Psychosexual Health and Well-Being of Trans and Gender-Diverse Individuals in Portugal

Abstract

This study aimed to explore and describe the perceptions of trans and gender-diverse individuals (TGD) in Portugal regarding the implications on their psychological, social, and psychosexual health. A qualitative investigation was conducted using an electronic interview answered by 32 participants. The data were examined through a thematic analysis, and the following themes were identified: experiences with healthcare services, social interaction, discrimination experiences, mental health, social support systems, self-esteem, social identity, sex and sexual health, quality of life, and sociopolitical enhancement strategy proposals. The analysis of these themes provides information on the perceptions and experiences of the participants and suggests factors that impact the well-being and quality of life of the individuals in the current sample.

1. Introduction

1.1. “Trans” and “Non-Binary” Concepts

The term trans encompasses the entire spectrum of people whose gender identity is not congruent with the sex they were assigned at birth [1] and it is important to consider the heterogeneity of this population [2,3] since the gender affirmation process is individual and self-determined with no mandatory steps to be followed [4,5]. However, these individuals are often associated with hormone therapy (HT) or gender-affirming interventions (GAI) as well as other legal procedures [3,6]. It is thus necessary to emphasize that they may or may not choose to undergo such procedures, even if they are considered important by many individuals in their affirmation processes. These procedures are increasingly sought after, especially by trans individuals within the binary framework [3,6], with the aim of achieving greater congruence between their body, gender expression, and gender identity [3,7]. However, it is worth mentioning that not all trans people feel that they have been born in the wrong body [8], as shown in a recent investigation with trans men, which found that masculinity is embodied in different ways based on different body patterns, which is a reflexive work in relation to the body and its expression of masculinity [9].

With this, it is important to note that not every trans person has a binary identity, meaning they do not necessarily identify as a man or a woman [10]. In this sense, the concept of non-binary emerges. Non-binary refers to people who are not identified in a static and crystallized way within the binary pole between men and women but may instead be fluid, agender, transgender, genderqueer, or any other designation/combination of gender identity designations [11]. These individuals are more likely to experience difficulties in accepting and recognizing their gender identity compared to trans people within the binary pole, which can lead to intensified feelings that their identity is not socially recognized and validated [12]. Therefore, it is important to recognize gender expressions and identities beyond the gender binary [3].

In the health context, the term gender dysphoria (GD) is used, which, according to DSM-5-TR, characterizes the persistent and prolonged distress associated with the incongruence felt between gender identity and sex attributed at birth [13]; in ICD-11, this phenomenon is labeled gender incongruence [14]. In Portugal, GD is a fundamental criterion to be diagnosed by two independent psychiatrists and/or psychologists specialized in clinical sexology for an individual to gain access to HT and/or GAI. Currently, these requirements are being challenged by public institutions, such as international political bodies and activist organizations advocating for the trans community, as human rights violations since they constrain individuals’ rights over their own bodies [3].

In this sense, health contexts can perpetuate stereotypes, as is the case of the binary concept of gender. Specifically, when a transgender individual seeks access to hormone therapy but has a non-binary identity or exhibits uncertainties regarding their gender-affirmation, many healthcare professionals tend to have reservations concerning the diagnosis of gender dysphoria. These reservations are based on their normative and binary views of the very concept of gender [10]. Thus, as a consequence, many trans individuals conceal their fears during the affirmation process to ensure they receive the GD diagnosis, aligning with the expectations held by healthcare professionals [10,15]. The concept of “regret” is often associated with transgender individuals. However, according to a Dutch study, 0.6% of transgender women and 0.3% of transgender men experience feelings of regret after a period ranging from a minimum of 46 to 271 weeks following the beginning of hormone therapy [16]. Nevertheless, the greater representation of trans and gender-diverse (TGD)1 individuals in the media and the increased accessibility and use of the Internet and social networks can be considered aspects that have influenced the increase in clinical sexology consultations by trans people in recent years and, consequently, greater social acceptance [16].

1.2. International Context

Internationally, TGD people are still underrepresented and are subject to stigmatization, discrimination, prejudice, harassment, abuse and violence [17,18], and their lives are led by anxiety and fear of experiencing these situations [18]. Discrimination rates are high in this community, as is the psychological, physical, and sexual violence to which they are exposed in different contexts (work, home, education, and health). As a result of this exposure, many TGD people experience negative consequences, ranging from psychological problems (depression and anxiety) to fear of leaving home or visiting certain places, especially if they need to present an identification document [17]. Furthermore, in many places around the world, TGD individuals have limited or non-existent access to legal gender recognition [19] and are subjected to gender-conversion therapies, aiming to make them cisgender people, which has a very negative impact [20].

It is important to note that although gender identity is not the same as sexual orientation, many countries use discriminatory laws regarding sexual orientation against TGD individuals [21]. There are 53 countries that, in some way, criminalize this population for asserting their gender identity, through persecutions, prison sentences, fines, and even physical punishments, such as flogging [21,22,23]. However, there are countries, such as Namibia, where the laws regarding penalties for TGD individuals are not very explicit. Furthermore, there are currently 11 countries that impose the death penalty on TGD individuals, namely: Afghanistan, Brunei, Iran, Mauritania, Nigeria, Pakistan, Qatar, Somalia, Saudi Arabia, United Arab Emirates, Yemen [22].

1.3. National Context

Portugal is the 11th country in the world and the 5th in Europe to legally recognize gender based on self-determination [9,24], which can be made at a minimum age of 16 years [25,26], together with the change of the given name, through the respective legal representatives and a medical report confirming ability in decision-making and informed consent [24,25]. Regarding current legislation and the legal recognition of gender, there have been positive impacts on the lives of people who have made this change in that they not only had greater satisfaction with life when compared to those who had not yet made this change but also showed greater psychological, interpersonal, and social well-being [27]. However, there is still no legal framework for non-binary gender [28], and when the Portuguese population was asked about this topic in the 2019 Eurobarometer, 43% were in favor and 42% were against [29].

This paradigm shift, at the national level, is largely due to the intervention of multiple associations and NGOs, which invest heavily in psychoeducation as a way of combating stigma and seek to work in partnership with public bodies so that these issues are discussed and subsequently bring about legislative and social advances. However, violent and discriminatory acts against TGD individuals continue to occur despite legal advances in Portugal and being prohibited by law. This leads many TGD people to feel that their freedom and self-determination are conditioned and that there is no coherence between the law and their day-to-day experiences, with the presence of violence, rejection, and exclusion in social and family relationships and in the job market [28].

1.4. Impact on Physical and Psychological Health

TGD people are exposed to multiple stressors throughout the different stages of their lives. These can be internal (internalized transphobia, hopelessness, fear of revealing their true identity, and victimization) and external (discrimination, violence in various forms, harassment, and rejection), which can have a negative impact on mental health [6,12,30,31]. Suicidal ideation and self-injurious behavior are the most prevalent psychopathologies in this population [12,31,32,33], as well as anxiety, depression, mood, and personality disorders [34,35,36]. Childhood is also shown to have a major impact on the lives of this population, which then ends up being expressed in adulthood. Most people report not only difficulties in emotional regulation but say they were also victims of abuse, neglect, and bullying, as well as parental mistreatment during their development years [37]. In addition to these difficulties, there is evidence that the teaching context itself is not prepared to intervene with TGD students, and that there is a lack of knowledge about the existence of protocols and/or guidelines for the prevention and identification of risk situations [38].

Following this logic, the impact of HT and/or GAI on the mental health of this population is generally positive, as it contributes to an increase in psychological well-being [6] and, consequently, a significant decrease in disruptive and self-injurious behavior [39].

In this context, it is important to explore how domestic violence is under-addressed and weakly punished when directed at TGD people [30], with trans women and non-binary people showing the highest frequency of physical, sexual, psychological, and emotional violence from those they live with, who are close to them, or even strangers [30,40]. Because these victims have already been exposed to violence in childhood, they often normalize the mistreatment they have experienced and are therefore very resistant to accepting that they are suffering from this type of violence [30].

Another type of violence that affects this community is the victimization of sex workers since the work context is not immune to the stigma associated with it. TGD individuals experience not only a high unemployment rate but also lower levels of dignity at work, resulting in greater precariousness [41,42]. These types of structural and interpersonal difficulties make this population more vulnerable, leading them to often resort to sex work to ensure survival [43,44]. As a result, the number of incidents of violence against TGD sex workers is higher than that against cisgender people (Cis) [45,46]. Additionally, being an immigrant is a risk factor that intensifies vulnerability to situations of violence in sex work. As a result of this source of survival, individuals internalize stigmas, especially when seeking health care [45].

The stigma and ignorance associated with TGD people is widespread and is incorporated into various contexts, including healthcare. TGD people who have used the National Health Service (NHS) report discriminatory acts, especially the use of prejudiced language by health professionals [47,48]. In this way, the NHS proves incapable of providing a dignified response to the needs of this population, as it can be seen not only in the lack of use of inclusive language, but also in the delay in the process of accessing GAIs [47], which is detrimental to the health and well-being of TGD people [10]. Often, as a way of responding to these shortcomings, TGD people tend to resort to private health services with high fees or even clandestine methodologies, which often prove to be harmful [10,28,49].

In this sense, based on a group of 32 self-identified TGD, this study aims to understand and analyze the components that make up their psychosexual health and well-being in the Portuguese context. Specifically, it examines their experiences with health services and the labor market, analyzes the existence of social and familial support networks, explores instances of discrimination in family, social, educational, and work contexts, identifies mental health challenges, delves into sexual matters, and understands the obstacles faced by these individuals. Additionally, it provides them with an opportunity to voice their suggestions for addressing these issues, thereby contributing to the scientific bibliography on this topic.

