Health Professionals' Experiences of Professional Bias, Harassment, and Discrimination in the Context of Gender Diversity in Southern Brazil: a thematic analysis of focus groups

Health Professionals' Experiences of Professional Bias, Harassment, and Discrimination in the Context of Gender Diversity in Southern Brazil: a thematic analysis of focus groups | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Health Professionals' Experiences of Professional Bias, Harassment, and Discrimination in the Context of Gender Diversity in Southern Brazil: a thematic analysis of focus groups Anna Martha Fontanari, Julia de Oliveira, Camila Guaranha, Angelo Costa This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7319508/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Transgender and gender-diverse individuals face significant barriers in accessing public health services due to stigma. While much research focuses on direct stigma experienced by these populations, less attention has been given to "stigma by association", which affects healthcare professionals providing their care. This study explores the experiences of healthcare professionals working with transgender and gender-diverse populations in southern Brazil, examining how stigma by association impacts their professional trajectories, institutional affiliations, and daily practices. Methods This qualitative study involved two focus groups comprising nine permanent staff members from primary and specialized transgender health services located in a Brazilian metropolitan region in southern Brazil. Participants were recruited through both personal and professional networks. Data collection employed a semi-structured protocol that examined sociopolitical conditions, operational challenges, and individual experiences of stigma by association. The transcripts underwent analysis using Braun and Clarke's reflexive thematic analysis, which utilized Taguette software for coding. Methodological integrity was upheld through participant diversity and researcher reflexivity. Results Four thematic areas were identified: structural/institutional stigma, contingent stigma (identity spoiling due to social proximity), affective costs of stigma, and strategies for managing stigma. The findings underscored that services often originated from personal commitment rather than formal planning, resulting in unstable foundations, inconsistent funding, and workforce-related challenges. Professionals encountered both explicit and subtle forms of discrimination, isolation, and demotivation. Advocacy and social movements played a pivotal role in addressing stigma. At the same time, personal identification with the lesbian, gay, bisexual, transsexual, travesti , and others (LGBT+) community frequently functioned as a protective factor for professionals. Conclusions Healthcare professionals delivering care to transgender and gender-diverse populations in southern Brazil encounter substantial stigma, both structurally and interpersonally. This phenomenon harms their well-being and the sustainability of services. Addressing these challenges necessitates targeted strategies to support professionals, enhance institutional support, and promote equitable healthcare practices for transgender populations. Future research should emphasize intersectional analyses and assess the experiences of both sexual and gender minority and cisgender heterosexual professionals within this domain. Transgender health stigma healthcare professionals Brazil qualitative research public health services Background Sexual and gender minorities (SGM) in Brazil have undergone different periods regarding categorical identities, policies, and cultural acceptance. Although today the country hosts the biggest pride parade in the world, 1 lesbians, gays, bisexuals, transsexuals, travestis , and other sexual and gender minorities (LGBT+) still face significant health challenges within the Brazilian scenario. 2 – 4 Specific to the trans and gender diverse identities, self-referred to as travestis and transexuals, social recognition and participation in policies gained momentum in the 1980s-1990s, primarily associated with the HIV-AIDS epidemic. 5 At the same time, the Brazilian Unified Health System, SUS, was being established, based on the founding principles of equity, universality, and integrality, which aimed to guarantee free access to healthcare for every citizen. 6 During this period, policies targeting the LGBT + community emerged, influenced more by the perceived need to control disease transmission than purely by genuine efforts to protect and care for these populations. It was later, initially with the 2004 policy Brazil Without Homophobia and, finally, with the 2011 National Policy for Integrated LGBT Health, that SGM health started being addressed through the lens of human rights, tackling stigma and discrimination in healthcare settings, and expanding access to comprehensive healthcare services. 2 , 7 In addition to the National Policy for Integrated LGBT Health, the subnational spheres also have their respective policies. In Rio Grande do Sul (RS), the state in which the study was carried out, the State Policy for Comprehensive LGBT Health Care was published in 2014 (Rio Grande do Sul, 2014), while in the state's capital, Porto Alegre, the Municipal Policy for Comprehensive Health for Lesbians, Gays, Bisexuals, Transvestites, Transsexuals, Queers, Intersex and People with Non-Binary Gender Identity (LGBTQI+) was established in 2019 (Porto Alegre, 2019). Of note, although all these policies mentioned above are overtly directed at the LGBT + population in general, the existing health initiatives not related to HIV or sexually transmitted diseases are mainly directed at the transsexual and travesti population, exemplified by the trans clinics mentioned in this paper. Nonetheless, despite policy advances, trans and gender-diverse individuals in Brazil still experience difficulties accessing healthcare services due to discrimination, insufficient information, and policies that fail to meet their needs. 3 , 8 This population faces significant stigma and encounters substantial barriers when accessing public health services, both globally and across Latin America. 8 – 10 A recurring theme in the literature is the pervasive impact of stigma within healthcare settings, which often leads individuals to avoid or delay seeking care due to fear of mistreatment or as a result of previous negative experiences, such as misgendering, deadnaming or explicit and subtle provider bias. 8 , 11 Provider-related barriers encompass a shortage of trans-competent clinicians and insufficient knowledge about gender-affirming care. 12 Although stigma by association has not been widely discussed within LGBT + health literature, it has emerged as a relevant provider-related barrier in other healthcare contexts. This phenomenon has been documented among caregivers of people living with HIV/AIDS, 13 individuals with mental illness, 14 those with neurodevelopmental disorders, 15 as well as in abortion care services, 16 and among professionals working with sex workers. 17 , 18 In these settings, healthcare and support professionals report experiences of isolation, reputational damage, moral judgment, and emotional exhaustion—factors that negatively affect their well-being and compromise the sustainability of their work. Briefly, stigma was first systematically theorized by Erving Goffman, who defined it as a deeply discrediting social attribute that reduces a person “from a whole and usual individual to a tainted, discounted one” (p. 3). Stigma arises from an “undesired differentness from what we had anticipated” (p. 5) and is embedded in social interaction. 19 Building on this framework, Link and Phelan 20 (2001) conceptualized stigma as the co-occurrence of labeling, stereotyping, separation, status loss, and discrimination within contexts marked by power differentials. While much of the literature has focused on the effects of stigma on those who are directly marked or marginalized, Goffman drew attention to its spillover effects. He noted that “ the problems faced by stigmatized persons spread out in waves of diminishing intensity among those they come in contact with 19 ”. This phenomenon—known variously as courtesy stigma, associative stigma, or stigma by association—affects individuals who are closely connected to stigmatized people, such as family members, friends, or professionals. 19 Stigma by association has been found to impact family dynamics and diminish the quality of care provided to stigmatized individuals. 21 It can also manifest in various social contexts through both close and incidental associations. Strong ties, such as kinship, friendship, or chosen affiliations, are potent conduits for stigma. 22 – 24 However, even coincidental or superficial proximity can trigger stigmatization; for example, being seated near a stigmatized person has been shown to affect third-party perceptions negatively. 25 Despite the increasing recognition of these dynamics, there is still a paucity of research specifically examining how stigma by association affects professionals who provide care for trans and gender-diverse populations. This gap is particularly concerning given the sociopolitical climate in which trans persons are frequently targeted by moral panic, misinformation, and institutional neglect. In such contexts, professionals may become secondary targets of prejudice, experiencing stigmatization for their association with trans people or for being perceived as “allies” or advocates. This phenomenon can lead healthcare professionals to abandon providing care or even deter them from specializing in this field, ultimately resulting in poorer health outcomes for transgender individuals. Thus, our study aims to explore the experiences of healthcare professionals who work with trans and gender-diverse populations in southern Brazil. Drawing on qualitative data from focus groups, we examine how stigma by association shapes professional trajectories, institutional affiliations, and daily practices. In doing so, we aim to contribute to a more nuanced understanding of the psychosocial costs of inclusive care work and inform the development of structural and educational strategies that can better support those who provide it, and, by extension, the population they care for. Methods Research Design Overview We understand knowledge as situated and relational, emerging through dialogue between researchers and participants. Therefore, we chose focus groups for our qualitative approach. In this context, we aim to emphasize reflexivity, power dynamics, and the ethical importance of creating spaces where participants feel safe to share sensitive experiences, particularly in the context of stigma by association. For the focus groups, participants signed a form indicating their free and informed consent. The invitation was made directly to the professional and had no direct relationship with the services. Anonymity and confidentiality were guaranteed (professionals and services), and the project was approved by our IRB board71170123.6.0000.5336. Researchers’ Characteristics The research team is profoundly implicated in this inquiry, both as health professionals and as LGBT + individuals. All the researchers identify as white Latinx and cisgender individuals; two of us are lesbian women, one is a gay man, and one is a heterosexual woman. One of us is a psychiatrist at a Trans and Gender Diverse Clinic. All of us are currently researching LGBT + health. Recruitment and Study Participants Recruitment Process We distributed the invitation through personal and professional networks. Friends and colleagues were encouraged to disseminate it further. No institution was directly approached, and no institutional space was used for recruitment. This strategy was deliberate: we considered that institutional recruitment could compromise participants’ freedom to share experiences of stigma by association or other sensitive matters they might find relevant. We exclusively invited permanent staff members to participate. Although these services commonly rely on temporary labor (e.g., students, volunteer interns, and residents) whose impressions are undoubtedly valuable, we opted for a smaller, more cohesive group. Our goal was to foster an atmosphere of trust and intimacy that would support the sharing of personal and potentially vulnerable experiences. Study Participants Nine participants took part in two focus groups. Group 1 included a psychologist, two managers (one at the state level and one at the municipal level), a social worker, and a family physician. Group 2 was composed of a psychiatrist, two psychologists, and another family physician. Across both groups, all key health services providing care for transgender populations in the region were represented. Participants self-identified as both black and white, and included heterosexual and homosexual individuals. Notably, no participant identified as lesbian, and no transgender person was identified as a permanent staff member within the services at the time of recruitment. For this reason, no trans professionals were included in the study. The trans absence in our study itself is a relevant contextual feature of the institutional landscape under investigation. For more details, see Table 1 . Table 1 Sociodemographic characteristics. Variable Category % Age 29–39 33.3% 40–49 16.7% 60–69 50.0% Education College Degree 33.3% Postgraduate Degree 66.7% Gender Identity Cisgender Man 50.0% Cisgender Woman 50.0% Trans or travesti 0% Sexual Orientation Heterosexual 50.0% Gay 33.3% Lesbian 0.0% Bisexual 16.7% Race or Ethnicity White 66.7% Black 33.3% Religion or Belief Catholic 16.7% Christianity (unspec.) 16.7% Afro-Brazilian Religion 16.7% Atheism 33.3% Not Informed 16.7% Note. Percentages are presented to describe the sample distribution. Absolute frequencies are not shown to protect participant anonymity, given the small sample size. No archival materials, documents, or previously collected datasets were used in this study. All data was generated through original focus group discussions. Due to the sensitive nature of the material and confidentiality agreements made with participants, the data is not currently housed in an open-access repository. The appropriate Institutional Review Board approved all study procedures (CAAE 71170123.6.0000.5336). Researcher–Participant Relationship Given the relatively small number of professionals working with transgender health in Brazil, the research team and participants were part of a closely interconnected professional field. Most participants knew one another—and the researchers—either directly or indirectly, before the study. Naturally, those with closer collegial ties to the researchers, and who might even be considered professional acquaintances or friends, were more inclined to participate, particularly considering the study's length and the absence of financial compensation. Nonetheless, despite these proximities, the relationships were not characterized by personal friendship or shared life histories. Participants brought highly diverse professional trajectories to the study, shaped by their positions across the health care system—from state health managers and primary care to specialized services. These differing pathways also informed the power dynamics and epistemological positions represented in the group. Aiming to provide comprehensive care and improve access for this population, Brazil has expanded its policies over the last decade, including the creation of national policies such as the National Policies for LGBT individuals, which helped articulate regional policies, centers, and clinics, such as the trans clinics in Porto Alegre and São Paulo. 8 Data Collection and Identification Procedures Data Collection Data for this study were collected through two focus groups with health professionals working directly or indirectly with trans and gender-diverse populations in a Brazilian metropolitan region. The choice of focus groups was informed by Minayo, 26 who emphasized the value of this technique for studying health issues from a social perspective, especially for understanding representations, relational dynamics, and professional practices in complex health systems. Compared to individual interviews, focus groups enable the observation of interactional dynamics among participants, which is essential given the study’s interest in institutional roles, collective memory, and affective resonance. Participants were selected based on their involvement in either specialized or primary care services focused on transgender health. Specialized care professionals included staff involved in the foundation and implementation of a long-standing federal outpatient clinic for trans health, which is affiliated with a leading research hospital and has performed over 300 gender-affirming surgeries. Primary care participants were professionals from open-door trans health clinics established in the last ten years —operating within Brazil’s primary care system with autonomy to prescribe hormonal therapy, up to a recent Federal Council of Medicine’s resolution, approved after this study was conducted, which prohibits family physicians from initiating hormonal therapy for trans individuals. Additionally, public administrators involved in implementing the National LGBT + Health Policy were also invited, reflecting the multi-level structure of transgender health governance in Brazil. Focus groups were guided by a semi-structured protocol, developed to elicit open and exploratory responses. Each session began with a round of introductions and a brief professional biography shared by each participant. The guiding questions were grouped into three thematic axes: (1) socio-political conditions that enabled the emergence of trans health services; (2) the current operational landscape, including barriers and facilitators; and (3) individual experiences of stigma by association, defined to participants as the prejudice or discrimination experienced by individuals due to their association with a stigmatized group, even when they do not share the stigmatized characteristic themselves. Examples of guiding questions included: “What do you believe enabled the creation of these care spaces?”, “What do you feel is the greatest challenge to their continuity in the current context?”, “Which factors do you see as potential facilitators?”, “How do these challenges and facilitators affect your daily work?”, “Have you ever experienced stigma or discrimination due to your work with sexual and gender minorities? If so, are you comfortable sharing a specific episode? Did it impact your professional path?”, “Have you ever felt fear or discomfort—e.g., around terminology use—in your work with vulnerable populations?", “Do you avoid certain contexts or settings in your professional activities? If so, which ones?”, and “Have you encountered specific challenges or advantages in securing funding (public or private) for work with these populations?”