“Sex is not just an act but also a place to be human, to be authentic.” A qualitative interview study on practices of healthcare professionals in sexological care for transgender and non-binary people

Abstract

Background

Transgender or non-binary (TNB) individuals face specific challenges regarding their sexual well-being. Transition is associated with changes in sexual self-concept, sexual development and sexual experiences. Scientific literature and clinical guidance on sexological care provision tailored to TNB clients who experience sexual problems is limited. However, healthcare professionals (HCPs) with experience in sexological care for TNB clients may hold valuable practice-based knowledge that could inform HCPs’ training in sexology.

Methods

To elucidate these practices, we conducted a qualitative interview study among 13 respondents. We analyzed these findings using thematic analysis.

Results

While sexological care for TNB and cisgender clients was not considered fundamentally different, HCPs described specific practices related to 1) reflecting on one’s positionality, practices, and the care context, 2) addressing societal narratives and personal sexual encounters, 3) providing inclusive information on sexuality, 4) unraveling entanglements between body image, transition, and sexual experiences, and 5) encouraging positive sexual experiences. HCPs highlight the importance of a biopsychosocial and positive approach to sexological care in all clients. Additionally, providing sexological care to TNB clients requires HCPs to be cognizant of how societal and identity-related factors may contribute to the experience of a sexual problem.

Conclusion & discussion

While little clinical guidance is available, HCPs with experience in sexological care provision to TNB individuals hold practice-based knowledge that can be used to inform tailored sexological care provision. Integrating these findings into medical and sexological curricula can promote expertise and critical reflection on the provision of tailored sexological care to TNB individuals.

Keywords:

• Gender incongruence
• sexological care
• sexology
• tacit knowledge
• transgender and non-binary people

Introduction

Individuals with a transgender or non-binary (TNB) identity may encounter specific challenges in attaining sexual well-being, compared to those experienced by cisgender people (Gieles et al., 2023; Holmberg et al., 2019; Mattawanon et al., 2021; Nikkelen & Kreukels, 2018; Özer et al., 2022; Prunas, 2019; Vedovo et al., 2021). Research suggests that TNB individuals generally report lower levels of sexual satisfaction and pleasure compared to cisgender people (Gieles et al., 2023; Kennis et al., 2022a; Kennis et al., 2023). As a growing body of literature underscores the importance of sexual well-being for general health and quality of life, there is a need to gain a deeper understanding of ways to promote sexual well-being among TNB people (Bauer & Hammond, 2015; Ford et al., 2021; Ford et al., 2019; Giblon & Bauer, 2017; Gruskin et al., 2019; Hull, 2008; Laan et al., 2021; LeBlanc et al., 2022; Mitchell et al., 2021; Nimbi et al., 2022; Philpott et al., 2006).

In recent years, various studies have provided insights into how the experience of gender incongruence and gender affirmation, including the effects of gender-affirming hormone therapy (GAHT) and gender-affirming surgery (GAS), may impact one’s sexual well-being. Various studies have shown that gender-affirming care increases sexual satisfaction overall, but may also result in specific sexual issues (Holmberg et al., 2019; Kerckhof et al., 2019). Previous literature on sexuality in TNB people mostly focused on negative sexual outcomes and the effect of medical transition on sexual function (Bauer & Hammond, 2015; Özer et al., 2023). More recently, studies sought to move beyond medicalizing and functional perspectives to provide insights into psychological and social sexual experiences aimed at enhancing sexual well-being (Gieles et al., 2023; Goldbach et al., 2022; Kennis et al., 2023). A recent review by Pipkin et al. (2023), illustrates how TNB people undergoing transition may go through a (re-)negotiation process to expand labels related to sexualities, the body and relationships. The attainment of sexual well-being and pleasure among TNB people may also involve expanding approaches to sexual embodiment, including the sexual function of genitalia and sexual scripts, beyond cis- and heterosexual norms (Anzani et al., 2021; Bauer & Hammond, 2015; Bauer, 2017; Gil-Llario et al., 2021; Goldbach et al., 2022; Lindley et al., 2022; Lindley et al., 2021; Özer et al., 2023).

It is important not only to consider TNB people’s sexual experiences in the light of gender transition. The specific social context that TNB people face may play an important role as well. For example, TNB people are still disproportionately confronted with stigmatization, sexual victimization and intimate-partner violence and may therefore find it more difficult to seek sexual contacts (Cense et al., 2017; Goldbach et al., 2022; Kerckhof et al., 2019; Peitzmeier et al., 2020). Understanding how axes of identity like gender, race, age, religion, class and education intersect to give rise to unique experiences or needs, has been coined “intersectionality” (Crenshaw, 1989). Applying an intersectional approach to sexological care in TNB people would entail that HCPs understand how intersecting social identities result in differences in sexual experiences and sexual health (Dhamoon & Hankivsky, 2011; Heredia & Rider, 2020). Many have argued that to provide tailored sexological care to TNB clients, healthcare professionals (HCPs) need to be aware of such contextual factors and address their impact on a sexual issue (Augustine, 2023; Goldbach et al., 2022; Heredia & Rider, 2020; Sitron & Dyson, 2012). For example, transgender women of color involved in sex work are more likely to face discrimination, fetishization and (sexual) violence and are disproportionately at risk for human immunodeficiency virus (HIV) (Ussher et al., 2020; Van Schuylenbergh et al., 2017).

In the Dutch context, sexological care is generally practiced by specialized psychotherapists, counselors or medical doctors and focuses on the assessment and treatment of problems related to sexuality, including sexual (dys)function, sexual well-being and sexual relationships. In general, HCPs working or training in sexology may refer to professional standards or protocols to tailor care to specific client groups. However, the scientific literature on sexological care provision to TNB people is limited, and specific standards or protocols are scarce (Alexander, 2019; Blumer et al., 2012; Cocchetti et al., 2021; Kennis et al., 2023; Spencer et al., 2017). This dearth may contribute to the commonly reported experience of TNB individuals of having to educate their HCP; a dynamic that has been marked as an important barrier in access to and quality of care (Guss et al., 2019; Lerner et al., 2021; Lerner & Robles, 2017; Snow et al., 2019; Stewart et al., 2022).

