higher demand for female-to-male surgeries (n = 1)

Comorbidity with neurodevelopmental disorders (n = 1)

Changes in scientifc knowledge (n = 6)

Shortcomings in human resources (n = 5) –

Changes in the law (n = 5) –

healthcare requests from younger people and higher demand for non-surgical care. One participant perceives a higher demand for female-to-male surgeries—as well as comorbidity with neurodevelopmental disorders.

Our participants stress that, throughout the years, there has been more knowledge and awareness about transgender healthcare and that there are marked diferences in healthcare provision to transgender people over time.

Overall, the answers to this question indicate that over time, the tangible changes toward better healthcare provision for this population coexist with several challenges at diferent levels that have allowed for more information and visibility. These changes encompass more strain within services framed by a lack of specialized resources to respond to more demands.

3. Results related to Question 3: “What challenges have you encountered, as a health professional, in the clinical monitoring of transgender people?”

The resulting categories emphasize that healthcare services are too centralized and that there is a shortage of trained professionals. They are expressed in categories: formal institutional challenges, informal institutional challenges, clinical challenges, patient challenges, social challenges, and professional-related challenges (Table 4).

Institutional challenges are perceived as hard to counteract. There is mention of formal – which aggregate answers related to the objective state or institutionalderived factors (e.g., policies; the existence of healthcare settings) -and informal institutional challenges- which include difculties found in practice that are hard to operationalize. Formal institutional challenges include a lack of formal education concerning transgender care, a lack of specifc guidelines for primary care and outdated surgical techniques, long waiting lists, and a lack of services articulation due to geographic inequalities in access to healthcare services

Informal institutional challenges are no less impacting, including a lack of updated knowledge from other clinicians not directly involved in transgender care, non-responsiveness from colleagues, and obstacles in translating policies and international guidelines into practices. Participants also emphasize clinical challenges, defned as those resulting from concealing the best clinical praxis, at diferent stages, beginning with building and maintaining the therapeutic relationship and generating a diferential diagnosis. On a related note, participants also mentioned as a challenge the presence of emotional disorders/psychopathology and the need to promote co-responsibility

The aforementioned clinical challenges are interconnected with specifc patient challenges, i.e., the ones derived from patients’ actions in clinical contexts, such as lack of compliance, hostility, or negative expectations towards health professionals There was also one mention of unrealistic expectations

Participants identifed critical social challenges, referring to contextual challenges emanating from systems outside the clinical settings where the patients are embedded. These challenges relate to family stigma and social discrimination.

Finally, professionals-related challenges, i.e., those challenges derived from participants’ refections and experiences and perceptions of professionals’ personal limits, include feelings of strangeness toward non-binary bodies, questioning the cost–beneft of gender-afrming surgery, and physicians’ prejudice.

Table 4 Final coding schema for question 3. “What challenges have you encountered, as a health professional, in the clinical monitoring of transgender people?”

Example

Very long waiting times for a specialist consultation response (ID11, Psychiatrist, S)

Difculty in articulating services, lack of professionals with national training, being very centralized in the large urban centers of Oporto, Lisbon and Coimbra (ID2, Physician, General Practice, NS)

Sub-categories

Long waiting lists (n = 3)

Lack of services articulation (n = 3)

Geographic inequalities in access to healthcare services (n = 2) Services remain centralized (ID20, Physician, General Practice, NS)

Inexistence of a follow-up program structured according to current evidence on primary healthcare causing isolation and worse primary healthcare of trans persons (ID2, Physician, General Practice, NS)

Primitive surgery techniques (ID10, Psychologist, Clinical and Health, NS)

Other health professionals thought everything was bizarre, including health professionals working in the area (ID10, Psychologist, Clinical and Health, NS)

Lack of training in the area (ID19, Physician, General Practice, S)

Resistance to applying international best practice, out of fear, for example for young trans people who would like to start hormone therapy. Doctors in endocrinology and psychiatry apply the age of 18 to start therapy, without analyzing on a case-by-case basis whether they could or would like to start earlier (ID7, Psychologist, Health and Sexology, S)

Difculties in getting other professionals from psychiatry, endocrinology to collaborate (not sharing e-mails, lack of responses, not giving their contacts, not writing collaboration letters, having to chase after them) (ID7, Psychologist, Health and Sexology, S)

Discussion

The current study explored qualitatively the perspectives of Portuguese clinicians who act in clinical sexology and TGD healthcare (N = 25) on the role of clinical sexology in TGD healthcare, on current diferences in healthcare provision to TGD clients from when they started their clinical practice, on challenges experienced in providing healthcare to TGD clients, and their proposed solutions/measures to tackle these challenges. It innovates by taking a comprehensive time-progressing approach to the clinician’s perspective and comparing the perceptions of those with and without specialized training in clinical sexology.

