‘There’s a lot that could have been done’: Primary healthcare professionals’ considerations on providing sexual healthcare to transgender and gender diverse people

Previous research: Policy and practice discrepancies

Sexual health, in this paper, is seen as a vital part of health and as a bio-psycho-social well-being in relation to sexuality, not merely as the absence of ill-health, and access to sexual healthcare is seen as a human right pertaining to sexuality (Starrs et al., 2018; WHO, 2015). According to The Swedish Health Care Act (SFS 2017:30) and The Patient Safety Act (SFS 2010:659), healthcare should be provided in accordance with proven experience and scientific knowledge and be of good quality. Additionally, the national strategy for sexual and reproductive health and rights, SRHR, stresses the importance of accessible high-quality sexual healthcare for all (Public Health Agency of Sweden, 2020). The national action plan for SRHR further highlights everybody’s unlimited right to autonomously define, be respected and strengthened in their gender identity, regardless of where care is provided, and primary care institutions, like healthcare clinics, are seen as vital actors (Public Health Agency of Sweden, 2023).

Policies in many countries stress the right to sexual health for all. Still, numerous studies show how education programs do not prepare HCPs (e.g., physicians, nurses, physiotherapists, social workers and psychologists), they lack training and guidelines, and are unsure of how to provide the relevant sexual healthcare for the patients they meet in primary healthcare settings and elsewhere, regardless of patients’ gender identity (Areskoug-Josefsson et al., 2019; Areskoug-Josefsson and Gard, 2015; Fennell and Grant, 2019; Howe, 2021; Klaeson et al., 2017; Merryfeather and Bruce, 2014; Palaiodimos et al., 2020; Poteat et al., 2013; Qin et al., 2021; Træen and Schaller, 2013).

A need to strengthen SRHR competence, including TGD+ competence, among healthcare professionals has been identified but transphobia can jeopardise such efforts (Public Health Agency of Sweden, 2020; Stroumsa et al., 2019). TGD+ people report lack of competence, sensitivity and understanding among care providers as barriers in healthcare, where they also risk being met with prejudice, discrimination, hetero- and cis-normativity (Carlström et al., 2021; Lacombe-Duncan et al., 2021; Lindroth 2016; Sbragia and Vottero 2020; Xavier et al., 2013). When midwifes and physicians in gynaecology and obstetrics in Sweden were interviewed regarding their experiences of providing care for TGD+ people, cis-normativity was found in digital systems and in information material, as well as among the informants and their colleagues (Kawsar and Linander, 2022). An understanding of sexual health-needs among TGD+ people was also displayed but not seen as a prioritised area. Since guiding policies were lacking, individual interest and initiatives among professionals were relied upon (Kawsar and Linander, 2022). These findings are in line with what medical and social services professionals providing care to transwomen within HIV care in Canada shared in interviews: an understanding for sexual healthcare needs within a cis-normative system was displayed (Lacombe-Duncan et al., 2021). Contrary to the Swedish and Canadian studies above, HCPs at youth sexual healthcare clinics in England did not describe their organisation – or themselves – as cis-normative (Lefkowitz and Mannell, 2017). Instead, young TGD+ people were seen, by several participants, as unstable and experimenting, displaying a confusion between clients’ sexual orientation and their gender identity. A similar confusion was seen when Norwegian HCPs meeting young people were interviewed (Stubberud et al., 2018). Despite an expressed wish for more knowledge to safeguard a respectful treatment, TGD+ youth were used as a source of knowledge and an essentialist view on gender was found (ibid.). Two Canadian studies, with physicians and physician residents, further show various factors potentially affecting care situations with TGD+ patients, such as the staff’s lack of competence or training and unease (Coutin et al., 2018; Snelgrove et al., 2012). Furthermore, the lack of supportive policy, transphobia and an assumed psychiatric co-morbidity among TGD+ people were mentioned (Snelgrove et al., 2012). These findings are similar to those from interviews with HCPs in the US (Carabez et al., 2016; Poteat et al., 2013). An understanding of vulnerability among TGD+ people has also been found in HCP interviewees, in addition to a wish for increased knowledge and competence (Carabez et al., 2016; Snelgrove et al., 2012; Willging et al., 2019). Summarising, there is a global gap between TGD+ inclusive sexual health policy and practice, and little is known of what role culture within healthcare organisations play in upholding this.

Aim

The purpose of this study was to gain a deeper understanding of how healthcare providers in primary healthcare clinics regard the provision of sexual healthcare or promotion to TGD+ people. More specifically, we wanted to explore how culture within these primary healthcare clinics can be related to professionals’ abilities and possibilities to promote TGD+ people’s sexual health.