. A trained moderator facilitated each session. Each group was conducted on a separate day and lasted approximately 90 minutes. Both sessions ended somewhat abruptly due to time constraints, despite participants’ strong engagement and the evident emotional need to share difficult professional experiences. Participants expressed the rarity of safe spaces to discuss their trajectories, often marked by institutional resistance, affective labor, and personal exposure to structural violence. Recording and Data Transformation Audio was recorded using two smartphones and temporarily stored in a Google Drive folder. A member of the research team later transcribed the recordings with the help of the audio transcription tool in Microsoft Word. Audio files were deleted immediately after transcription to preserve participant confidentiality. Analysis Data-Analytic Strategies The primary goal of the analysis was to identify patterns of meaning related to the professional experiences of stigma by association and institutional dynamics in the context of transgender healthcare in Brazil. Analysis was conducted on the full transcriptions of two focus group sessions, treated as the units of analysis. Data analysis followed Braun and Clarke’s reflexive thematic analysis approach, which emphasizes the active role of the researcher in identifying, analyzing, and reporting patterns within the data. Thematic analysis was conducted through a recursive six-phase process: (1) familiarization with the data, (2) generation of initial codes, (3) searching for themes, (4) reviewing themes, (5) defining and naming themes, and (6) producing the report. 27 Coding was performed using the qualitative data analysis software Taguette, an open-source tool selected for its accessibility and collaborative features. 28 Throughout the process, the research team maintained reflexive memos to document evolving interpretations and analytic decisions. Discrepancies in coding and interpretation were addressed through discussion and consensus-building among team members. The resulting analytic scheme captured themes related to the formation of trans-specific services, ethical tensions between care and gatekeeping, and personal accounts of stigmatization in professional roles. These themes were used to structure both the presentation of results and their interpretation in light of broader sociopolitical and institutional contexts. Methodological Integrity Researchers were committed to ensuring fidelity to the lived realities of professionals working in trans health. Two main strategies were employed. First, diversity among participants was actively sought and achieved, allowing for a more nuanced understanding of both structural and affective dynamics within the field. Second, the research team engaged in structured reflexivity by maintaining memos throughout the study to critically examine their positionalities and assumptions. Data were analyzed inductively and iteratively, with thematic patterns grounded in participants’ own words. Taguette software —a free, open-source qualitative data analysis tool—was used to organize and systematize coding and reflections. 28 To enhance credibility and resonance, preliminary findings were discussed with select participants, and the full manuscript was later returned to them for feedback and validation. Results Four thematic areas identified as representing different dimensions or manifestations of stigma experienced by health professionals working with trans and gender-diverse populations: 1. Structural/Institutional Stigma; 2. Contingent Stigma; 3. The Affective Costs of Stigma, and 4. Dealing with Stigma. These are further subdivided into themes that range from precarious foundations and institutional fragility to voice and narrative control. 1. Structural/Institutional Stigma. 1.1 Precarious Foundations and Institutional Fragility. The establishment of all health services analyzed, whether in primary or specialized care, shared a particularly striking feature: they were born from a combination of coincidence and personal commitment, rather than formal institutional planning or political initiative. "What I perceive, and what is common in practically all of these services, is that none of them emerged from a governmental project or program. Everything I've seen and followed arises from professionals within the system—people who are sensitive, who understand the importance—because the demands are already there." In describing the origins of his work in LGBT + health, one of the participants recalls stumbling upon an underutilized sector "I discovered within the Secretariat that there was a technical area for LGBT + health. Kind of like, hey! There's a technical area? That’s great—something I'd love to work on." At that time, the area "began the 2015 administration without anyone assigned." After informal coordination with colleagues, the manager was able to assume responsibility for it. And it was a lot of responsibility. “And the only thing I could think was that all these people have no idea that I'm the poor devil who has to think about public health policy for all of them. That's such a heavy responsibility, right? But, since I accepted the invitation, I thought, well, if I don't accept, who else in this department will? Another participant described a long history of improvisation, creativity, and personal networks to ensure access to gender-affirming care. "Because we lost in an injunction—again and again. So we made a direct agreement between the hospital and the State to fund two surgeries per month.” The federal regulation that eventually enabled the procedure, they explained, was only published "because Fulano was the judge at the time—he’s gay and identifies with the issue." Fortuitous relationships and personal beliefs took place in the absence of public policies. Participants emphasized the chronic lack of political and institutional responsibility for addressing the healthcare needs of trans populations: "We have no recourse, right? We pick up other people's leftovers,” and "The LGBT agenda, man, it never came up. Never, guys, never came up. Not once. The national policy hadn’t been created yet, but even after 2011, this discussion was not initiated by the municipality, the regional office, or anyone." Institutional fragility continued to cast a long shadow over these services, even after they were established. A tremendous effort is required to ensure the service exists and continues to operate. It manifested as unstable or improvised funding, often dependent on parliamentary amendments or personal fundraising efforts; as scarcity of physical infrastructure, such as consultation rooms or equipment; and as lack of a qualified, dedicated, and stable workforce, particularly in contexts of high staff turnover or outsourced services. Together, these elements formed a fragile ecosystem in which professionals operated despite the system, rather than because of it. See Table 2 . Table 2 Institutional Fragility. Fragility Citation Lack of a qualified, dedicated, and stable workforce "Started with two weekly appointments at a community health center, with residents and one physician." "There was no dedicated team, we depended on whoever was available from other services." Unstable or improvised funding "The service depended on parliamentary amendments to purchase hormones for users." "We had to pass the hat to carry out our work." Scarcity of physical infrastructure "There are only two rooms, and when there is a campaign, we have to cancel the clinic." "We have no proper infrastructure, only a borrowed room with no privacy." These conditions directly impact service access and quality. Patients face long wait times, interruptions in care, and inappropriate referrals. Health professionals spoke of a system that routinely fails to integrate trans care across levels of attention, leaving certain services overwhelmed. Even at well-known institutions, care is hindered by siloed structures and restrictive resources. Institutional weaknesses and limited resources may also lead to physical and mental overload for workers who, to provide healthcare to trans individuals, accept working under unfavorable or precarious conditions. In this regard, some participants reported engaging in volunteer work and accumulating extra hours that were either unrecognized or unpaid by the institutions with which they were affiliated. Few workers reported having a workload fully dedicated to trans healthcare, as most participants had to divide their working hours between trans-specific services and one or more other points of care within the network. 1.2 Professional Trajectories Between Activist Commitment and Academic Formation. In the absence of political or institutional incentives, the first generation of health professionals dedicated to trans care emerged primarily from the LGBT + social movement. Their entry into the field was not driven by state policy or technical specialization, but by a profound sense of ethical responsibility and personal commitment. As one participant recalled: "So, I was already familiar with the subject, because I am a gay man. Something that also weighs heavily on me is a sense of social responsibility, let's say, because it's hard to reach these spaces, right? Closely following people within the social movement, putting pressure on from the outside, doing all this movement. It's hard. It's hard for us to reach these spaces of management, politics, public management." Despite their dedication, these early professionals often lacked technical guidance or institutional support. Their work was marked by loneliness, improvisation, and empirical learning, with creativity usually compensating for the absence of formal training: "I didn't have people, I was quite alone, I would say... I didn't have, right, uh... teachers, I didn't have employees, I didn't have anything, I had... me and I had my one colleague. That's how we went on, empirically, organizing the program." "I had no idea that there were specific demands for trans population health and I had no idea what the role of psychology would be in caring for these people. But since I like a good challenge, right, I said, let's go, right, let's go. Let's see what we can do. I felt embarrassed to ask, to do, to say something stupid." "It was challenging in the sense of the technical aspect. What we were looking for—there was only a regulation from the Federal Council of Psychology, giving basic guidelines. We didn't find anyone else to ask." In contrast, the second generation of professionals benefited from academic exposure and formal training in gender studies. Some of these newer professionals were recruited explicitly because of their previous engagement with trans issues during medical or psychology school: "Since my undergraduate studies, I was directly involved with issues related to mental health and the LGBT population" and "Fortunately, when I was appointed, they asked me to send them my resume. During my training, they saw courses and events that I had been involved in throughout my academic and professional career. They saw this affinity with working with the LGBT population and then offered me the possibility of joining the outpatient clinic." These represent two distinct professional trajectories. The first is shaped by activism, trial and error, and the ethical imperative to provide care where no institutional pathways existed. The second is shaped by academic training and emerging institutional recognition, made possible by the groundwork laid by the pioneers themselves. While the first generation had to invent paths to care, often in precarious or informal conditions, the second generation enters a field already partially legitimized and codified. Notably, the creativity that characterized the pioneers' approach, necessary to respond to urgent needs, might not have been tolerated had it been exercised in other, more normative areas of healthcare. 2. Contingent Stigma: Identity Spoiling Through Social Proximity. Stigma by association emerged in participants’ accounts as a pervasive, though often subtle and ambiguous, form of professional discrimination. Health workers involved in trans care were, at times, delegitimized or questioned simply for being associated with a stigmatized population. This stigma manifested in both interpersonal relationships, among colleagues, supervisors, and peers, as well as within institutional dynamics that isolate and devalue certain forms of care. Sometimes, the stigma was explicit and aggressive. One senior psychiatrist recounted a moment of interpersonal hostility that left a lasting mark: “And then he called me, ‘Oh, I wanted to talk to you and stuff’, (...) ‘Why are you exposing yourself to these trannys?’ That was the term, right. That was the term. ‘Exposing yourself to these trannys.’ A criticism thrown at me... honestly, I don't remember my answer—I just remember the phrase.” In other cases, the stigma was expressed through silence—the absence of collaboration, avoidance of discussion, or implicit devaluation of one’s work. Participants described being excluded from knowledge-sharing routines, not being consulted for input, or being assigned complex cases by default, as if their expertise—or labor—was only relevant in the context of this marginalized group. One professional described how colleagues failed to take shared responsibility for a trans patient's care: “There was a certain questioning of my technical ability to assess these patients. Like, ‘How could you not see that this person was manipulating the situation?’ It’s as if, because we work with the trans population, we’re either too involved or somehow less technically sound.” Another participant noted that working with trans patients often made one the default go-to person in their service, regardless of workload or specialization required: “Colleagues in other services avoid these cases and send them all to us. It's like, if you're in a trans clinic, then it’s your job to solve everything.” These examples reflect the delegitimization of professionals who work in trans health not only through overt prejudice but also through institutional avoidance, overburdening, and technical undermining. As one participant put it: “Sometimes it’s not the patients, it’s the professionals themselves—from within the same institution—who react with discomfort, like ‘What do we do with this case? Where do we admit this person?’ Something that should be basic.” This constellation of reactions contributes to an environment in which those providing care to trans populations are themselves stigmatized, rendered professionally suspect, or subtly excluded. 3. The Affective Costs of Stigma: Isolation, Conflicts, and Demotivational. A recurring topic among the participants was the feeling of isolation and loneliness in working with the trans population. Participants reported that colleagues, politicians, institutional managers, and even some LGBT + activists could act as sources of stigma or delegitimization. “And I feel really bad because I was criticized a lot. I'm very... People write things about me [...] they talk without, in a disrespectful way... Without even knowing what's going on, right, without even knowing what an institution like ours is”. The burden of care, coupled with insufficient systemic support, not only isolated trans clinics from other health sectors but also fueled tensions and divisions among trans health providers themselves. Disagreements and perceived distance emerged particularly between primary care services and specialized clinics: “I’m not talking about (Center Y), because they think of themselves as the fucking shit, you know? With their own problems, but that they can manage” and “As someone here representing (Center Y), I don't think I'm the fucking shit, right, quite on the contrary. We're there in an ongoing battle to amplify access and services, you know. (...) And when we personify a service, uh, it ends up affecting us, too, right?”. At the same time, there was a strong sense of unity among workers at each clinic in reporting the difficulties they sometimes had to overcome together, some of which are still ongoing and stem from outside factors. “There’s this really institutional thing, right, that Clinic A will not be a priority. It'll be oncology, then cardiology, then, you know, it's all the way down right”, “And that's what we feel, right, and it's truly difficult to classify priorities for the general hospital, a high complexity one.” , and “We hear a lot about a story, uh… of a fight by the professionals and some patients, right, resisting, uh… well, and resisting from, uh, such as, there's no money for the vaccine and you want to operate on these people? In a context where resources are scarce, as is the case with Brazil’s Unified Health System (SUS), the health of trans people has never been a priority, and this statement highlights that reality. Notably, members from only one primary care clinic attended each of the focus groups. Although we initially had members from two different clinics in the second group, one of the clinics informed us that they would not continue participating that evening. Nevertheless, there was a desire - more than just a willingness - a recognized need to put aside differences to strengthen their cause. “But I think the idea is to strengthen, like, this network, right? I think it is important that we can dialogue and even unite in order to think over alternatives, together”. Such a statement appears to confirm the importance of promoting spaces for exchange and collective building among health workers involved in the care of trans people, thereby strengthening existing initiatives. In addition to conflicts and feelings of isolation, stigma may discourage professionals from applying to or remaining in trans health services. “There are a lot of schizophrenia, depression to treat, psychiatrists, right, to waste their time” and “I opened five, five selection processes. Medical professionals, nurses to work in the trans outpatient clinic. All [recruitment processes] failed.” 4. Dealing with Stigma : 4.1 Advocacy and Social Movements: Strategies for Reclaiming Normality or Restructuring Interaction. Perhaps the one element that was unequivocally present across all participants’ statements was the central role of advocacy and social movements. Professionals recognized that resisting stigma and advancing care depended not only on technical competence but also on political engagement and collective mobilization. “ I believe that the professionals and the social movement were, like, fundamental, each with their own part, for us to be able to construct, for example, the important services of the clinic. ” Social engagement and advocacy are recognized as essential for implementing laws and policies, as well as for continuing to address the challenges already discussed. “The social movement has been guiding, demanding, and participating for years and years and years.” and “Right, but it was a very important demand, a social movement demand, to have this trans clinic, right? It started with meetings.” Advocacy often filled the institutional void left by political indifference, ensuring essential resources like medications through external political strategies. “We began offering the inputs for hormonization because of parliamentary amendments. And there's no reason not to say these names: Luciana Genro, Roberto Robaina, Melchionna. Because until recently it was them guaranteeing these inputs. ” It is worth noting that the individuals named are political-party figures linked to the promotion and protection of human rights, and have been engaged by the social movement and workers to support and legitimize the cause. 