Recognizing the importance of providing professional guidance, the World Professional Association for Transgender Health (WPATH) included a chapter on sexual health in their Standards of Care 8 (Coleman et al., 2022). In addition, several HCPs, primarily based in the Unites States, have published books on providing sexological care to TNB individuals, drawing from their clinical expertise (Alonzo, 2018; Fielding, 2021; Lev & Sennott, 2021; Nichols, 2014, 2020; Spencer et al., 2017). While most of this knowledge is explicit and, therefore, easier to transfer from person to person, several authors have argued that understanding of effective care practices also required insight into tacit knowledge (Fernandez et al., 2020; Kothari et al., 2011; Lin et al., 2022; Polanyi, 1966; Reinders, 2010; Sanford et al., 2020).

Knowledge had been described by Polyani to exist on a spectrum from explicit knowledge, i.e. codifiable and easily transferable, to tacit knowledge, which is more implicit, embodied and rooted in context-dependent practices (Grant, 2007; Polanyi, 1966; Thornton, 2006). Tacit knowledge has been argued to be fundamental to the clinician-client relationship and the quality of care, particularly in fields like sexology, where physical, mental and social aspects intersect over longer-term care interactions (Kothari et al., 2011; Reinders, 2010; Thornton, 2006). For example, through practice, HCPs may have acquired ways to facilitate the discussion of a sensitive topic with their clients. This may be by using certain words or drawing a figure but it may also relate to their posture or tone. Some of this tacit knowledge can be made explicit (i.e. externalization), while due to its embodied and personal nature, some cannot be articulated or transferred (Grant, 2007; Kumagai, 2014). A study from the Netherlands among people working in sexual and reproductive health and rights (SRHR) argued that while tacit knowledge mostly remains neglected, gaining insight into such knowledge is vital to facilitate knowledge transfer between research, policy and practice (de Haas & van der Kwaak, 2017).

In the Netherlands there is a growing number of HCPs who have built up long-term clinical experience in working with TNB clients in sexology. Their insights and practices may be valuable for professional development in the field of sexology and important for the promotion of sexual well-being among TNB individuals. This paper seeks to elucidate and describe insights from experienced HCPs in sexological care for TNB clients to promote learning and critical reflection on the provision of tailored sexological care. We conducted a qualitative interview study with the following research question: What do these experienced HCPs do in sexological care to promote sexual well-being among TNB people?

Methods

Ontologically, this study is concerned with the practices of HCPs in sexological care. It takes ontological elements such as beliefs, views and experiences (of and about clinical interactions) as relevant to these practices. In this study, we took an interpretive/constructivist epistemological stance. A qualitative methodology was selected given the explorative nature of the study. We used semi-structured interviews to provide space for in-depth and nuanced insights into HCPs’ clinical practices.

Setting

In the Netherlands and Flanders, sexological care is usually offered in private sexology practices or as part of multidisciplinary care contexts such as in hospitals and mental healthcare centers. Some centers for gender-affirming medical care (GAMC) also provide sexological care, but the capacity to provide long-term care in this context is typically limited. Professional registration of HCPs in sexology in the Netherlands is organized via the Dutch Scientific Society for Sexology (in Dutch: Nederlandse Wetenschappelijke Vereniging voor Seksuologie (NVVS)). Training in sexology involves a two-year degree with a biopsychosocial focus for HCPs trained as a medical doctor, psychotherapist and health psychologists.

Participant selection and recruitment

We included HCPs who have previous experience in providing sexological care to TNB clients. We recruited via our professional networks and through recommendations of respondents. We aimed to include HCPs with a variety of professional backgrounds, genders, ages and current work settings. Most respondents provided sexological care to both cisgender clients and TNB clients. All procedures performed in this study were in accordance with the ethical standards of the Amsterdam UMC and with the 1964 Helsinki declaration and its later amendments. The Medical Ethics Review Committee of the Amsterdam UMC (location VUmc) reviewed the protocol of the study and declared that this study is not subject to the Medical Research Involving Human Subjects Act (2021.0755, IRB00002991, 29^th of December 2021). Respondents received an information letter about the study in advance which emphasized that participation was voluntary and could be withdrawn at any point during the research process. Informed consent was obtained from all individual respondents included in the study. The names of respondents used in this manuscript are pseudonyms.

Data collection

Data were collected between February and November 2022. NG conducted all 13 interviews. Nine interviews were held in-person at the respondent’s chosen location, while three interviews were held online. In four interviews the respondents were acquainted with the interviewer as indirect (former) colleagues of the same multidisciplinary GAMC center. All interviews were audio-recorded, transcribed verbatim, with pseudonyms used for privacy. The interview guide was based on previous literature and the research team’s professional experience, and was iteratively restructured twice after the first and eighth interview. We noted that certain practices may be difficult to explain as they are largely tacit or “taken for granted that they find them hard to explain” (p.194, Barton, 2015). Therefore, we adopted verbal elicitation techniques such as stimulated recall, where participants were asked to recall their practices with particular clients during the interview, to foster the articulation of implicit practices through stories or clinical cases (Barton, 2015; van Braak et al. 2018; Whyte & Classen, 2012). The interview guide included open-ended questions related to experience and practices such as: Could you describe your experience in providing sexological care with TNB clients? What do you generally find important points of focus? Can you give an example of a case or situation and describe what you found important to focus on and why? What would you recommend other HCPs who want to start providing sexological care to TNB people?

Data analysis

We analyzed the data using a reflexive thematic analysis approach (Braun & Clarke, 2006, 2019, 2023). NG read and reread the transcripts to foster data emersion. Subsequently, NG coded the transcripts inductively using open coding in MAXQDA 2022 software (VERBI Software, 2021). To explore alternative approaches and understanding of practices, KG and BK each independently coded one interview. After comparing these with the interviews coded by NG and exchanging insights, NG went back to the first three transcripts and added additional codes. Following the initial open coding of all 13 transcripts, NG developed axial codes for all transcripts, which were discussed among the research team. Based on this exchange, NG defined initial (sub)themes and subsequently discussed these with the research team in two meetings. After refining these themes, each member of the research team individually selected relevant quotes illustrating each (sub)theme. Subsequently, we discussed these quotes together until we reached consensus on the final selection of quotes.