2. Materials and Methods

2.1. Participants

A total of 130 contacts were made, of which 32 individuals who self-identified as TGD (11 trans men (34.4%), 10 trans women (31.3%), 6 non-binary (18.8%), 3 fluid trans (9.4%), 1 trans feminine (3.1%), and 1 bigender (3.1%)) fully responded to the sociodemographic questionnaire and electronic interview, which made up the convenience sample for data analysis. The participants had an average age of 29.56 years (SD = 10.73), ranging from 18 to 59 years. In terms of sexual orientation, 31.3% self-identified themselves as bisexual, 21.9% as pansexual, and 15.6% as heterosexual. When asked about their satisfaction with life and their body or body image, using a Likert scale from 1 to 6 (1 = very dissatisfied; 6 = very satisfied), there were averages of 3.69 (SD = 1.09), and 3.41 (SD = 1.13), respectively. All sociodemographic information regarding the participants is described in more detail in

Table 1. Sociodemographic data of participants (n = 32).

Variable	Categories	n	%
Gender	Trans man	11	34.40
	Trans woman	10	31.30
	Non-binary	6	18.80
	Trans fluid	3	9.40
	Trans feminine	1	3.10
	Bigender	1	3.10
Sexual Orientation	Bisexual	10	31.30
	Pansexual	7	21.90
	Straight	5	15.60
	Queer	4	12.50
	Lesbian	2	6.30
	Gay	1	3.10
	Asexual	1	3.10
	Polysexual	1	3.10
	No label	1	3.10
Sexual Attraction 1	Cisgender women	21	22.30
	Cisgender men	10	10.60
	Trans women	15	16.00
	Trans men	9	9.60
	Non-binary people	11	11.70
	Fluid people	10	10.60
	Agender people	7	7.40
	Bigender	6	6.40
	People	2	2.10
	Feminine or androgynous people	1	1.10
	Women in general	1	1.10
	None	1	1.10
Marital Status	Single not dating	20	62.50
	Single but dating	10	31.30
	Separated	1	3.10
	Divorced	1	3.10
Education	Up to 9 years of school	1	3.10
	Up to 12 years of school	14	43.80
	BA	9	28.10
	Post-graduate	7	21.90
	Professional degree	1	3.10
Place of Residence	Small rural place	5	15.60
	Big rural place	3	9.40
	Small town	11	34.40
	Big city	13	40.60
Socioeconomic Status	Low	5	15.60
	Low-middle	14	43.80
	Middle	10	31.30
	Middle-high	3	9.40
Relevance of Interventions for Gender Affirmation	Yes, and I’ve already done some things	18	58.10
	I’m not sure/I have doubts	5	16.10
	Yes, but I haven’t done anything yet	4	12.90
	Yes, and the process is complete	2	6.50
	No and I don’t plan on doing anything	2	6.50
Others’ Perception of Your Gender	Passes as cisgender (gender congruent with the sex assigned at birth)	15	46.90
	Is seen as a trans or non-binary person	8	25.00
	Don’t know/not sure	5	15.60
	It depends	4	12.50
Hormonal Therapy	Yes	16	50.00
	No	16	50.00

¹ Multiple-response item, reflected in frequency and percentage.

.

2.2. Design and Procedures

This qualitative study aims to deepen our understanding of the phenomenon in question by exploring the experiences and perceptions of the people directly involved without claiming that the results are generalizable. To achieve the desired sample, and based on scientific literature, which has shown that the internet is a particularly viable source for sample collection, such as the TGD population [50], to reach the intended sample, an online protocol built for the purposes of this research, consisting of a sociodemographic questionnaire and an electronic interview, was disseminated through personal contacts and social networks, and remained online from 27 September 2023, to 7 November 2023. The sociodemographic questionnaire consisted of questions such as age, gender identity, sexual orientation, education, and marital status, and consisted of ten open-ended questions designed according to the main themes and objectives of the study to guide the data collection process (

Table 2. Questions submitted to the electronic questionnaire.

Many trans and non-binary people need to access health services, whether physical or psychological. In your case, how do you describe your experiences of contact with physical and/or psychological health services?

Regarding your day-to-day life, as a trans or non-binary person, how do you describe your social experiences, in relation to public and private services, neighbors, community groups, workplace, that is, your social interactions and activities?

If you deal (or have dealt) with experiences of discrimination, prejudice and/or stigmatization due to your gender identity (transphobia), how do you deal (or have you dealt) with them? What are its main sources (family, society, school, work, etc.). What impact do they have (or had) on your well-being?

For many trans and non-binary people, navigating a social context that does not always understand and respect non-cis gender identities may not be an easy task, leading to possible difficulties in emotional management. So, regarding your mental health, what types of challenges do you experience? Do you have a diagnosis of mental illness? Self-harm or suicidal behavior? Do you take any type of psychopharmacological medication? Do you have psychological/psychiatric support outside of clinical sexology consultations?

Regarding social support, how do you describe your support system from family, friends, or other people or community groups? Do you have people or groups you can count on, trust, or confide in? Who are these people (other trans or non-binary people, cis people, etc.)?

As a trans or non-binary person there are several factors that have had or have an impact (positive or negative) on your self-esteem, general well-being, or quality of life. Could you give us some examples?

Regarding your gender identity, as a trans or non-binary person, how would you characterize the experience of living as a gender minority in today’s society? For example, regarding issues such as access to housing, employment, education, health, income, etc.

Regarding issues of a sexual nature (sex and sexual health), what would be the main challenges you would like to highlight? (If applicable) (For example, issues regarding sexual behavior and pleasure; sexually transmitted infections; body image; rejection; sexual problems or difficulties; etc.)

If it were in your hands to take concrete measures to directly improve the quality of life of trans and non-binary people in Portugal, what would you recommend?

Is there anything else that you haven’t mentioned about this topic that you would like to add? Please elaborate.

). The study was conducted in accordance with the Declaration of Helsinki for studies involving humans, and it was approved by the Ethics Committee of the University of Beira Interior (Portugal)—CE-UBI-Pj-2024-022-ID2212. Participation was voluntary; there was no monetary compensation for it, and informed consent was obtained since all participants were aware of the research objectives and agreed to provide their personal data for this purpose. Confidentiality and anonymity issues were also ensured, with personal data protection guaranteed, including IP address encryption and database confidentiality. The inclusion criteria for this study were: self-identification as trans, non-binary, or another non-cis gender identity; being at least 18 years old; understanding the Portuguese language; and residing in Portugal.

2.3. Design Analysis and Tools

The data consisted of direct transcripts imported from the information provided by the participants in the electronic questionnaires, and thematic analysis was used to identify repeated patterns of meaning, that is, sets of information expressing similar ideas [51]. This analysis consisted of the following stages: familiarization with the data, creation of initial codes, searching for themes, reviewing themes, defining, and naming themes, and producing a report [52]. During this process, the Consolidated Criteria for Reporting Qualitative Research (COREQ) criteria [53] were considered as reliability criteria to guarantee credibility, dependability, confirmability, and transferability. In this study, we adopted an inductive approach, also known as the bottom-up approach, and theoretical saturation was used to avoid redundancies throughout the report’s production. This choice is in line with the aim of exploring in depth the experiences of the TGD people who took part, thus allowing a focus on the subjective experiences reported without the imposition of a pre-existing frame of reference. As for the level of identification of the themes, the study followed a predominantly semantic approach, and a codebook was drawn up to facilitate a more consistent and reliable interpretation of the data as well as better identification and categorization of the themes. These categories made it possible to compare the responses between participants to identify patterns and differences. For this study, we chose to use the codebook because of its ability to combine the reliability of coding with more reflective elements of thematic analysis [51]. This approach proved to be advantageous, as it allowed data analysis to be relatively objective while simultaneously involving a certain amount of controlled subjectivity. Supporting quotes from different participants are also provided throughout the presentation of the results as a way of adding transparency to the findings and interpretations of the data.

3. Results

Content analysis of the 32 participants’ responses revealed recurring themes spanning 10 categories, as shown in

Table 3. Themes and categories.