4.2 Personalizing Institutional Roles: Managing (Dis)Creditability in Formal Settings. In this precarious environment, the personal commitment of individual professionals often becomes intertwined with institutional identity. Participants described how, due to the scarcity of trained and engaged workers, their personal actions, ethics, and visibility became symbolic of the entire service or policy they represented. This personalization of institutional roles carries a dual effect. On the one hand, it can serve as a potent tool for advocacy, allowing professionals to leverage their personal histories, social positions, and ethical commitments to champion trans rights and healthcare access. On the other hand, personalization intensifies professional vulnerability, making individuals the focal point of frustrations directed at institutional failures, political disputes, or unmet expectations. At the same time, personification can also cause the health service or the action being developed to be easily dismantled, since by isolating that particular person, everything they actively represent is also isolated. It can even give rise to a figure who, by personifying the cause, renders it null or even iatrogenic. In this context, the successes and failures of institutional actions are often perceived as personal achievements or shortcomings. Professionals become not only caregivers but also the public faces of broader political struggles, often without the structural support necessary to sustain these battles over time. As a result, while personalization fuels resistance and advocacy, it also exposes the profound fragility of services that rely on a few committed individuals rather than stable institutional backing. Thus, the burden of solely (or with very few others) carrying the responsibility of planning, executing, and monitoring health actions for trans people falls almost entirely on that individual worker, as if it were a personal or team-specific issue, rather than the result of broader social structures sustained by transphobia. 4.3 Voice and Narrative Control: Claiming (or Being Granted) the Floor in Stigmatized Interactions. Professionals often speak from experiences of sexual orientation and/or gender identity non-conformity, which may be a crucial factor in their commitment to advocate for trans healthcare. "I was already familiar with the subject, even because I am a gay man. Something that also weighs heavily on me is a sense of social responsibility... It's hard for us to reach these spaces of management, politics, public management." This concept is closely tied to the speaking place , a notion that is prominently discussed within social justice and academic circles, particularly through the work of philosopher Djamila Ribeiro. It refers to the understanding that a person's social position and identity shape their perspective and experiences, thereby influencing their ability to speak with authority on specific topics. 29 Ribeiro advocates that individuals should speak from their experiences, particularly when addressing issues related to their social location, aiming to challenge power structures by amplifying the voices of marginalized groups and acknowledging how social inequalities influence whose voices are heard and valued. 30 Across different participants, speaking place appeared as a powerful driver of professional commitment and advocacy. Professionals often did not separate their personal and professional identities; instead, their lived experiences with marginalization informed their motivation to advocate, resist stigma, and create spaces for trans health care. "I think it’s important that we understand that people who are on the front line, who are willing to be in these spaces, are generally people who have some personal implication and defend this from that place." Whereas being part of the LGBT + community does not eliminate stigma by association, it appears to change how it is perceived or buffer its emotional impact. “[...] due to the fact that I'm gay, the issue of stigma is already a part of it [...]” . Professionals who are LGBT + may have learned coping strategies to deal with stigma, based on their own life experiences, and these strategies seem to be transferred into their professional resilience. “Perhaps because we already have a personal history of identification, we build up some resources that allow or hinder us to perceive certain things in association with an identity category.” Among these resilience strategies, emotional distancing and cognitive reframing, as well as building supportive peer networks and channeling adversity into activism, repeatedly appeared in the focal groups. Discussion Our study sheds light on a relatively underexplored dimension of trans health care: the stigma experienced by health professionals who provide care for trans and gender-diverse populations in Brazil. From policy advances to institutional backlash: are there any physicians left willing to work in trans and gender diverse healthcare? Echoing findings from other contexts where associative stigma has been documented, 13 , 16 our participants described working in precarious institutional environments marked by limited resources, unstable funding, and a lack of political commitment. These observations align with those reported by Miskolci et al. in their qualitative study on LGBT + health in Latin America, where institutional fragility and precarious foundations emerged as key barriers to service sustainability. 4 Together, these findings reflect broader systemic issues in Brazil, including the incomplete implementation of national health policies, chronic underfunding, and a shortage of qualified professionals equipped to deliver gender-affirming care. 31 Brazil’s recent political trajectory consists of a succession of political shifts marked by hostility toward marginalized groups, particularly the LGBT + communit, and trans and travestis populations most acutely. Overall, the early 2000s, particularly during the administration of President Luiz Inácio Lula da Silva and the Workers’ Party (PT), marked an important, albeit still insufficient, period of advancement for SGM populations in Brazil. A key milestone was the launch of the “Brazil Without Homophobia” program in 2004, coordinated by the Secretariat of Human Rights in partnership with the Ministry of Health. This initiative aimed to promote citizenship and human rights for LGBT + individuals, including specific directives on health rights that spanned policy development, research, and professional education. One notable outcome was the formal establishment of the Technical Committee on LGBT + Health within the Ministry of Health, which played a pivotal role in shaping the National Policy on Comprehensive Health for Lesbians, Gays, Bisexuals, Transvestites, and Transsexuals, officially adopted in 2011. It is also important to note that Brazil’s public health system, Sistema Único de Saúde (SUS), is founded on principles of popular participation and social control. In the field of LGBT + health, the organized social movement served as the primary driving force behind these early policy advances. The National Policy of Comprehensive Health of Lesbians, Gays, Bisexuals, Travestis , and Transsexuals represented a pivotal advancement in the quest for equity within the Brazilian healthcare system. 32 This policy sought to eliminate institutional discrimination, reduce inequalities, and solidify the Unified Health System as a universal, comprehensive, and equitable healthcare provider. 31 The subsequent years, however, have witnessed a notable rise in conservative political forces, particularly since 2016, which have actively opposed and dismantled many of these advancements. 31 This political shift has led to substantial setbacks for public health policies targeting LGBT + populations, characterized by budget cuts, reduced support for specific health programs, and hindrance of initiatives designed to address health disparities. 31 After the completion of this study, the Federal Council of Medicine issued Resolution No. 2.427/2025, which revoked both the authorization for gender-affirming surgeries in trans children and adolescents and the right of family physicians to initiate hormonal therapy for transgender individuals (Conselho Federal de Medicina, 2025). This resolution has since been publicly challenged by organizations such as the Brazilian Society of Family and Community Medicine and the National Association of Travestis and Transsexuals. Given this broader sociopolitical context, it is perhaps unsurprising that a recurring theme in participants’ narratives was the apparent lack of interest among medical professionals in working with trans and gender-diverse populations. This trend did not appear to extend to other professional categories. One participant illustrated this issue by recalling that five consecutive public selection processes aimed explicitly at hiring physicians for a trans-specialized healthcare service failed to attract a single applicant. Another participant pointed out that “there are a lot of schizophrenia, depression to treat, psychiatrists, right, to waste their time”. The apparent disinterest among physicians in trans health care seems to stem from a complex interplay of factors, with the rise of conservative and transphobic discourses in Brazil’s political and social spheres emerging as a central and cross-cutting influence. 31 These discourses are also reflected within professional bodies such as the Federal Council of Medicine, shaping attitudes across the medical field. Consequently, Brazilian medical schools provide limited training on gender-affirming care and trans-specific health needs, implicitly reinforcing the notion that trans health is neither a professional priority nor a necessary area of competence, despite being vaguely mentioned in the Curricular Directives. This educational gap contributes to physicians’ sense of technical unpreparedness, leading many to avoid providing care out of fear of making mistakes, facing litigation, or suffering reputational harm. Referring trans patients to specialized clinics—where available—becomes a common strategy for managing this perceived risk. Physicians who do choose to engage in trans health care often face stigma by association, being labeled as “activists” or “biased,” and may encounter explicit hostility from colleagues. In the context of Brazil’s overstretched public health system, where physicians already navigate heavy workloads and institutional pressures, the prospect of assuming additional emotional and reputational burdens makes trans health care an unattractive option for many. The lack of financial incentives compounds this: healthcare for transgender individuals in the public sector is typically underfunded, with limited opportunities for private practice, research funding, or academic recognition. For physicians making career decisions in a resource-constrained environment, trans health may be perceived as a low-reward and high-risk field. This scenario underscores a critical structural barrier to ensuring adequate medical care for trans individuals. It highlights the urgent need for targeted strategies to address workforce gaps when formulating equitable health policies for marginalized populations. Regarding the current workforce in this area, our findings revealed two markedly different professional trajectories among participants working in trans health care: one rooted in loneliness and improvisation, and the other shaped by academic training and institutional recruitment. For the first generation of providers, entry into the field was often unplanned, driven by a personal identification with LGBT + rights or an ethical responsibility to address an unmet need in the healthcare system. Self-training and improvisation to fill institutional voids appeared frequently during the interviews. In contrast, a second generation of professionals reported that their engagement with trans health began during their academic formation, often linked to formal education in gender and diversity issues. However, even among this second generation, the decision to work in trans health was rarely neutral or institutionally incentivized. Instead, it was influenced by pre-existing personal commitments, often as LGBT + individuals themselves. We also emphasize that, regardless of the pathway that led each worker to engage in this field, whether through past or present involvement in the LGBT + social movement, through academia, or through being sensitized to the issue during their professional trajectory, what was common among the experiences shared was an ethical and technical commitment to trans issues, with a strong sense of responsibility and social justice among participants. At the same time, the divergent institutional logics and histories that shaped participants’ perspectives at times generated tensions within the group. While these conflicts occasionally made dialogue more challenging, they also underscored the complexity of the field. They revealed the layered and sometimes conflicting meanings of “care” and “access” within trans health in Brazil. The model of trans health care remains a contested terrain, even among professionals directly engaged in this field. Stigma by association's impact and the speaking place: absent, managed, or unnamed? Although stigma by association was part of our guiding research questions and featured explicitly in our focus group prompts, its appearance in the participants' narratives was notably limited. One plausible explanation for this relatively low reporting is the social positioning of our participants. As permanent staff members with open-ended contracts, most had spent several years within the same institutional environments, developing long-term relationships with colleagues, managers, and service users. This employment stability may have allowed for the gradual testing, refinement, and implementation of coping strategies to navigate stigma by association over time. Indeed, to minimize the psychosocial risks associated with stigma by association, workers may have learned to employ methods such as caution, contextual awareness, and silent institutional maneuvering whenever the sociopolitical environment becomes unfavorable. When conservative forces are advancing and setbacks in the field of human rights (particularly those of trans people) are taking place, it becomes essential to navigate this field carefully, without provoking further resistance. The possibility of implementing health actions aimed at trans people seems to be tied to a prior psychosocial calculation: for activities to continue being carried out, extraordinary care must be taken with what is said, to whom it is said, and how it is said. These strategies, while enabling the continuation of the work and reducing the risks of stigma by association, may also render the stigma more covert and, consequently, more difficult to detect. Another possible explanation is methodological. Our recruitment strategy targeted professionals who were still engaged in trans health services and had chosen to remain despite years of exposure to structural and interpersonal stigma. This self-selection may have resulted in a "survivor cohort"—individuals who had either found ways to cope with stigma by association or who did not perceive it as a central concern. Studies with broader samples, including professionals who left trans health services or chose not to enter the field, might reveal a different picture. Finally, it is essential to note that some participants may have experienced stigma by association but lacked the conceptual vocabulary to name it as such. As Hammond and Kingston note in their research with sex work researchers, professionals often struggle to articulate stigma when it is diffused, normalized, or embedded within broader institutional cultures of marginalization. 17 In this sense, participants' speaking place as members of the LGBT + community seems to serve as a protective factor in recognizing stigma by association, although not necessarily in confronting it. These professionals described a kind of stigma "immunity" cultivated over years of navigating both personal and professional marginalization. For some, experiences of homophobia in their personal lives appeared to act as an inoculation against new forms of work-related stigma, or as a buffer, “diluting” whatever stigma they felt came their way. Conversely, cisgender heterosexual participants, especially during the early years of their careers, were more likely to report explicit experiences of stigma by association. In this context, it is also important to note that the relationship between the medical establishment and the trans community has evolved over the years. Initially, while the process of removing homosexuality from the DSM was underway, some members of the APA (sometimes the same ones) were advocating for the inclusion of “ transexualism ” as a medical diagnosis. At that time, this was supported by the trans community to ensure access to gender-affirming care, such as surgeries and hormonal treatment. However, over time, this has changed, and today the trans community fights for the exclusion of trans identity-related diagnoses, understanding that pathologization reinforces stigma and discrimination. 