Throughout the analysis, we noticed that all participants stressed that sexological care provision to TNB clients is not essentially different from that to cisgender clients. At the same time, they highlighted how they adapted their clinical practice to TNB clients. In this paper, we decided to foreground the specific practices of HCPs in providing sexological care to TNB clients (as opposed to cisgender clients). After the analysis, we invited all respondents to attend a group interview which served as a member check. Three respondents were able to attend the in-person member check which took place in July 2023. As this session yielded additional insights into our findings, we transcribed and selected fragments that provided further depth to the findings of the individual interviews.

Research team

The members of the research team had a variety of professional backgrounds: NG is a medical doctor (M.D.) trained in sexology and a PhD candidate who also works clinically in sexology and GAHT. KG is a trained ethicist, qualitative researcher in health care and psychiatrist in training. EZ is a health psychologist and sexologist who works in GAMC and a sexology department. SB is a health psychologist, sexologist and senior researcher in sexology. BK is a professor in medical psychology focusing on diversity in gender and sex primarily doing research in the context of transgender healthcare. Our professional backgrounds may have sensitized us to tacit clinical practices and helped us in building rapport with respondents. Additionally, NG, who carried out the interviews, was a sexology trainee during the process and several respondents were aware of this. This may have influenced the way they engaged with her, possibly by assuming that she was aware of certain practices that they deemed obvious and hence, “needless to say”. Being cognizant of this possibility, she tried as much as possible to maintain an “unknowing stance”. For her, this project was also rooted in her own experience during sexology training, struggling to find clinical guidance for working with TNB clients.

Besides our professional backgrounds, we recognize that our social identities and lived experiences also shape the research questions we ask and the way we engage with stories of others, and thus the way we interpret the data in research. We are a group of Dutch cisgender, able-bodied researchers with various ages, genders and sexual orientations. To enhance critical reflexivity on how these positionalities and our professional backgrounds influenced our relationship with respondents and analytical decisions, we engaged in multiple dialogues on these topics throughout the research process. Besides building on our clinical experience in transgender care and sexology, we reviewed and discussed articles on sexuality and (sexological) care experiences of transgender people to inform the interview guide and analysis.

Results

We approached 18 healthcare professionals via e-mail, of whom 13 agreed to participate in the study. Two indicated that felt that they lacked enough clinical experience working with TNB clients to participate, and three did not reply after two reminders. All respondents were mental HCPs trained in psychiatry or psychology as well as sexology. The duration of the interview was between 41 and 70 min with a mean of 51 min. To maintain confidentiality in a small field of expertise in the Netherlands, we decided not to include age, specific professional background or other demographics in this paper. Information about the work settings of each respondent at the time of the interview can be found in Table 1.

Table 1. Work settings of each respondent.

	Setting of sexological care
Pseudonym	GAMC	Mental health care institution	Independent practice
Laura	y	n	n
Maya	n	n	y
Kate	y	y	n
Ahmed	n	y	n
Ruth	y	n	y
Rob	n	y	y
George	n	y	y
Emily	y	y	y
Rosa	y	y	n
Jackson	y	n	n
Marc	n	n	y
Sita	n	n	y
Rachel	y	y	n

We identified five main themes. In sexological care with TNB clients, HCPs focus on

1) reflecting on one’s positionality, practices and the care context, 2) addressing societal narratives and personal sexual encounters, 3) providing inclusive information on sexuality, 4) unraveling entanglements between body image, transition and sexual experiences and 5) encouraging positive sexual experiences. These specific practices were identified within a context in which all HCPs shared the notion that sexological care for TNB people is not essentially different from that for cisgender people. This context, which we present as theme 0, should be considered as an umbrella for the five specific themes.

Context: “Transgender people are sexually not that different from cisgender people”

All respondents emphasized that providing sexological care to TNB clients is not essentially distinct from or inherently more complex than it is to cisgender clients. Maya explained: “I think it’s important to realize that transgender people are sexually not that different from cisgender people. They may [for example] have ‘new’ genitals but in general it’s about the same: about pleasure, desire and learning to explore.” HCPs described that they approach a sexual problem with any client from a biopsychosocial perspective. While acknowledging the potential impact of gender incongruence or GAMC on sexuality, HCPs cautioned against assuming their centrality to a sexual problem.

HCPs considered it important to be aware of co-existing medical or psychological conditions, as these may play a role in a sexual problem. They emphasized that this was important in all clients regardless of gender identity. Ahmed elaborated: “Because co-morbidity in some cases really has consequences for sexuality, but also for the way in which people can interact with others.” In case of TNB individuals, many HCPs specifically highlighted the significance of being aware of the intersections between gender incongruence with neurodivergence or post-traumatic stress disorder (PTSD). Maya described how sexual changes upon starting testosterone may be experienced as more intense by neurodivergent TNB clients as a result of different stimulus processing:

[I have seen clients] [w]ho said that the friction of their pants when running already caused too much arousal. […] I often hear that that difference [after starting testosterone] can be really quite a lot, especially among transgender boys with for example autism. (Maya)

In the case of PTSD, HCPs emphasized the need to refer for trauma therapy in addition to sexological care.