The Role of Clinical Sexologists in TGD Healthcare

Participants reported that the role of clinical sexologists in transgender healthcare is one of providing specialized care (e.g., promoting sexual, physical, and mental health and fostering skills to overcome stigma-related social challenges) together with general healthcare services (e.g., providing integrated and developmental care), as well as delivering psychoeducation and unbiased information on the medical procedures (referred to as the “transition” process), and to conduct referrals to mental health assessment. To our knowledge, only one study explored the perceived role of clinical sexology in TGD health provision (Gieles et al., 2024), and its results were more focused on providing sexual health information, while ours seem to point out that participants see the role of clinical sexology as not exclusively targeting sexual health. Another diference was that participants in our study did not mention central issues related to positionality and addressing societal biased narratives on TGD (sexual) health. Also, participants in our study do not seem to echo (at least not explicitly) the importance of providing information on the impact of afrmative medical care on sexual health and body image, as found by Gieles et al. (2024). On the other hand, participants in the current study seem to have a more all-encompassing view of the role of clinical sexologists, particularly in providing rigorous information regarding gender-afrming medical options, as well as in conducting referrals to other healthcare specialties, namely mental health assessment. This seems to echo the reported increased acknowledgment by healthcare providers of the need for trans-specialized care (e.g., Motmans et al., 2019; Veale et al., 2022). However, it should be noted that responses regarding the need for mental health evaluation were highly focused on the assessment of psychopathology (e.g., the need for a gender dysphoria diagnosis) rather than on mental health and well-being as a whole and that afrmative therapy was mentioned only once (with a framing of multidisciplinary care) which may be an expression of low focus on afrmative care and an emphasis on medically supported transition. While other studies seem to suggest that clinicians, although recognizing the need for mental health assessment, voice

concerns regarding the potential disadvantages of mental health screenings (e.g., delay in initiating afrming medical care; opposition to psychiatric gatekeeping) (Stroumsa et al., 2019), our results seem to be in line with other existing results suggesting an a priori assumption by clinicians that TGD clients have mental health challenges that should be screened before medical care (Snelgrove et al., 2012). We cannot establish if this is due to the specifc requests presented by patients or due to an overmedicalization of transgender healthcare that neglects a global approach to patients’ overall well-being during afrmative practices.

Nevertheless, although results provide a clear shift towards transgender acceptance from previous studies on Portuguese health professionals attitudes towards transgender clients (e.g., Moleiro & Pinto, 2009), this seems to indicate an overall overfocus on a medically-centered approach to clinical aspects of “transitioning” and the perceived lack of proper training, articulation, and bureaucratic conditions to provide evidence-based healthcare to trans people. Another possible explanation for this absence of content regarding sexual health (including sexual functioning) is the fear of hypergenitalizing transgender healthcare, thus failing to address an essential aspect of health. Some studies have explored transgender sexual health (e.g., sexual function and pleasure), namely changes in arousal and erogenous sensations infuenced by hormone therapy and surgical procedures (see Stephenson et al., 2017). However, studies suggest that the perceived politicization of transgender issues contributes to clinicians´ fears of professional repercussions for spousing opinions “that don’t go with the majority” (e.g., Mollitt, 2022).

Perceived Changes in Providing TGD Healthcare

To our knowledge, our study was the frst to qualitatively explore clinicians’ perceived changes in providing healthcare to TGD clients throughout their professional activity. Thus, a direct comparison with existing literature is not possible. Participants identifed six changes in providing healthcare to transgender people from when they started practicing: increase in scientifc knowledge (e.g., on cryopreservation of gamete, puberty blockers), changes in the law (where gender identity is now self-determined and the process of changing name/gender marker and access to healthcare is facilitated), higher visibility and awareness of TGD issues, shortcomings in human resources, and demand for healthcare (namely higher demand for non-surgical care, and more requests from younger people and from non-binary clients). This seems to echo previous studies that report clinicians’ concern with the need to develop specialized training in healthcare provision to TGD youth and nonbinary individuals (e.g., Linander et al., 2019). In regards to the clinicians’ perceptions of an increase in non-binary identities, one should note that providing scientifcally sound evidence on the frequency of non-binary individuals over the years is necessarily biased by the scientifc process being dependent on existing paradigms and defnitions (e.g., conceptualization, operationalization and attitudes of researchers towards the object of analysis) in a certain period (e.g., Koselleck, 1992), as well as by sample selection biases (e.g., non-binary individuals seem to be less likely to socially and medically “transition”) (e.g., Factor & Rothblum, 2008; Scheim &

