Transfeminine women in South Africa have a high HIV risk due to structural, behavioural, and psychosocial factors. Transfeminine women and feminine identifying men who have sex with men (MSM) are often conflated or grouped with transgender or MSM categories in HIV service programming, although they don’t necessarily identify as either. We aimed to investigate gender expression among feminine identifying people who were assigned male at birth. We examined how local conceptualizations of sexuality and gender intersect with the key population label of ‘transgender’ imported into local HIV programming.A qualitative cohort nested within the HPTN 071 (PopART) trial included longitudinal, in-depth interviews with eight transfeminine women (four who disclosed as living with HIV). Data were collected approximately every six weeks between January 2016 and October 2017. We discuss gender identification presented in participants’ daily lives and in relation to HIV service access.Of the eight participants, only one accepted ‘transgender’ as a label, and even she used varying terms at different times to describe her identity. For participants, a feminine identity included dressing in normatively feminine clothes; using feminine terms, pronouns and names; and adopting stereotypically feminine mannerisms. Participants would switch between typically feminine and masculine norms in response to contextual cues and audience. For example, some participants accepted identification as masculine gay men amongst their family members, but amongst peers, they expressed a more effeminate identity and with partners they took on a feminine identity.Our findings are amongst the first exploratory and descriptive data of transfeminine women in South Africa. We show how transfeminine women navigate fluid gender identities that could pose a challenge for accessing and utilizing HIV services that are currently set up for transgender individuals or MSM. More work needs to be done to understand and respond to the diverse and shifting ways people experience their gender identities in this high HIV burden context. Over the past six years, heightened focus has been placed on transgender women in HIV research worldwide , 2. ‘TraIn this paper, we use the term ‘transfeminine’ to refer to people assigned male at birth who identify as women in major parts of their lives but have fluid ways of expressing their gender identity . TransgeIn HIV service programming, transfeminine women are often categorized as transgender women, gay men or MSM . ConflatIn a recent study, Brumbaugh-Johnson et al.  used a gVery little is known about the experiences of transfeminine women in South Africa, a country that accounts for approximately one fifth of all people living with HIV in the world . We aimeThis was an exploratory study using secondary data from a qualitative cohort. We made use of a mixed methods approach combining thematic analysis and case study descriptions. Data used for this study were accessed from a sub-sample of a qualitative cohort study nested in the HPTN 071 (PopART) trial. As part of the nested social science evaluation, we conducted qualitative research with a cohort of approximately 90 families spread across nine study communities in the Western Cape, South Africa. Eight of these families included at least one transfeminine woman .We approached a variety of community members; clinic staff; trial intervention staff; Lesbian, Gay, Bisexual, Transgender, Queer and Intersex (LGBTQI) community members; and men’s health clinic staff to identify potential participants. Through this process, thirteen transfeminine women were initially approached for participation, five of whom were lost to follow up or opted out of participation in the study. Of the remaining eight, four disclosed to us that they were living with HIV.in situ in study communities – usually in participants’ homes, but also often as they moved about the study community completing their daily activities. Researchers interacted with households for several hours per interaction and multiple times over the course of the data collection period, which took place from January 2016 to October 2017. Apart from recorded interviews, we also collected data via field notes, reflection documents, photographs and participatory research activities  during visits. Data collection was done by pairs of graduate social science researchers. The first author (LdV) was one of the researchers who visited all eight participants involved in this analysis and transcribed most of the interview data. We would often do extended visits with the participants, walking around in their community, accompanying them to clinic visits and modelling/drag show events. Due to the sensitive nature of the work and spending time in people’s personal lives, we found that the longitudinal nature of the engagement helped build rapport between researchers and participants. In addition, the strong connections developed with participants allowed us to manage the discussion of events in their lives which were traumatic, and might re-invoke trauma, sensitively. In total, discussions and observation activities with the eight participants and their household members took place over 146 hours, of which 82 hours of interviews were with the transfeminine women.Data collection was informed by ethnographic and participatory research principles. Our team recorded the discussions with voice recorders and semi-structured field notes and took pictures of relevant activities. All interactions with participants happened We conducted a thematic analysis of the terms and concepts used by participants related to their gender identification. This was an open coding process, done with NVivo 12  software. These themes are presented in All participant household members signed consent forms to have their households participate in the qualitative cohort. The consent also expressed research outside of the households and documents various other parts of the participants. For any events and activities researchers ensured participant willingness. Each household member also had a personal choice to participate or not. Participants were informed during the consent process about the possible