Design, setting and participants

Qualitative research interviews (Kvale and Brinkmann, 2014) were conducted with eight HCPs employed by municipal, primary healthcare centres. In Swedish municipal, primary healthcare centers, physicians and nurses typically provide general or non-specialised health promotion and care to inhabitants of all ages, along with interventions from e.g. occupational therapists, social workers, psychologists and physiotherapists. Participants were found via convenience sampling. The first author contacted approximately 100 managers in primary healthcare clinics in southern Sweden – one of 21 national healthcare regions, about spreading information on the study (aim, ethical considerations, method and contact information to both authors) to their co-workers at each clinic. Interested HCPs contacted the first author. Inclusion criteria were to be registered (e.g., nurse, psychologist, physician, physiotherapist or social worker) and had worked for at least 1 year, with or without the experience of providing sexual healthcare to TGD+ people. During February and March 2023, four digital and four in-person interviews were conducted by the first author, lasting between 60 and 90 minutes each. The participants’ professions were nurse, psychologist, physiotherapist and social worker – sometimes with different specialisations, employed by seven different municipal healthcare clinics. A semi-structured interview guide was constructed and used, based on previous research and the study aim, covering the following three areas: (1) TGD+ people and sexual health needs (2) the possibilities and challenges of providing sexual healthcare to TGD+ people and (3) the healthcare organisation. Memos were taken in connection to the interviews, and all interviews were recorded and transcribed verbatim by the first author.

Analysis and theoretical framework

Deductive reflexive thematic analysis was applied, and patterns and themes were extracted from the data, starting after the first interview, and based on the authors’ subjective reflections with the theoretical framework (see below) in mind (Braun and Clarke, 2006, 2019; Braun et al., 2022). As Braun and Clarke (2019: 594) describe, the themes evolving in this process were treated as ‘creative and interpretive stories about the data, produced at the intersection of the researchers’ theoretical assumptions, their analytic resources and skill and the data themselves’. The six phases of reflexive thematic analysis (familiarisation with the data, initial coding, the production of themes, sorting through themes, defining and refining themes and writing an augmenting presentation) were a point of departure (Braun and Clarke 2006, 2019). The phases were not adhered to in a linear fashion; rather, they acted as an encouragement and constant reminder for us, to commute between the transcribed text, the codes, previous research and the chosen theoretical framework. This abductive process resulted in four themes: i) Two aspects, many pitfalls, (ii) External changing winds, internal lulls and resistance, (iii) Strong emotions while wanting to do good rather than harm and (iv) Arbitrary navigation following one’s own compass while wishing for guidance.

To better understand the connection between the culture within healthcare clinics, and HCPs’ abilities and possibilities in their work, Bourdieu’s (1992, 1995) key notions of field, doxa and habitus were used as a theoretical framework. The concept of field was understood as independent, yet time-and space-dependent social areas characterised by specific interests and logics, internal fights and fights in relation to other fields (Bourdieu, 1992; Carlhed, 2011; Järvinen, 2002). Healthcare in general along with the primary healthcare centres were here seen as fields, and their employed HCPs as field inhabitants or agents. While willingly participating in and embracing the field’s work, agents within it are also subordinate to its power (Bourdieu, 1992, 1995; Carlhed, 2011). Every field has its own specific doxa, understood as a natural order or a field-specific value system which delineates right from wrong, normal from abnormal and upholds the rules and routines within a field in a subtle common-sense kind of way, often without being visible for the field’s inhabitants (Carlhed, 2011; Järvinen, 1998, 2002). We thus anticipated the HCPs, as field agents, to have a common understanding of their fields’ (here the healthcare organisation or the healthcare centres) engagement and interest in sexual health provision to TGD+ people. This common understanding can be seen as the doxa, but also the power of it, as it secures and constructs the field, its stakes and fights, as well as what is silently and unconsciously being accepted (Bourdieu, 1992; Järvinen, 2002). Habitus was understood as an individual, unique incorporated system that affects people’s e.g. thoughts, feelings and actions to different stimuli, a system accumulated through implicit or explicit learning throughout life (Bourdieu, 1992, 1995; Carlhed, 2011; Järvinen, 1998). Every HCP was understood to be having its habitus, a praxis-guiding incorporated scheme of both private and professional experiences.

Ethical considerations and researchers’ reflexivity

The study was tested by the Swedish Ethical Review Authority. Ethical guidelines on information, consent and confidentiality were followed throughout. Study information was given to the participants in writing before deciding to take part and being interviewed and orally reasoned before starting the interviews. Participant names used in this text are pseudonyms.

