‘The medical world is very good at cis people, but trans is a specialisation’. Experiences of transgender and non-binary people with accessing primary sexual and reproductive healthcare services in the Netherlands

ABSTRACT

Transgender and non-binary (TNB) people are at increased risk of adverse sexual and reproductive health (SRH) outcomes compared to cisgender people. With this qualitative study, we investigated the experiences of TNB people with access to primary SRH care in the Netherlands. We conducted semi-structured, explorative interviews with fourteen TNB individuals. Data were analysed using thematic analysis. We identified three themes: ‘navigating cisgender assumptions’, ‘depending on your healthcare provider’ and ‘access requires labour’. In primary SRH care, respondents felt that healthcare providers made incorrect assumptions about their care needs which required respondents to actively disclose their gender identity or medical history. However, some respondents felt disclosure also exposed them to clinical bias, or reduced them to a medical category ‘transgender’ that their healthcare providers perceived to require specialised knowledge. In this context, respondents felt the onus was on them to ensure their SRH care needs were met. Using the concept of trans erasure, we highlight how TNB people are put at risk of adverse SRH outcomes. Creating equitable care access requires not only that providers are educated on TNB health needs and their own cisnormativity, but also an ongoing, critical reflection on the use of gender- and sex-based categories in medicine.

KEYWORDS:

• Sexual health
• sexual and reproductive health services
• health services for transgender people
• access to primary care
• health equity

Introduction

In recent years, gender identity has increasingly received attention as a topic of significant clinical and research-related relevance (Lo & Horton, 2016). ‘Gender identity’ refers to one’s sense of self in the context of culturally normative conceptions of roles, expressions and activities associated with maleness or femaleness (Gilbert, 2008; Martin, 2004; West & Zimmerman, 1987). Across time and cultures, gender has been socially recognised or defined in different ways, and experiences of gender and gender identity are varied, fluid, and transcend socially constructed categories of gender identification (Herdt, 2020; Jacobson & Joel, 2019; Joel et al., 2014). However, in healthcare and medical research settings the term ‘gender diversity’ is often used to refer to people who are not cisgender, i.e. whose sex assigned at birth is not in line with their gender identity, such as transgender people with binary incongruent gender identity (transgender men and transgender women) and people with non-binary gender identities. The estimated proportion of transgender and gender diverse people (i.e. people who do not conform to their society’s norms for their assigned gender at birth) in studies published between 2009 and 2019 was 0.5–4.5% in adults and 2.5–8.4% in children and adolescents, and these numbers are expected to increase further in coming years (Thorne et al., 2019; Zhang et al., 2020). For some transgender and non-binary (TNB) people, gender incongruence causes distress referred to as ‘gender dysphoria’ and some may seek gender-affirming medical care (GAMC), such as endocrine or surgical care. In the Netherlands, the prevalence of people seeking GAMC was estimated at 1:3,800 for people assigned male at birth and 1:5,200 for people assigned female at birth in 2015 (Wiepjes et al., 2018). However, not all TNB people desire or have access to GAMC services (Coleman et al., 2022).

Sexual and reproductive health of TNB individuals

Consistently and globally, studies report that TNB people are at increased risk of adverse sexual and reproductive health (SRH) outcomes (Lo & Horton, 2016; Reisner et al., 2016). For example, compared to cisgender people, studies have reported higher prevalence rates of sexually-transmitted infections (STI), such as HIV, chlamydia, gonorrhoea, and syphilis as well as high rates of sexual- and intimate partner violence (Peitzmeier et al., 2020; Stutterheim et al., 2021; Van Gerwen et al., 2020). The risk for adverse SRH outcomes is particularly pronounced among TNB people of multiple marginalised identities and experiences related to gender, race, sexuality, class, occupation and migration status, such as in transfeminine individuals of colour doing sex work (Castro et al., 2022; Poteat & Simmons, 2022; Stutterheim et al., 2021; Van Gerwen et al., 2020; Van Schuylenbergh et al., 2018; Wesp et al., 2019). However, the high STI rates may not be representative for the entire TNB population as most studies have reported on an overrepresentation of specific, high-risk study populations such as transgender women doing sex work or those visiting specialised transgender care settings, and an underrepresentation of TNB individuals in the general population that may visit a primary care setting with a care question relating to their SRH (Van Schuylenbergh et al., 2018). Although one study from the Netherlands that investigated high-risk groups, including TNB persons who had engaged in sex work, found high STI rates, the lack of research among the general TNB population limits the insight into their SRH care needs (Drückler et al., 2022).

This lack of insight into SRH risk among the general population of TNB people limits the formulation of broader policy recommendations for preventative and curative primary SRH care, for instance for general practitioners (GPs) or community-based SRH clinics (Bauer & Hammond, 2015; Bauer & Scheim, 2013; Van Schuylenbergh et al., 2018). Instead of specialised GAMC- or STI-treatment centres, the primary care setting may offer a more representative image of SRH risk and care needs in the general population of TNB people. As primary care does not require a referral letter and is covered by the standard health insurance that is legally obliged for every documented person in the Netherlands, it is the most accessible line of care. As the primary care setting is also the place where SRH-related concerns can be detected, handled or treated early, it may be a most suitable point of care to detect and reduce SRH inequities among TNB people.

Institutional SRH risk environment

Recent literature suggests that to understand adverse SRH outcomes among TNB people, it is essential to look beyond individual risk factors to how intersecting social marginalisations give rise to a risk environment in which TNB people’s physical and mental health is compromised (Dickey et al., 2016; Wesp et al., 2019). This risk environment may be institutionally reinforced through healthcare and public health when these fail to meet care needs of TNB people (Bauer & Hammond, 2015; Cense et al., 2017; Francis et al., 2018; Light et al., 2014; Lunde et al., 2021; Potter et al., 2015; Stephenson et al., 2017; Wesp et al., 2019). For example, transgender men and non-binary individuals with a cervix have been identified as risk groups for cervical cancer because cervical cancer screening uptake in this group is low while the rates of high-risk human papillomavirus are similar to cisgender women (Berner et al., 2021; Connolly et al., 2020; Lunde et al., 2021; Potter et al., 2015; Weyers et al., 2021). Globally, studies have reported that TNB people consistently face institutional barriers to both general primary and secondary healthcare including lack of knowledge of healthcare providers on transgender identity and health concerns, costs, denial of care and transphobic discrimination (Giblon & Bauer, 2017; Heng et al., 2018; Kcomt et al., 2020; Lerner et al., 2021; Lerner et al., 2022; Lovejoy et al., 2023; Safer et al., 2016; Skuban et al., 2022; Snelgrove et al., 2012; Treharne et al., 2022). These structural barriers to care do not only directly impact the risk environment that underlies transgender health inequities, but also result in some TNB people avoiding healthcare, creating further risk of adverse outcomes (Burgwal & Motmans, 2021; Kcomt et al., 2020; Lovejoy et al., 2023; Transgender Europe, 2017; Wesp et al., 2019).