HCPs described applying a broad range of interventions which they considered “generic.” These include psychoeducation on intimacy, sexual responses and pleasure as well as body exploration, sensate focus exercises, cognitive behavioral therapy, couples therapy and pelvic floor exercises. In general, HCPs considered these interventions similarly suitable to TNB and cisgender clients. However, when working with TNB clients, various HCPs payed more attention to use inclusive language, for example when referring to pronouns and anatomy. Laura described:

I rewrite all words that are too ‘cis’ or, if your client finds ‘vagina’ a loaded term, we call it genital, for example. Do the same exercises that you do for dyspareunia or a vaginistic reaction, but make them trans-sensitive. […] Similar to cis persons, it is always a puzzle to find out what someone needs […] and then you also make a tailored plan. With a trans person I just look at the exercises a bit more critically. (Laura)

While many HCPs perceived their approach to sexological care for TNB clients as largely similar to that for cisgender clients, they also stressed specific areas warranting attention. For example, Rosa described:

When genital hair removal hasn’t been done completely, and you ask someone to explore through masturbation how it [i.e., the vagina] feels and someone comes back to you saying: ‘I don’t like to put something inside [of my vagina], because when I feel the hair that is still there, I block completely.’ When you talk about factors that stimulate or inhibit arousal, that clearly is an inhibiting factor. With a cis woman, I never ask about hair on the inside [of the vagina], for example. There is a difference there and at the same time there is also a lot of overlap. (Rosa)

Some HCPs described that some sexual problems may be particularly prevalent among TNB clients, such as reduced sexual desire among clients using anti-androgens. However, Rachel felt that in general, TNB people are particularly well-equipped to navigate and overcome sexual problems:

I find it a very nice group to work with because in comparison to the cisgender people that I work with, I notice that, maybe not all, but on average, transgender people have already had to address part of their thinking regarding their gender identity. This has often also brought them the introspection to think more creatively about their sexuality. And that offers self-awareness, guidance, and skills to deal with that [i.e., a sexual problem]. (Rachel)

In the remainder of this paper, we focus on the specific practices that HCPs describe in sexological care with TNB clients. As Jackson put it:

I don’t think there’s a difference in the sense that [TNB clients] have a different desire, physiology or brain, or that you should create a separate kind of sexology for that. No, I don’t believe any of that. […] But I do think you should look beyond that ‘meta’-level. Like, what do you do in therapy concretely, what do you focus on?

“We’re all humans and our frame of reference always creeps in”: reflecting on one’s positionality, practices and the care context

Throughout the interviews, many HCPs described reflecting on the way 1) their positionality, 2) cis- and heteronormativity in sexological practice and 3) their care setting influences sexological care to TNB clients.

Reflecting on one’s positionality

HCPs described reflecting on how their positionality, specifically related to their cisgender identity, influences their sexological care provision to TNB clients. Some HCPs, such as Tim, felt that sexological care to TNB clients would benefit from involving more TNB care providers, as it would create a more relatable care interaction: “I think that it would help patients if there are more trans colleagues […] but the image [of HCPs in sexological care] is still white, cisgender, hetero.” However, most HCPs described that as long as they had the required attitudes and knowledge, they did not consider it necessary to have a TNB identity themselves to be able to provide sexological care. Sita described that she had gained these necessary insights through her clinical work: “That’s [i.e. through clinical experience] how I’ve become a bit more informed […] I’ve just been cis and straight for years, you know? […] But I’m curious and open-minded enough to still support someone [with a TNB identity].”

Reflecting on cis- and heteronormativity in sexological practice

The importance of being “curious and open-minded,” as Sita put it, was reiterated by several other HCPs, such as Rachel: “Depart from a clean slate and don’t try to have a preconceived idea of where people should be headed. Just listen to what they need at that moment, what they think, what is bothering them.” To do this, various HCPs highlighted that it is necessary to be aware of potential internalized cis- and heteronormativity in one’s clinical practices. Rachel explained:

Even among sexologists who have received ample training, who have learned to hold a firm theoretical framework, and not to take their own experiences as a vantage point, I think that it’s not strange that at the end of the day we’re all humans and our frame of reference always creeps in. […] That’s a very human thing […] but it’s something we should scrutinize on a daily basis. (Rachel)

Laura emphasized the need to recognize and avoid making assumptions on relevant sexual activities or the role of gender dysphoria in a clients’ experience of a sexual problem:

I think it’s very important to have an open attitude. […] That you don’t have too much of a binary idea of what a body should look like or what sexual needs people have. Because that’s extremely varied among the group we work with. […] I’ve seen a number of transgender men, for example, who want or can enjoy vaginal penetration, or have done so in the past, while they do identify as man and live as such. As a clinician you shouldn’t think ‘Huh, that’s strange because you feel you’re a man, why would you want to be penetrated?’ I can imagine that people who are not very familiar with the group we work with may think that’s odd. Or if such a man has complaints of dyspareunia or a vaginistic reaction, that you don’t instantly say: ‘Well yes, that must be because of your dysphoria, because it’s not logical to experience that as a man.’ for example. (Laura)

Laura added that this open attitude can also be extended to language use in sexological care. She felt it was helpful to attune to clients’ description of certain sexual activities or body parts:

What’s definitely very important is one’s approach: How do you address someone? And how do you refer to their genitals, for example. […] It’s good to connect with the way someone refers to themselves […] that you tune in with how someone feels about that. (Laura)

Reflecting on the care setting

Several HCPs, especially those who also practiced in GAMC, touched upon the importance of reflecting on the setting in which sexological care takes place. They described that when a client experiences a sexual problem and also has an unfulfilled wish for GAMC, clients may feel restrained to openly discuss experienced sexual problems, as they fear that expressing these could limit their access to GAMC. To ensure safety in discussing sexuality, Ahmed, who did not work in GAMC but who had often heard these stories from his TNB clients, stressed the importance of understanding the specific motivation for a TNB client to seek care:

People come to you to get a green light for somatic treatment [i.e., GAMC]. To them, talking about sexuality can become connected to the context of assessment. I’ve heard from some people [i.e., TNB clients] that this can be complicated and experienced as crossing a line. (Ahmed)

Maya, who had previously worked in GAMC but currently practiced in an independent psychotherapy/sexology practice, confirmed these observations from her own experience in working in these two contexts:

I don’t have that role [i.e., as an assessor] here and that feels freer. I notice that people [i.e., TNB clients] are more open here [i.e., at her independent practice] as well. […] They say: ‘I’d rather be here for a while because I can express my doubts, while I can’t do that there [i.e., in a GAMC setting].’ I think that’s very bad; that apparently the feeling prevails that you can’t express your doubts there. (Maya)