Both authors are HCPs: the first author works as a registered social worker at a hospital and this study was part of her master’s dissertation in sexology. The second author is a registered nurse, PhD, and works as an associate professor, acting as supervisor in the master’s dissertation process. The dissertation has been condensed into the present paper. In this process, we tried – as much as possible – not to let our pre-understanding get in the way of new insights while simultaneously using previous knowledge, from practice and research when conducting and interpreting the findings. For instance, the first author’s extensive experiences from having structured conversations as a social worker were used during the interviews. The second author’s experiences of conducting and interpreting interview studies on sexual health were used in supervision of the master’s dissertation, and in the condensation, analysis and writing up phase of the paper.

Two aspects, many pitfalls

Providing sexual healthcare to TGD+ people was an unusual and delicate mission that was difficult to balance in relation to protruding principles in the healthcare setting – principles such as patient self-determination, autonomy, participation and equal care. Participants were neither used to meeting TGD+ people nor being asked about – or addressing – sexual health needs and they reflected upon this dual sparsity. Some expressed thoughts that patients might be unfamiliar with the possibility of bringing up sexual health needs or were just not comfortable in doing so. Fred speculated, on lacking experiences of meeting TGD+ patients:

‘We rarely meet these kinds of patient. And why is that? Probably because they don’t seek care, I believe. ’Cause they should have similar care needs.’

In line with previous studies (e.g., Stubberud et al., 2018; Træen and Schaller, 2013), the dual rarity of meeting TGD+ people and of addressing sexual health issues appeared to have shaped participants’ habitus and thereby how they regarded this work. Some HCPs compared work including provision of sexual healthcare to TGD+ people, with experiences from meeting members of other minority groups (e.g., related to faith) or other tabooed health areas (e.g., mental health). Participants were also aware that they could not always know whether they were meeting a TGD+ person. Equalling or mixing the concepts of gender identity and sexual orientation were however not particularly obvious among participants, unlike what has previously been seen (Lefkowitz and Mannell, 2017; Stubberud et al., 2018). Neither were unsympathetic thoughts nor discriminating notions displayed. On the contrary, many reflections regarding potentially exposed positions for TGD+ patients in various situations were shared such as misgendering, and inadequate or disrespectful treatment, seen also in previous research (Carlström et al., 2021; Kawsar and Linander, 2022; Lacombe-Duncan et al., 2021; Sbragia and Vottero, 2020). One of these pitfalls, as described by Henny, could occur even before the TGD+ person met the HCP:

‘Yes, that they’re not being taken seriously. They might come with a woman’s social security number, but identify as a man, and. It easily becomes difficult, and conflicted. They only need to meet a caregiver in the reception to be questioned. So little is needed for it (gender identity) to be questioned. It’s sensitive for the patient from the start.’

Participants stressed the importance of providing care patients said they wanted; the principles related to patient self-determination, autonomy, participation and equal care thus appeared as self-evident in the field’s doxa. However, issues regarding the two aspects (non-normative gender identity and sexual health) appeared challenging for participants, making it difficult for them to adhere to their principles. Boo tells of a meeting, however related to sexual orientation, when a patient had expressed needs that Boo had not addressed:

‘I remember. I had one who said something like: ‘My parents wouldn’t accept if I…’. So, I just got a feeling that (the patient) was homosexual but I never got around to asking.’

Some deemed it important to have information about a patient’s gender identity. Others, like Fred, did not:

‘In my professional role, it doesn’t matter at all. It’s just, a body is a body. Eh, I treat a body. I don’t treat a gender, or a gender identity, in any way.’

Varying ways of achieving equal care were described and most interviewees reflected upon this as a central and unnegotiable principle. Boo, among others, however, expressed ambivalence:

‘To treat everyone about the same. That’s what I’m thinking is preferable. But of course, it’s important, like you say, to maybe bring the issue up. [. . .] It’s important for the individual perhaps, the gender identity, I don’t know.’

Experiences of providing sexual healthcare to TGD+ people varied greatly among our participants. Altogether, it was described as an unusual and delicate mission that we understand as difficult to balance in relation to a doxa permeated with established and taken-for-granted healthcare principles and routines. The HCPs’ rare work with providing sexual healthcare to TGD+ people could have strengthened and established the doxa in a circular fashion, marking out that systematic work with sexual health promotion for all is not a priority for the field. However, participants’ habitus varied, and some had experiences that made them more prone to seeing sexual health among TGD+ people as part of their work.