While the number of studies on the specific context of primary SRH care are limited, qualitative studies have shown how TNB people from a diverse range of countries face highly similar barriers to attaining SRH care, including negative attitudes or a lack of knowledge among SRH care providers (Calderón-Jaramillo et al., 2020; Guss et al., 2019; Lindroth, 2016; Luvuno et al., 2019; Müller et al., 2018). In the European context, TNB people included in the study by Lindroth (2016) experienced that their sexual healthcare providers often had little knowledge about their SRH care needs and upheld cis- and heteronormative views. While in the Netherlands studies have reported alarming numbers of STI’s and sexual victimisation among TNB people, to our knowledge, no studies have reported on the experiences of TNB people accessing primary SRH care services (Cense et al., 2017; Drückler et al., 2022). The lack of insight into experiences of the general population of TNB people accessing primary SRH care in the Netherlands limits the development of tailored SRH services and health policies.

As the demand for access to TNB-responsive primary SRH care services is growing, the need to gain insight into the SRH care needs of this population becomes even more urgent. To meet this need, we conducted an explorative, qualitative interview study into the experiences of TNB people accessing primary SRH care in the Netherlands.

Materials and methods

Dutch primary SRH care system

In the Netherlands, primary SRH care can be accessed through two main routes: the GP or via specialised primary sexual health clinics called the ‘Municipal Health Services’ (MHS, in Dutch: ‘Gemeentelijke of Gemeenschappelijke Gezondheidsdienst (GGD)’). GPs provide a range of preventative and curative SRH services, including STI care and contraception according to national primary care guidelines (in Dutch: Nederlands Huisartsen Genootschap (NHG) standaarden). The GP also performs cervical swabs when clinically indicated and for individuals who are invited for the national cervical cancer screening program, for which regular invitations are sent out to people age thirty and over who are registered as female in the Municipal Administration (in Dutch: Gemeentelijke Basisadministratie Persoonsgegevens: GBA). The MHS focusses on sexual health promotion by providing preventative services such as public awareness campaigns, contraceptive counselling and pre-exposure prophylaxis programs, as well as curative services such as free-of-charge STI consultations for high-risk groups (Drückler et al., 2022). While most primary SRH services are covered by mandatory health insurance, STI tests at the MHS are free of charge only for certain groups marked as at-risk for STI’s which includes transgender people. GAMC is not regularly provided in primary care but in specialised tertiary care centres for which a referral by one’s GP is necessary. In specific cases, SRH services are offered by GAMC centres, however, such care is mostly provided as part of another gender-affirming medical trajectory, such as gender-affirming hormone therapy or fertility preservation.

Conceptual framework: Trans erasure

To better understand and contextualise how TNB people in the Netherlands experience their access to primary SRH care, we applied the concept of ‘transgender erasure’. This concept was first posited by Namaste (2000) and has been defined as a ‘systematic deficiency in acknowledging and validating trans identities, bodies and experiences’ (Bauer et al., 2009; Namaste, 2000; Snelgrove et al., 2012). A qualitative study by Bauer et al. (2009) illustrated how in accessing healthcare, members of the transgender community in Canada experienced two types of erasure: informational and institutional. This resulted in difficultly accessing healthcare services and negative experiences in the healthcare setting (Bauer et al., 2009). Bauer and colleagues understand informational erasure as a lack of knowledge regarding transgender people and the notion that this knowledge is not available or perceived to be not available. In addition, they understand institutional erasure as a lack of policies accommodating for trans identities or trans bodies in forms, documents, policies, practices and health care infrastructure (Bauer et al., 2009). Previous studies have used the concept of transgender erasure to investigate and describe ways in which the healthcare access of TNB people is compromised (Müller, 2018; Tenney et al., 2021). Applying this concept to our data, we aim to evaluate if and to what extent TNB individuals describe experiencing trans erasure, and how this may influence their experiences of access and quality of primary SRH care.

Recruitment and sampling

We included transgender men, transgender women and non-binary people of eighteen years and older. To improve the ethical solidity and relevance of our research, we learned from and considered the guidelines for ethical research involving transgender people as proposed by Vincent (2018) and the Canadian Professional Association for Transgender Health (Bauer et al., 2019). We used purposive, maximum variation sampling aiming to recruit people of different sexualities, educational and occupational backgrounds, ethnicities, ages and medical transition status, and with different experiences receiving primary SRH care (Green & Thorogood, 2018). Respondents were recruited through Transgender Network Netherlands, a national, non-profit trans advocacy organisation, as well as through the professional and personal networks of the researchers. All respondents received an information letter to inform them about the study’s objective and procedures. It was emphasised that participation was voluntary, and that respondents could withdraw at any point during the research process. All respondents provided written consent. This study was approved by the ethical committee of the Amsterdam University Medical Centre, location VUmc.