Bauer, 2015). Nevertheless, non-binary individuals seem to be growingly reported in population-based research (e.g., Chew et al., 2020), with studies suggesting that more research is needed to adequately inform specialized healthcare provision of non-binary individuals (Veale et al., 2022).

The Challenges of Providing Healthcare to TGD Clients

Although participants have identifed positive changes toward more knowledge, awareness, and access to specialized technical resources, they still reported core challenges in providing healthcare to transgender clients. Participants identify formal institutional challenges, informal institutional challenges, clinical challenges, patient challenges, social challenges, and professional-related challenges. Our results echo previous ones that found institutional and organizational challenges/barriers to providing healthcare to TGD clients, namely difculties in identifcation, availability, and quality of referral networks and information sources regarding trans medical care and lack of specialized training (Grant et al., 2021; Snelgrove et al., 2012; Soled et al., 2022). While organizational barriers found in literature seem to focus more on limited care options available due to a lack of professionals with expertise in specifc treatment options (Snelgrove et al., 2012; Vance et al., 2015), results from our study are more focused on structural challenges within the organizations (e.g., long waiting lists, lack of articulation between services, geographic inequalities in access to healthcare services). Contrary to other studies, participants did not report the clients´ fnancial ability to access healthcare as a barrier/challenge. Although some previous studies report that clinicians fnd clients’ ability to pay for health services as a barrier to providing healthcare (e.g., insurance coverage of mental health screenings) (Stroumsa et al., 2019; Torres et al., 2015), participants in our study have not reported fnancial concerns, perhaps because Portugal has a welfare state in which access to gender-afrming medical care is provided in the public national healthcare service free of costs. Also, similarly to previous studies (Mikulak et al., 2021; Soled et al., 2022), participants have identifed social and family stigma as challenges in providing TGD healthcare. However, while in previous studies stigma is presented in terms of clinicians´ prejudice towards TDG individuals (e.g., use of stigmatized language, unfounded beliefs that TGD are promiscuous homosexuals, TGD clients described as difcult patients and with high prevalence of personality disorders), in our study stigma is presented as something that clinicians should be aware of, specifcally its impact on mental health and suicidality, and is reported as something that clinicians should fght against by normalizing and educating the public on TGD issues. While previous studies found that structural binary and cisheteronormative medical care and health systems present challenges in TGD healthcare (e.g., Gieles et al., 2024; Snelgrove et al., 2012), participants in our study have not reported it when discussing challenges to TGD healthcare. Professionals-related challenges were reported, primarily associated with engaging with and providing healthcare to non-binary individuals, but also regarding the efcacy of their care. The participants reported experiencing strangeness towards non-binary bodies and reported ethical doubts about the cost–beneft of

gender-afrming surgeries due to their irreversibility. Lack of understanding towards non-binary identities has been reported in previous studies, including discomfort in prescribing hormone therapy to non-binary clients (e.g., Soled et al., 2022). Contrary to other studies where lack of understanding towards non-binary individuals seems to be rooted in perceiving them as “strange” (Soled et al., 2022) and in having difculty using non-binary pronouns (e.g., “they”) (Mikulak et al., 2021) or in keeping up with the evolving terminology (e.g., Rider et al., 2019), in this study, only one participant reported “strangeness” towards non-binary clients. In contrast, the challenges with non-binary care focused on a lack of perceived efcacy and knowledge on which procedures are more efcacious. Nonetheless, these attitudes and concerns might not only refect a lack of appropriate technical training, as those without specialized training reported them. Still, they may also indicate an underlying prejudicial stance towards non-binary bodies. This is a critical point to consider when refecting on factors contributing to the lack of specialized and profcient transgender care: while insufcient training is widely reported by healthcare providers (e.g., Korpaisarn & Safer, 2018; Snelgrove et al., 2012), prejudice towards trans people (and not lack of training) predicts incompetence in providing trans healthcare (e.g., Powell & Cochran, 2021; Stroumsa et al., 2019). Contrary to previous studies (e.g., Soled et al., 2022), participants did not report experiencing organizational pressures to provide medical treatment (e.g., hormone therapy) to non-binary individuals. Similarly to other studies (e.g., Snelgrove et al., 2012), participants reported the uncertainty of the cost-benefts of gender-afrming medical procedures as a challenge in providing TGD healthcare, mainly due to fears of participants regret. Still, contrary to these previous studies, participants have not reported fears of legal repercussions of providing medical procedures to someone who later on may regret it.