External changing winds, internal lulls, and resistance

Even though providing sexual healthcare to TGD+ people was not always experienced as a salient part of their work, participants reflected upon ongoing changes. Some stressed that changes were warranted, in society as well as in healthcare, while others meant that changes had already taken place. The societal changes were seen as possible prerequisites for professional changes, but the healthcare organisation was seen as a slow adapter. When reflecting upon other organisations using gender-neutral language, Boo said:

‘It’s been quite some time, I think, since this was looked into, but I don’t know if healthcare is….less able [laughing]’.

Experiences of receiving relevant knowledge related to non-normative gender identity, sexuality or sexual health during their professional training were lacking for almost all, even among HCPs recently trained. Training received had been experienced as a small part of their education and as normative, as Chris states:

‘It (sexology) is a very tiny part. And, as I’ve said, “This is what counts, this is the normal” – within what’s normal, so to speak – and then that’s it, basically.’

Within the healthcare clinics, educational efforts pertaining to non-normative gender identity or sexual health were rare too. The reasons given for this were lack of financial resources, time and energy. Some, such as Fred, also mentioned the general unwillingness among colleagues to learn, evolve and change, an unwillingness that might be accentuated in matters of non-normative gender identity and sexual health:

‘Well, there’s always resistance among certain individuals when it comes to change and maybe it’s not about the change per se. More about having to change. People find that tough. And then there’s a certain – this (TGD+ people and sexual health) is, after all, something that is more sensitive than any other subject, which might make it even tougher for some people.’

Some participants sometimes saw problems with how to adequately refer TGD+ patients with or without sexual health needs, both within and outside their own workplace. Some had not really reflected upon this – or on access to education or support – but said that these thoughts emerged during the interview. Some shared that support could be found, from managers or colleagues, while others doubted this and claimed the healthcare organisation to be inadequate in providing support. Instead, non-governmental organisations were mentioned, by Gabi amongst others, as potential resources:

‘What support could I get regarding these matters? I don’t think that the healthcare organisation has very much to offer. I mean, I might have to turn to those organisations that exist. I’m thinking about the RFSU (Swedish Association for Sexuality Education) and there’s others. I’m trying to think about where I’d turn to. I really don’t know.’

Societal changes related to non-normative gender identity and sexual health have been fundamental in the last 50 to 100 years. Still, the finding that training is lacking was clear among the participants and in line with previous research (e.g., Areskoug-Josefsson et al., 2019), showing that neither educational institutions nor the healthcare field in Sweden have taken action to fill the gap when it comes to professional training for HCPs regarding non-normative gender identity, sexuality issues in general, or sexual health. Reflections participants made on the discrepancies between societal changes and their actual work and workplace indicate a manifest resistance within the medical field, a doxa characterised by inertia. This resistance to change has effects: rendering TGD+ people and sexual health needs invisible or difficult to handle. This can be due to non-adapted support systems and other organisational factors such as time and space, while upholding institutionalised transphobia (Kawsar and Linander, 2022; Klaeson et al., 2017; Lacombe-Duncan et al., 2021; Lindroth, 2016; Poteat et al., 2013; Snelgrove et al., 2012; Willging et al., 2019). The HCPs’ experiences show that the doxa affected habitus and vice versa, resulting in or, rather, upholding a status quo.

Strong emotions while wanting to do good, rather than harm

When participants reflected upon their ability to provide sexual healthcare to TGD+ people, they displayed strong emotions and were, overall, eager to do good and help, but also avoid doing harm. Although some said that they were confident in sexual health-related work, most expressed negatively connotated emotions like being embarrassed and uncomfortable, especially when it came to elderly patients. Day, sometimes felt uncertain about how to assess patients’ sexual practice:

‘Or I’m thinking about, like, sexual preferences, generally. Where’s the line for, like, pleasure and when does it become more self-destructive? [. . .] And I think it’s difficult, and I feel, [. . .] what is normal, and what is pathological? [. . .] I don’t know how I would address these kinds of questions.’

When adding to the hypothesised sexual health promotion or care situation, that the patient was a TGD+ person, additional negatively connotated emotions were expressed: low self-esteem, being perplexed or stressed or experiencing fear. For instance, Day and Fred both expressed frustration and stress:

‘Like a discrepancy, exactly. The will [to do good] and the lack of tools. It becomes tough.’ (Day)

Day and Fred illuminate a dual fear of not being able to do good and, therefore, of potentially doing harm. The participants related their fear of doing harm while wanting to do good to a lack of competence, and this provoked Chris:

‘I become a bit provoked. Because I think it’s a huge knowledge gap. So much knowledge is missing. We could have done a so much better job if we’ve had a little more knowledge about this’.