Data collection and analysis

We carried out fourteen semi-structured, face-to-face interviews with six transgender men, seven transgender women, and one non-binary person. One interview involved two respondents; a transgender woman and her cisgender female partner. All interviews were conducted by MZ and SP and guided by a topic list. Respondents were interviewed at a location of their choosing. Case descriptions narrating experiences of fictional TNB people accessing primary SRH care were used as vignettes to facilitate the conversation about experiences with SRH care, which could involve discussing potentially sensitive topics (Green & Thorogood, 2018). Respondents were asked to reflect on these vignettes, for instance whether they believed access was compromised, or to what extent the narratives presented in the vignettes were relatable or imaginable. Then, respondents were asked to share their own experiences with visiting the primary care physicians for SRH-related issues or care needs, or with visiting the MHS. In addition, respondents were asked to reflect on the trans-inclusivity and feasibility of several online screening questionnaires used by the Amsterdam MHS to identify risk groups eligible for free of charge STI care. Finally, respondents were also asked to share their perspectives on ways to improve access to and quality of current primary SRH services. The interviews lasted between one and one and a half hours. All interviews were audio-recorded and transcribed verbatim. To secure respondent confidentiality, traceable details such as personal names were omitted from the transcripts. Summaries of transcripts were returned to respondents to check for accuracy in order to increase the credibility of the data (member checking) (Birt et al., 2016).

We analysed our data using a thematic approach (Green & Thorogood, 2018). The analysis was performed using MAXQDA 2022 software (VERBI Software, 2021). First, all interview transcripts were read and reread by individual team members, and subsequently discussed within the research team to achieve intersubjective agreement. We used open coding to describe and mark meaningful expressions and concepts; we then used axial coding to explore connections between our codes; finally, we used selective coding to identify themes and subthemes within our data (Frambach et al., 2013). To ensure confirmability, NG and MM reviewed the academic literature on access to SRH care for TNB people and discussed recurring themes that emerged from the data (Frambach et al., 2013).

Reflections on the researcher’s positions

As researchers, the personal experiences resulting from our social positions and identities, i.e. ‘our positionalities’, influence not only which issues we engage with and which we overlook, but also our relative distance to the topics we study, and our ability to ask research questions that connect to the needs of the communities that might benefit from our research (Bauer et al., 2019; Galupo, 2017; Vincent, 2018). The overrepresentation of cisgender individuals in research into transgender topics, including health, has been addressed and critiqued by trans scholars and activists; such critiques ask the legitimate question whether knowledge (re)produced through dominant cisgender viewpoints can adequately and equitably represent the diversity of transgender experiences. Therefore, we believe it is important to actively acknowledge how our own backgrounds have impacted our research process.

We are a group of white, able-bodied researchers with various gender identities and sexual orientations. Several of us have identities that align with gender or sexual minority experiences. While some of our social identities might facilitate the reliability of our interpretations, others might introduce bias. Compounding with our social positions, our educational backgrounds and professional trajectories profoundly shape which research questions we ask, how and where we seek information, what we understand to be legitimate knowledge and how we interpret research findings. Most of the research team has experience with both clinical work and research in sexual health and gender-affirming care. We hold various educational backgrounds and professional perspectives including ethics, medical anthropology, endocrinology, psychiatry and sexology.

Results

The study population consisted of fifteen people; one non-binary, seven (transgender) women and six (transgender) men (Table 1). Anna is a cisgender woman and the partner of Helena. Some, but not all respondents, had received or were currently receiving GAMC. There was a diversity in sexual orientations, experiences and behaviours. Apart from one transgender woman, all respondents had previous sexual experience with a sexual partner and several currently had a sexual partner. One respondent had worked as a sex worker in the past. Respondents reported different preferences regarding the settings to receive primary SRH care, where some indicated that the MHS was preferable due to the anonymity, free services and their expertise on SRH care for transgender people:

They just treat me like a woman, like normal. [At the MHS] you don’t have to be ashamed of yourself or the things you do. […] They are used to it. You can speak openly there. Just like with PrEP [pre-exposure prophylaxis] and all, that you also get from them, even for free. (Chrissy, 44, transgender woman)

Others, such as Sylvia (43, transgender woman), preferred their GP because they had a personal connection to them and felt certain that they would accept them:

Table 1. Characteristics of the respondents.

Pseudonym	Age	Gender identity	Ethnicity	Educational background	Place of residence	Gender-affirming medical care	Note
Tamsin	67	woman	Dutch	higher professional education/university education	urban	unknown
Chrissy	44	woman	Dutch	secondary vocational education	urban	yes
Delilah	29	woman	Dutch	higher professional education/university education	urban	yes
Sophia	58	woman	Hindustani-Surinamese	higher professional education/university education	urban	no
Mirah	58	woman	Dutch	unknown	urban	unknown
Helena	78	woman	Dutch	higher professional education/university education	rural	no
Anna	67	woman	Dutch	unknown	rural	not applicable	Cisgender woman and partner of Helena
Sylvia	43	woman	Dutch	higher professional education/university education	urban	yes
Dennis	18	man	Dutch	university education	urban	unknown
Elijah	32	non-binary	Dutch	unknown	urban	no
Julian	35	man	Dutch	university education	urban	yes
Arthur	27	man	Dutch	unknown	urban	yes
Marc	28	man	Dutch	university education	urban	yes
Thijs	24	man	Dutch	university education	urban	yes
Edward	25	man	Dutch	university education	urban	yes

Otherwise I have to tell the whole story again and I don’t know who I’m going to get in front of me and it’s always the question how that person reacts to you [..] There [at the GP] I don’t have to worry about that.

Some respondents preferred to visit a doctor alone whereas others would bring another person to support them. Some respondents preferred healthcare providers to be of a certain age or gender. However, most respondents did not mind the identity of their healthcare provider as long as they had the required expertise, like Mirah (58, transgender woman): ‘Young or old, if they graduated I assume they know what they’re doing. If one can’t trust that, then that’s it’. Some respondents were positive about their past SRH care experiences, whereas others were not.

Theme 1. ‘They say: we have never seen that here before’: navigating cisgender assumptions

In accessing primary SRH care, all respondents had experienced that having a gender identity that is not in line with one’s sex assigned at birth was often considered unusual or ‘other’ by primary healthcare providers. Various respondents described that based on their gender expression or registration, incorrect assumptions were made about their anatomy and resulting SRH care needs, so that they felt obliged to be explicit about their TNB identity. Disclosing one’s identity and trans history, however, also posed the risk of being perceived to exist outside of the ‘normal’ categories of male and female which, for some respondents, meant that their primary healthcare providers did not feel competent to provide care to them. As a result, respondents sensed a dilemma where disclosure of their trans history was simultaneously necessary and precarious when accessing primary SRH care.