Most HCPs who also worked in GAMC described being aware of this tension but underlined the importance of informing clients about the potential interactions between GAMC and sexuality. They described that openness can be benefited by explicitly discussing the reasons for bringing up sexuality, being transparent about the role of the HCP in access to GAMC and connecting to the care questions of the client:

To what extent are HCPs clear about the position they are working from [i.e., indicating for GAMC or sexological care]? Or does that position, for the largest part, remain implicit for clients? I think it’s very important to be transparent to clients so they can consider whether they want this [i.e., discussing a sexological care question in a GAMC setting] or not. (Jackson)

“Take a stance against normativity in society”: addressing societal narratives and personal sexual encounters

Various HCPs highlighted how they dedicate ample time to address 1) societal narratives on transgender sexuality and 2) personal sexual encounters with their TNB clients. Through these conversations, HCPs aimed to gain insight into how these factors may have impacted their clients’ sexual development and current sexual self-perception. Emily, who works mostly with young clients, explained:

[I]t [i.e., negative narratives on transgender sexuality] keeps young adults from entering into relationships with others while they would love to do that, because they’re afraid it will become physical […] [out of the] fear that they would then have to share something about themselves for which they fear stigma, being rejected, trans hate, being outed. […] They seem to internalize many things that do not benefit their sexual development. (Emily)

Addressing societal narratives on transgender sexuality

Several HPCs considered it important to discuss the information, narratives and representations regarding sexuality their clients had received or had been exposed to in the past and to address whether this influenced their perception of their potential for intimacy, sexuality and relationships. In their experience, various sexual problems partly stem from growing up in a cisgender- and heteronormative society or being exposed to negative media representation of transgender people. To counter these, Rachel critically evaluates them with her TNB clients. She considered it important

[t]o take a stance against normativity in society. […] [P]eople seem to not have realized that the images they grew up with and have internalized may not serve them. […] There lies an important task for sexologists: […] to be the one who critically questions [these images, and] makes them stop and think: Is this right? Does it have to go like that? (Rachel)

Marc, who identifies as a member of the LGBTQIA + community, emphasized that these societal norms not only prevail in the broader society but also within the LGBTQIA + community. He critically reflected on the way that from his clinical experience, rejection from within the LGBTQIA + community may be even more detrimental for one’s (sexual) well-being:

I find it very painful to see that it [i.e., the need for acceptance] still is and has to be on the [clinical] agenda. Because once people have been through their transition or have been in therapy, they have to go on living in a society which is still too often trans- or homophobic, also within the [LGBTQI+] community. There where you don’t expect it, when you come out, open up […] you get hurt by your own people, by your own kind. […] [Y]ou can carry water to the sea if we don’t cleanse ourselves of the toxicity we have incurred. We cannot take it out on each other. (Marc)

Addressing personal sexual encounters

Various HCPs also addressed how past sexual encounters affected one’s sexual self-perception. In these conversations, HCPs described encountering several common narratives: for some TNB clients sexuality was a confronting reminder of their transgender history, others feared that their body was not considered attractive or, conversely, some feared that they were fetishized because of being TNB. HCPs reflected with their clients on such feelings of vulnerability and the importance of safety in experiencing sexuality. HCPs approached the notion of safety in different ways. Some, such as Maya, did so practically:

I always point out to people that they are vulnerable. So, for example, I give them tips on where to meet [for a date]. […] [O]n neutral ground I mean, not at someone’s house. Because I have indeed heard many stories that things went wrong. […], that people have been beaten up during a date, […] so I try to protect people a little bit from that in a certain way. (Maya)

Rob, on the other hand, addressed the need of safety in a sexual encounter as a prerequisite for a positive sexual experience:

This therapy focuses mostly on normalizing how scary it can be to be intimate, how special that actually is. That sex is not an act per se, but that sexuality is also a place to be human, to be authentic, to start a relationship and literally be touched. Being touched, and that this also comes hand in hand with vulnerability. And that there has to be a certain degree of safety, which you must be able to feel in order to experience that vulnerability. I think that’s what the therapy focuses on. (Rob)

“I explained to her: the moment cis women get aroused, their genitals also swell”: providing inclusive information on sexuality

The majority of HCPs noted allocating significant time to provide inclusive information about sexuality because their TNB clients frequently lacked access to comprehensive information about sexuality or felt that publically available information was not applicable to them. Emily described:

The 18 to 23 years olds—the group I often work with—[…] don’t dare to speak about sexuality in general. They have a lot of questions and they lag behind in terms of information and knowledge. [I notice] that they have no role models to compare themselves to, whereas that is the case for ‘typical’ adolescents or young adults. [I also notice] that they struggle with several questions [like]: ‘Am I normal? Is this okay?’ [and] that in case they have questions they don’t know where to go with them, so that those questions have barely been addressed. (Emily)

HCPs particularly described providing 1) tailored general information on sexuality and 2) specific information on GAMC and sexuality.

Providing tailored general information on sexuality

Because HCPs considered it essential to have correct sexuality-related information in overcoming a sexual problem, they described providing general information but attuning this to their particular client. They related touching upon the wide array of biopsychosocial factors that may influence their client’s sexual experiences, as well as explaining the commonalities in sexual function among all humans regardless of sex assigned at birth. Rosa’s clinical case illustrated how the latter helped one of her clients to reframe her perception of genital swelling after vaginoplasty:

[S]he still noticed a certain swelling with sexual arousal, and for her that was very much associated with an erection, with the ‘male’ sexual arousal she used to know. And then I explained to her, well, the moment cis women get aroused, [their genitals] also swell. So, you could look at it a little more with that mindset and that made such a difference to her, like, […] seeing it [i.e., the swelling] in the context of female arousal instead of a male erection. (Rosa)

HCPs noted that they also spend a lot of time setting straight sexual myths, or nuancing stereotypical or simplistic notions of sexuality. Laura recounted:

[I] explain that sex is more than penetration […] or [challenge the notion] that you may not be enough of a man if you do not have a penis or if you cannot penetrate. There are many trans men who struggle with ‘I’m not a real man because I cannot penetrate my wife,’ while their partner may not even want that, or thinks: ‘We can do other things.’ So [I’m] spending a lot of time correcting certain misconceptions. (Laura)

Besides providing information herself, Laura actively encourages her TNB clients to seek advice from other TNB people who have positive experiences with love, sexuality and relationships. She shared how in her experience, hearing positive stories from other TNB people, instead of from your HCP, is much more effective in countering negative associations:

I generally tell everyone to ask among people with similar lived experiences how they handled this [i.e., exploring sexuality]. Because there are plenty of trans people who are happily in love, find nice partners, who don’t run into problems. So that can also be inspiring, like oh yes, it doesn’t always have to be difficult. […] And you take that [advice] best from people who have experienced it themselves. As a [cisgender] care provider I can easily proclaim that [i.e., that one can have positive sexual experiences] but then they think, yes sure. So I try to encourage that [i.e., seeking advice from other TNB people] very much, ask each other how you have handled that, or ask for recommendations. (Laura)

Providing specific information on GAMC and sexuality

Several HCPs also touched upon specific information on the effects of GAMC vis-à-vis their clients’ sexual experiences. For example, Emily described: “With testosterone we see an increase in desire, that is something I also discuss, that you may experience more arousal: ‘How are you going to deal with that given that you also experience dysphoria?’” Some HCPs, such as Maya, described providing information on their clients’ specific sexuality-related needs after GAMC: “[C]ompared to […] a vagina of a cisgender woman, there are differences […] for example concerning lubrication. [I tell my clients] that it is best to use lubricants, for example.” Others, such as Ruth, recounted gauging her clients’ expectations of GAMC in relation to sexuality and providing realistic information, as in her experience, unrealistic sexual expectations are likely to result in sexual dissatisfaction after GAMC: “[I]f someone insists on wanting to be able to be penetrated, I do think that’s a risk factor with regard to how satisfied someone will be after vaginoplasty, because that’s not always possible.”

“How is the relationship with your own body?”: Unraveling entanglements between body image, transition and sexual experiences

In sexological care to TNB clients, several HCPs emphasized the strong interconnectedness between sexuality, body image and GAMC. To provide more insights into how these domains influenced each other, together with their clients, HCPs unraveled whether and how 1) body image or medical transition influences one’s sexual experiences and 2) sexual experiences influence one’s body image or medical transition.

Unraveling how one’s body image or medical transition influences one’s sexual experiences

All HCPs described addressing the impact of one’s body image on the experience of a sexual problem. Discussing body image was often described as a way to discuss sexual wishes and boundaries. Rob elaborated: “So that it can be about, how is your relationship with your genitals? How is your relationship with your body? May someone touch your breasts? So, a lot around body image.” Emily often asked her clients to draw a body map:

We draw a gender body […] and then you start to explore [with the client] ‘Where is your dysphoria, where are the plusses and minuses, what are particularly neutral aspects […] what is just healthy and okay?’ Just to create space for someone to speak about the body, about genitalia, about sexuality. Because if you can’t do that yet and know these things for yourselves, then you can’t do it in a relationship with someone else either. So, for me, that’s fundamental. (Emily)

When TNB clients approached them after they had undergone GAMC, respondents described how sexological care may require the unraveling of an intricate interplay between past sexual experiences, body image and complications or unmatched expectations with the outcomes of GAMC. In this context, Marc emphasized the significance of discussing specific medical issues, such as pain, within the broader context of an individual’s psychological and sexual well-being. He used the example of a transgender woman who had developed vaginal adhesions after her vaginoplasty and suffered from pain during sexual intercourse as a result

[f]or example, with adhesions, or when the vagina closes. Those are specific medical issues that stagnate social or personal development. If people are in pain, they are more withdrawn, less in touch with others, more prone to feel down. So, there is always that interplay, and particularly in trans people [who received GAMC], […] there may be a specific medical issue [that you have to attend to]. (Marc)

Several HCPs, noted the importance of stressing that clients may require time to (re-)familiarize themselves with their body after GAMC. Laura said: “With this group I really try to normalize that sexual problems arise. […] If you’ve had certain genitalia for years and that suddenly changes, it takes time to get used to that.”

Unraveling how sexual problems influence one’s body image or medical transition

Based on their practice, several HCPs described how someone’s sexual problem may influence their body image and needs for GAMC. For example, several HCPs highlighted the importance of understanding whether past negative sexual experiences or traumas affected one’s body image and GAMC wishes, and advising to seek trauma therapy if necessary. However, HCPs related how in most cases such interconnectedness is hard to unravel, or may seem bidirectional. For example, Laura described a case involving a transmasculine client who could initially enjoy penetrative sex and did not want a genital operation, but started to suffer more from genital dysphoria when he developed dyspareunia. In turn, Laura hypothesized that the dyspareunia had resulted from vaginal atrophy following the initiation of testosterone and was sustained by pelvic floor hypertonia resulting from the pain and genital dysphoria. She described that together with her client, they spend considerable time going through the possible causal chain to see how his dyspareunia could be alleviated. Other HCPs also described how for some clients, positive sexual experiences influenced their need for genital surgery. In most cases these experiences were gained masturbating or with a sexual partner. A small number of HCPs described that they had supported clients in seeking a sexual surrogate, a care provider trained to support people with experiencing their body, intimacy and sexuality. Kate explained how gaining these sexual experiences with a sexual surrogate and later with a sexual partner shaped her clients’ considerations concerning genital surgery:

[W]e checked if there was a sexual surrogate working for that company, and there was, and then he started visiting them. Because I thought, you may need to gain some sexual experiences to see: ‘What do I really want? Do I want genital surgery, or not?’ And that’s what this person started to do, and at some point he also started dating someone he had met. At a certain point he came to the conclusion: ‘Yes, […]…sure, I would’ve liked it very much to be born with a penis, but I notice that, yes, I am also very satisfied now, and that I feel comfortable, so that I don’t need that surgery now.’ (Kate)

“Don’t stop, but keep exploring how sexuality can feel good”: stimulating to seek positive sexual experiences

All HCPs stressed how they encourage clients to gain positive sexual experiences. To do so, they encouraged their clients to 1) explore sexual pleasure and with these insights, to 2) communicate sexual wishes and boundaries to their partner(s). Recognizing that sexual desires and boundaries may change throughout one’s life, and in particular after GAMC, HCPs emphasized that this process requires regular checking in with oneself and partner(s).