Themes	Categories
Interactions with Health Services	Interactions with Health Services s4 (4×), s6, s7, s9, s10, s11 (2×), s12, s13 (2×), s14, s19 (2×), s20, s22, s23, s24, s26, s27 (2×), s28 (2×), s30 (2×), s31 (2×)
Social Interactions	Experiences in the Job Market s4, s10, s11 (2×), s12 (2×), s13, s17, s18, s19, s21, s23, s26, s28, s31, s32 Sense of Socio-community Belonging s1, s5, s19, s20, s23
Discrimination Experiences	Discrimination s1 (2×), s2, s3, s4, s6, s11, s12, s13, s14, s17, s22, s23, s25 (2×), s26 (3×), s27, s29, s30 (2×), s31 (3x), s32 (2×) Transphobia s1 (3×), s4, s7, s10, s13 (2×), s14, s18 (3×), s21, s22 (2×), s23, s27, s28 (3×) Prejudice s1, s2, s15, s17 (2×), s19, s32 (3×) Restrooms s1, s4, s12, s13, s20, s24 Violence s6, s7, s12, s13 (3×) Genitalism s10, s12, s27
Mental Health	Psychological Support s1, s2 (2×), s3, s5 (2×), s6, s8, s9, s10, s11, s12, s13 (2×), s14, s18, s19, s22, s24, s25 (2×), s26, s27 (2×), s31, s32 Depression s1, s3, s5, s6, s7, s10, s12, s13 (2×), s14, s18, s19 (2×), s27, s28, s30, s31 (3×), s32 Psychiatric Support s3, s5 (2×), s6, s7, s12, s13, s14, s18, s19, s26, s27, s30 Dysphoria s3, s4, s5, s9, s12, s13, s14, s21, s25, s26, s29, s30 Anxiety s2, s3, s5, s12, s13 (2×), s17, s18 (2×), s19, s26, s27, s30, s31 Coping s1, s3, s4, s5, s6, s8, s11, s13, s21, s22, s26 (2×), s31 Suicidal Ideation s1 (2×), s5, s8 (2×), s12, s13, s18, s19 (2×), s27, s30, s31 Mental Illnesses s3, s6, s13, s18, s21, s26, s27, s31 Gender Discomfort s2, s4, s8, s12, s13, s15, s27 Self-harm s4, s5, s7, s8, s12, s31 Suicide s4, s7, s10, s12, s18 Internalized Transphobia s5, s7, s25, s31
Social Support System	Family Support s1 (3×), s3, s4, s5, s7, s8, s9, s10 (2×), s11, s12 (2×), s13 (4×), s14, s15, s17 (2×), s18 (3x), s19, s2, s21, s22, s23, s24, s26, s27, s28, s30, s31 Support from Friends s4, s6, s7, s8, s9, s10 (2×), s11, s12, s14, s17 (2×), s19, s20, s21, s23, s24, s25, s26 (2×), s27, s28 (2×), s29, s31, s32 Social Support s1 (3×), s2 (3×), s3, s4 (2×), s5, s6, s10 (2×), s11, s18, s20, s21, s22, s23, s24, s25, s26 (2×), s27 Meaningful Relationships s7 (x2), s8, s11, s13, s15
Self-esteem	Self-esteem s1 (3×), s5, s10, s13 (2×), s15, s17, s18 (2×), s19 (3×), s22, s23, s24, s27, s28, s32 Self-confidence s1 (2×), s13, s15, s17, s23, s25, s26 Cis Comparison s2, s27, s29
Social Identity	Invisibility s1, s2 (3×), s5, s6, s7, s8 (2×), s12, s13, s15, s16 (2×), s19 (4×), s21, s25, s26, s27, s30 Passing/Blending s1(3×), s3, s13, s14, s17, s19, s25 Visibility s1 (3×), s4, s13, s15, s19, s27 GAI s4 2×, s5, s11, s21, s32 (2×) Housing s1, s2, s7, s18, s31
Sex and Sexual Health	Health and STIs s1, s2, s9, s17, s20, s26 Sexual Discomfort s4, s8, s10, s12, s30 Sexual Objectification s1, s2, s9, s26, s31 Packer Usage s4, s10, s13 (2×) Sexual Intercourse s6, s11, s18
Quality of Life	Well-being s1, s12, s13, s18, s23, s24 (2×), s27, s31, s32 Fear s1, s2, s4, s5, s7, s15, s19, s30 Acceptance and Respect s1 (3×), s2, s11, s20, s24, s28 Quality of Life s1, s18, s23
Sociopolitical Enhancement Strategy Proposals	Legal Factors s1, s2 (2×), s13, s17, s19 (3×), s20, s22, s25 (3×), s26 (3×), s28 (2×), s29, s31 (5×), s32 Investment in Education and Awareness on the Topic s1 (2×), s2, s13, s15, s17 (2×), s19, s22, s23, s24, s26 (2×), s28 Faster and More Effective Health Services s4, s6, s7, s8, s17, s21, s24, s27, s28, s29, s30 Greater Training of Professionals Across the Country s6, s11, s12, s19, s22, s24, s27 Health Specifics for LGBTQIAPN+ People s6, s7, s8, s13, s22, s29 Integration of TGD People in The Job Market s13, s15, s16, s17, s18 (2×) Greater Visibility in the Media s1, s13, s18, s24 Inclusion of Neutral/Fluid/Non-binary/Trans Genders Topics in the Law s7, s9, s19, s20 Economic Reinforcement of the NHS s6, s10 (2×), s27 Facilitate Access to Hormone Therapy s12, s14, s25 Control of Discrimination Against TGD People s19, s31

Note. S represents each participant who reported a certain category when analyzing the results. GAI = gender-affirming interventions. STI = sexually transmitted infections.

. Below are the descriptions and discussions of these themes, providing illustrative quotes from the participants.

3.1. Interactions with Health Services

Several TGD people describe the existence of discrimination and non-inclusion in their experiences of contact with health services from going through situations where ethics are not complied with, where there is a refusal to perform GAI, and the assessment of the individual’s gender identity based on the domestic tasks they perform [47]. These individuals also experience situations of ridicule, hear that the changed sex on their identity card is incorrect, and experience situations of discouragement from exploring their gender identity and denial of this by doctors [48], as well as the denial of services and information [54,55]. There are several difficulties that this population experiences in accessing health services [56], something that is present in this investigation, whereas some participants reported experiences of discrimination in these contexts, as can be seen in the following transcriptions:

I choose the ones I know are inclusive, as I have been a victim of queerphobia and denial of care. (Non-binary, 27 years old, queer)

Terribly, there is basically no public health in this country, especially aimed at the LGBTQIAPN+ population. (Trans man, 28 years old, pansexual)

On the other hand, several subjects mentioned long waiting times, something that has already been described in the literature [47] by a response from such services as something negative:

In hospitals it has been a somewhat difficult experience, due to bureaucracy and long waiting lists for 15-min appointments. (Trans man, 24 years old, bisexual)

The entire process has gone well, despite some delays and setbacks, which become frustrating. (Trans woman, 55 years old, lesbian)

Some participants reported positive experiences with these services despite long waiting times, demonstrating being satisfied with them:

My experience has been very positive, I am very satisfied with the service provided at a hospital, in Lisbon, despite the big problem with the National Health System, where everything takes forever. (Trans woman, 47 years old, bisexual)

As a woman who uses the National Health System for general medicine consultations, I am very satisfied with the service. (Trans woman, 59 years old, pansexual)

Finally, it is known that there are TGD individuals who use private health services [10,28], as is the case with some participants in the present investigation, since they felt that public health services are unable to provide an adequate response:

I turned to private health insurance, having found it easier for those who have conditions like mine, but for those who don’t, unfortunately, I feel that there is a gap in public care for trans lives. (Trans man, 24 years old, bisexual)

Contact with public health services was rubbish, having resorted to the private sector, after several attempts at public follow-up, where there were constant cancellations of appointments, and when I finally managed to get follow-up there, in the second consultation, the doctor retired, no having been replaced by another. (Trans man, 25 years old, heterosexual)

3.2. Social Interactions

3.2.1. Experiences in the Job Market

It is known that in work contexts, TGD people are more vulnerable to experiencing discrimination when looking for a job [56,57], which can take different forms, such as difficulties in finding a job, being fired or denied promotions, consequently developing health problems and experiencing moral or sexual harassment [58], and it is possible to verify that such events have been felt by some of the participants in the following transcripts:

I was fired after a month of experience in a store, solely and exclusively for not having a cisgender appearance, having been told that I didn’t have the company’s image. (Non-binary, 22 years old, pansexual)

Looking for work is one of the situations in which I feel most vulnerable to transphobia, to the point of being unemployed. (Transfeminine, 29 years old, bisexual)

To mitigate instances of discrimination, such as those previously mention situations, some individuals choose to conceal their TGD identity, their history affirmations, or their association with the TGD community in various contexts, particularly in the workplace, out of fear of negative responses from others [59,60], as we can observe in these reports:

Regarding work, I hide my transition at all costs because I was always fired because of who I am and I was known at one job as the guy who urinated while sitting down. (Trans man, 22 years old, heterosexual)

It is known that TGD people often end up resorting to sex work due to the low employability they are affected by, the existing discrimination, and because of the prospective income they can achieve by doing this work [43], as seen in the following quotes:

I have been working in the sex industry for 5 years between Brazil and Portugal, despite it being a job that provides me with good financial results and security, and through it I was able to have my surgeries, I don’t feel happy. (Trans woman, 36 years old, heterosexual)

However, some participants reported positive experiences in the job market, with feelings of belonging and a low frequency of discrimination experiences:

I am welcomed by my co-workers even though there is always one or two who don’t respect me. (Trans man, 24 years old, bisexual)

I have never experienced any transphobic situations in work environments. (Trans woman, 36 years old, asexual)

3.2.2. Sense of Socio-Community Belonging

As they experience stigmatization, prejudice, and discrimination, TGD individuals may feel that their access to social support is compromised, and this phenomenon is intensified by the presence of internalized transphobia, which in turn leads to feelings of guilt and shame [61]. As we can see in the following transcript, an individual reported feeling little socio-community belonging:

Almost non-existent social support, few people know. (Trans woman, 29 years old, bisexual)

On the contrary, in the present sample, we also found individuals who felt integrated in their social contexts, as can be seen:

The vast majority of the social interactions I have are positive, both in the neighborhood and in the community groups in which I am part. (Non-binary, 23 years old, no labels)

I don’t feel like I’m a gender minority, I feel integrated into society like anyone else, with normal access to all contexts. (Trans woman, 59 years old, pansexual)

It is important that TGD people have a sense of belonging to their community, which is an important protective factor for their mental health and resilience, functioning as a support and promoting stability [62,63]. Some individuals tended to unite with people with similar life experiences as a way of finding a sense of belonging:

I have feelings of belonging due to the unity within the community itself. (Fluid trans. 28 years old, queer)

The vast majority of people I can count on are cis, although they are part of the community in other ways. (Non-binary, 20 years old, bisexual)

3.3. Discrimination Experiences

3.3.1. Discrimination

Discrimination is something that is very present and experienced by people who identify as TGD, and the more they affirm and live their identities openly, the more vulnerable they are to situations of discrimination compared to people who, on the contrary, hide it [64]. In the following reports, we analyzed the situations of verbal and non-verbal discrimination:

I experienced a situation of discrimination in the center of a city in the interior of the country, in which an individual verbally attacked me, shouting threats, at around 3pm. (Non-binary, 23 years old, no labels)

Social interactions are good, when they don’t know about the transition; after becoming aware of it, everything changes, it becomes unpleasant due to the looks and comments. (Trans man, 22 years old, heterosexual)

At university, being in the field of chemical engineering, I sometimes feel resistance to my presence, as if they subtly wanted me to change programs. (Non-binary, 22 years old, pansexual)

This last individual’s revelation is consistent with the findings that engineering students have more negative attitudes towards TGD people than other academic areas [65].