For example, Helena (78, transgender woman), reflected on a dilemma that for her was inherent to visiting a healthcare provider, namely that while it may be desirable for people to ‘pass’ (i.e. be perceived as their gender by others), this may also pose the risk of incorrect work-up and diagnoses. She recalled an experience where her gender was initially affirmed by the administrative staff of her GP practice and entered correctly into the system, however, this positive encounter resulted in several precarious ones a few weeks later when her prostate needed to be checked:

When I put my driving licence on the counter, with my current name and photo […] no one has ever asked me ‘are you a man or a woman’? So I just get registered [at the practice] as a woman. So I [tell the doctor] that I probably have a prostate problem. She looks at me weirdly and starts shifting on her chair. […] It turned out she was trying to figure out if I was fooling her, or if I was one of those dumb-dumbs who doesn’t know a woman doesn’t have a prostate.

Feeling forced to disclose her trans history to clarify her care question, she was then referred to the nurse for a blood draw. Here, the referral information was incomplete, so that she encountered a similar reaction when she passed the nurse her laboratory form:

The nurse took a look at the form and told me to go right back to my GP because [the prostate blood test] made no sense. I explained the situation to her nicely, which embarrassed her a bit. She hadn’t anticipated it at all, which was a miss actually.

Similarly, when Sylvia (43, transgender woman) called the MHS for a free STI test, she was initially pleased that the person she talked to assumed her to be a cisgender woman. However, because cisgender women are not eligible for free STI tests, Sylvia still had to disclose her transgender identity to access care:

The lady on the phone gendered me as a woman. And as a cis woman you are not eligible for a free STI test. […] So I say, very gently: ‘Yes, but I am trans’. […] It was awkward but the opposite [of what usually happens]. […] This time it went well, with the downside that I had to explain on the phone that I am trans.

Assumptions were not only made about one’s anatomy, but also about one’s sexual activities and hence, the kind of STI test that was required. Thijs (24, transgender man) realised that his healthcare provider had made incorrect assumptions about his sexual behaviour when they handed him an STI test for anal infections:

[The healthcare provider must have been thinking]: ‘You have sex with men so then it has to be anal, or something.’ And I was just thinking: ‘What are you talking about?’ Because that’s not the case at all. But I didn’t say that, so she gave me a test for it.

Binary cisgender assumptions were not only made by individual healthcare providers, but were also experienced at the level of institutions. A frequently mentioned example was the Dutch national population cancer screening which relies on gender markers in the municipal administration to send out regular screening invitations. Several transgender men described that they were not invited for the cervical cancer screening, while some transgender women in the study had received invitations. Marc (28, transgender man), described how this created logistical and financial hurdles for him to access timely cervical swaps:

Everyone legally registered woman is automatically invited every five years, that is all arranged for them. And then trans people would then all have to arrange this themselves, and on top of that also pay for it yourself first […] those are all barriers […] So it shouldn’t be based on gender registration, but on whether you have a cervix or not. But that’s a computer issue.

Although several transgender women, who did receive an invitation for the screening, said that receiving it was funny or described it as gender-affirming, Edward (25, transgender man) described that not receiving an automated invitation made him feel as if preventing cervical cancer in his body was considered less important: ‘As if […] the possibility of having cervical cancer is less important [in me] than in cis people. That it’s not important enough to change the system in such a way that it can include someone.’

While disclosing one’s transgender identity was necessary to receive appropriate SRH care, not only did respondents feel bad about having to actively disclose they were not cisgender, some respondents expressed that this also posed another risk. They experienced that disclosure confined them to a third category of ‘the transgender individual’ which exists in the mind of the healthcare provider as outside of the men/woman binary. Not being cisgender made some respondents feel like they were instantly treated as a different ‘category’ of humans. Several respondents described a fear that once healthcare providers knew about their TNB identity, they would no longer consider all possible diagnoses, but instead, consider their symptoms in relation to gender identity or gender-affirming care. As a result, some respondents also described feeling hesitant to be open about their transgender identity. Arthur (27, transgender man) expressed his frustration about his general health issues being considered in relation to gender-related care: ‘You can also just have an infected toe. […] That has nothing to do with those hormones.’ Edward (25, transgender man) emphasised that although there may be specific things to know about his body, he does not want it to be considered ‘alien’: ‘It’s not some alien body, it’s also just normal, standard, well, maybe not standard, but simply a body.’ Sylvia (43, transgender woman) called for healthcare providers to treat her as how they would treat other (cisgender) people:

Act normally [I would say]. And what would be normal? I don’t like that word, […] Just act as you do with other people. Just treat me equally. […] It is a body, it’s just a body.

Some respondents described that upon disclosing their transgender identity, their healthcare providers felt uncomfortable or incompetent to provide care to them. As a consequence, respondents, such as Thijs (24, transgender man) were often referred to a tertiary care centre specialised in transgender care for care questions that, for cisgender people, are handled in the primary care setting:

You can see that they are sometimes a bit uncomfortable or something. But also because it’s new [for them], they say: ‘Oh, we have never seen that here before.’ So about some things [in SRH care] they say: ‘Just do that at the VU [tertiary care centre for gender-affirming care], you know, because we are not very good at that.’

Some respondents did not want to be referred to a tertiary care centre because they felt it concerned care questions that the GP could easily handle. Others expressed that if the healthcare provider did not have the required knowledge or did not feel comfortable, they preferred to be referred to a tertiary care centre. While Marc (28, transgender man) expressed that the GP would be the place where he wanted to receive primary SRH care, he also realised the GP may not have the knowledge required to provide tailored contraceptive counselling for people using testosterone therapy:

Many [trans guys] say: ‘I use testo [testosterone] so I am no longer fertile, so I don’t have to use [contraception] now’, while that is not the case at all. Only that even a lot of GPs don’t consider this. They could also think like, yeah, if your cycle has stopped then it must be fine.

Helena (78, transgender woman) emphasised that making care inclusive to transgender people would not have to be a specialist endeavour, but instead, could be learned by primary healthcare providers too, as long as they are willing to learn:

With the current media attention [for transgender issues], [doctors] can get familiarised with it. But they have to be open to it. […] If you […] learn about it, if you try to empathise, I believe it shouldn’t be too difficult.