33 – 35 Thus, we hypothesize that participants who do not self-identify as LGBT + may occupy the speaking place solely of healthcare professionals, representing the medical establishment, and therefore have a more difficult time navigating the combination of stigma by association from health professionals and institutions, as well as possible critiques from the LGBT + social movements themselves. Limitations This study has several limitations that should be taken into account when interpreting its findings. First, there were no trans individuals among either the research team or the study participants. This absence reflects the structural barriers that currently limit trans people's access to higher education and formal employment in Brazil. The near-zero rate of trans people occupying spots in public universities and formal job positions in Brazil has prompted the development of targeted affirmative action policies in the State of Rio Grande do Sul in recent years, aimed at increasing trans representation in public service positions and health specializations (State of Rio Grande do Sul, 2021, 2022). It is important to note that this is one of several emerging experiences of affirmative action policies for trans people in Brazil. As a relatively recent policy development, its implementation has yet to be systematically evaluated. Second, the study design was based on focus groups with permanent staff members from a limited number of services in a single metropolitan area. While this recruitment strategy allowed for rich, contextually grounded discussions among experienced professionals, it may have limited the diversity of perspectives, particularly from younger, early-career, or precariously employed professionals (such as residents, interns, or temporary staff), who may experience stigma by association in distinct ways due to their more vulnerable employment status. Third, although our thematic analysis was methodologically rigorous and grounded in participants' narratives, the relatively small sample size and the regional specificity of the setting limit the generalizability of our findings. Additionally, while the research team engaged in ongoing reflexivity and employed strategies to enhance analytic rigor, it is essential to acknowledge that our positionalities (as cisgender, white, both heterossexual and LGB researchers) may have influenced both data interpretation and participant engagement. Finally, despite explicitly including stigma by association as a focus in both our research questions and discussion prompts, participants mentioned the phenomenon less frequently than anticipated. This low salience may reflect a combination of factors, including social desirability bias, normalization of stigmatizing interactions over time, or the development of adaptive coping strategies that minimize participants' perception or recollection of stigma by association. Future studies could address these limitations by employing mixed-methods designs, expanding the geographic scope, incorporating the perspectives of trans professionals, and applying quantitative measures specifically validated for stigma by association in healthcare contexts. Conclusions This study sheds light on a relatively underexplored dimension of trans healthcare: the "stigma by association" experienced by health professionals who provide care for transgender and gender-diverse populations in Brazil. Our findings reveal the significant structural and interpersonal challenges these professionals face, highlighting the precarious institutional environments and the often-subtle forms of discrimination that impact their well-being and the sustainability of the services they provide. By documenting the professional trajectories, challenges, and stigma-related experiences of health workers providing care to trans and gender-diverse individuals, this study contributes to the growing body of literature on stigma by association within healthcare settings. Our findings underscore the importance of addressing both structural and interpersonal dimensions of stigma, highlighting the urgent need for intersectional, multi-stakeholder, and context-specific strategies to support health professionals and advance the right to health for trans populations in Brazil. However, we find it essential to acknowledge areas for future research that, although not directly explored in our work, emerged throughout the study. The issue of race and intersectionality, for example, emerged organically when participants discussed barriers to accessing care. In the Brazilian context, systemic racism and socioeconomic inequalities impose substantial barriers to healthcare access for Black and other racialized populations, compounding the discrimination already experienced by trans and gender-diverse individuals. National indicators highlight that Black trans people are disproportionately affected by violence, poverty, educational exclusion, and restricted access to health services. 4 Given these intersecting forms of oppression, future research should prioritize intersectional analyses that examine how race, gender identity, and other social categories (such as class, geography, and disability) shape the experiences of stigma by association among healthcare professionals working with trans populations. Additionally, future studies might wish to investigate the experiences of sexual and gender minority professionals themselves within Brazil’s trans-specialized health services. Given their shared minority status, these professionals may face unique forms of stigma and may deploy distinct strategies for coping and professional resilience. Understanding their experiences could shed light on the dual role they often occupy - as both providers and members of marginalized communities. At the same time, it is equally important to explore how cisgender heterosexual professionals working in trans health settings navigate stigma, ethical tensions, and professional vulnerabilities. As key actors within this field, they too bear responsibility for advancing equity and challenging transphobia within healthcare institutions. Another issue raised by participants was the scarcity of structured, collective spaces for reflection and support among professionals engaged in trans health care. Participants voiced a clear need for more frequent opportunities for interprofessional dialogue, emotional support, and shared strategizing to address institutional challenges and stigma-related stressors. Considering this, we recommend that future research incorporate participatory and action-oriented methodologies that not only capture narratives of stigma but also facilitate the creation of collaborative networks and safe spaces for mutual support and engagement. These collective forums could help foster resilience, strengthen inter-service alliances, and ultimately promote more equitable and sustainable trans health care practices. Abbreviations LGBT+ - Lesbian, Gay, Transexual and Travesti, and other sexual and gender minorities LGBTQI+ - I Lesbians, Gays, Bisexuals, Transvestites, Transsexuals, Queers, Intersex and People with Non-Binary Gender Identity PT – Working Party SGM - Sexual and Gender Minorities SUS - Brazilian Unified Health System Declarations Ethics approval and consent to participate The project was reviewed and approved by the Pontificia Universidade Catolica do Rio Grande do Sul (PUCRS's) Institutional Review Board under the number 71170123.6.0000.5336. Participants signed a form indicating their free and informed consent. The invitation was made directly to the professional and had no direct relationship with the services. Consent for publication Consent for publication was obtained from all participants. Availability of data and materials The datasets generated and/or analyzed during the current study are not publicly available due to the sensitive nature of the material and confidentiality agreements made with participants but are available from the corresponding author on reasonable request. Competing interests A.M.F. - Employed at one of the trans clinics represented in the study (Clinic T). C.G. - Employed at the State Health Secretariat. The other authors declare that they have no competing interests Funding No funding was granted specifically for this research. All of the researchers have been granted funding for research on LGBT health-related issues. Authors’ contributions A.B.C. - made substantial contributions to the conception and design of the work, to the data interpretation, and to the drafting and revision of the work. A.M.V.F. - made substantial contributions to the conception and gn of the work, to the data acquisition, analysis, and interpretation, and to the drafting and revision of the work. C.G. - made substantial contributions to the interpretation of data and to the drafting and revision of the work. J.Z.O. - made substantial contributions to the conception and design of the work, to the data acquisition, analysis, and interpretation, and to the drafting and revision of the work. All authors have approved the submitted version and have agreed both to be personally accountable for the contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author individually was not personally involved. Acknowledgments Not applicable. References Hunt R. Guinness world records 2024 [Internet]. Guinness World Records Limited, editor. [Guinness World Records Limited]; 2023 [cited 2025 Jul 20]. 0–256 p. 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LGBTQIA + health: a rapid scoping review of the literature in Brazil. Cien Saude Colet [Internet]. 2022 Sep 16 [cited 2025 Jul 20];27(10):3835–48. Available from: https://www.scielo.br/j/csc/a/LQDJPWqyCjTsrLLXZY8PZzN/?lang=en Drescher J. Queer diagnoses: Parallels and contrasts in the history of homosexuality, gender variance, and the Diagnostic and Statistical Manual. Arch Sex Behav [Internet]. 2010 Apr 25 [cited 2025 Jun 9];39(2):427–60. Available from: https://link.springer.com/article/ 10.1007/s10508-009-9531-5 Drescher J. Queer diagnoses revisited: The past and future of homosexuality and gender diagnoses in DSM and ICD. International Review of Psychiatry [Internet]. 2015 Sep 3 [cited 2025 Jun 9];27(5):386–95. Available from: https://www.tandfonline.com/doi/abs/ 10.3109/09540261.2015.1053847 Hectors A. Homosexuality in the DSM: a critique of depathologisation and heteronormativity. New Zealand Sociology 2023; v 38, n 1, p 18–28 [Internet]. 2023 [cited 2025 Jun 11]; Available from: https://natlib.govt.nz/records/51995417 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7319508","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":502742374,"identity":"dbe7cf3f-fa5b-4c82-8172-5b80693b07cf","order_by":0,"name":"Anna Martha Fontanari","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7klEQVRIiWNgGAWjYDADAyD+8AFIsLETqUMCqIVx5gyQFmZStMzmATEJaeGf3Xvw042ae3Xm7GcMm21+bZPnY2Zg/PAxB4/pd84lS+ccK5aw7MkxbM7tu23YxszALDlzGx5rbuQYSOewJUgYHEhLf5zbc5sRqIWNmRePFvkbOca/c/4BtZx/lths2XPbnqAWgxs5ZtK5bUAtN5IPNjP8uJ1IUIshUIt1bl+C5IYbjw829jbcTm5jZmzG6xc5oMNu53xL4Dc4n9jY8OPPbdv57c0HP3zE530UwNgGJhuIVQ8Cf0hRPApGwSgYBSMFAAAqRlLI8H+uzwAAAABJRU5ErkJggg==","orcid":"","institution":"Federal University of Rio Grande do Sul","correspondingAuthor":true,"prefix":"","firstName":"Anna","middleName":"Martha","lastName":"Fontanari","suffix":""},{"id":502742376,"identity":"4ffe2949-972f-4132-a6f9-4d9bbf2fc2b0","order_by":1,"name":"Julia de Oliveira","email":"","orcid":"","institution":"Pontifical Catholic University of Rio Grande do Sul","correspondingAuthor":false,"prefix":"","firstName":"Julia","middleName":"","lastName":"de Oliveira","suffix":""},{"id":502742377,"identity":"d4468832-0751-4a9e-964d-53efa94faa2e","order_by":2,"name":"Camila Guaranha","email":"","orcid":"","institution":"Federal University of Rio Grande do Sul","correspondingAuthor":false,"prefix":"","firstName":"Camila","middleName":"","lastName":"Guaranha","suffix":""},{"id":502742379,"identity":"4173d3bd-a6db-4148-b0a6-28a3fcd575d8","order_by":3,"name":"Angelo Costa","email":"","orcid":"","institution":"Pontifical Catholic University of Rio Grande do Sul","correspondingAuthor":false,"prefix":"","firstName":"Angelo","middleName":"","lastName":"Costa","suffix":""}],"badges":[],"createdAt":"2025-08-07 13:53:29","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7319508/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7319508/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":92493466,"identity":"d20d04fb-2d4d-407c-912f-ae20e79ea16e","added_by":"auto","created_at":"2025-09-30 09:54:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":858905,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7319508/v1/d780c23b-5287-4e7a-a80d-f9f139753396.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eHealth Professionals' Experiences of Professional Bias, Harassment, and Discrimination in the Context of Gender Diversity in Southern Brazil: a thematic analysis of focus groups\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eSexual and gender minorities (SGM) in Brazil have undergone different periods regarding categorical identities, policies, and cultural acceptance. Although today the country hosts the biggest pride parade in the world,\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e lesbians, gays, bisexuals, transsexuals, \u003cem\u003etravestis\u003c/em\u003e, and other sexual and gender minorities (LGBT+) still face significant health challenges within the Brazilian scenario.\u003csup\u003e\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eSpecific to the trans and gender diverse identities, self-referred to as \u003cem\u003etravestis\u003c/em\u003e and transexuals, social recognition and participation in policies gained momentum in the 1980s-1990s, primarily associated with the HIV-AIDS epidemic.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e At the same time, the Brazilian Unified Health System, SUS, was being established, based on the founding principles of equity, universality, and integrality, which aimed to guarantee free access to healthcare for every citizen.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eDuring this period, policies targeting the LGBT\u0026thinsp;+\u0026thinsp;community emerged, influenced more by the perceived need to control disease transmission than purely by genuine efforts to protect and care for these populations. It was later, initially with the 2004 policy Brazil Without Homophobia and, finally, with the 2011 National Policy for Integrated LGBT Health, that SGM health started being addressed through the lens of human rights, tackling stigma and discrimination in healthcare settings, and expanding access to comprehensive healthcare services.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eIn addition to the National Policy for Integrated LGBT Health, the subnational spheres also have their respective policies. In Rio Grande do Sul (RS), the state in which the study was carried out, the State Policy for Comprehensive LGBT Health Care was published in 2014 (Rio Grande do Sul, 2014), while in the state's capital, Porto Alegre, the Municipal Policy for Comprehensive Health for Lesbians, Gays, Bisexuals, Transvestites, Transsexuals, Queers, Intersex and People with Non-Binary Gender Identity (LGBTQI+) was established in 2019 (Porto Alegre, 2019).\u003c/p\u003e\u003cp\u003eOf note, although all these policies mentioned above are overtly directed at the LGBT\u0026thinsp;+\u0026thinsp;population in general, the existing health initiatives not related to HIV or sexually transmitted diseases are mainly directed at the transsexual and \u003cem\u003etravesti\u003c/em\u003e population, exemplified by the trans clinics mentioned in this paper.\u003c/p\u003e\u003cp\u003eNonetheless, despite policy advances, trans and gender-diverse individuals in Brazil still experience difficulties accessing healthcare services due to discrimination, insufficient information, and policies that fail to meet their needs.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e This population faces significant stigma and encounters substantial barriers when accessing public health services, both globally and across Latin America.\u003csup\u003e\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e A recurring theme in the literature is the pervasive impact of stigma within healthcare settings, which often leads individuals to avoid or delay seeking care due to fear of mistreatment or as a result of previous negative experiences, such as misgendering, deadnaming or explicit and subtle provider bias.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e Provider-related barriers encompass a shortage of trans-competent clinicians and insufficient knowledge about gender-affirming care.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e Although stigma by association has not been widely discussed within LGBT\u0026thinsp;+\u0026thinsp;health literature, it has emerged as a relevant provider-related barrier in other healthcare contexts. This phenomenon has been documented among caregivers of people living with HIV/AIDS,\u003csup\u003e13\u003c/sup\u003e individuals with mental illness,\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e those with neurodevelopmental disorders,\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e as well as in abortion care services,\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e and among professionals working with sex workers.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e In these settings, healthcare and support professionals report experiences of isolation, reputational damage, moral judgment, and emotional exhaustion\u0026mdash;factors that negatively affect their well-being and compromise the sustainability of their work.\u003c/p\u003e\u003cp\u003eBriefly, stigma was first systematically theorized by Erving Goffman, who defined it as a deeply discrediting social attribute that reduces a person \u0026ldquo;from a whole and usual individual to a tainted, discounted one\u0026rdquo; (p. 3). Stigma arises from an \u0026ldquo;undesired differentness from what we had anticipated\u0026rdquo; (p. 5) and is embedded in social interaction.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e Building on this framework, Link and Phelan\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e (2001) conceptualized stigma as the co-occurrence of labeling, stereotyping, separation, status loss, and discrimination within contexts marked by power differentials. While much of the literature has focused on the effects of stigma on those who are directly marked or marginalized, Goffman drew attention to its spillover effects. He noted that \u0026ldquo;\u003cem\u003ethe problems faced by stigmatized persons spread out in waves of diminishing intensity among those they come in contact with\u003c/em\u003e\u003csup\u003e\u003cem\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/em\u003e\u003c/sup\u003e\u0026rdquo;. This phenomenon\u0026mdash;known variously as courtesy stigma, associative stigma, or stigma by association\u0026mdash;affects individuals who are closely connected to stigmatized people, such as family members, friends, or professionals.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eStigma by association has been found to impact family dynamics and diminish the quality of care provided to stigmatized individuals.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e It can also manifest in various social contexts through both close and incidental associations. Strong ties, such as kinship, friendship, or chosen affiliations, are potent conduits for stigma.\u003csup\u003e\u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e However, even coincidental or superficial proximity can trigger stigmatization; for example, being seated near a stigmatized person has been shown to affect third-party perceptions negatively.