Encouraging sexual pleasure

Various HCPs described encouraging their clients to explore their body and respect their boundaries to see what brings pleasure. Ruth said: “So more [focus on] positive sexual development. […] I do think that is very important, more attention to positive sexuality, and with that also looking for possibilities.” Various HCPs noted having concerns when their clients decided to disengage from sexuality entirely until they had received GAMC because they felt that in this way clients would skip fundamental steps in their sexual development, for example pertaining to intimacy, communication and consent. Some HCPs described that they felt that clients who had postponed engagement with intimacy and sexuality altogether until after GAMC, tended to incur more sexual problems or negative sexual experiences. For example, they mentioned that clients sometimes went ‘too fast’ once they did start to engage with sexuality. While HCPs were adamant to respect their clients’ wishes and boundaries, they also warned them against disengaging from sexuality altogether. Here is Ruth:

That people don’t stop, but keep exploring how can sexuality feel good for me? […] Sometimes [there’s the] black-and-white thought: “this [i.e., experiencing sexuality] is only possible when I have completed my transition’. And well, I don’t think that’s true. Of course, people can make their own decisions in this regard. But sometimes there’s perhaps too much of a focus on: ‘well, then [i.e., after GAMC], then I’ll be happy and then it [i.e., sexuality] will work out.’ Sometimes, that’s not the case. (Ruth)

Respondents highlighted that the continuous (re-)exploration of the body and sexual pleasure continues after GAMC. Some HCPs, like Kate, described motivating clients to explore their body on their own before they do so with partner(s):

In case you [i.e., the client] have had surgery, are you able to start by exploring [sexuality] a little on your own? So well, to see what it looks like, when you’re ready for that. And touch yourself there, how does that feel? Because if that feels comfortable at a certain point, I can imagine that it’ll be a bit easier when you start doing that together. (Kate)

Encouraging the communication of sexual wishes and boundaries to one’s partner(s)

Various HCPs emphasized the significance of gaining experience in communicating with sexual partner(s) about needs, wishes and boundaries. Rachel uses the body map as a tool to aid communication between partners:

That you [ask TNB clients and their partner(s) to] make a sketch of each other’s body and indicate several zones: those that are always ‘OK’ [and] those where you want the other to check whether they are ‘OK’ [to touch during sexuality]. […] That sounds very practical and organized […] but for me it’s not at all about the body map but about the fact that people have learned that you can have boundaries and that you can communicate these in important moments.

Rob explained that he tried to motivate clients to express their insecurities to their partner(s) as well:

When it comes to sexual problems, well, then I think it’s mainly about the skills you have to communicate about them with your sexual partner, sexual assertiveness, so to say. Can I express what I find pleasurable, where I want you to touch me? Can I be active in sexuality, can I provide my partner with what I think my partner wants? And can I ask for that? Like, ‘Hey, I am insecure [because] I can’t penetrate well, and maybe you just want a man who penetrates.’ (Rob)

HCPs such as Rosa stressed that her practices in sexological care are not necessarily sequential, but integrated with and attuned to the needs and wishes of the client:

I once counselled a rather young couple, a transgender man and a cisgender woman. For three conversations or so, regarding ‘[H]ow are you going to shape [sexuality] together again?’ So [I provided] some psycho-education, but also invited them to explore what was pleasurable for both of them. And in our conversations, we mostly touch upon sexual communication, like ‘What do you like, what don’t you like?’ [Discussing] desires, boundaries, and how these had changed after surgery. To create space for that [i.e., ongoing exploration]. (Rosa)

Discussion

In this study, we aimed to gain insight into the practices of HCPs in sexological care provision to TNB clients. Although respondents did not consider sexological care with TNB clients fundamentally different from care for cisgender clients, they described specific practices that were deemed to require particular attention. First, respondents reflected on their positionality, clinical practices in relation to cis- and heteronormativity and the role of the care context. Second, HCPs addressed the ways societal narratives and earlier sexual encounters may have influenced their clients’ sexual development and self-perception. Third, HCPs provided inclusive information regarding sexuality. Fourth, together with their clients, HCPs unraveled how body image and GAMC impact their sexual experiences and vice versa. Finally, HCPs encouraged their clients to gain positive sexual experiences by exploring their wishes and boundaries and to communicate these to sexual partner(s).

Tacit knowledge

The knowledge underlying the described practices exists on a spectrum from explicit to tacit knowledge. Various qualitative studies have expounded valuable tacit knowledge of HCPs, illustrating its centrality to good care, especially where healthcare is highly context-dependent or rapidly evolving (de Haas & van der Kwaak, 2017; Eriksen et al., 2014; Fernandez et al., 2020; Kothari et al., 2011; Lin et al., 2022; Reinders, 2010; Sanford et al., 2020; Thornton, 2006). For instance, Lin et al. (2022) studied how mental healthcare nurses in Taiwan promote medication adherence among individuals living with schizophrenia. Robertson et al. (2018) studied tacit knowledge of mental HCPs in the promotion of men’s mental health, such as by creating safe and trusted contexts and using gender-sensitive language (Robertson et al., 2018).