Throughout the interviews, respondents reflected that ‘in an ideal world’ healthcare providers would not act on assumptions but instead would be educated to distinguish between sexual behaviour, gender identity, sexual orientations and (genital) anatomy. This would remove the experienced burden of deliberating the risks and benefits of being open about their transgender identity.

Theme 2. ‘She just accepts me […] so I am quite happy with my GP’: depending on your healthcare provider

Several respondents described that meeting one’s SRH care needs could depend strongly on the individual healthcare provider they encountered. When they first met their healthcare provider, respondents described wanting to become aware of their healthcare provider’s personal moral convictions on gender diversity and their knowledge on trans-related health concerns. Most respondents were happy with any healthcare provider who was respectful and knowledgeable to their SRH care needs, while others had a strong preference for a healthcare provider with a particular positionality (e.g. female or older), which was often a result of negative previous experiences.

For several respondents, discussing their transgender identity came with a certain degree of reluctance due to the anticipation of a negative reaction, or even rejection by a healthcare provider. Mirah (58, transgender woman) described that while it never stopped her from visiting a medical doctor, she always considered the way in which she disclosed her transgender identity in advance to minimise the likelihood of ‘inappropriate comments’ being made:

Well sometimes I hesitate, of course, I can’t deny that. And then it is important that [healthcare providers] adopt the right attitude and don’t make any inappropriate comments. […] That is always in the back of your mind. […] No, it doesn’t stop me [from visiting my doctor]. I may think about how I can minimise the possibility, so, how do I bring it across?

For Delilah (29, transgender woman), it was important that her GP did not treat her differently because of her transgender identity:

She also knows I am transsexual [sic]. That doesn’t affect her very much, it’s just a piece of data, that’s all it is. […] She just accepts me […] there is no prejudice or anything. So, I am quite happy with my GP.

Several respondents described hoping for a respectful treatment by their GP. An example of respectful treatment for Sylvia (43, transgender woman) was the use of her pronouns. Although her healthcare provider already knew about them from previous visits, she described that every visit she felt anxious whether they would be used correctly: ‘Afraid to death you are sitting in the waiting room. Everyone gets called out and it’s all gendered. And then you’re already like okay and now what, will they just say mister again, or will they finally say miss?’.

Respondents differed in the extent to which they felt the behaviour or approach of their healthcare provider could influence their experienced access to primary SRH. While for Mirah (58, transgender woman) it influenced the questions she dared to ask: ‘Because one wrong comment […] can make you terribly insecure. It can cause you not to ask the question you would like to ask or provide the answer you would like to give.’ For Arthur (27, transgender man) an underlying sense of goodwill was most important: ‘My GP sometimes formulates things a little clumsily but he always means well, and that comes through. So sometimes I let it go, I don’t always feel like correcting him.’ On the other hand, Delilah (29, transgender woman) also feared that the perceived need by healthcare providers not to make potentially hurtful remarks would make her healthcare provider refrain from performing a necessary physical examination. She feared that this ‘correctness’ could pose risks to her health, such as the risk of undetected prostate cancer:

If one says: ‘You are absolutely not allowed to see someone as a man, so we [healthcare providers] will not perform a prostate examination because people would find that hurtful as it reminds them of their ‘being a man’’. That’s of course unacceptable. Because you just have a real risk of prostate cancer. […] I may be a bit harsh in that sense. That is my vision.

Some respondents also felt dependent on the knowledge of the individual healthcare provider. Several respondents found it difficult to find correct information about their SRH needs with their healthcare provider, such as Delilah (29, transgender woman): ‘GPs know just as little about my body as I do. So it remains a pattern for me that I know very little about my own body and I really want to do something about that’.

While most respondents did not want their GP to perceive them differently, it was appreciated when healthcare providers would be cognisant that certain SRH-related topics, including physical examination may be sensitive or complex for TNB people such as in case of Elijah (32, non-binary individual):

For example, if I were to visit because of a lump in my breast, […] I don’t like my breasts at all. That I could say: ‘I think it’s all very scary’ and that you then get some understanding, some care or empathy. […] And that it’s not like: ‘Oh there comes a human/object [sic], let’s check whether something is going on and if so, we will refer you.’

Mirah (58, transgender woman) highlighted that for her to be open, the GP must create a safe environment in which the necessary information can be brought to the table:

[If] there have been various sexual contacts, I think it is the duty of the GP to ask for that. ‘What [kind of tests] do you want?’ Then [the GP] does not have to call it by name, but: ‘What kind of tests do you want? What are you afraid of?’ Then [the patient] can very easily say: ‘I also want an anal test’ […] [The GP] can offer that opening much more easily than that [the patient] can ask.

Some respondents, all of whom were transgender women, shared experiences of misconduct or abuse by healthcare providers, which affected their trust in healthcare providers in general. Delilah (29, transgender woman) described the moment she was sexually assaulted by a male healthcare provider under the disguise of clinical curiosity. Since then, she only feels safe with female healthcare providers. Besides the traumatic experience in itself, she also reflected on wondering whether she was violated ‘because’ of her transgender identity, because she is a woman, or both:

I was once assaulted by an emergency medicine doctor. And that was specifically because I am transsexual [sic]. The doctor appropriated my body because I have a different body than other people. I was, I think, one of the few transsexual people he has seen as a medical professional. So he asked if I had implants and started to touch my breasts saying: ‘Let’s feel it, let’s see how they did this’, without permission. And at that moment I had a panic attack so I wasn’t able to give consent on that either. […] Whether that depends on the doctor, or whether he might have done this to another woman as well. That you will never know, you know. That’s kind of disturbing. […] I just have bad experiences with men and just don’t trust them. […] With women I just feel I have to be less on guard.