\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eDespite the increasing recognition of these dynamics, there is still a paucity of research specifically examining how stigma by association affects professionals who provide care for trans and gender-diverse populations. This gap is particularly concerning given the sociopolitical climate in which trans persons are frequently targeted by moral panic, misinformation, and institutional neglect. In such contexts, professionals may become secondary targets of prejudice, experiencing stigmatization for their association with trans people or for being perceived as \u0026ldquo;allies\u0026rdquo; or advocates. This phenomenon can lead healthcare professionals to abandon providing care or even deter them from specializing in this field, ultimately resulting in poorer health outcomes for transgender individuals.\u003c/p\u003e\u003cp\u003eThus, our study aims to explore the experiences of healthcare professionals who work with trans and gender-diverse populations in southern Brazil. Drawing on qualitative data from focus groups, we examine how stigma by association shapes professional trajectories, institutional affiliations, and daily practices. In doing so, we aim to contribute to a more nuanced understanding of the psychosocial costs of inclusive care work and inform the development of structural and educational strategies that can better support those who provide it, and, by extension, the population they care for.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eResearch Design Overview\u003c/h2\u003e\u003cp\u003eWe understand knowledge as situated and relational, emerging through dialogue between researchers and participants. Therefore, we chose focus groups for our qualitative approach. In this context, we aim to emphasize reflexivity, power dynamics, and the ethical importance of creating spaces where participants feel safe to share sensitive experiences, particularly in the context of stigma by association.\u003c/p\u003e\u003cp\u003eFor the focus groups, participants signed a form indicating their free and informed consent. The invitation was made directly to the professional and had no direct relationship with the services. Anonymity and confidentiality were guaranteed (professionals and services), and the project was approved by our IRB board71170123.6.0000.5336.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eResearchers’ Characteristics\u003c/h3\u003e\n\u003cp\u003eThe research team is profoundly implicated in this inquiry, both as health professionals and as LGBT\u0026thinsp;+\u0026thinsp;individuals. All the researchers identify as white Latinx and cisgender individuals; two of us are lesbian women, one is a gay man, and one is a heterosexual woman. One of us is a psychiatrist at a Trans and Gender Diverse Clinic. All of us are currently researching LGBT\u0026thinsp;+\u0026thinsp;health.\u003c/p\u003e\n\u003ch3\u003eRecruitment and Study Participants\u003c/h3\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eRecruitment Process\u003c/h2\u003e\u003cp\u003eWe distributed the invitation through personal and professional networks. Friends and colleagues were encouraged to disseminate it further. No institution was directly approached, and no institutional space was used for recruitment. This strategy was deliberate: we considered that institutional recruitment could compromise participants\u0026rsquo; freedom to share experiences of stigma by association or other sensitive matters they might find relevant.\u003c/p\u003e\u003cp\u003eWe exclusively invited permanent staff members to participate. Although these services commonly rely on temporary labor (e.g., students, volunteer interns, and residents) whose impressions are undoubtedly valuable, we opted for a smaller, more cohesive group. Our goal was to foster an atmosphere of trust and intimacy that would support the sharing of personal and potentially vulnerable experiences.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudy Participants\u003c/h3\u003e\n\u003cp\u003eNine participants took part in two focus groups. Group 1 included a psychologist, two managers (one at the state level and one at the municipal level), a social worker, and a family physician. Group 2 was composed of a psychiatrist, two psychologists, and another family physician. Across both groups, all key health services providing care for transgender populations in the region were represented.\u003c/p\u003e\u003cp\u003eParticipants self-identified as both black and white, and included heterosexual and homosexual individuals. Notably, no participant identified as lesbian, and no transgender person was identified as a permanent staff member within the services at the time of recruitment. For this reason, no trans professionals were included in the study. The trans absence in our study itself is a relevant contextual feature of the institutional landscape under investigation. For more details, see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSociodemographic characteristics.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e29\u0026ndash;39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e33.3%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e40\u0026ndash;49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16.7%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e60\u0026ndash;69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e50.0%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eEducation\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCollege Degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e33.3%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePostgraduate Degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e66.7%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eGender Identity\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCisgender Man\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e50.0%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCisgender Woman\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e50.0%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTrans or \u003cem\u003etravesti\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u003cb\u003eSexual Orientation\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHeterosexual\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e50.0%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGay\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e33.3%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLesbian\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.0%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBisexual\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16.7%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eRace or Ethnicity\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWhite\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e66.7%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBlack\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e33.3%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003e\u003cb\u003eReligion or Belief\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCatholic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16.7%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eChristianity (unspec.)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16.7%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAfro-Brazilian Religion\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16.7%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAtheism\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e33.3%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNot Informed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16.7%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003cem\u003eNote.\u003c/em\u003e Percentages are presented to describe the sample distribution. Absolute frequencies are not shown to protect participant anonymity, given the small sample size.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eNo archival materials, documents, or previously collected datasets were used in this study. All data was generated through original focus group discussions. Due to the sensitive nature of the material and confidentiality agreements made with participants, the data is not currently housed in an open-access repository. The appropriate Institutional Review Board approved all study procedures (CAAE 71170123.6.0000.5336).\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eResearcher\u0026ndash;Participant Relationship\u003c/h2\u003e\u003cp\u003eGiven the relatively small number of professionals working with transgender health in Brazil, the research team and participants were part of a closely interconnected professional field. Most participants knew one another\u0026mdash;and the researchers\u0026mdash;either directly or indirectly, before the study. Naturally, those with closer collegial ties to the researchers, and who might even be considered professional acquaintances or friends, were more inclined to participate, particularly considering the study's length and the absence of financial compensation.\u003c/p\u003e\u003cp\u003eNonetheless, despite these proximities, the relationships were not characterized by personal friendship or shared life histories. Participants brought highly diverse professional trajectories to the study, shaped by their positions across the health care system\u0026mdash;from state health managers and primary care to specialized services. These differing pathways also informed the power dynamics and epistemological positions represented in the group.\u003c/p\u003e\u003cp\u003eAiming to provide comprehensive care and improve access for this population, Brazil has expanded its policies over the last decade, including the creation of national policies such as the National Policies for LGBT individuals, which helped articulate regional policies, centers, and clinics, such as the trans clinics in Porto Alegre and S\u0026atilde;o Paulo.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eData Collection and Identification Procedures\u003c/h3\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003eData Collection\u003c/h2\u003e\u003cp\u003eData for this study were collected through two focus groups with health professionals working directly or indirectly with trans and gender-diverse populations in a Brazilian metropolitan region. The choice of focus groups was informed by Minayo,\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e who emphasized the value of this technique for studying health issues from a social perspective, especially for understanding representations, relational dynamics, and professional practices in complex health systems. Compared to individual interviews, focus groups enable the observation of interactional dynamics among participants, which is essential given the study\u0026rsquo;s interest in institutional roles, collective memory, and affective resonance.\u003c/p\u003e\u003cp\u003eParticipants were selected based on their involvement in either specialized or primary care services focused on transgender health. Specialized care professionals included staff involved in the foundation and implementation of a long-standing federal outpatient clinic for trans health, which is affiliated with a leading research hospital and has performed over 300 gender-affirming surgeries. Primary care participants were professionals from open-door trans health clinics established in the last ten years \u0026mdash;operating within Brazil\u0026rsquo;s primary care system with autonomy to prescribe hormonal therapy, up to a recent Federal Council of Medicine\u0026rsquo;s resolution, approved after this study was conducted, which prohibits family physicians from initiating hormonal therapy for trans individuals. Additionally, public administrators involved in implementing the National LGBT\u0026thinsp;+\u0026thinsp;Health Policy were also invited, reflecting the multi-level structure of transgender health governance in Brazil.\u003c/p\u003e\u003cp\u003eFocus groups were guided by a semi-structured protocol, developed to elicit open and exploratory responses. Each session began with a round of introductions and a brief professional biography shared by each participant. The guiding questions were grouped into three thematic axes: (1) socio-political conditions that enabled the emergence of trans health services; (2) the current operational landscape, including barriers and facilitators; and (3) individual experiences of stigma by association, defined to participants as the prejudice or discrimination experienced by individuals due to their association with a stigmatized group, even when they do not share the stigmatized characteristic themselves.\u003c/p\u003e\u003cp\u003eExamples of guiding questions included: \u0026ldquo;What do you believe enabled the creation of these care spaces?\u0026rdquo;, \u0026ldquo;What do you feel is the greatest challenge to their continuity in the current context?\u0026rdquo;, \u0026ldquo;Which factors do you see as potential facilitators?\u0026rdquo;, \u0026ldquo;How do these challenges and facilitators affect your daily work?\u0026rdquo;, \u0026ldquo;Have you ever experienced stigma or discrimination due to your work with sexual and gender minorities? If so, are you comfortable sharing a specific episode? Did it impact your professional path?\u0026rdquo;, \u0026ldquo;Have you ever felt fear or discomfort\u0026mdash;e.g., around terminology use\u0026mdash;in your work with vulnerable populations?\", \u0026ldquo;Do you avoid certain contexts or settings in your professional activities? If so, which ones?\u0026rdquo;, and \u0026ldquo;Have you encountered specific challenges or advantages in securing funding (public or private) for work with these populations?\u0026rdquo;.\u003c/p\u003e\u003cp\u003eA trained moderator facilitated each session. Each group was conducted on a separate day and lasted approximately 90 minutes. Both sessions ended somewhat abruptly due to time constraints, despite participants\u0026rsquo; strong engagement and the evident emotional need to share difficult professional experiences. Participants expressed the rarity of safe spaces to discuss their trajectories, often marked by institutional resistance, affective labor, and personal exposure to structural violence.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eRecording and Data Transformation\u003c/h2\u003e\u003cp\u003eAudio was recorded using two smartphones and temporarily stored in a Google Drive folder. A member of the research team later transcribed the recordings with the help of the audio transcription tool in Microsoft Word. Audio files were deleted immediately after transcription to preserve participant confidentiality.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eAnalysis\u003c/h2\u003e\u003cdiv id=\"Sec13\" class=\"Section3\"\u003e\u003ch2\u003eData-Analytic Strategies\u003c/h2\u003e\u003cp\u003eThe primary goal of the analysis was to identify patterns of meaning related to the professional experiences of stigma by association and institutional dynamics in the context of transgender healthcare in Brazil. Analysis was conducted on the full transcriptions of two focus group sessions, treated as the units of analysis. Data analysis followed Braun and Clarke\u0026rsquo;s reflexive thematic analysis approach, which emphasizes the active role of the researcher in identifying, analyzing, and reporting patterns within the data. Thematic analysis was conducted through a recursive six-phase process: (1) familiarization with the data, (2) generation of initial codes, (3) searching for themes, (4) reviewing themes, (5) defining and naming themes, and (6) producing the report.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eCoding was performed using the qualitative data analysis software Taguette, an open-source tool selected for its accessibility and collaborative features.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e Throughout the process, the research team maintained reflexive memos to document evolving interpretations and analytic decisions. Discrepancies in coding and interpretation were addressed through discussion and consensus-building among team members. The resulting analytic scheme captured themes related to the formation of trans-specific services, ethical tensions between care and gatekeeping, and personal accounts of stigmatization in professional roles. These themes were used to structure both the presentation of results and their interpretation in light of broader sociopolitical and institutional contexts.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eMethodological Integrity\u003c/h2\u003e\u003cp\u003eResearchers were committed to ensuring fidelity to the lived realities of professionals working in trans health. Two main strategies were employed. First, diversity among participants was actively sought and achieved, allowing for a more nuanced understanding of both structural and affective dynamics within the field. Second, the research team engaged in structured reflexivity by maintaining memos throughout the study to critically examine their positionalities and assumptions.\u003c/p\u003e\u003cp\u003eData were analyzed inductively and iteratively, with thematic patterns grounded in participants\u0026rsquo; own words. Taguette \u003cem\u003esoftware\u003c/em\u003e\u0026mdash;a free, open-source qualitative data analysis tool\u0026mdash;was used to organize and systematize coding and reflections.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e To enhance credibility and resonance, preliminary findings were discussed with select participants, and the full manuscript was later returned to them for feedback and validation.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eFour thematic areas identified as representing different dimensions or manifestations of stigma experienced by health professionals working with trans and gender-diverse populations: 1. Structural/Institutional Stigma; 2. Contingent Stigma; 3. The Affective Costs of Stigma, and 4. Dealing with Stigma. These are further subdivided into themes that range from precarious foundations and institutional fragility to voice and narrative control.\u003c/p\u003e\n\u003cp\u003e\u003cspan\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e1. Structural/Institutional Stigma.\u003c/em\u003e\u003c/p\u003e\u003cspan\u003e\n \u003cp\u003e\u003cem\u003e1.1 Precarious Foundations and Institutional Fragility.\u003c/em\u003e\u003c/p\u003e\n\u003c/span\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003eThe establishment of all health services analyzed, whether in primary or specialized care, shared a particularly striking feature: they were born from a combination of coincidence and personal commitment, rather than formal institutional planning or political initiative. \u003cem\u003e\u0026quot;What I perceive, and what is common in practically all of these services, is that none of them emerged from a governmental project or program. Everything I\u0026apos;ve seen and followed arises from professionals within the system\u0026mdash;people who are sensitive, who understand the importance\u0026mdash;because the demands are already there.