In the present study, the sample included some individuals originally from Brazil, who currently live in Portugal, with the following report of discrimination, which occurred in the participant’s country of origin:

I was attacked for being transgender, tortured for 1h40 min with punches, kicks, belts, scissors, and a firearm, it was traumatizing. (Trans man, 28 years old, pansexual)

One form of discrimination most felt by our participants was not seeing their identity respected, often being addressed by their legal name rather than their social name, and experiencing cisnormative and heteronormative assumptions about their identity [54], as we can analyze in the following passages:

People don’t respect my gender identity or immediately assume that I have the gender I was assigned at birth and with which I don’t identify, which is worse when these people are close to us and/or even family members. (Trans man, 21 years old, pansexual)

In the case of public or private services, administrative staff, due to lack of knowledge or will, do not respect the social name. (Trans woman, 47 years old, bisexual)

It is known that respect for the social name chosen by TGD people predicts lower depressive symptoms and ideation, as well as suicidal behavior [66]. In this investigation, we also found individuals who reported not suffering any type of discrimination in their lives, as we can analyze in the following transcripts:

I am fortunate to not experience discrimination or any type of negative attention from other people. (Non-binary, 33 years old, polysexual)

I have never felt discrimination, prejudice, or stigmatization, because I am trans, I feel perfectly accepted by the world around me. (Trans woman, 59 years old, pansexual)

3.3.2. Prejudice and Transphobia

TGD individuals report receiving negative social messages regarding their gender identity, often being seen as aberrations with mental problems and deviant sexual behavior and as inherently being liars for being dishonest about their gender [67]. These individuals are often victims of harassment, trauma, and sexual assault, with non-binary individuals presenting the highest values [68]. In this investigation, we found individuals who suffered from prejudice and transphobia on a daily basis, occurring in different contexts:

Transphobia is daily, it accompanies me just because it exists. (Trans man, 28 years old, pansexual)

I don’t often receive openly transphobic attacks, but microaggressions and covert transphobia are (too) normal in my daily life, coming from everywhere. (Transfeminine, 29 years old, bisexual)

There were individuals who, out of fear of prejudice, tended to hide their identity as a way of preventing this from happening, as we can analyze in the following report:

For fear of prejudice, I don’t talk about being trans with anyone outside my family circle. (Trans man, 45 years old, bisexual)

3.3.3. Restrooms

TGD people tend to face discrimination related to the use of public bathrooms [69], and many are prohibited from accessing the toilet they identify with. In these moments, they end up not being treated by the correct pronouns [70,71], as we can analyze in the following report:

At a nightclub I was kicked out of the women’s bathroom twice, the one I identify with and feel safe going to. (Non-binary, 23 years old, no labels)

These events result in, in many cases, total avoidance of using public bathrooms due to discriminatory barriers to access [71] and the insecurity they feel [70], leading individuals to try to hold their need to urinate for as long as possible and feel safe when using individual bathrooms. These circumstances lead to fear and trepidation in these people regarding the use of such spaces, as we can see in the following statements:

Constant fear of using the gym changing rooms and similar spaces, or of someone who doesn’t accept it, is foolish, finds out and wants to harm me. (Trans man, 22 years old, pansexual)

As there aren’t always bathrooms with doors, I have to hold my urine for hours until I find a bathroom with a door and a toilet, it’s inhumane and certainly affects the self-esteem of any trans man. (Trans man, 28 years old, pansexual)

3.3.4. Violence

As previously mentioned, TGD people are vulnerable to various forms of violence, both physical and psychological (see: [17,28,30,40]. In the following transcripts, we can analyze the experiences of these two forms of violence felt by two individuals:

The biggest source of my mental health challenges is the psychological violence that my mother and I suffered from my father. (Trans man, 20 years old, bisexual)

I have already been raped by a cisgender woman and I was never taken seriously, because I am trans and because I am a man. (Trans man, 22 years old, heterosexual)

3.3.5. Genitalism

Genitalism is what we conventionally call the set of ideas, signs, and symbols that have been constructed over time to create a discourse in our society about the idea of genitalia. This was mentioned by some of our participants:

I have always been physically rejected and I apologize in advance for citing the expression I hear most often: “you have a vagina, how disgusting!”, only being able to engage with me, if there was no type of contact with my body. (Trans man, 22 years old, heterosexual)

I went through an episode of genitalism, but I didn’t let it affect me. (Trans man, 24 years old, bisexual)

Some TGD individuals reported not feeling respected and accepted by cis people belonging to other sexual minorities [67], as we can analyze in the following transcript:

I have been rejected many times by gay cis men, for having female genitalia and making them confused or not being shaved like many cis women, they diminish the man I am because I don’t have a penis like them and that affects me. (Trans man, 24 years old, bisexual)

3.4. Mental Health

This population experiences significant disparities in mental health [72] and, in addition to the stressors that the general population experiences, they are vulnerable to higher rates of discrimination, violence, and rejection due to their identity and/or gender expression [73] as well as internalized transphobia [74]. It presents a higher prevalence of mental health problems [75], with symptoms of anxiety and depression [56,69] as well as suicidal ideation [56]. In the following transcripts, it is possible to analyze how these two participants felt about their mental health:

I feel like my mental health is often affected by my trans experience. (Non-binary, 22 years old, pansexual)

Our emotional and psychological lives are very shaken. (Trans woman, 36 years old, heterosexual)

This phenomenon of TGD people experiencing very specific stressors due to their gender identity and/or expression is known as minority stress, a process that develops on a continuum from distal stressors, which involve events external to proximal stressors, which are more subjective, as they depend on individual perception and assessment [76]. Distal and proximal stressors are positive predictors of suicide attempts and depressive and anxiety symptoms; in contrast, they are negative predictors of well-being [2,77,78]. This specific stress can be analyzed in the following excerpts:

A certain way of acting and dressing is often imposed on me, with which I do not identify, which causes me some suffering. (Trans fluid, 19 years old, bisexual)

As a trans person, I feel like I don’t have much space to be vulnerable, I feel a constant need to be and do my best. (Non-binary, 22 years old, pansexual)

3.4.1. Psychological Support

In the present sample, we found individuals who currently benefited or have benefited in the past from psychological support, as we can analyze in the following quotes:

I am lucky enough to undergo psychological therapy with a person trained in gender and trans-identity studies. (Non-binary, 33 years old, polysexual)

In psychological terms, I was very well supported through a community organization, which helped me with everything in the beginning of my process and I owe it everything I managed to achieve. (Trans man, 24 years old, bisexual)

3.4.2. Depression

Higher levels of clinically significant depressive symptoms are found in TGD people [2], as well as anxiety and psychological suffering, which in turn score lower in relation to well-being [68,77]. It is known that among gender-minority individuals, non-binary people present greater depressive symptoms and psychological suffering [68,78]. It is also known that people with TGD life experiences who have low levels of resilience tend to have higher levels of depressive symptoms [56]. In the following transcripts, we can see reports from individuals who mentioned having been diagnosed with depression or having been diagnosed with depression in the past.