She also expressed a general fear of stigmatisation by a healthcare provider due to the lack of knowledge they may have about her body. For her, knowledge on transgender bodies goes hand in hand with acceptance and a feeling of safety with your healthcare provider. Due to a lack of knowledge about her body, she sometimes felt afraid about how her healthcare provider will consider her body:

Sometimes I am afraid that people find my body dirty, or ugly or scary. If a doctor would have those ideas, I would absolutely not feel safe. It would be very problematic. […] If you [as a doctor] are informed, you know that a trans woman’s body is not dirty. Not dirtier than a male, and not dirtier than a female body. I have to outline that really clearly for myself.

Theme 3. ‘Stand up for yourself, it is your health!’: access requires labour

Talking about access to primary SRH care, respondents stressed the importance of feeling personally responsible to ensure their sexual health. Considering potential barriers to care, they marked the importance and possibility of taking agency to ensure their SRH care needs were met. Several respondents described that while on the one hand one must be considerate of a lack of knowledge on the part of the healthcare provider, on the other it was considered necessary to be upfront about one’s SRH care needs. To ensure one’s healthcare providers had all the necessary information for grounded medical decision making, they described the need to be open about their gender identity, anatomy and sexual behaviour to counter potential erroneous assumptions that the physician may otherwise make. While Edward (25, transgender man) did not always feel eager to share his transgender identity with his healthcare provider, he considered it necessary to do so nonetheless, so that his healthcare provider had the necessary information: ‘I always just have a button that I switch. I do find it annoying in general, but in such a situation you just have to do it, otherwise you may as well not go’. This ‘switch of a button’ required a lot of energy for some respondents. For example, Elijah (32, non-binary person) described deliberating in which situations they would find it worth the effort to ask their healthcare provider to use their gender marker and pronouns. Although it was necessary to ensure not being addressed incorrectly as this would cause distress, they also felt that bringing up the topic always required a lot more explaining. They experienced that disclosure also posed the risk of incorrect assumptions, for example that their non-binary identity meant that they also received GAMC:

Well it kind of depends whether I am in the mood [to ask to be addressed as ‘they’], […] because sometimes I really don’t feel like explaining it all. […] Because that is often such a hassle. Coincidentally, last week I did tell the doctor at the hospital [about my non-binary identity], because she kept saying ‘Madam this, madam that’ and then eventually I said ‘Okay, no, please stop calling me madam’. And then I think she instantly assumed I was in transition, and then I thought: ‘Okay, well no, that’s also not the case’.

Besides fatigue, respondents also described feeling anxious to correct assumptions of their healthcare provider on their sexual behaviour. Delilah (29, transgender woman) stressed the importance of overcoming fear of stigmatisation about one’s sexual behaviour and being upfront about it so you can receive the necessary care:

Stand up for yourself, it’s your health. If you have anal sex, say it! I understand that you are afraid to be judged, because it’s kind of a taboo, people might think ‘yikes, nasty’ […] . But it is still important for your sexual health.

While correcting the assumptions of their healthcare provider often felt necessary, it also posed the risk of being confronted with how one’s sexual behaviour was not considered as such by the healthcare system, such as Elijah (32, non-binary individual) who, after correcting their healthcare provider on a faulty claim in the referral paper, was told by their healthcare provider that in the medical world this was not how ‘sexually active’ was defined:

I was referred to the gynaecologist by my GP and [referral letter] said ‘not sexually active’ so I was like: ‘Excuse me?!’. [the GP said]: ‘Well, no not with [cisgender] men, so in medical terms we call that not sexually active.’ Then I thought: This is really not okay. Because this feels as if, well, that my whole sexual orientation does not exist medically, or something like that? […] It really shocked me, that I had to stand up for myself and say: ‘No, I am sexually active’ […] that really felt bad and degrading.

In some cases, when their healthcare provider did not know about their SRH needs, respondents felt that they had to take the duty of care upon themselves and educate their healthcare provider, such as Marc (28, transgender man):

Sometimes it’s kind of annoying that you have to explain things again and again, like: ‘This is going on and this is what we are currently working on.’ So that you actually have to educate your GP instead of your GP telling you how things should be done.

Aside from providing your doctors with all necessary information, some respondents expressed the need to clearly state their boundaries and ensure these do not get crossed, such as Sophia (58, transgender woman) expressed: ‘It mainly depends on you. You must determine what your boundaries are and you have to make sure your boundaries do not get crossed.’ For Thijs (24, transgender man), educating his healthcare provider on a binder and explaining that he did not want to take it off, helped his healthcare provider to respect his boundaries:

Well yeah, that was sometimes uncomfortable, because then you stand there and they say: ‘Oh, what is that you are wearing?’ ‘Yeah, that is my binder, you know this and that, and yes I don’t want to take it off’. So: ‘Okay, fine’, with the GP that was always just fine, they were very understanding there.

Helena (78, transgender woman) and Anna (67, cisgender female, partner of Helena) reflected on one of the cases in which a transgender woman visits her GP for a prostate examination, which surprised the GP because of her female gender identity. They agreed that initially you should explain the situation: H: ‘Just talk about it calmly.’ A: ‘That will solve it. Imagine you don’t say anything, or feel too ashamed […] Put a smile on about it, a bit of humour.’ However, if your healthcare provider is unwilling to meet your needs, such as using the correct pronouns, they agreed that you should seek another provider: H: ‘Then you look for a different doctor. But you should give him a chance because such a person may also not be used to that.’

In contact with her primary SRH care provider, Sophia (58, transgender woman) wanted to feel that she is treated equally to other people. If that is not the case, it would be a reason for her to seek a different GP:

I have to feel that person-to-person I am considered equal. If I feel like I’m being dismissed as a novelty or something, you notice that in their approach, treatment and the distance that arises, then I think you should be down-to-earth and search for a different GP.

For some respondents, taking agency over one’s access to SRH care meant not visiting your healthcare provider but instead, seeking the necessary information online or via peer groups. As Marc (28, transgender man) expressed: ‘I don’t think I would even go to a doctor. I think I would search all over the internet and figure it out by myself.’ Specific SRH-related information, such as the fact that you do not get an invitation for the cervical cancer screening, was also communicated to Thijs (24, transgender man) by peers online:

Yes, yes, I’ve heard this before. Also online like: ‘Yes guys, you will no longer be invited [for cervical cancer screening]’. And that you have to be very attentive to it yourself, so that it does happen [getting a cervical swap]. But then it’s our responsibility again. Because we have to go after it […], otherwise we will not get [access to] that examination.