Participants interestingly report patient-centered challenges. Specifcally, they report transgender clients´ lack of compliance (e.g., with the psychological assessment process), hostility towards health professionals (which is perceived as resulting both from frustration with the morose and bureaucratic process but also from a perception of trans people being highly demanding and entitled to a preferential treatment comparatively to cisgender people), and unrealistic expectations (e.g., regarding the timeframe of the medical process). To our knowledge, this is the frst study that found a clear mention of transgender hostility towards healthcare professionals, while the majority of studies suggest the contrary (e.g., Ross et al., 2023; Snelgrove et al., 2012; Snow et al., 2019). One possible explanation for this result is the rapid change in the legal recognition of gender identity with the self-determination law (Law 38/2018) and its consequent shift in the medical-patient relationship due to a decrease in medical gatekeeping (Saleiro, 2021), which may result in clinicians perceiving clients empowered, self-determined, and afrming stances as hostile and demanding. This may refect resistance in adapting to the shift from physicians as sole providers of medical information to a more collaborative patient-centered approach (where transgender people are crucial to the medical decision-making process by adding to it their “experiential knowledge”; Borkman, 1976), which is inscribed in the overall health social movements that advocate for patients being active policy actors (Hofman et al., 2011). Another possible explanation is that

transgender clients’ noncompliance and hostility may result from transgender people encountering a frustrating, highly morose, and redundant process to access medical afrming interventions. In Portugal, until 2021, gender-afrming surgeries were provided in the public health sector only by one multidisciplinary team (Circular 27/2017/ACSS/DGS; Administração Central do Sistema de Saúde, IP & DireçãoGeral da Saúde, 2017), thus limiting access due to the centralized and morose process. Additionally, until 2021, the Portuguese Medical Association was required to authorize gender afrming surgeries, even after the medical team’s approval, which also contributed to the delay in the process. Also, in the public healthcare sector, a diagnosis of gender dysphoria is required to have access to hormone therapy, and two reports attesting to gender dysphoria are needed to access surgeries (which seems to refect a transmedicalist stance, given that not all trans people experience gender dysphoria; e.g., Galupo et al., 2021), which may contribute to frustration and potentially difculties in the clinician-client therapeutic relationship. Nonetheless, challenges in the therapeutic relationship have already been reported, namely the impact of mutual distrust on establishing a therapeutic relationship (e.g., confict due to difering expectations of treatment) (Soled et al., 2022), as well as patients’ unrealistic expectations to the physical results of treatment (Snelgrove et al., 2012). It is worth noting that professionals also recognize experiences of stigma and prejudice that emanate from clinicians, which, together with the report of lack of responsiveness from services and colleagues, suggest a complex thread of possible negative interactions, negative expectations, and distrust in the context of patient-clinician relationship but also among health professionals. This may lead to additional professional strain (e.g., Wolfe, 2023), a feld worth exploring in future studies.

Proposed Measures to Improve TGD Healthcare

Participants suggest an array of solutions/measures to overcome the identifed challenges to providing healthcare to TGD people. Participants with specialized training suggested social and political changes are needed, including developing transgender health guidelines for the Portuguese context to standardize procedures, which may result from refections raised by their specialized training. This echoes previous studies with clinicians who suggest developing clinical guidelines for TGD healthcare, although highlighting that its implementation should be fexibly applied in a caseby-case manner (Snelgrove et al., 2012). Also, all participants suggest the inclusion of both sex and gender identity in current medical records to conduct adequate trackback of sex-related diseases (e.g., transmasculine people being referred for cervical cancer screening). This is in line with previous studies that suggest clinicians fnd technical challenges in providing TGD healthcare, such as the inability to record the gender and also the natal sex of a person, which can exclude crucial check-ups and scans (Mikulak et al., 2021). They also point out the importance of conducting more research focused on the Portuguese context. This echoes the need for medical guidelines and standardization of procedures, such as those developed by the Portuguese Psychologists Association for providing mental healthcare to LGBT+ clients (Moleiro et al., 2015). It also echoes calls for more research on transgender issues