I have been diagnosed with major depression. (Fluid trans, 28 years old, queer)

I already had depression and I had a good team at the National Health Service, who helped me overcome it. (Trans woman, 55 years old, lesbian)

3.4.3. Psychiatric Support

In the present sample, some individuals said they had received psychiatric care, as can be seen in the following transcripts:

I have regular psychiatry appointments. (Non-binary, 22 years old, pansexual)

I am followed at a public hospital in psychiatry. (Trans man, 24 years old, bisexual)

3.4.4. Dysphoria

Individuals who experience GD have higher levels of depressive symptoms and those who experience less GD have higher scores in terms of well-being [77]. As we can see in the following transcript, an individual felt an improvement in his GD after performing GAI:

My dysphoria and feeling unwell have reduced considerably since I managed to have the mastectomy privately, however my dysphoria is coming back with a vengeance, due to the waiting time for phalloplasty. (Trans man, 22 years old, pansexual)

However, GD is a dynamic process in the sense that as some dysphorias are resolved in the individual, others may emerge, as can be seen at the end of the previous transcription. In the present study, it was also possible to analyze the existence of several participants who reported the negative impact that GD had on themselves:

One of the main challenges I feel is that I have a vagina and breasts, while I would like to have a penis. (Trans man, 18 years old, bisexual)

It’s always a challenge to get out of bed, look in the mirror and only be able to see a female body and not one that corresponds to how I identify, ending up not being able to look in the mirror some days. (Non-binary, 20s, bisexual)

There are temporary ways to try to mitigate the effects of GD on individuals such as tucking, which is a practice used predominantly by trans women, or TGD individuals, with a penis aiming to hide the contour of the penis and testicles. It is common for these techniques to be reinforced with compression underwear or specific clothing for this purpose as well as with adhesive tape. These techniques can lead to dermatological lesions due to genital compression, which can be avoided through appropriate anogenital care [79]. This practice can be analyzed in the following excerpt:

At the time I was missing the name, dysphoria… in fact it was about not being able to enjoy seeing that little lump in my groin. I tried to ignore it, then I wore underwear that was a size smaller than mine (it left me very sweaty with marks, causing me discomfort or pain quite a few times). Nothing about my clothing brought me comfort until the first day I looked in the mirror with my penis tucked in and my groin area smooth, since then it has become something I have done, for a year and a half, daily, something that has allowed me looking in the mirror and not feeling disgusted… tucking gave me confidence, it made me feel like myself. At the same time, it’s something that I had to investigate on my own and “invent” for myself, I feel that even today I’m reinventing the tucking I do, improving it. I feel that there is a lack of information on how to do it specifically and especially how to do it comfortably and without health risks. (Non-binary, 22 years old, pansexual)

It is important to highlight that GD occurs in a certain context and space of time, with the following transcription exemplifying this phenomenon:

Inside the bubble, life runs naturally, outside bubble, dysphoria takes place. (Fluid trans, 34 years old, pansexual)

3.4.5. Anxiety

TGD individuals experience more symptoms of anxiety and social anxiety [2] than cis individuals, as shown in the following transcripts:

I feel like I’m an anxious person and sometimes I have panic attacks, there are phases in which I don’t want to go out for anything, and I wait for it to pass, trying to distract myself. (Trans woman, 29 years old, heterosexual)

I have been diagnosed with generalized anxiety disorder. (Fluid trans, 28 years old, queer)

Non-binary individuals tend to suffer more anxiety than trans people within the gender binary pole [68], as can be seen in the following excerpts:

Mainly I feel anxiety, and I’ve felt that something more could happen to me at any moment (attacks…), but I’m better regarding that now. (Non-binary, 24 years old, gay)

I have a diagnosis of anxiety for which I take sertraline and sedoxil every day, and in emergency cases, victan. (Non-binary, 20 years old, bisexual)

3.4.6. Coping

In general, TGD individuals tend to use some strategies to deal with situations of discrimination [55,80], such as affirming their identity [62], disseminating information, and defending their rights, but also through internalization, distancing, and resistance, such as drug use [69], with cannabis being the most prevalent [81]. Resilience in this population is a protective factor against the effects of stigmatization on mental health [62]. However, it is known that perceived discrimination predicts loneliness experienced by TGD people, with coping strategies playing a mediating role between perceived discrimination, psychological health, and loneliness [82]. Below, we can analyze some representative excerpts of coping strategies used by some of the participants in this study:

I am a transgender activist; I have made public publications about LGBTQIAPN+ rights vs. Law. (Trans man, 28 years old, pansexual)

In relation to situations of discrimination, I run away if I can, otherwise I don’t respond and leave the place. (Trans woman, 36 years old, asexual)

When people stigmatize me, I tend to tell people to fuck off. (Trans woman, 22 years old, lesbian)

3.4.7. Suicidal Ideation

It is known that TGD individuals have a higher prevalence of risk factors when it comes to suicidal issues, both in terms of ideation and attempts [2], because of discrimination exposure and the shame they feel in their daily lives [56], depressive symptoms, lack of social support, minority stress, and social disintegration, which many of these people feel throughout their lives [83]. In contrast, there is a reduction in suicidal ideation when there are higher levels of resilience [56]. In this sample, some participants were identified with levels of suicidal ideation, as verified in the following excerpts:

Sometimes I think about going to sleep and not waking up, that would be the best solution for my problems. I wish I had the courage to end my own life, but I never tried to make any attempt. More recently and for the first time, I had the idea of taking a pack of calming medications, but I only had the idea for a few seconds, I didn’t have it in my head, and I quickly eliminated this thought. (Non-binary, 23 years old, no labels)

I have already planned suicide and suicidal thoughts appear with some regularity. (Trans fluid, 19 years old, bisexual)

3.4.8. Mental Illnesses

Individuals in the present sample reported the presence of mental disorders, particularly those related to neurodivergence, which has been increasingly correlated with TGD identities. There has been a noted prevalence of autism spectrum disorders and attention deficit hyperactivity disorder, although the latter shows results with limited significance [84,85,86]. However, further studies are necessary to understand the reasons and specifics of these correlations (See: [87]). Next, we can analyze some participants in the research who revealed some of these characteristics:

I’m Asperger. (Trans woman, 36 years old, asexual)

I am a neurodivergent person (autism and ADHD) and dyslexic. (Non-binary, 22 years old, pansexual)

I have diagnosed C-PTSD/ADHD. (Trans woman, 22 years old, lesbian)

Additionally, there were instances of bipolar and borderline personality disorders and alcohol consumption disorders, as evidenced by the following transcripts:

I am diagnosed with bipolar disorder. (Trans man, 18 years old, bisexual)

I am treated for alcoholic disorders. (Trans man, 28 years old, pansexual)

I am currently diagnosed with borderline personality disorder. (Trans man, 24 years old, bisexual)

3.4.9. Gender Discomfort

Throughout the interviews, the gender discomfort felt by some of the participants was notable, from the discomfort felt when using public bathrooms to the inability to see their image reflected in the mirror, to the discomfort that makes it impossible to reach sexual satisfaction with the presence of orgasm, as can be seen in the following quotes:

Related to gender discomfort, I go through it when I go to a public health place and want to use a bathroom. (Non-binary, 24 years old, gay)

My lack of comfort with my body can make it difficult for me to reach orgasm when I’m having sex with my girlfriend, I feel the need for a lot of physical contact or to be covered up. (Fluid trans, 19 years old, bisexual)

Not being able to see myself in the mirror, going to the beach. (Trans man, 22 years old, heterosexual).

When I go to the beach, I wear a shirt, even though I’ve already had surgery. I don’t swim in pools, as I don’t go shirtless in public. (Trans man, 45 years old, bisexual)

3.4.10. Self-Harm and Suicide

TGD individuals are more likely to engage in self-injurious behaviors [68,88], think about suicide [57,68], and have attempted suicide in the past, with non-binary individuals showing higher levels of self-harm and suicidal ideation [68]. As protective factors for these behaviors, significant relationships with family and other people stand out [88], higher education levels, and lower levels of internalized transphobia [89]. Access to HT is also associated with a lower likelihood of attempting suicide [2]. In the present investigation, we found some individuals with self-injurious behaviors and suicide attempts, as well as the two combined, as we can observe in the following transcripts:

I only made one attempt, and it was 2 years ago, during a suicidal episode. (Transfeminine, 29 years old, bisexual)

I have made several suicide attempts and have been cutting myself since 8th grade. (Trans man, 20 years old, bisexual)

I’ve been hospitalized for a few months for self-injurious and suicidal behavior. (Trans man, 22 years old, pansexual)

In some cases, participants resorted to socially accepted forms of self-mutilation, such as getting tattoos and piercings, as it can be seen in the following transcript:

I developed masochistic characteristics, my interest in tattooing and piercing is related to the stimulus of controlled pain. (Trans woman, 22 years old, lesbian)

3.4.11. Internalized Transphobia

Minority individuals tend to internalize negative attitudes and prejudices associated with them [73], as part of their own value system, adapting their self-concept to be congruent with stigmatizing responses [90]. In the case of TGD people, this process is known as internalized transphobia, which can be conceptualized in four dimensions, namely, pride, passing, alienation, and shame, and it is possible to analyze this as a process of minority stress [91]. This phenomenon is not directly observable but is still potentially harmful [73], as it increases the likelihood of developing psychological problems, such as depressive and anxiety symptoms, as well as being related to feelings of greater loneliness, less social support, and psychological well-being since these individuals have the perception of being alone in a world where stigma exists [61,92].