Discussion

We explored the experiences of TNB people with accessing primary SRH care in the Netherlands. Respondents described navigating a healthcare system that operated within a binary cisgender framework, resulting in a lack of acknowledgement of part of their gendered, embodied and sexual realities. This was experienced in individual care interactions, where healthcare providers made incorrect assumptions or lacked knowledge, as well as in institutional practices such as registration forms, STI testing and cervical cancer screening invitations. During a healthcare visit respondents face a dilemma where disclosure of one’s gender, anatomy or sexual behaviour was simultaneously necessary and precarious; disclosure corrected assumptions of healthcare providers, but also posed the risk of being essentialised as ‘the transgender individual’. Respondents experienced that, in the mind of some of their healthcare providers, the SRH needs of ‘the transgender individual’ are only related to their gender identity or medical transition, and therefore require specialist care and a referral. For many respondents, receiving good primary SRH care seemed to depend on being ‘fortunate’ enough to meet an informed healthcare provider with a respectful attitude. Overall, a visit to primary SRH services for TNB people in the Netherlands came with cognitive and emotional labour; this labour sometimes entailed being persistent despite blunt remarks or educating healthcare providers, while other times it meant switching healthcare providers or seeking for SRH care information online.

Trans erasure

The experiences of the TNB respondents accessing primary SRH care show, as was found in previous studies, how erasure forms a fundamental barrier to healthcare access (Bauer et al., 2009; Müller, 2018; Stewart et al., 2022; Tenney et al., 2021; Tordoff et al., 2022). The clinical categorisation of ‘male’ and ‘female’ as uncomplicated, binary, mutually exclusive constructs, and the assumption that gender identity follows simply from one’s sex assigned at birth has consequences for the way in which TNB experiences, bodies and care needs are (mis)understood by physicians. In a healthcare system that relies on this ‘cisgender’ assumption, the existence of TNB people is not conceptualised in the mind of their healthcare provider to whom their care needs seem inconceivable. The onus is then on TNB individuals themselves to make their existence and healthcare needs visible, such as Helena did by disclosing her transgender background to access prostate examination, or such as Sylvia did by disclosing her transgender identity to access a free STI test.

Our findings are in line with a qualitative study among gay, lesbian and queer individuals in South Africa, which showed that respondents experienced their realities to be incomprehensible for healthcare providers and that they felt annihilated in healthcare systems (Müller, 2018). The conceptual challenge to this cisgender binary framework that TNB people represent once they make themselves known, is then circumvented by creating a third category of ‘the transgender individual’ whose realities are essentialised or deemed too complex for primary care (Stewart et al., 2022). A study by Snelgrove et al. (2012) also reported how the large discrepancy in primary care providers’ comfort and competence in providing care to transgender individuals resulted in strongly differing referral policies. As a result, respondents in our study faced a double bind: disclosing one’s transgender identity is both necessary to counter incorrect assumptions, but also poses a risk of being reduced to ‘the transgender individual’ (Bauer et al., 2009). For our respondents, this meant that on the one hand their trans identity stood in the way of accessing primary SRH care, while on the other hand, primary care providers may not have sufficient knowledge and skills to provide TNB-responsive care (Giblon & Bauer, 2017). The consideration of TNB people as a ‘third’ category besides ‘male’ and ‘female’ that requires specialist care reinforces the notion of primary healthcare providers that they are unskilled to provide SRH care to TNB people which, in turn, reproduces erasure (Bauer et al., 2009; Stewart et al., 2022; Tordoff et al., 2022).

Erasure does not only take place in the mind of healthcare providers, but is also operationalised in institutions, medical technologies and knowledge production (Bauer et al., 2009). Indeed, as phrased by Marc, the fact that he does not receive an invitation for the cervical cancer screening is ‘a computer issue’. Erasure also results in certain knowledge being deemed valid while other knowledge, such as knowledge on or by TNB people is dismissed. For example, when Elijah was told that their sexuality was perceived to be medically irrelevant, and therefore their reality of ‘being sexually active’ did not exist. This is indicative of the medical paradigm, in which a body, behaviour or narrative is ‘relevant’ when it contains a clue about clinical risk. However, erasure of sexual realities such as these in care systems poses a barrier to SRH care access. We therefore argue that the systematic erasure of TNB people that takes place in individual care interactions, as well as in (preventative) health programs and in knowledge production puts TNB people at risk of adverse health outcomes (Bauer et al., 2009; Namaste, 2000; van Heesewijk et al., 2022).

Labour

Due to the erasure of their realities, most respondents of our study felt that the responsibility for meeting their own SRH care needs was on them. Participants described several strategies to take agency over their care experiences, which we understand as TNB people having to perform labour to ensure meeting their SRH care needs. This labour may be informational in nature, including correcting the lack of knowledge of one’s healthcare provider or educating them on your care needs, such as Marc (28, transgender man) who had to instruct his GP on what should be the next step in his work-up. The need to educate healthcare providers or the feeling that their healthcare provider is learning ‘through them’ is a barrier to care that has been described in various healthcare settings by other studies and puts a great burden on TNB people (Fix et al., 2020; Guss et al., 2019; Lerner et al., 2021; Lerner & Robles, 2017; Snow et al., 2019; Stewart et al., 2022). The labour required may also be emotional, such as being vigilant that one’s boundaries are not getting crossed after disclosing a TNB identity. While most of the time, respondents encountered professionals who respected these boundaries, sometimes this labour was not enough to protect respondents from harm. This precariousness is tragically reflected in the experience of Delilah, who was sexually assaulted by a physician whose care she depended on. Other qualitative studies have also described emotional labour that is required to visit a healthcare professional, where TNB participants described having to gather courage, ‘steel themselves’ or withstand humiliation to ensure access to healthcare (Bauer et al., 2009; Guss et al., 2019; Lindroth, 2016; Stewart et al., 2022). The experiences of respondents in trying to gain agency over their care interactions showed how the physicians duty of care seemed to tilt towards a duty of self-care. While several respondents expressed being able to meet their primary SRH care needs, examples such as Thijs’ (24, transgender man) who did not correct his healthcare provider when they gave him an incorrect STI test, show that overcoming erasure is not always possible as it may depend on one’s knowledge, power differentials, the clinical setting and other factors, which leaves TNB people at risk of adverse health outcomes.