(e.g., longitudinal studies, studies with multiple informants, studies exploring clinicians’ attitudes, studies examining the impact of political discourse on TGD identities on access to healthcare), which seem to have been understudied in the Portuguese context, perhaps due to a lack of social and legal visibility up until the last decade (see Saleiro, 2021).

Participants with specialized training suggest the development of awarenessraising actions, such as the development of materials and health protocols targeting the specifcities of transgender healthcare, engagement with community activities to fght stigma and discrimination (e.g., awareness-raising initiatives at schools and universities), increase in medical literacy for lay people through the media, and cultivating openness and the awareness of gender diversity by health professionals, which may have been infuenced by their own pursue of professional development and the difculties they face to navigate their colleagues’ prejudice towards TGD healthcare. It is worth noting that although these participants recognized the importance of promoting awareness of the diversity of gender identities, issues of positionality (being a cisgender professional providing care to a transgender client) were absent from participants’ responses. This was acknowledged by healthcare providers working in clinical sexology in a recent study (Gieles et al., 2024) and is an ongoing discussion on the role of personal experience in conducting research (e.g., Galupo, 2017) and in providing (mental) healthcare to transgender clients (e.g., Austin & Craig, 2015), mainly regarding the need for clinicians to check their personal biases and prejudices. Contrary to our results (which were more focused on social, systemic, and clinical/training solutions), results from another study were more focused on clinicians as agents of change: reducing hierarchical power dynamics through partnering with patients, being humble and transparent regarding limited knowledge, communicating honestly, realistically, and prioritizing the patient’s goals, and contributing to the organizational culture of diversity, for example by hiring a diverse and culturally competent staf including transgender people (Soled et al., 2022).

Participants stress the importance of increasing access to specialized health services, namely improving access to NHS by coordinating with the private sector and private solidarity institutions, the inclusion of transgender people in multidisciplinary teams, and decentralizing the specialized healthcare provision (outside Lisbon, Coimbra, and Oporto) to increase access to remote populations and reduce waitinglists for afrming care. Also, participants suggest the development of an interdisciplinary platform that appropriately articulates health services and provides a list of specialized trained professionals. This aligns with what seems to be the most salient challenge experienced by the participants, namely the lack of institutional articulation and training and the lack of trans-specialized care in primary healthcare. Clinical contact with TGD health may occur and pose challenges in diverse clinical contexts, such as mental healthcare and primary care. For example, a recent study with primary care physicians has highlighted that professionals recognize their role in TGD healthcare, although they are not provided proper training throughout their education (Rodrigues et al., 2024).

Indeed, participants suggest increasing the training of healthcare professionals via their professional associations, which should be provided to healthcare professionals at large, as well as primary care (including administrative staf) and

mental health professionals. The diferences found among the two groups (with and without specialized training) suggest that training opportunities must be stepwise and tailored according to existing professionals’ backgrounds, as they may have diferent needs and face diferent professional challenges.