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn describing the origins of his work in LGBT\u0026thinsp;+\u0026thinsp;health, one of the participants recalls stumbling upon an underutilized sector \u003cem\u003e\u0026quot;I discovered within the Secretariat that there was a technical area for LGBT\u0026thinsp;+\u0026thinsp;health. Kind of like, hey! There\u0026apos;s a technical area? That\u0026rsquo;s great\u0026mdash;something I\u0026apos;d love to work on.\u0026quot;\u003c/em\u003e At that time, the area \u003cem\u003e\u0026quot;began the 2015 administration without anyone assigned.\u0026quot;\u003c/em\u003e After informal coordination with colleagues, the manager was able to assume responsibility for it. And it was a lot of responsibility. \u003cem\u003e\u0026ldquo;And the only thing I could think was that all these people have no idea that I\u0026apos;m the poor devil who has to think about public health policy for all of them. That\u0026apos;s such a heavy responsibility, right? But, since I accepted the invitation, I thought, well, if I don\u0026apos;t accept, who else in this department will?\u003c/em\u003e Another participant described a long history of improvisation, creativity, and personal networks to ensure access to gender-affirming care. \u003cem\u003e\u0026quot;Because we lost in an injunction\u0026mdash;again and again. So we made a direct agreement between the hospital and the State to fund two surgeries per month.\u0026rdquo;\u003c/em\u003e The federal regulation that eventually enabled the procedure, they explained, was only published \u003cem\u003e\u0026quot;because Fulano was the judge at the time\u0026mdash;he\u0026rsquo;s gay and identifies with the issue.\u0026quot;\u003c/em\u003e Fortuitous relationships and personal beliefs took place in the absence of public policies.\u003c/p\u003e\n\u003cp\u003eParticipants emphasized the chronic lack of political and institutional responsibility for addressing the healthcare needs of trans populations: \u003cem\u003e\u0026quot;We have no recourse, right? We pick up other people\u0026apos;s leftovers,\u0026rdquo; and \u0026quot;The LGBT agenda, man, it never came up. Never, guys, never came up. Not once. The national policy hadn\u0026rsquo;t been created yet, but even after 2011, this discussion was not initiated by the municipality, the regional office, or anyone.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eInstitutional fragility continued to cast a long shadow over these services, even after they were established. A tremendous effort is required to ensure the service exists and continues to operate. It manifested as unstable or improvised funding, often dependent on parliamentary amendments or personal fundraising efforts; as scarcity of physical infrastructure, such as consultation rooms or equipment; and as lack of a qualified, dedicated, and stable workforce, particularly in contexts of high staff turnover or outsourced services. Together, these elements formed a fragile ecosystem in which professionals operated despite the system, rather than because of it. See Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eInstitutional Fragility.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFragility\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCitation\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLack of a qualified, dedicated, and stable workforce\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026quot;Started with two weekly appointments at a community health center, with residents and one physician.\u0026quot;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026quot;There was no dedicated team, we depended on whoever was available from other services.\u0026quot;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnstable or improvised funding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026quot;The service depended on parliamentary amendments to purchase hormones for users.\u0026quot;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026quot;We had to pass the hat to carry out our work.\u0026quot;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eScarcity of physical infrastructure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026quot;There are only two rooms, and when there is a campaign, we have to cancel the clinic.\u0026quot;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026quot;We have no proper infrastructure, only a borrowed room with no privacy.\u0026quot;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eThese conditions directly impact service access and quality. Patients face long wait times, interruptions in care, and inappropriate referrals. Health professionals spoke of a system that routinely fails to integrate trans care across levels of attention, leaving certain services overwhelmed. Even at well-known institutions, care is hindered by siloed structures and restrictive resources.\u003c/p\u003e\n\u003cp\u003eInstitutional weaknesses and limited resources may also lead to physical and mental overload for workers who, to provide healthcare to trans individuals, accept working under unfavorable or precarious conditions. In this regard, some participants reported engaging in volunteer work and accumulating extra hours that were either unrecognized or unpaid by the institutions with which they were affiliated. Few workers reported having a workload fully dedicated to trans healthcare, as most participants had to divide their working hours between trans-specific services and one or more other points of care within the network.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e1.2 Professional Trajectories Between Activist Commitment and Academic Formation.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn the absence of political or institutional incentives, the first generation of health professionals dedicated to trans care emerged primarily from the LGBT\u0026thinsp;+\u0026thinsp;social movement. Their entry into the field was not driven by state policy or technical specialization, but by a profound sense of ethical responsibility and personal commitment. As one participant recalled: \u003cem\u003e\u0026quot;So, I was already familiar with the subject, because I am a gay man. Something that also weighs heavily on me is a sense of social responsibility, let\u0026apos;s say, because it\u0026apos;s hard to reach these spaces, right? Closely following people within the social movement, putting pressure on from the outside, doing all this movement. It\u0026apos;s hard. It\u0026apos;s hard for us to reach these spaces of management, politics, public management.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDespite their dedication, these early professionals often lacked technical guidance or institutional support. Their work was marked by loneliness, improvisation, and empirical learning, with creativity usually compensating for the absence of formal training: \u003cem\u003e\u0026quot;I didn\u0026apos;t have people, I was quite alone, I would say... I didn\u0026apos;t have, right, uh... teachers, I didn\u0026apos;t have employees, I didn\u0026apos;t have anything, I had... me and I had my one colleague. That\u0026apos;s how we went on, empirically, organizing the program.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;I had no idea that there were specific demands for trans population health and I had no idea what the role of psychology would be in caring for these people. But since I like a good challenge, right, I said, let\u0026apos;s go, right, let\u0026apos;s go. Let\u0026apos;s see what we can do. I felt embarrassed to ask, to do, to say something stupid.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;It was challenging in the sense of the technical aspect. What we were looking for\u0026mdash;there was only a regulation from the Federal Council of Psychology, giving basic guidelines. We didn\u0026apos;t find anyone else to ask.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn contrast, the second generation of professionals benefited from academic exposure and formal training in gender studies. Some of these newer professionals were recruited explicitly because of their previous engagement with trans issues during medical or psychology school: \u003cem\u003e\u0026quot;Since my undergraduate studies, I was directly involved with issues related to mental health and the LGBT population\u0026quot; and \u0026quot;Fortunately, when I was appointed, they asked me to send them my resume. During my training, they saw courses and events that I had been involved in throughout my academic and professional career. They saw this affinity with working with the LGBT population and then offered me the possibility of joining the outpatient clinic.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThese represent two distinct professional trajectories. The first is shaped by activism, trial and error, and the ethical imperative to provide care where no institutional pathways existed. The second is shaped by academic training and emerging institutional recognition, made possible by the groundwork laid by the pioneers themselves. While the first generation had to invent paths to care, often in precarious or informal conditions, the second generation enters a field already partially legitimized and codified. Notably, the creativity that characterized the pioneers\u0026apos; approach, necessary to respond to urgent needs, might not have been tolerated had it been exercised in other, more normative areas of healthcare.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2. Contingent Stigma: Identity Spoiling Through Social Proximity.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eStigma by association emerged in participants\u0026rsquo; accounts as a pervasive, though often subtle and ambiguous, form of professional discrimination. Health workers involved in trans care were, at times, delegitimized or questioned simply for being associated with a stigmatized population. This stigma manifested in both interpersonal relationships, among colleagues, supervisors, and peers, as well as within institutional dynamics that isolate and devalue certain forms of care.\u003c/p\u003e\n\u003cp\u003eSometimes, the stigma was explicit and aggressive. One senior psychiatrist recounted a moment of interpersonal hostility that left a lasting mark: \u003cem\u003e\u0026ldquo;And then he called me, \u0026lsquo;Oh, I wanted to talk to you and stuff\u0026rsquo;, (...) \u0026lsquo;Why are you exposing yourself to these trannys?\u0026rsquo; That was the term, right. That was the term. \u0026lsquo;Exposing yourself to these trannys.\u0026rsquo; A criticism thrown at me... honestly, I don\u0026apos;t remember my answer\u0026mdash;I just remember the phrase.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn other cases, the stigma was expressed through silence\u0026mdash;the absence of collaboration, avoidance of discussion, or implicit devaluation of one\u0026rsquo;s work. Participants described being excluded from knowledge-sharing routines, not being consulted for input, or being assigned complex cases by default, as if their expertise\u0026mdash;or labor\u0026mdash;was only relevant in the context of this marginalized group. One professional described how colleagues failed to take shared responsibility for a trans patient\u0026apos;s care: \u003cem\u003e\u0026ldquo;There was a certain questioning of my technical ability to assess these patients. Like, \u0026lsquo;How could you not see that this person was manipulating the situation?\u0026rsquo; It\u0026rsquo;s as if, because we work with the trans population, we\u0026rsquo;re either too involved or somehow less technically sound.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAnother participant noted that working with trans patients often made one the default go-to person in their service, regardless of workload or specialization required: \u003cem\u003e\u0026ldquo;Colleagues in other services avoid these cases and send them all to us. It\u0026apos;s like, if you\u0026apos;re in a trans clinic, then it\u0026rsquo;s your job to solve everything.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThese examples reflect the delegitimization of professionals who work in trans health not only through overt prejudice but also through institutional avoidance, overburdening, and technical undermining. As one participant put it: \u003cem\u003e\u0026ldquo;Sometimes it\u0026rsquo;s not the patients, it\u0026rsquo;s the professionals themselves\u0026mdash;from within the same institution\u0026mdash;who react with discomfort, like \u0026lsquo;What do we do with this case? Where do we admit this person?\u0026rsquo; Something that should be basic.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis constellation of reactions contributes to an environment in which those providing care to trans populations are themselves stigmatized, rendered professionally suspect, or subtly excluded.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e3. The Affective Costs of Stigma: Isolation, Conflicts, and Demotivational.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA recurring topic among the participants was the feeling of isolation and loneliness in working with the trans population. Participants reported that colleagues, politicians, institutional managers, and even some LGBT\u0026thinsp;+\u0026thinsp;activists could act as sources of stigma or delegitimization. \u003cem\u003e\u0026ldquo;And I feel really bad because I was criticized a lot. I\u0026apos;m very... People write things about me [...] they talk without, in a disrespectful way... Without even knowing what\u0026apos;s going on, right, without even knowing what an institution like ours is\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe burden of care, coupled with insufficient systemic support, not only isolated trans clinics from other health sectors but also fueled tensions and divisions among trans health providers themselves. Disagreements and perceived distance emerged particularly between primary care services and specialized clinics: \u003cem\u003e\u0026ldquo;I\u0026rsquo;m not talking about (Center Y), because they think of themselves as the fucking shit, you know? With their own problems, but that they can manage\u0026rdquo;\u003c/em\u003e and \u003cem\u003e\u0026ldquo;As someone here representing (Center Y), I don\u0026apos;t think I\u0026apos;m the fucking shit, right, quite on the contrary. We\u0026apos;re there in an ongoing battle to amplify access and services, you know. (...) And when we personify a service, uh, it ends up affecting us, too, right?\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAt the same time, there was a strong sense of unity among workers at each clinic in reporting the difficulties they sometimes had to overcome together, some of which are still ongoing and stem from outside factors. \u003cem\u003e\u0026ldquo;There\u0026rsquo;s this really institutional thing, right, that Clinic A will not be a priority. It\u0026apos;ll be oncology, then cardiology, then, you know, it\u0026apos;s all the way down right\u0026rdquo;, \u0026ldquo;And that\u0026apos;s what we feel, right, and it\u0026apos;s truly difficult to classify priorities for the general hospital, a high complexity one.\u0026rdquo;\u003c/em\u003e, and \u003cem\u003e\u0026ldquo;We hear a lot about a story, uh\u0026hellip; of a fight by the professionals and some patients, right, resisting, uh\u0026hellip; well, and resisting from, uh, such as, there\u0026apos;s no money for the vaccine and you want to operate on these people?\u003c/em\u003e In a context where resources are scarce, as is the case with Brazil\u0026rsquo;s Unified Health System (SUS), the health of trans people has never been a priority, and this statement highlights that reality.\u003c/p\u003e\n\u003cp\u003eNotably, members from only one primary care clinic attended each of the focus groups. Although we initially had members from two different clinics in the second group, one of the clinics informed us that they would not continue participating that evening. Nevertheless, there was a desire - more than just a willingness - a recognized need to put aside differences to strengthen their cause. \u003cem\u003e\u0026ldquo;But I think the idea is to strengthen, like, this network, right? I think it is important that we can dialogue and even unite in order to think over alternatives, together\u0026rdquo;.\u003c/em\u003e Such a statement appears to confirm the importance of promoting spaces for exchange and collective building among health workers involved in the care of trans people, thereby strengthening existing initiatives.\u003c/p\u003e\n\u003cp\u003eIn addition to conflicts and feelings of isolation, stigma may discourage professionals from applying to or remaining in trans health services. \u003cem\u003e\u0026ldquo;There are a lot of schizophrenia, depression to treat, psychiatrists, right, to waste their time\u0026rdquo;\u003c/em\u003e and \u003cem\u003e\u0026ldquo;I opened five, five selection processes. Medical professionals, nurses to work in the trans outpatient clinic. All [recruitment processes] failed.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e4. Dealing with Stigma\u003c/em\u003e:\u003c/p\u003e\u003cspan\u003e\n \u003cp\u003e\u003cem\u003e4.1 Advocacy and Social Movements: Strategies for Reclaiming Normality or Restructuring Interaction.\u003c/em\u003e\u003c/p\u003e\n\u003c/span\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003ePerhaps the one element that was unequivocally present across all participants\u0026rsquo; statements was the central role of advocacy and social movements. Professionals recognized that resisting stigma and advancing care depended not only on technical competence but also on political engagement and collective mobilization. \u0026ldquo;\u003cem\u003eI believe that the professionals and the social movement were, like, fundamental, each with their own part, for us to be able to construct, for example, the important services of the clinic.\u003c/em\u003e\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eSocial engagement and advocacy are recognized as essential for implementing laws and policies, as well as for continuing to address the challenges already discussed. \u003cem\u003e\u0026ldquo;The social movement has been guiding, demanding, and participating for years and years and years.\u0026rdquo;\u003c/em\u003e and \u003cem\u003e\u0026ldquo;Right, but it was a very important demand, a social movement demand, to have this trans clinic, right? It started with meetings.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAdvocacy often filled the institutional void left by political indifference, ensuring essential resources like medications through external political strategies. \u003cem\u003e\u0026ldquo;We began offering the inputs for hormonization because of parliamentary amendments. And there\u0026apos;s no reason not to say these names: Luciana Genro, Roberto Robaina, Melchionna. Because until recently it was them guaranteeing these inputs.