The lack of competence was described as potentially ruining the ability to act normally and could lead to HCPs becoming more formal, instead of building a trusting relationship:

‘And all of a sudden, I might become more formal and more professional, just because I don’t really, maybe I feel that I’m in unfamiliar territory [laughs]’. (Gabi)

The importance of strategies to avoid doing harm was mentioned, such as being aware of what one was signalling to the patient. A need for reflection – not only knowledge – was shared by Gabi:

‘Yes, I mean the knowledge around this needs to be improved, absolutely. And that we can, it’s not about learning something theoretically, it’s more about a deeper, more of, well, a more emotional [laughs], I was going to say emotional training. No, but to understand something, somehow. Like, it’s not A and B, it’s more multifaceted.’

HCPs revealed that it was difficult to be non-judgmental while lacking knowledge – reflections previously described (Coutin et al., 2018; Fennell and Grant, 2019; Snelgrove et al., 2012; Wendt et al., 2011). The wish to do good and not harm is central for HCPs and the strong emotions shared can be seen as the effects of an omitting doxa – a lukewarm interest in questions regarding sexual health and non-normative gender identities within the field, that shaped but still conflicted with the HCPs’ habitus. Also, reflections on prejudice, one’s own and those of colleagues, are understood – also by the interviewees themselves – as not in line with ideals on how to act professionally, nor the standards within the healthcare organisation (i.e., the field). This, too, was seemingly upheld partly by a doxa within the field, silently signalling that knowledge that might prevent such prejudice was not important.

Arbitrary navigation following one’s own compass while wishing for guidance

Participants described various ways in which they tried to handle their work – strategies that were marked by the previously seen views of the task as delicate and hard to balance with caring principles to do good and not harm and by the lack of competence and structural support. To secure the caring situation, for both them and for the patient, participants described an arbitrary navigation following one’s own compass. Organisational guidance and education were wanted, but absent, leaving the HCPs to create their own ways of working and gaining knowledge. Some, such as Eli, said they felt left out but still tried to structure their work as well as they could:

‘Yes, and it’s a lot of that, in many places, that you create your own. [. . .] But I come up with small adjustments [. . .]. Instead of it coming from above, as a structured way of working.’

Many refrained from bluntly asking patients about their sexual health or gender identity, especially as the latter was said to be too sensitive to approach. Among those who did address the issue or were open to doing so, like Eli, a direct way of asking was preferred:

‘Yeah, a straight question: “What about sexuality? How’s the intimate life? Do you feel that it’s working? Do you need help with anything?” Pam pam pam.’

During the interviews, new ideas were shared of how one could ask about gender identity, along with reflections on that the professional role entailed asking about many other potentially sensitive issues, to which gender identity could be added. Aino suggests:

‘Nah [sighs], well, of course I could ask that question too, really, it’s not that much. I pose a lot of strange questions like that to patients. [. . .] ‘Do you have suicidal thoughts? Do you have a, erm, are you using substances?’ Etcetera, etcetera, etcetera.’

Strategies to overcome rigid binary documentation systems were also given, for instance, adding information showing first on the patients file, about preferred name and a different gender than that registered. Existing keywords for sexual health in the documentation system were however mostly overlooked, leaving such issues undocumented. Not only were suggestions given on how to work with issues related to non-normative gender identity and sexual health, but it was also stressed that, to overcome the arbitrary handling, structural support was needed, and Fred suggested:

‘But, of course, if our managers would say that ‘Now we are going to work in a structured fashion, so that everyone at the clinic starts asking these questions’, for instance, for us to become better at it. It would probably lead to most people doing it.’

That HCPs are left to navigate on their own regarding how to address gender identity and sexual health is analogue to previous research findings (Coutin et al., 2018; Kawsar and Linander, 2022; Klaeson et al., 2017; Palaiodimos et al., 2020; Snelgrove et al., 2012). This opened the way for arbitrary solutions, where some just omitted sexual health-related work, regardless of their patients’ gender identity, as previously described (Arikan et al., 2015; Palaiodimos et al., 2020). Again, participants’ statements revealed how experiences had formed habitus which, in turn, was reproduced in actions or non-actions. A disappointment with the healthcare organisation was, however, seen alongside individual solutions to solve problems – actions thus born out of habitus but also harmonising with, and thereby reproducing the doxa. Standardised, mandatory questions were mentioned as a possible routine practice to facilitate and safeguard systematic work concerning sexual health and non-normative gender identity. Similar suggestions have previously been mentioned (Areskoug-Josefsson and Gard, 2015; Fennell and Grant, 2019; Kawsar and Linander, 2022; Willging et al., 2019). Based on participants’ reasoning in this paper, the organisational implementation of standardised training and working methods for professionals are understood as a vital precondition for changes and improvements.