Limitations and Future Studies

The current study has several limitations that should be considered when interpreting results. The study was conducted online, raising questions about whether this context promotes or hinders disclosure. Future studies in this feld should compare online and face-to-face data to map out diferences. Also, it should be noted that clinical sexology/sexual medicine is a relatively small feld in Portuguese academia, so responses may have been biased by social desirability and/ or fear of identity disclosure, even though anonymity was guaranteed in informed consent and by reduced sociodemographic and work-related questions. Additionally, some of the ambiguity of the responses could have been clarifed by followup questions in a face-to-face interview format, which the current study did not conduct. Also, future studies should consider conducting focus groups to assess whether diferent organizational issues and solutions to providing specialized transgender healthcare emerge. Moreover, it should be noted that a considerable number of participants (56%), although working in clinical sexology, reported not having a specialty or competence as clinical sexologists recognized by professional associations. This may not only be a symptom of the morosity of advanced clinical degrees recognitions or that some participants were still trainees in clinical sexology, but also a sign that healthcare institutions have an immediate need for human resources with enough training in transgender care. This may indicate that, although motivated to learn and implement evidence-based care (as depicted by the acknowledgment of lack of training by a signifcant number of participants), there are still clinicians called to provide healthcare to transgender clients before acquiring proper expertise. This calls for the speed-up of bureaucratic procedures that provide clinical expertise recognition and higher investment in training in transgender healthcare and human resources to implement evidence-based care. Finally, only one pedo-psychiatrist was present, although many reported providing care to clients with diferent ages and developmental stages. Providing healthcare to TGD youth requires a specifc set of not only technical skills (e.g., providing information on chest binding, genital tucking, and co-deciding on the appropriate hormone therapy option) but also ethical profciency (e.g., assessment of short-term versus long-term cost-benefts of medical procedures) in a still-evolving scientifc feld (Coleman et al., 2022). Future studies should explore the specifc challenges experienced by clinicians working in the feld of clinical sexology/sexual medicine in providing healthcare to TGD youth, both in terms of navigating stigma and societal pressures (Turban et al., 2021), as well as their perceptions of the developmental trajectories (Brik et al., 2020) and how these impact medical decision-making when providing healthcare to TGD youth.

Conclusions

The current qualitative study suggests that Portuguese clinicians working in the feld of clinical sexology and who provide healthcare to TGD people (1) identify the role of clinical sexologist as of helping cope with intrapersonal and interpersonal issues (e.g., coming out, tackling discrimination, fnding support groups), of providing evidence-based psychoeducation, and promoting articulation between healthcare services; (2) perceive an increase of TGD visibility, awareness and scientifc knowledge, including by TGD clients themselves, comparatively to when they started practicing; (3) identify as primary challenges the lack of training in trans-specifc health, of medical guidelines for standardized care, resistance from general clinicians, professional skills in conducting accurate assessment (especially when psychopathological symptoms are present), as well as lack of compliance, hostility, and unrealistic expectations from TGD clients; and (4) they suggest as potential solutions to overcome these challenges social and political changes that increase investment in specialized training and human resources, raising awareness of both general practitioners (by developing TGDfocused materials and protocols) and the general population (by conducting psychoeducational actions in schools and universities), and improving specialized health services by decentralizing gender afrming healthcare and by increasing interdisciplinary articulation, thus contributing to reduce inequities in healthcare and promote good health and well-being in a gender equality framework that consideres the specifties of TGD healthcare.

Acknowledgements The authors would like to thank the Sociedade Portuguesa de Sexologia Clínica and the Sociedade Portuguesa de Andrologia for their immeasurable help in advertising the current study, without which it could not have been successfully conducted Also, we would like to thank the two representatives of two LGBTQI+ associations for their feedback on our survey, which helped greatly to improve it.

Funding Open access funding provided by FCT|FCCN (b-on). The frst author is supported by FCT –Fundação para a Ciência e Tecnologia, under the Individual Call to Scientifc Employment Stimulus – 4th Edition 2021; ref: 2021.01871.CEECIND. The second author is supported by FCT – Fundação para a Ciência e Tecnologia, under the Individual Call to Scientifc Employment Stimulus – 5th Edition 2022; ref: 2022.07175.CEECIND. The third and fourth authors are supported by national funds from FCT –Fundação para a Ciência e Tecnologia, I.P., under the project UIDB/05380/2020.

Data Availability Data will be made available upon reasonable request.

Declarations

Confict of interest There are no conficts of interest to disclose.

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directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/ licenses/by/4.0/ References

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Authors and Afliations

Sérgio A. Carvalho1,2 · Teresa Forte1 · Andreia A. Manão2,3 · Patrícia M. Pascoal2,3,4,5

* Sérgio A. Carvalho sergiocarvalho@fpce.uc.pt

1 Center for Research in Neuropsychology and Cognitive Behavioral Intervention (CINEICC), University of Coimbra, Coimbra, Portugal

2 Sociedade Portuguesa de Sexologia Clínica, Bragança, Portugal

3 HEI-Lab: Laboratórios Digitais de Ambientes e Interacções, Universidade Lusófona, Humanas, Portugal

4 Clínica Universitária de Psiquiatria e Psicologia Médica, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal

5 PSYLAB, Instituto de Saúde Ambiental (ISAMB), Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal

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