In line with these studies, our study shows how tacit knowledge is often embedded in language, attitudes and norms, for example when Laura reflected on adapting the language of exercises for her TNB clients. Additionally, tacit knowledge shows in the adaptation of practices to the specific care context. In our study this became particularly evident in the way HCPs addressed sexuality within vs. outside the context of GAMC. In the context of GAMC, HCPs ought to be aware of the long waiting lists for GAMC as a potential barrier to discussing sexuality. Furthermore, they must be cognizant of the historical background of pathologizing sexuality-related inquiry into TNB people, which can make clients hesitant to be open to their sexological HCP in GAMC (Prunas, 2019). These findings show how qualitative study of tacit knowledge can provide valuable insights for care provision that would remain invisible through other evidence-based research methods.

Comprehensive and positive sexological care for TNB clients

All respondents in our study emphasized the importance of a biopsychosocial and sex-positive approach to sexological care, and warned against considering TNB clients as distinct from cisgender clients. Nonetheless, there were specific practices that they considered particularly important with TNB clients. Other studies have also highlighted the importance of attention for sex-positivity in clinical care for intersectionally marginalized or minority groups such as TNB people (Alexander, 2019; Iantaffi, 2012; Mosher, 2017). HCPs must be aware of how intersecting societal and identity-related factors contribute to the experience of a sexual problem (Alexander, 2019; Augustine, 2023). This awareness should extend into the consultation room, where the identity, attitude and care context of the sexological care provider may affect the therapeutic relationship. HCPs in sexology should therefore be able to critically reflect on their personal views and attitudes on sexual identities, beliefs and behaviors to ensure a sex-positive and safe context for sexological care (Augustine, 2023; Graham, 2023; Nimbi et al., 2022; Sanabria & Murray, 2018; Sitron & Dyson, 2012).

The findings of our study confirm how a sexual problem is rarely “a personal issue”, but one that emerges in a society where TNB individuals may face unique challenges to their sexual well-being. HCPs in our study touched upon several socio-cultural factors that they considered important in understanding a sexual problem in a TNB client, such as a lack of positive sexual role models, stigmatization, (the fear of) rejection and a lack of access to sexuality-related information, which have been described previously by several authors (i.e. Anzani et al., 2021; Goldbach et al., 2022; Iantaffi & Bockting, 2011; Kennis et al., 2022b; Prunas, 2019; Spencer et al., 2017; Ussher et al., 2020). Many HCPs considered it central to sexological care to collaboratively evaluate, and sometimes deconstruct, their clients’ views on sexuality in case these, as Rachel said: “may not serve them.” While Nimbi et al. (2022) highlighted that socio-cultural factors too often remain neglected in sexological care in general, our study underscores their particular significance in sexological care provision to TNB people.

Educating providers: whose care?

The need to educate one’s HCP about one’s healthcare needs is an important barrier to care for TNB people (Guss et al., 2019; Lerner et al., 2021; Lerner & Robles, 2017; Snow et al., 2019; Stewart et al., 2022). In sexology, the lack of clinical guidance or education on sexological care provision to TNB clients reinforces this issue. While a qualitative study by Graham (2023) stressed the importance of clinical intuition, she also noted that when “encountering novel issues, [clinical] intuition may be insufficient due to a lack of experience” (p. 309). Some respondents in our study, like Sita, also described her learning process on care provision to TNB clients through her clinical experience. To her, “curiosity and open-mindedness” had been the vehicles to necessary insights for sexological care provision. However, we argue that this example also illustrates the need for inclusion of information and tools related to sexological care provision to TNB clients in sexological education programs. This could better equip HCPs in sexology and prevent TNB people from having to educate sexological care providers with less clinical experience.

Particularly in the United States, several scholars have raised awareness for the need to tailor education of counselors in training to properly support TNB clients in relation to sexuality (Alexander, 2019; Augustine, 2023; Emelianchik-Key et al., 2022). To do so, research in this field is vital. Moreover, existing information and tools should be incorporated in the curricula of programs preparing HCPs for practicing in sexology, for example to aid a critical reflection on norms and biases, or in broadening conceptualizations of sexual attraction beyond a static and binary sexual orientation (Augustine, 2023; Cocchetti et al., 2021; Fielding, 2021; Graham, 2023; Nichols, 2020; Sitron & Dyson, 2012; Spencer et al., 2017; Spencer & Vencill, 2017). In addition, to prevent the essentialization of clients with a single-axis marginalized identity, sexological HCPs-in-training need to be supported to think intersectionally to understand how multiple axes of identity or social positions influence the experience of a sexual problem (Alexander, 2019; Augustine, 2023; Emelianchik-Key et al., 2022; Heredia & Rider, 2020).

Limitations and future research

Inquiry about clinical practices can never reveal the true complexity of clinical practice (Kumagai, 2014; Polanyi, 1966). By asking respondents to provide case descriptions to illustrate their practices, we tried to gain insight into their practice-based knowledge. The findings of this study could be supplemented by, or contrasted with findings using ethnographic methods (Reinders, 2010). The current study focused on practice-based of HCPs providing sexological care to TNB clients in the Netherlands and Flanders. Similar studies in different care context could provide additional depth and enable critical reflection on the current findings. No transgender people were involved directly in the design or conduct of this study. Direct involvement of transgender people in the design and analysis could improve the credibility, applicability and relevance of future studies.

Conclusion

In this qualitative interview study, we elucidated practice-based knowledge of experienced HCPs who provide sexological care to TNB clients. All HCPs emphasized that TNB sexuality and sexual issues should not be considered fundamentally different from the sexuality and sexual issues of cisgender people. However, HCPs described specific practices related to self-reflection on one’s positionality and care context and addressing the influence of societal cisnormativity in relation to a sexual issue. Respondents also related how they provide inclusive information on sexuality and unraveled the interactions between experiences of body image, GAMC and sexuality. Finally, they recounted stimulating their TNB clients to seek positive sexual experiences. As little scientific information exists on positive sexological care for TNB people, these insights can benefit providers-to-be in providing sexological care to TNB clients with a sexual issue. In the training of future sexologists, additional focus on self-reflexivity and client diversity could improve sexological care provision and sexual well-being of TNB people.

Acknowledgements

We would like to thank all respondents for participation. We would like to thank Ruth van Gelder for her support in transcribing the manuscript.

Disclosure statement

The authors report there are no competing interest to declare.

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.