Some of these individuals are aware that the negative social messages associated with them have an impact on the development of beliefs that their identity is wrong, having already questioned at some point whether such messages are valid and having already experienced difficulties in affirming their identity as a gender, feeling satisfaction with their own body, and believing in the value of their life [67]:

Misgenders make me feel as if to be a man I need to be as masculine as possible. Being trans makes me feel, and I’ve been told, like I’m a freak. I don’t feel normal. I just want to be normal. (Trans man, 20 years old, bisexual)

There are times when I feel a kind of impostor syndrome, like I’m not trans enough. (Non-binary, 33 years old, polysexual)

Internalized stigma can be directed towards oneself and towards others [90], as we can see in the following quote:

I still have a certain amount of internalized transphobia, which makes me feel strange when I interact with people with a non-conforming gender expression, not because I disregard their experiences, but because my attraction complex is formatted in a cisnormative way, and I have been instilled with an idealized notion of the female body to which I feel attracted. (Trans woman, 22 years old, lesbian)

3.5. Social Support System

3.5.1. Family Support

TGD individuals are more likely to experience insults and ridicules in the family context [71] and receive less support from them [57], which is related to greater depression and anxiety symptomatology [92]. In the following excerpts, we can analyze individuals have felt discriminatory behaviors and lack the support of their family members:

Most of the transphobia I received was from my own family, and it hurt me more than anyone else. (Trans man, 20 years old, bisexual)

I tend to hide it from my family because they try to dissuade me from the hormonal treatments. (Trans woman, 36 years old, asexual)

On the contrary, when parents accept and affirm their gender identity, the positive impact on their children’s mental health is notable [70], as we can analyze in the following transcripts:

I am a person who relatively has support from my family, and I believe that this also makes the process much easier. (Trans man, 24 years old, bisexual)

I have my family, who is very supportive and accepting of me, even though I think they could do better, I know I’m luckier in that regard than other queer people. (Transfeminine, 29 years old, bisexual)

3.5.2. Support from Friends

TGD people tend to establish relationships with people with experiences close to them, often developing family feelings towards them, as we can analyze in the following quotes:

I have support from a family that I consider mine now, which are my best friends, one of them is also trans and has been an important pillar, we have been through everything together, we are both waiting to have gender-affirmation surgery. (Trans man, 22 years old, pansexual)

I count on a range of trans people, some who helped me in some situations, others who I helped. (Trans man, 24 years old, pansexual)

It is known that TGD individuals have lower levels of perceived social support and psychological well-being [93], which often occur due to situations such as the following:

Some friends ended up moving away… Well, those weren’t really friends, so it ended up being positive. (Trans woman, 55 years old, lesbian)

3.5.3. Meaningful Relationships

There were individuals who identified with whom they maintained romantic relationships as a source of support, as we can analyze in the following transcripts:

I have an incredible boyfriend; I feel safe and good with him. (Trans man, 20 years old, bisexual)

My main source of support is my girlfriend. (Fluid trans, 19 years old, bisexual)

These people often realize that society stigmatizes individuals who are attracted to them [67].

3.6. Self-Esteem

3.6.1. Self-Esteem and Self-Confidence

The self-esteem of TGD people often deteriorates because of high levels of internalized transphobia [94] and exposure to victimization and discrimination, as shown in the following excerpt:

After an event of discrimination, I felt a loss of confidence and self-esteem to assert my identity in society and regressed my entire process. Not being able to be myself 24/7 as I would like, because of my insecurities and fears about social responses about myself, obviously has an impact on depressive feelings and sadness. (Non-binary, 23 years old, no labels)

On the contrary, when a person sees and accepts their identity, there is a positive impact on their self-esteem and confidence as well as a reduction in internalized transphobia. Therefore, self-recognition and acceptance translate into greater freedom of identity [62]:

Acceptance of my own identity began when I started my hormonal treatment; this had a very positive impact on my self-esteem, on feeling alive, on wanting to live on my well-being, and overall quality of life. (Trans feminine, 29 years old, bisexual)

I consider that both my self-esteem and my general well-being have improved exponentially with the progress of the process of (re)constructing myself. (Trans man, 34 years old, queer)

3.6.2. Cis Comparison

A phenomenon that could be accessed in the analysis of the present sample was the comparison that TGD people feel towards cis people, whether these are in terms of beauty standards and gender expression or in terms of legal terms and rights, as we can see in the following transcripts:

Something that has a negative impact on me is the comparison I face as a feminine guy, in relation to cis women. (Non-binary, 24 years old, gay)

I think we have rights, but not as many as cis men, which should be changed, because we are people like everyone else. (Bigender, 19 years old, queer)

3.7. Social Identity

3.7.1. Invisibility

Invisibility occurs when an individual’s gender identity is not affirmed by another, for example, a trans woman, being seen and treated as “sir.” This situation is very stressful for those who experience it [95], causing feelings of devaluation, or even exclusion from different sociocultural contexts, often leading to feelings of ridicule [67]. In the following excerpts, we can analyze the impact of these situations on our participants.

There is always a part of me that does not feel fulfilled, because I believe I would not be fully understood, so I end up passing as cis, which often deteriorates me mentally, having a direct impact on alienation and depressive levels. (Fluid trans, 28 years old, queer)

In health services I have been treated as a man since that is my predominant physical appearance. (Trans woman, 48 years old, heterosexual)

In terms of relationships, some of my partners had problems making our relationship public to others. (Non-binary, 24 years old, gay)

3.7.2. Passing/Blending

Passing, also known as blending, is an increasingly used term within the TGD community [60]. It involves the process by which TGD individuals within the gender binary strive to affirm the gender with which they identify, using various esthetic and surgical procedures. Consequently, they feel more accepted the closer their appearance aligns with that of a cisgender person, and simultaneously, their likelihood of facing rejection decreases [96]. Next, it is noticeable that individuals who have achieved a certain level of passability, as one individual notes, also experienced a reduction in instances of discrimination:

Having a certain degree of passability as we call it, increased the probability of getting a job. (Trans man, 28 years old, pansexual)

Ironically, I think I pass as a cis person enough times that I don’t feel discrimination. (Non-binary, 33 years old, polysexual)

However, although passing/blending may provide relief from marginalization in certain contexts, it may also impact the devaluation of the true identity of TGD individuals, thus becoming a minority stress factor [60]. Furthermore, it can cause distress by reinforcing binary gender norms, creating a distinction between those who “pass” and those who are excluded [96]. Additionally, TGD individuals may pass as cisgender even if they do not intend to conceal their TGD identity [60]. In the following excerpt, we can observe the impact that not passing as a cisgender woman has on a trans woman:

Not being able to be cisgender has many consequences in terms of social discrimination. (Trans woman, 36 years old, asexual)

It is important to note that many individuals who do not “pass” often maintain a fluidity between genders or a lack of definition thereof [96]. Moreover, they may choose to adapt by engaging in passing/blending and, in doing so, conceal behaviors and aspects of their appearance [60]. As we can observe in the following citations, non-binary and gender-fluid trans individuals may have succeeded in passing/blending as cisgender but experienced psychological impacts as a result:

I can still pass as a cis man when I want to, making it easier to adapt to society and have its respect. (Non-binary, 23 years old, no labels)

I end up passing as cis, which often deteriorates me mentally. (Fluid trans, 28 years old, queer)

3.7.3. Visibility

The affirmation of gender identity consists of social recognition and the support received from other people for their expression of identity, and when this recognition occurs, TGD individuals tend to express their identity with greater confidence and self-esteem [62]. As can be seen in the following transitions:

Being able to express myself and be myself in the community groups I am part of. (Non-binary, 23 years old, no labels)

I’m not ashamed to say that I’m a trans boy, I’m proud of my scars, whether physical or internal. (Trans man, 24 years old, bisexual)

3.7.4. GAI

There are several TGD people who wish to undergo GAI, based on a motivation not directly related to GD but, on the contrary, an extrinsic motivation, with the aim of avoiding the consequences of structural stigmatization present in society [78]. However, there are also people who performed GAI for intrinsic motivations, with the aim of improving the relationship they have with their body, as they started to see it as they always wanted and identified, having a very positive impact on their lives, as we can analyze in the following quotes:

Having my breasts removed was the best thing in my life. (Trans man, 25 years old, heterosexual)

I’m happier after my surgeries. (Trans woman, 36 years old, heterosexual)

3.7.5. Housing

TGD individuals tend to face discrimination when looking for housing [69], as can be seen in the following transcript, where one individual was refused a room to rent:

I’ve been refused to rent a room because I’m apparently a prostitute. (Trans woman, 22 years old, lesbian)

However, there are people in this research who reported having access to housing, being aware that this is not a reality for all transgender people:

I’m incredibly lucky in terms of housing, but I know how difficult it is for other trans people. (Trans man, 20 years old, bisexual)

I recently moved and tried to find a room where all the people living in the apartment were comfortable living with a trans person. (Non-binary, 23 years old, no labels)

3.8. Sex and Sexual Health

3.8.1. Health and STIs

It was possible to have access to individuals who reported in terms of STIs that they felt disbelief in the use of contraceptives by their sexual partners, since there was no chance of getting pregnant, as well as reference to good medical monitoring by the infectious disease department, as can be seen in the following transcriptions:

There is a lot of pressure from some sexual partners not to use condoms, because they think that there is no possibility of getting pregnant and forget/are unaware of the various diseases and respective consequences. (Non-binary, 23 years old, no labels)

Regarding infectious diseases, I feel guided, either by luck in having happened upon a doctor with queer and deconstructed knowledge or perhaps because it is a more open medical environment. (Non-binary, 22 years old, pansexual)

3.8.2. Sexual Discomfort

The existence of sexual discomfort was mentioned by some participants in the sense that they do not feel comfortable having physical contact with parts of the body they do not identify with, as well as the inability to achieve orgasm due to the lack of bodily comfort, as shown in the following transcriptions:

I don’t like people touching me, at least until my phalloplasty is done. Without this surgery I cannot, for example, be intimately with no one. (Trans man, 22 years old, pansexual)

My lack of comfort with my body can make it difficult for me to reach orgasm when I’m having sex with my girlfriend, I feel the need for a lot of physical contact or to be covered up. (Trans fluid, 19 years old, bisexual)

3.8.3. Sexual Objectification

Sexual objectification occurs when an individual is reduced to the characteristics of their body and sexual functioning, which can happen in terms of sexualized comments and images in the media, non-consensual sexual touching, and—in extreme cases—sexual abuse [97]. In the following quotes, it is possible to analyze how this phenomenon is present in the lives of some participants:

My sexual experience mostly involves interaction with heterosexual men, who often look for people like me exclusively as a source of pleasure and few who seek it as an opportunity to get to know more than just the sexual field. (Non-binary, 23 years old, no labels)

I feel that as a trans feminine person, when I find myself in an environment with a large presence of cis men, it becomes difficult not to feel objectified and used for fetishization. (Non-binary, 22 years old, pansexual)

I am considered abnormal, and this leads to either disgust or fetishism of my condition. I am constantly approached by men which leads to harassment in several cases. (Trans woman, 22 years old, lesbian)

3.8.4. Packer Usage

A packer is an object that has a physical appearance with varying degrees of realism or abstract form and is typically worn by trans men or TGD individuals without a penis, helping them assert their gender identity and expression [98], as can be seen in the following quotes:

I’ve been using a packer for about 2 years, and I can only have sexual relations with it, I don’t feel comfortable letting other people touch my birth genitalia. (Trans man, 24 years old, bisexual)

Many expect a man to have volume, hence the daily use of what we call FTM packers (they are penises made of elastic material that allows urine, sex, volume, and masturbation. They are expensive, especially the quality ones and require maintenance). (Trans man, 28 years old, pansexual)

However—as can be seen in the following quote—for some individuals, the use of such objects may have a temporary effect:

I can’t use packer anymore, not even to add volume, I feel fake, like I’m a fake man. (Trans man, 22 years old, pansexual)

3.8.5. Sexual Intercourse

Regarding sexual relations, we gained access to the understanding of several experiences, such as difficulties in exploring sexual experiences, the use of applications to seek sexual interaction, and pain at the time of penetration:

Having a body that we don’t 100% identify with is a huge psychological challenge, and because of that I don’t feel comfortable having someone see me in a body that I still haven’t completely accepted, if at all. Therefore any experience of a sexual nature, alone or with someone, is something difficult and leaves a negative psychological burden on me, and I also have the fear that the person themselves will not accept my body. (Trans man, 21 years old, pansexual)

I use apps to have sexual relations, which are many and perhaps not the healthiest. (Non-binary, 27 years old, queer)

I’ve always had pain during penetration, but I don’t feel any difficulties with anything in my body. (Trans man, 25 years old, heterosexual)

3.9. Quality of Life

3.9.1. Well-Being and Quality of Life

It is well known that TGD individuals usually have lower levels of psychological well-being [93], which can be explained by the experience of discriminatory events, such as the following:

The transphobic events that I have experienced clearly have a negative impact on my well-being and quality of life. (Non-binary, 23 years old, no labels)

Experiences of discrimination have a huge impact on my well-being, so much so that I have been depressed and tried to commit suicide. (Trans man, 22 years old, heterosexual)

One individual mentioned that maintaining his level of well-being is the hope for favorable political changes, family support, and the level of passing/blending:

What maintains my well-being is my desire for public political changes in the world, my family having welcomed me, and having a certain degree of passability. (Trans man, 28 years old, pansexual)

3.9.2. Fear

TGD people report encountering negative messages about their identity, more specifically, about their appearance, personal characteristics, and the validity of their gender. As these individuals are undervalued by society, they understand that fear and anxiety have a significant presence and are perceived as normal in their lives [67,99]:

Living as a gender minority in today’s society honestly makes me afraid, I don’t know if I will be able to meet basic needs, precisely for that reason. (Non-binary, 20s, bisexual)

I would like to have more fluid gender expression, but I am blocked by the fear of being treated as the gender I do not identify with. (Trans man, 20 years old, bisexual)

3.9.3. Acceptance and Respect

In the present study, it was possible to observe the existence of several participants who reported having people in their lives who respected them, indicating a positive climate surrounding their identities:

Everyone I have around me respect and support me as much as possible. (Trans man, 25 years old, heterosexual)

In my social experiences I have always been treated with respect. (Trans woman, 55 years old, lesbian)

3.10. Sociopolitical Enhancement Strategy Proposals

3.10.1. Legal Factors

Several changes in legal factors were suggested with a view to improving the quality of life of TGD people in Portugal, which included the creation of laws that guarantee the well-being and safety of these individuals in society, the implementation of inclusive public bathrooms and laws that promote gender self-determination, the creation of housing projects and the officialization of neutral language, as can be analyzed in the following quotes:

I would highly recommend that political parties get to know a minority like the trans community closely, to understand and create laws in the best possible way, for the well-being and safety of these citizens in our society. (Non-binary, 23 years old, no labels)

I think there is a lot of work to be done, I feel that if I could, I would create more dialogue with politicians, create campaigns, and to generate the need to know each other and speak more, to generate importance. In this sense, facilitate public services and bureaucracies, implement mixed public bathrooms or the possibility of using a reduced mobility toilet for people who do not want to use the female or male toilet. (Non-binary, 22 years old, pansexual)

Create housing projects to take trans people off the streets and out of prostitution. (Trans woman, 29 years old, heterosexual)

The establishment of social housing dedicated to trans people and the support services they require. The acknowledgement of trans and trans friendly spaces, social and economic support in their social and cultural initiatives. The promotion of trans/queer art and culture and the exploration of trans reality in our social structure. (Trans woman, 22 years old, lesbian)

Officialization of oral and written neutral language system. Reinforcement of LGBTQIA+ phobia as a crime punishable by law. (Trans fluid, 28 years old, queer)

3.10.2. Investment in Education and Awareness on the Topic

Investment in education and awareness were quite notable in terms of the importance given by the participants, highlighting the need for greater social education about TGD people since childhood:

There must be greater social education about the existence of people like us, with the aim of understanding us better and unlinking all the prejudices entailed in our existence, so that they understand that we are completely normal people like cis people. This education should also happen for children, because for example, if I had had this type of information when I was younger, I wouldn’t have lived 15/16 years of my life thinking that I was the only person in the world who was the way I was. People should be teaching greater respect for others regardless of their characteristics. (Non-binary, 23 years old, no labels)

Sexual and gender identity education plans to at least offer basic knowledge to people, and even workshops aimed for adults to have their questions answered and for useful information to be disseminated about trans people. (Non-binary, 22 years old, pansexual)

Provide detailed information from primary school on the trans reality, to help those who question themselves, and promote empathy and natural acceptance of those who are not trans. (Trans woman, 59 years old, pansexual)

3.10.3. Faster and More Effective Health Services

The need felt by some individuals to reduce waiting times in health services and to be more efficient in their processes is notable, as can be seen in the following quotes:

Speed up waiting times. Considering hormones and surgeries, etc., with the due importance they really have, do you want people to be sure?! Leave the sexology consultations, but not with 3 to 8 months of waiting in between and with years waiting for surgeries. (Trans man, 22 years old, pansexual)

Facilitate and expand access to healthcare, especially regarding transitional and mental health treatments. (Trans man, 34 years old, queer)

3.10.4. Greater Training of Professionals Across the Country

TGD individuals criticize the need for a wide range of examinations to obtain GAI and the small number of professionals available in the area, which inevitably delays the gender-affirmation process [47]. In this sense, we verified the need felt by several participants to increase the training of professionals throughout the country.

Including more (information) education for health professionals is urgent and crucial. (Trans man, 34 years old, queer)

People specialized in healthcare and more surgical centers. (Trans man, 25 years old, heterosexual)

3.10.5. Health Specifics for LGBTQIAPN+ People

Healthcare professionals should understand the individuality of minority-stress-related experiences that TGD people experience and how these experiences are related to vulnerabilities in their mental health and resilience, as well as their inability to access and become involved in healthcare [73]. In this sense, several participants called for the need for greater specificity of health for LGBTQIAPN+ people as follows:

Specialized care centers for the LGBTQIAPN+ population. (Trans man, 28 years old, pansexual)

Make psychological support more accessible to young people to allow them to identify with their gender relatively early, whether this leads to them starting to take puberty blockers or not. (Trans fluid, 19 years old, bisexual)

3.10.6. Integration of TGD People in the Job Market

Participants in this investigation highlighted the importance of integrating TGD people into the job market through training in companies on sexual and gender diversity and the creation of allied companies, with the aim of creating safe workspaces for TGD individuals:

Public employer policies so that companies are prepared to deal with sexual and gender diversity, welcoming and employing these people. (Trans man, 28 years old, pansexual)

Develop partner companies that employ trans people. (Trans man, 45 years old, bisexual)

One participant also called for the inclusion of TGD people in the job market as a highly vulnerable group:

Recognition of labor insertion as a highly vulnerable group. (Trans woman, 48 years old, heterosexual)

3.10.7. Greater Visibility in the Media

TGD people do not feel represented in the media, as there is no care to accurately represent the diversity of individuals that make up different communities [67], and some of them only feel visibility when people like them appear in the news because they are victims of homicide. Even so, the majority of reports are negative and invalidating [67]. In this way, the individuals in the present study showed the importance of representation and visibility of TGD people in the media:

It is important that there is more representation in the media of trans people who do not live in a street/prostitution context, that there are trans people who are not expelled from their homes, who are loved, who have the support of their parents and who are college students or work socially accepted jobs. Seeing this representation in the media would really help me feel seen and represented. (Non-binary, 23 years old, no labels)

It took me 26 years to understand who I am. If I had done it earlier, my life would have been better, but I’m happy that younger people have access to the visibility, representation, and community that I didn’t have. We must continue to work to ensure this visibility for young queer people. (Trans feminine, 29 years old, bisexual)