\u003c/em\u003e\u0026rdquo; It is worth noting that the individuals named are political-party figures linked to the promotion and protection of human rights, and have been engaged by the social movement and workers to support and legitimize the cause.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e4.2 Personalizing Institutional Roles: Managing (Dis)Creditability in Formal Settings.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn this precarious environment, the personal commitment of individual professionals often becomes intertwined with institutional identity. Participants described how, due to the scarcity of trained and engaged workers, their personal actions, ethics, and visibility became symbolic of the entire service or policy they represented. This personalization of institutional roles carries a dual effect. On the one hand, it can serve as a potent tool for advocacy, allowing professionals to leverage their personal histories, social positions, and ethical commitments to champion trans rights and healthcare access. On the other hand, personalization intensifies professional vulnerability, making individuals the focal point of frustrations directed at institutional failures, political disputes, or unmet expectations. At the same time, personification can also cause the health service or the action being developed to be easily dismantled, since by isolating that particular person, everything they actively represent is also isolated. It can even give rise to a figure who, by personifying the cause, renders it null or even iatrogenic.\u003c/p\u003e\n\u003cp\u003eIn this context, the successes and failures of institutional actions are often perceived as personal achievements or shortcomings. Professionals become not only caregivers but also the public faces of broader political struggles, often without the structural support necessary to sustain these battles over time. As a result, while personalization fuels resistance and advocacy, it also exposes the profound fragility of services that rely on a few committed individuals rather than stable institutional backing. Thus, the burden of solely (or with very few others) carrying the responsibility of planning, executing, and monitoring health actions for trans people falls almost entirely on that individual worker, as if it were a personal or team-specific issue, rather than the result of broader social structures sustained by transphobia.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e4.3 Voice and Narrative Control: Claiming (or Being Granted) the Floor in Stigmatized Interactions.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eProfessionals often speak from experiences of sexual orientation and/or gender identity non-conformity, which may be a crucial factor in their commitment to advocate for trans healthcare. \u003cem\u003e\u0026quot;I was already familiar with the subject, even because I am a gay man. Something that also weighs heavily on me is a sense of social responsibility... It\u0026apos;s hard for us to reach these spaces of management, politics, public management.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis concept is closely tied to the \u003cem\u003espeaking place\u003c/em\u003e, a notion that is prominently discussed within social justice and academic circles, particularly through the work of philosopher Djamila Ribeiro. It refers to the understanding that a person\u0026apos;s social position and identity shape their perspective and experiences, thereby influencing their ability to speak with authority on specific topics.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e Ribeiro advocates that individuals should speak from their experiences, particularly when addressing issues related to their social location, aiming to challenge power structures by amplifying the voices of marginalized groups and acknowledging how social inequalities influence whose voices are heard and valued.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eAcross different participants, \u003cem\u003espeaking place\u003c/em\u003e appeared as a powerful driver of professional commitment and advocacy. Professionals often did not separate their personal and professional identities; instead, their lived experiences with marginalization informed their motivation to advocate, resist stigma, and create spaces for trans health care. \u003cem\u003e\u0026quot;I think it\u0026rsquo;s important that we understand that people who are on the front line, who are willing to be in these spaces, are generally people who have some personal implication and defend this from that place.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWhereas being part of the LGBT\u0026thinsp;+\u0026thinsp;community does not eliminate stigma by association, it appears to change how it is perceived or buffer its emotional impact. \u003cem\u003e\u0026ldquo;[...] due to the fact that I\u0026apos;m gay, the issue of stigma is already a part of it [...]\u0026rdquo;\u003c/em\u003e. Professionals who are LGBT\u0026thinsp;+\u0026thinsp;may have learned coping strategies to deal with stigma, based on their own life experiences, and these strategies seem to be transferred into their professional resilience. \u003cem\u003e\u0026ldquo;Perhaps because we already have a personal history of identification, we build up some resources that allow or hinder us to perceive certain things in association with an identity category.\u0026rdquo;\u003c/em\u003e Among these resilience strategies, emotional distancing and cognitive reframing, as well as building supportive peer networks and channeling adversity into activism, repeatedly appeared in the focal groups.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur study sheds light on a relatively underexplored dimension of trans health care: the stigma experienced by health professionals who provide care for trans and gender-diverse populations in Brazil.\u003c/p\u003e\u003cp\u003e\u003cem\u003eFrom policy advances to institutional backlash: are there any physicians left willing to work in trans and gender diverse healthcare?\u003c/em\u003e\u003c/p\u003e\u003cp\u003eEchoing findings from other contexts where associative stigma has been documented,\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e our participants described working in precarious institutional environments marked by limited resources, unstable funding, and a lack of political commitment. These observations align with those reported by Miskolci \u003cem\u003eet al.\u003c/em\u003e in their qualitative study on LGBT\u0026thinsp;+\u0026thinsp;health in Latin America, where institutional fragility and precarious foundations emerged as key barriers to service sustainability.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Together, these findings reflect broader systemic issues in Brazil, including the incomplete implementation of national health policies, chronic underfunding, and a shortage of qualified professionals equipped to deliver gender-affirming care.\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eBrazil\u0026rsquo;s recent political trajectory consists of a succession of political shifts marked by hostility toward marginalized groups, particularly the LGBT\u0026thinsp;+\u0026thinsp;communit, and trans and \u003cem\u003etravestis\u003c/em\u003e populations most acutely. Overall, the early 2000s, particularly during the administration of President Luiz In\u0026aacute;cio Lula da Silva and the Workers\u0026rsquo; Party (PT), marked an important, albeit still insufficient, period of advancement for SGM populations in Brazil. A key milestone was the launch of the \u0026ldquo;Brazil Without Homophobia\u0026rdquo; program in 2004, coordinated by the Secretariat of Human Rights in partnership with the Ministry of Health. This initiative aimed to promote citizenship and human rights for LGBT\u0026thinsp;+\u0026thinsp;individuals, including specific directives on health rights that spanned policy development, research, and professional education. One notable outcome was the formal establishment of the Technical Committee on LGBT\u0026thinsp;+\u0026thinsp;Health within the Ministry of Health, which played a pivotal role in shaping the National Policy on Comprehensive Health for Lesbians, Gays, Bisexuals, Transvestites, and Transsexuals, officially adopted in 2011. It is also important to note that Brazil\u0026rsquo;s public health system, Sistema \u0026Uacute;nico de Sa\u0026uacute;de (SUS), is founded on principles of popular participation and social control. In the field of LGBT\u0026thinsp;+\u0026thinsp;health, the organized social movement served as the primary driving force behind these early policy advances.\u003c/p\u003e\u003cp\u003eThe National Policy of Comprehensive Health of Lesbians, Gays, Bisexuals, \u003cem\u003eTravestis\u003c/em\u003e, and Transsexuals represented a pivotal advancement in the quest for equity within the Brazilian healthcare system.\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e This policy sought to eliminate institutional discrimination, reduce inequalities, and solidify the Unified Health System as a universal, comprehensive, and equitable healthcare provider.\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThe subsequent years, however, have witnessed a notable rise in conservative political forces, particularly since 2016, which have actively opposed and dismantled many of these advancements.\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e This political shift has led to substantial setbacks for public health policies targeting LGBT\u0026thinsp;+\u0026thinsp;populations, characterized by budget cuts, reduced support for specific health programs, and hindrance of initiatives designed to address health disparities.\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eAfter the completion of this study, the Federal Council of Medicine issued Resolution No. 2.427/2025, which revoked both the authorization for gender-affirming surgeries in trans children and adolescents and the right of family physicians to initiate hormonal therapy for transgender individuals (Conselho Federal de Medicina, 2025). This resolution has since been publicly challenged by organizations such as the Brazilian Society of Family and Community Medicine and the National Association of \u003cem\u003eTravestis\u003c/em\u003e and Transsexuals.\u003c/p\u003e\u003cp\u003eGiven this broader sociopolitical context, it is perhaps unsurprising that a recurring theme in participants\u0026rsquo; narratives was the apparent lack of interest among medical professionals in working with trans and gender-diverse populations. This trend did not appear to extend to other professional categories. One participant illustrated this issue by recalling that five consecutive public selection processes aimed explicitly at hiring physicians for a trans-specialized healthcare service failed to attract a single applicant. Another participant pointed out that \u0026ldquo;there are a lot of schizophrenia, depression to treat, psychiatrists, right, to waste their time\u0026rdquo;.\u003c/p\u003e\u003cp\u003eThe apparent disinterest among physicians in trans health care seems to stem from a complex interplay of factors, with the rise of conservative and transphobic discourses in Brazil\u0026rsquo;s political and social spheres emerging as a central and cross-cutting influence.\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e These discourses are also reflected within professional bodies such as the Federal Council of Medicine, shaping attitudes across the medical field. Consequently, Brazilian medical schools provide limited training on gender-affirming care and trans-specific health needs, implicitly reinforcing the notion that trans health is neither a professional priority nor a necessary area of competence, despite being vaguely mentioned in the Curricular Directives. This educational gap contributes to physicians\u0026rsquo; sense of technical unpreparedness, leading many to avoid providing care out of fear of making mistakes, facing litigation, or suffering reputational harm. Referring trans patients to specialized clinics\u0026mdash;where available\u0026mdash;becomes a common strategy for managing this perceived risk.\u003c/p\u003e\u003cp\u003ePhysicians who do choose to engage in trans health care often face stigma by association, being labeled as \u0026ldquo;activists\u0026rdquo; or \u0026ldquo;biased,\u0026rdquo; and may encounter explicit hostility from colleagues. In the context of Brazil\u0026rsquo;s overstretched public health system, where physicians already navigate heavy workloads and institutional pressures, the prospect of assuming additional emotional and reputational burdens makes trans health care an unattractive option for many. The lack of financial incentives compounds this: healthcare for transgender individuals in the public sector is typically underfunded, with limited opportunities for private practice, research funding, or academic recognition. For physicians making career decisions in a resource-constrained environment, trans health may be perceived as a low-reward and high-risk field. This scenario underscores a critical structural barrier to ensuring adequate medical care for trans individuals. It highlights the urgent need for targeted strategies to address workforce gaps when formulating equitable health policies for marginalized populations.\u003c/p\u003e\u003cp\u003eRegarding the current workforce in this area, our findings revealed two markedly different professional trajectories among participants working in trans health care: one rooted in loneliness and improvisation, and the other shaped by academic training and institutional recruitment. For the first generation of providers, entry into the field was often unplanned, driven by a personal identification with LGBT\u0026thinsp;+\u0026thinsp;rights or an ethical responsibility to address an unmet need in the healthcare system. Self-training and improvisation to fill institutional voids appeared frequently during the interviews. In contrast, a second generation of professionals reported that their engagement with trans health began during their academic formation, often linked to formal education in gender and diversity issues. However, even among this second generation, the decision to work in trans health was rarely neutral or institutionally incentivized. Instead, it was influenced by pre-existing personal commitments, often as LGBT\u0026thinsp;+\u0026thinsp;individuals themselves.\u003c/p\u003e\u003cp\u003eWe also emphasize that, regardless of the pathway that led each worker to engage in this field, whether through past or present involvement in the LGBT\u0026thinsp;+\u0026thinsp;social movement, through academia, or through being sensitized to the issue during their professional trajectory, what was common among the experiences shared was an ethical and technical commitment to trans issues, with a strong sense of responsibility and social justice among participants.\u003c/p\u003e\u003cp\u003eAt the same time, the divergent institutional logics and histories that shaped participants\u0026rsquo; perspectives at times generated tensions within the group. While these conflicts occasionally made dialogue more challenging, they also underscored the complexity of the field. They revealed the layered and sometimes conflicting meanings of \u0026ldquo;care\u0026rdquo; and \u0026ldquo;access\u0026rdquo; within trans health in Brazil. The model of trans health care remains a contested terrain, even among professionals directly engaged in this field.\u003c/p\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eStigma by association's impact and the speaking place: absent, managed, or unnamed?\u003c/h2\u003e\u003cp\u003eAlthough stigma by association was part of our guiding research questions and featured explicitly in our focus group prompts, its appearance in the participants' narratives was notably limited.\u003c/p\u003e\u003cp\u003eOne plausible explanation for this relatively low reporting is the social positioning of our participants. As permanent staff members with open-ended contracts, most had spent several years within the same institutional environments, developing long-term relationships with colleagues, managers, and service users. This employment stability may have allowed for the gradual testing, refinement, and implementation of coping strategies to navigate stigma by association over time. Indeed, to minimize the psychosocial risks associated with stigma by association, workers may have learned to employ methods such as caution, contextual awareness, and silent institutional maneuvering whenever the sociopolitical environment becomes unfavorable. When conservative forces are advancing and setbacks in the field of human rights (particularly those of trans people) are taking place, it becomes essential to navigate this field carefully, without provoking further resistance. The possibility of implementing health actions aimed at trans people seems to be tied to a prior psychosocial calculation: for activities to continue being carried out, extraordinary care must be taken with what is said, to whom it is said, and how it is said. These strategies, while enabling the continuation of the work and reducing the risks of stigma by association, may also render the stigma more covert and, consequently, more difficult to detect.\u003c/p\u003e\u003cp\u003eAnother possible explanation is methodological. Our recruitment strategy targeted professionals who were still engaged in trans health services and had chosen to remain despite years of exposure to structural and interpersonal stigma. This self-selection may have resulted in a \"survivor cohort\"\u0026mdash;individuals who had either found ways to cope with stigma by association or who did not perceive it as a central concern. Studies with broader samples, including professionals who left trans health services or chose not to enter the field, might reveal a different picture.\u003c/p\u003e\u003cp\u003eFinally, it is essential to note that some participants may have experienced stigma by association but lacked the conceptual vocabulary to name it as such. As Hammond and Kingston note in their research with sex work researchers, professionals often struggle to articulate stigma when it is diffused, normalized, or embedded within broader institutional cultures of marginalization. \u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eIn this sense, participants' speaking place as members of the LGBT\u0026thinsp;+\u0026thinsp;community seems to serve as a protective factor in recognizing stigma by association, although not necessarily in confronting it. These professionals described a kind of stigma \"immunity\" cultivated over years of navigating both personal and professional marginalization. For some, experiences of homophobia in their personal lives appeared to act as an inoculation against new forms of work-related stigma, or as a buffer, \u0026ldquo;diluting\u0026rdquo; whatever stigma they felt came their way. Conversely, cisgender heterosexual participants, especially during the early years of their careers, were more likely to report explicit experiences of stigma by association.