The harm and benefit of categorisation

The experiences of TNB people accessing primary SRH care in the Netherlands reiterate an ongoing debate on whether the primary care system should accommodate for prevention, risk assessment and treatment of common health concerns for all people including TNB individuals, or whether all healthcare needs of TNB people should be considered ‘specialist’ care. This raises questions related to the usefulness of categorisation in care; do TNB individuals form a separate category with specific healthcare needs, or is the in-group diversity similar to cisgender people who may also exist on the spectrum of gender and sexuality-related experiences? Respondents in our study were on their guard not to be considered ‘a novelty’, as Sophia put it, but also had to be vigilant to make sure their needs were met – which shows up in Marc’s example about needing additional contraception when using testosterone therapy.

While for some healthcare needs, such as transition-related care, care questions of TNB people are specific, most of their healthcare needs are the same as those of cisgender people (Whitlock et al., 2019). Studies have highlighted that even the experience of gender diversity may not be as fundamentally different between cisgender and transgender people (Joel et al., 2014; Snelgrove et al., 2012). The creations of seemingly oppositional category ‘cis’ vs ‘trans’ therefore neglects not only the commonality in health determinants, but also the in-group diversity (Diamond, 2003). A well-studied example is the relatively high prevalence of HIV among transgender people, which has direct policy implications: for example, the Dutch MHS offers STI services free of charge for transgender people (Drückler et al., 2022; Stutterheim et al., 2021; Van Gerwen et al., 2020). The overrepresentation of TNB individuals with an increased risk at the intersections of race, class and occupation in these studies could result in ‘trans’ being used by researchers and policy makers as a determinant for HIV-risk in itself, neglecting other SRH care needs of the general population of TNB people (Bauer & Scheim, 2013; Drückler et al., 2022; Stutterheim et al., 2021; Van Schuylenbergh et al., 2018). Accommodating for TNB people in primary SRH care may not come down to the bridging of a significant difference, but instead would require educating healthcare providers to address structural determinants of health, including structural factors such as racism and poverty, as well as how cisnormativity influences their clinical decision-making.

Educating (future) physicians

In recent years, there has been a growing number of publications proposing recommendations to accommodate for transgender people in primary care. These publications include guidelines on inclusive clinical communication around gender identity and relationships, on addressing cisnormativity in care and offering an affirming care environment (Braybrook et al., 2022; Braybrook et al., 2023; Coleman et al., 2022; Guss et al., 2019; Puckett et al., 2022; T'Sjoen & Motmans, 2022; Townsend & Clark, 2022). To support physicians in clinically sound decision-making and addressing the specific care needs of transgender individuals, guidelines for SRH care have also been published, such as Standards of Care by the World Professional Organization for Transgender Health Version 8, as well as other guiding documents (Coleman et al., 2022; Riggs et al., 2022; Safer et al., 2016; Whitlock et al., 2019; Wylie et al., 2016). To equip future healthcare providers with the necessary knowledge and clinical skills, this guidance should also be included in medical curricula (Burgwal et al., 2021; Fraser & Knudson, 2019; van Heesewijk et al., 2022). van Heesewijk et al. (2022) proposed that information should be integrated throughout the curriculum to teach students to move away from the perception that TNB people are distinctly different from cisgender people and ‘to consider gender and sex as a universally lived experience, where cisgender and transgender (and intersex) patients have diversity and complexity’. This complexity entails that students should be able to consider how several components of someone’s identity may impact their risk environment, their healthcare access and health outcomes (Muntinga et al., 2020; Wesp et al., 2019). However, to increase comfort in providing care to TNB people, previous studies have shown that education should not only aim to increase knowledge, but also focus on the role of stigmatization and clinical bias (Mehta et al., 2018; Stroumsa et al., 2019). A study among medical students (N = 358) in the Netherlands reported that they experience a lack of attention for LGBTI + -related topics in the medical curriculum and that at the end of their medical degree, almost half felt insufficiently equipped to provide care to LGBTI + patients (Roze in, 2022). Addressing the needs of TNB individuals in primary SRH care requires physicians in the Netherlands to receive training to address these structural determinants of health, including gender experience, as well as training about how bias may impact clinical decision-making.

Strengths and limitations

To our knowledge this is the first study that qualitatively assessed primary SRH care experiences of TNB people in the Netherlands. To ensure a representative sample, we included respondents with various gender identities, ages, socioeconomic backgrounds, sexual orientations, and sexual activities. Some but not all respondents received some degree of GAMC. Using vignettes to prompt conversations, we were able to gather experiences on sensitive topics that may otherwise not be discussed. Limitations of the study include that most respondents lived in an urban area, had a Dutch ethnicity and a higher educational background. Fertility care was not explicitly addressed in the conversations. Few (N = 1) non-binary individuals were included in this study who may have specific SRH care needs or barriers when accessing SRH care.

Conclusion

This study qualitatively explored the experiences TNB individuals accessing primary SRH care in the Netherlands. The stories of respondents show how meeting one’s SRH care needs in primary care can be a risky balancing act: where openness is required to correct faulty assumptions on one’s physical and sexual realities while this may pose a risk of being reduced to one’s trans identity or being referred to tertiary care. The satisfaction and trust in one’s primary healthcare provider varied widely and seemed to depend mostly on their attitude towards TNB people and the knowledge they had on their healthcare needs. While the use of categories may be useful to identify risk groups in primary SRH care, categories can also erase certain realities or create seeming oppositions between groups with highly similar healthcare needs. The systemic erasure (of part) of the respondents’ realities puts TNB people at risk of adverse SRH outcomes. To accommodate for a diversity in gender and sexuality-related experiences in primary SRH care, more critical use of categorisation is necessary. It also requires education of healthcare providers on the consequences of clinical bias and the general and specific healthcare needs of TNB people.

Competing interest

The authors report there are no competing interests to declare.

Disclosure statement

No potential conflict of interest was reported by the author(s).