3.10.8. Inclusion of Neutral/Fluid/Non-Binary/Trans Genders in the Law

Diverse gender identities and expressions that expand outside the binary concept in our society are increasingly visible. However, for these individuals, there is no legal category referring to their identity as the law proceeds to propagate the use of markers, such as males and females [24,100]. Subsequently, it is possible to analyze the appeal of some individuals regarding the importance of the inclusion of neutral gender in legal documents:

Non-binary gender in official documents. (Fluid trans, 28 years old, queer)

The neutral gender or “X” should be added. (Trans man, 20 years old, bisexual)

3.10.9. Economic Reinforcement of the NHS

Some participants highlighted the need for economic reinforcement of the NHS so that it could provide efficient responses to requested needs:

Investment in the NHS to respond more efficiently to requests for help from many people who need to start their transition. (Trans man, 24 years old, bisexual)

Need for economic reinforcement of the NHS. (Non-binary, 27 years old, queer)

3.10.10. Facilitate Access to Hormone Therapy

Facilitating access to HT was mentioned by several participants, including making this access free, training more pharmaceutical professionals, and expanding pharmacies that provide HT administration services, as can be seen in the following reports:

Make access to hormone therapy free. (Trans man, 22 years old, heterosexual)

Training pharmaceutical professionals and others on the intramuscular injection of testosterone because it is not something done everywhere. (Trans man, 24 years old, pansexual)

3.10.11. Control of Discrimination Against TGD People

Some participants reflected on the need for greater moderation in cases of discrimination against TGD people:

There needs to be moderation of hateful comments online. (Fluid trans, 28 years old, queer)

The creation of a body aimed at discrimination at work, social bodies, and institutions towards trans people, with the capacity to pursue legal processes charges and enforce the law, always in defense of the private interests of trans people. (Trans woman, 22 years old, lesbian)

4. Discussion

To our knowledge, this is the first study to explore the psychosexual health and well-being of trans and gender-diverse individuals in a Portuguese context. Although scientific interest in this demographic is growing, there remains a considerable journey ahead.

This investigation revealed that the most significant theme was the experiences of interactions with healthcare services, where multiple individuals reported instances of discrimination. For example, one participant stated, “I choose those who are inclusive because I have already been a victim of queerphobia and denial of care” (non-binary, 27 years, queer). This finding aligns with other studies demonstrating that healthcare services predominantly continue to foster non-inclusive and discriminatory environments for TGD individuals [101,102]. Another topic that emerged within this theme was the long waiting times, which have also been observed in other studies [47,103]. Some TGD individuals resort to private healthcare services to expedite their processes, a phenomenon also noted in the literature [10,28,49]. However, this investigation also accessed TGD individuals who reported positive experiences with public healthcare services. This study also explored proposals for sociopolitical improvement strategies. In the healthcare domain, the importance of reducing waiting times was emphasized: “Facilitate and expand access to healthcare, especially concerning transition treatments and mental health” (trans man, 34 years, queer). Additionally, there was a call for increased training: “Specialized health professionals and more operation centers” (trans man, 25 years, heterosexual), addressing a gap that leads to delays in gender-affirmation processes [47].

The experiences of TGD individuals in the labor market revealed vulnerabilities to discrimination, dismissal, and both moral and sexual harassment. One participant noted that “Job seeking is one of the situations where I feel most vulnerable to transphobia, to the point of being unemployed” (transfeminine, 29 years, bisexual), a finding consistent with other studies [56,57,58,102]. Another participant chose to conceal their trans identity to avoid workplace discrimination: “Regarding work, I hide my transition at all costs because I have always been fired for being who I am and was known in one job as the guy who peed sitting down” (trans man, 22 years, heterosexual), a scenario also documented in the literature [59,60]. More research is needed to understand the impact of concealing TGD identities on individuals. This study also accessed a participant engaged in sex work: “I have been working in sex work for five years between Brazil and Portugal. Although it provides good financial results and safety, and allowed me to undergo my surgeries, I am not happy” (trans woman, 36 years, heterosexual). This context is often sought due to the employment barriers faced by many TGD individuals and the income levels achievable through sex work [43]. Nonetheless, two participants reported positive experiences in the labor market. Participants proposed measures such as integrating TGD individuals into employment and better preparing companies to accommodate diversity: “Public employment policies so that companies are prepared to handle sexual and gender diversity, welcoming and employing these individuals” (trans man, 28 years, pansexual). Another participant highlighted the need to recognize TGD individuals as a highly vulnerable group in employment: “Recognition of employment inclusion as a highly vulnerable group” (trans woman, 48 years, heterosexual).

The discrimination experienced by these individuals [104], along with their internalized transphobia, impacts their well-being, quality of life, and mental health [56,67]. One participant expressed, “Being misgendered makes me feel like I need to be as masculine as possible to be seen as a man. Being trans makes me feel, and I’ve been told, that I’m a freak. I don’t feel normal. I just want to be normal” (trans man, 20 years, bisexual). Exposure to discrimination and stigmatization, which promote internalized negative beliefs, alongside the health and psychological impacts, often leads to self-harming behaviors, suicidal ideation, and suicide attempts. In this study, of 32 individuals, 10 reported suicidal ideation, 5 had attempted suicide, and 6 had or currently have self-harming behaviors, findings consistent with the scientific literature [105,106,107]. Therefore, developing specific prevention programs for self-destructive behaviors in TGD individuals is essential.

In addition to the needs highlighted for improving their well-being and quality of life, several participants called for the creation of laws ensuring their well-being and safety, emphasizing the importance of “Improving gender self-determination laws, abolishing name lists, and removing mandatory gender markers” (non-binary, 33 years, polysexual). Another participant noted, “I think a lot of work needs to be done. More dialogue with politicians is needed (…) Facilitating public services and bureaucracies, implementing mixed public restrooms, or allowing reduced mobility restrooms for those who do not want to use male or female restrooms” (non-binary, 22 years, pansexual). The importance of educating and raising awareness among the general population about TGD individuals was also mentioned: “Providing detailed information from primary school about the trans reality to help those questioning and promote empathy and natural acceptance for those who are not” (trans woman, 59 years, pansexual). Visibility in the media was another key point: “It took me 26 years to understand who I am. If I had understood myself sooner, my life would have been better, but I am happy that younger people now have access to the visibility, representation, and community I did not have. We must continue to work to ensure this visibility for young queer people” (transfeminine, 29 years, bisexual). Finally, there was a call for measures to mitigate discrimination against TGD individuals: “The creation of an agency dedicated to discrimination in the workplace, social institutions, and against trans people, with the authority to pursue legal processes and enforce laws always in defense of the specific interests of trans people” (trans woman, 22 years, lesbian).

Recognizing that the TGD population is not homogeneous, it is crucial to assess the specific and unique needs and difficulties of each individual [2]. This responsibility falls on healthcare professionals, educators, and teachers to promote better well-being, quality of life, and mental health for these individuals in Portuguese society.

4.1. Limitations and Recommendations

This investigation is not without its limitations. First, being a study of voluntary participation implies that perceptions of other individuals who, for various reasons, choose not to participate are not included, and whose experiences may vary from those observed on various subjects. Second, it is possible that social desirability bias may occur in some topics, with the aim of some participants being to avoid giving responses that reveal socially undesirable attitudes and/or behaviors and instead reporting a higher level of desirable attributes. Third, as this was an investigation conducted through an electronic survey, it conditioned the analysis of some of the answers given by the participants. Furthermore, the qualitative nature of this investigation prevents generalization of the results. However, this approach allows for a deeper and richer understanding of the phenomenon under study and ultimately contributes to filling a gap in the literature on this topic.

Furthermore, the qualitative nature of this investigation inhibits the generalization of the results. However, this approach allows for an extensive and richer comprehension of the phenomenon in question, and ultimately, this study contributes to filling a gap in the literature on this subject.

To expand the investigation initiated with this work, it is important that future studies invest in different methods to complement these findings, such as in-person interviews, focus groups, and case studies, allowing a deeper exploration of the contributions made by the participants and a greater understanding of the processes through which people with a non-normative and conventional gender identity may occur in the course of their lives, in both Portuguese and European contexts. Additionally, quantitative studies would provide a generalization of the data, facilitating better theoretical comprehension of this population.

It is necessary to pay attention to situations of violence and discrimination that many of these people are vulnerable to, with the intention of limiting such occurrences. Moreover, it is necessary to explore the experiences of TGD individuals with more than a minority characteristic in comparison to the social context in which they are inserted from an intersectional perspective, considering that their identity is dynamic and varies depending on the context, such as the culture, country, and time in which they express themselves [108].

4.2. Implications

The present study serves as a valuable source of information for both TGD people as well as for physical and mental health professionals and researchers. As it highlights the necessary action towards developing a more inclusive environment regarding the diverse gender identities and expressions that exist and promotes the health and well-being of this population, which is much more vulnerable to mental health issues. The role of specialized professionals in this field is essential for intervention, as is strengthening an NHS that provides an appropriate and necessary response to this population and creating inclusive social laws supported by scientific evidence to promote and ensure the psychosexual health and well-being of this population. This study also serves as a source to teachers at different levels of education about the reality lived by these individuals in educational settings; and to social agents who come into contact with this population, with the goal of contributing to the reduction of stigma, prejudice, discrimination, and violence experienced by this group. Thus, this investigation not only fosters dialogue with other studies but also provides further information on TGD individuals, including information to guide future interventions, such as prevention, promotion, and education, designed to improve the well-being and quality of life of these individuals in Portuguese society. Hopefully, these conclusions may contribute to eventual social changes towards greater inclusion and respect for this population in our society in general.