\u003c/p\u003e\u003cp\u003eIn this context, it is also important to note that the relationship between the medical establishment and the trans community has evolved over the years. Initially, while the process of removing homosexuality from the DSM was underway, some members of the APA (sometimes the same ones) were advocating for the inclusion of \u0026ldquo;\u003cem\u003etransexualism\u003c/em\u003e\u0026rdquo; as a medical diagnosis. At that time, this was supported by the trans community to ensure access to gender-affirming care, such as surgeries and hormonal treatment. However, over time, this has changed, and today the trans community fights for the exclusion of trans identity-related diagnoses, understanding that pathologization reinforces stigma and discrimination.\u003csup\u003e\u003cspan additionalcitationids=\"CR34\" citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThus, we hypothesize that participants who do not self-identify as LGBT\u0026thinsp;+\u0026thinsp;may occupy the speaking place solely of healthcare professionals, representing the medical establishment, and therefore have a more difficult time navigating the combination of stigma by association from health professionals and institutions, as well as possible critiques from the LGBT\u0026thinsp;+\u0026thinsp;social movements themselves.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eLimitations\u003c/h2\u003e\u003cp\u003eThis study has several limitations that should be taken into account when interpreting its findings. First, there were no trans individuals among either the research team or the study participants. This absence reflects the structural barriers that currently limit trans people's access to higher education and formal employment in Brazil. The near-zero rate of trans people occupying spots in public universities and formal job positions in Brazil has prompted the development of targeted affirmative action policies in the State of Rio Grande do Sul in recent years, aimed at increasing trans representation in public service positions and health specializations (State of Rio Grande do Sul, 2021, 2022). It is important to note that this is one of several emerging experiences of affirmative action policies for trans people in Brazil. As a relatively recent policy development, its implementation has yet to be systematically evaluated.\u003c/p\u003e\u003cp\u003eSecond, the study design was based on focus groups with permanent staff members from a limited number of services in a single metropolitan area. While this recruitment strategy allowed for rich, contextually grounded discussions among experienced professionals, it may have limited the diversity of perspectives, particularly from younger, early-career, or precariously employed professionals (such as residents, interns, or temporary staff), who may experience stigma by association in distinct ways due to their more vulnerable employment status.\u003c/p\u003e\u003cp\u003eThird, although our thematic analysis was methodologically rigorous and grounded in participants' narratives, the relatively small sample size and the regional specificity of the setting limit the generalizability of our findings. Additionally, while the research team engaged in ongoing reflexivity and employed strategies to enhance analytic rigor, it is essential to acknowledge that our positionalities (as cisgender, white, both heterossexual and LGB researchers) may have influenced both data interpretation and participant engagement.\u003c/p\u003e\u003cp\u003eFinally, despite explicitly including stigma by association as a focus in both our research questions and discussion prompts, participants mentioned the phenomenon less frequently than anticipated. This low salience may reflect a combination of factors, including social desirability bias, normalization of stigmatizing interactions over time, or the development of adaptive coping strategies that minimize participants' perception or recollection of stigma by association. Future studies could address these limitations by employing mixed-methods designs, expanding the geographic scope, incorporating the perspectives of trans professionals, and applying quantitative measures specifically validated for stigma by association in healthcare contexts.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study sheds light on a relatively underexplored dimension of trans healthcare: the \"stigma by association\" experienced by health professionals who provide care for transgender and gender-diverse populations in Brazil. Our findings reveal the significant structural and interpersonal challenges these professionals face, highlighting the precarious institutional environments and the often-subtle forms of discrimination that impact their well-being and the sustainability of the services they provide.\u003c/p\u003e\u003cp\u003eBy documenting the professional trajectories, challenges, and stigma-related experiences of health workers providing care to trans and gender-diverse individuals, this study contributes to the growing body of literature on stigma by association within healthcare settings. Our findings underscore the importance of addressing both structural and interpersonal dimensions of stigma, highlighting the urgent need for intersectional, multi-stakeholder, and context-specific strategies to support health professionals and advance the right to health for trans populations in Brazil.\u003c/p\u003e\u003cp\u003eHowever, we find it essential to acknowledge areas for future research that, although not directly explored in our work, emerged throughout the study. The issue of race and intersectionality, for example, emerged organically when participants discussed barriers to accessing care. In the Brazilian context, systemic racism and socioeconomic inequalities impose substantial barriers to healthcare access for Black and other racialized populations, compounding the discrimination already experienced by trans and gender-diverse individuals. National indicators highlight that Black trans people are disproportionately affected by violence, poverty, educational exclusion, and restricted access to health services.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Given these intersecting forms of oppression, future research should prioritize intersectional analyses that examine how race, gender identity, and other social categories (such as class, geography, and disability) shape the experiences of stigma by association among healthcare professionals working with trans populations.\u003c/p\u003e\u003cp\u003eAdditionally, future studies might wish to investigate the experiences of sexual and gender minority professionals themselves within Brazil\u0026rsquo;s trans-specialized health services. Given their shared minority status, these professionals may face unique forms of stigma and may deploy distinct strategies for coping and professional resilience. Understanding their experiences could shed light on the dual role they often occupy - as both providers and members of marginalized communities. At the same time, it is equally important to explore how cisgender heterosexual professionals working in trans health settings navigate stigma, ethical tensions, and professional vulnerabilities. As key actors within this field, they too bear responsibility for advancing equity and challenging transphobia within healthcare institutions.\u003c/p\u003e\u003cp\u003eAnother issue raised by participants was the scarcity of structured, collective spaces for reflection and support among professionals engaged in trans health care. Participants voiced a clear need for more frequent opportunities for interprofessional dialogue, emotional support, and shared strategizing to address institutional challenges and stigma-related stressors. Considering this, we recommend that future research incorporate participatory and action-oriented methodologies that not only capture narratives of stigma but also facilitate the creation of collaborative networks and safe spaces for mutual support and engagement. These collective forums could help foster resilience, strengthen inter-service alliances, and ultimately promote more equitable and sustainable trans health care practices.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eLGBT+ - Lesbian, Gay, Transexual and \u003cem\u003eTravesti,\u003c/em\u003e and other sexual and gender minorities\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLGBTQI+ - I Lesbians, Gays, Bisexuals, Transvestites, Transsexuals, Queers, Intersex and People with Non-Binary Gender Identity\u003c/p\u003e\n\u003cp\u003ePT – Working Party\u003c/p\u003e\n\u003cp\u003eSGM - Sexual and Gender Minorities\u003c/p\u003e\n\u003cp\u003eSUS - Brazilian Unified Health System\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe project was reviewed and approved by the \u003cem\u003ePontificia Universidade Catolica do Rio Grande do Sul\u003c/em\u003e (PUCRS's) Institutional Review Board under the number 71170123.6.0000.5336.\u003c/p\u003e\n\u003cp\u003eParticipants signed a form indicating their free and informed consent.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe invitation was made directly to the professional and had no direct relationship with the services.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConsent for publication was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are not publicly available due\u0026nbsp;to the sensitive nature of the material and confidentiality agreements made with participants\u0026nbsp;but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA.M.F. - Employed at one of the trans clinics represented in the study (Clinic T).\u003c/p\u003e\n\u003cp\u003eC.G. - Employed at the State Health Secretariat.\u003c/p\u003e\n\u003cp\u003eThe other authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was granted specifically for this research. All of the researchers have been granted funding for research on LGBT health-related issues.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors’ contributions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA.B.C. -\u0026nbsp;made substantial contributions to the conception and design of the work, to the data interpretation, and to the drafting and revision of the work.\u003c/p\u003e\n\u003cp\u003eA.M.V.F. -\u0026nbsp;made substantial contributions to the conception and gn of the work, to the data acquisition, analysis, and interpretation, and to the drafting and revision of the work.\u003c/p\u003e\n\u003cp\u003eC.G. -\u0026nbsp;made substantial contributions to the interpretation of data and to the drafting and revision of the work.\u003c/p\u003e\n\u003cp\u003eJ.Z.O. -\u0026nbsp;made substantial contributions to the conception and design of the work, to the data acquisition, analysis, and interpretation, and to the drafting and revision of the work.\u003c/p\u003e\n\u003cp\u003eAll authors have\u0026nbsp;approved the submitted version and have agreed both to be personally accountable for the contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author individually was not personally involved.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgments\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHunt R. 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Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.sciencedirect.com/science/article/pii/S0277953603006166\u003c/span\u003e\u003cspan address=\"https://www.sciencedirect.com/science/article/pii/S0277953603006166\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCorrigan PW, Watson AC, Miller FE. Blame, shame, and contamination: The impact of mental illness and drug dependence stigma on family members. Journal of Family Psychology [Internet]. 2006 Jun [cited 2025 Jul 20];20(2):239\u0026ndash;46. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.researchgate.net/publication/7027443_Shame_blame_and_contamination_A_review_of_the_impact_of_mental_illness_stigma_on_family_members\u003c/span\u003e\u003cspan address=\"https://www.researchgate.net/publication/7027443_Shame_blame_and_contamination_A_review_of_the_impact_of_mental_illness_stigma_on_family_members\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMehta SI, Farina A. Associative Stigma: Perceptions of the Difficulties of College-Aged Children of Stigmatized Fathers. J Soc Clin Psychol [Internet]. 1988 Jun [cited 2025 Jul 20];7(2\u0026ndash;3):192\u0026ndash;202. 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Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pubmed.ncbi.nlm.nih.gov/12456519/\u003c/span\u003e\u003cspan address=\"https://pubmed.ncbi.nlm.nih.gov/12456519/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHebl MR, Mannix LM. The Weight of Obesity in Evaluating Others: A Mere Proximity Effect. Pers Soc Psychol Bull [Internet]. 2003 Jan [cited 2025 Jul 20];29(1):28\u0026ndash;38. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e/doi/pdf/10.1177/0146167202238369?download\u0026thinsp;=\u0026thinsp;true\u003c/span\u003e\u003cspan address=\"/doi/pdf/10.1177/0146167202238369?download\u0026thinsp;=\u0026thinsp;true\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMinayo MC de S. O desafio do conhecimento: pesquisa qualitativa em sa\u0026uacute;de. 1992;269\u0026ndash;269.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBraun Virginia, Clarke Victoria. Thematic analysis : a practical guide. 2022 [cited 2025 Jul 20];338. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://books.google.com/books/about/Thematic_Analysis.html?hl=pt\u003c/span\u003e\u003cspan address=\"https://books.google.com/books/about/Thematic_Analysis.html?hl=pt\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e-BR\u0026amp;id=mToqEAAAQBAJ\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRampin R, Rampin V. Taguette: open-source qualitative data analysis. J Open Source Softw [Internet]. 2021 Dec 10 [cited 2025 Jul 20];6(68):3522. 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Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.scielo.br/scielo.php?script=sci_arttext\u003c/span\u003e\u003cspan address=\"http://www.scielo.br/scielo.php?script=sci_arttext\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u0026amp;pid=S0104-71832019000200361\u0026amp;tlng=pt\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFerreira B de O, Nascimento M. A constru\u0026ccedil;\u0026atilde;o de pol\u0026iacute;ticas de sa\u0026uacute;de para as popula\u0026ccedil;\u0026otilde;es LGBT no Brasil: perspectivas hist\u0026oacute;ricas e desafios contempor\u0026acirc;neos. Cien Saude Colet [Internet]. 2022 Sep 16 [cited 2025 Jan 11];27(10):3825\u0026ndash;34. 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New Zealand Sociology 2023; v 38, n 1, p 18\u0026ndash;28 [Internet]. 2023 [cited 2025 Jun 11]; Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://natlib.govt.nz/records/51995417\u003c/span\u003e\u003cspan address=\"https://natlib.govt.nz/records/51995417\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Transgender health, stigma, healthcare professionals, Brazil, qualitative research, public health services","lastPublishedDoi":"10.21203/rs.3.rs-7319508/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7319508/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eTransgender and gender-diverse individuals face significant barriers in accessing public health services due to stigma. While much research focuses on direct stigma experienced by these populations, less attention has been given to \"stigma by association\", which affects healthcare professionals providing their care. This study explores the experiences of healthcare professionals working with transgender and gender-diverse populations in southern Brazil, examining how stigma by association impacts their professional trajectories, institutional affiliations, and daily practices.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis qualitative study involved two focus groups comprising nine permanent staff members from primary and specialized transgender health services located in a Brazilian metropolitan region in southern Brazil. Participants were recruited through both personal and professional networks. Data collection employed a semi-structured protocol that examined sociopolitical conditions, operational challenges, and individual experiences of stigma by association. The transcripts underwent analysis using Braun and Clarke's reflexive thematic analysis, which utilized Taguette software for coding. Methodological integrity was upheld through participant diversity and researcher reflexivity.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eFour thematic areas were identified: structural/institutional stigma, contingent stigma (identity spoiling due to social proximity), affective costs of stigma, and strategies for managing stigma. The findings underscored that services often originated from personal commitment rather than formal planning, resulting in unstable foundations, inconsistent funding, and workforce-related challenges. Professionals encountered both explicit and subtle forms of discrimination, isolation, and demotivation. Advocacy and social movements played a pivotal role in addressing stigma. At the same time, personal identification with the lesbian, gay, bisexual, transsexual, \u003cem\u003etravesti\u003c/em\u003e, and others (LGBT+) community frequently functioned as a protective factor for professionals.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eHealthcare professionals delivering care to transgender and gender-diverse populations in southern Brazil encounter substantial stigma, both structurally and interpersonally. This phenomenon harms their well-being and the sustainability of services. Addressing these challenges necessitates targeted strategies to support professionals, enhance institutional support, and promote equitable healthcare practices for transgender populations. Future research should emphasize intersectional analyses and assess the experiences of both sexual and gender minority and cisgender heterosexual professionals within this domain.\u003c/p\u003e","manuscriptTitle":"Health Professionals' Experiences of Professional Bias, Harassment, and Discrimination in the Context of Gender Diversity in Southern Brazil: a thematic analysis of focus groups","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-25 12:14:18","doi":"10.21203/rs.3.rs-7319508/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2584ca8d-e50c-4897-be5c-d149bacddc8b","owner":[],"postedDate":"August 25th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-30T09:53:56+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-25 12:14:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7319508","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7319508","identity":"rs-7319508","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}