sensitive nature of the interviews. Pseudonyms are used here for each participant, family members, neighborhoods and towns to protect confidentiality. Participants were not given incentives. Instead, research staff received allowances of approximately 80 South African Rands (about 6 USD) per visit to share household costs, contribute to shared meals, and/or gifts for participants and their households.For participants, expressing their ‘feminine identity’ included dressing in normatively feminine clothes, using feminine terms, pronouns and names, as well as other feminine attributes and mannerisms. Participants’ gender identity and expression changed often in the way they referred to themselves and how others referred to them in different contexts. We first provide a descriptive table of terms that participants and people used throughout the study for referring to their gender identity. We then present case descriptions as examples to illustrate how gender was navigated by different participants in different contexts.Participants used a variety of gender identity expressions and ways of referring to themselves. These terms and gender expressions were, however, context bound, referring to people, time and place. The table illustrates pseudonym birth given names of the participants  and then some participants used self-assigned names and nicknames connected to their feminine identity. All names here are fictional pseudonyms that illustrate this pattern. For example, Simone’s birth given name is Owen Andrews, but she has chosen the name Simone as it more accurately connects to her feminine gender identity. Alongside gender-typical names, we show a variety of terms used by participants throughout the study in their interviews. These are terms that others might use to refer to them or ones that they use to refer to themselves. The term “moffie” for example is a derogatory Afrikaans term used to refer to effeminate gay men, with possible origins from the Dutch “mofrodiet” for ‘hermaphrodite’ , 19. Mos24-year-old Simone Owen Andrews is from Town D, a mixed metro and low-income community in the Western Cape. Simone is living with HIV and identifies with the term “transgender woman”, however she also uses the term “gay”. Growing up she always felt and behaved in a feminine manner, playing mostly with girls, cross-dressing, and in this way of being, she told us that people could distinguish that she was not a heterosexual boy. She often uses the term ‘gay’ to refer to herself. Some people still call her by her masculine birth name, Owen, which could potentially mean her having to negotiate a masculine component of her identity (that in some ways she is still seen as a man by some people). Below is an excerpt from an interview in April 2017 where she uses a ‘gay’ identity term:Researcherokay but then how do you see yourself? You know if they talk about LGBT- or a range of categories, what, how do you categorise yourself?Simonefor now it is “gay”Researcherjust gay?SimoneyesFor Simone and most of the study participants, their feminine gender identity was present from a young age and they have seen it develop over time as they started dressing in feminine clothes, participating in drag/modelling shows and being the woman in their romantic and sexual relationships.Stacey (born Benjamin Martins) is a 29-year-old self-identified ‘femgay’ individual also living with HIV. She lives in an informal community at the outskirts of a winelands farming town in the Western Cape. Stacey does not live with her immediate family. She lives a very mobile/transient lifestyle, moving between different houses in the immediate neighbourhood and relying on extended family members, friends and other femgay peers to support her with a place to stay, food and other necessities. Even though Stacey might fall under the transgender umbrella as a transfeminine woman, she actually took offence when in an early interview the interviewer mistakenly labelled her gender identification as transgender, as seen in the excerpt below in June 2016:ResearcherWe have a lot of things we are interested in, in sex and love and like how many partners people have had and like where does a person meet, like that’s very interesting for me, especially if a person’s transgender, like(Stacey interrupts her)StaceyMe? transgender? (As her voice squeaked in disbelief and she seems to be taken aback).I’m femgay (she proudly responds)Curella (Conry Jenkings), a 28-year-old transfeminine woman, also identifies as ‘femgay ‘. She lives outside the Cape Town metropole with her mother, sister and her mother’s boyfriend. Her family and extended family, living with her, address her as Conry and it’s also how she refers to herself. However, dressing and being a woman is how she feels most comfortable and one of the places that she gets to be her full, cross-dressing and feminine self is at cross-dressing modelling shows. Her modelling and feminine name is Curella. She explained her ‘femgay’ identity below (August 2016):Researcherwhat is a drag queen?Conrya drag queen is similar to us in that they also do shows (pause) like put on dresses, and like heels and stuff like that (pause) and then you getResearcherbut is a drag queen necessarily someone who is gay?Conryyes … and you have them, they are gay but he doesn’t put on women’s clothes, he wears normal men’s clothesResearcherand so you would distinguish between the two?Conryyes you get uhm femgay and then you get (drag queens)Steven Jansen lives in a small wooden house, which is in the backyard of her aunt’s house, with her mother, father and sister, who all view her as a gay man. Steven, like most of the women we interviewed, used a variety of terms to refer to her gender and sexual identity, including gay, femgay and ‘moffie’. Steven has also navigated her gender identity from a young age and even though she is more assured of her feminine gender identity, it still takes navigation in different spaces as she explains about going out socialising at night:Now a lot of them have made the excuse that “you are more of a woman than … women really are”. That is their excuse … like last night I was sitting in company … then a guy brought me water and I told him, “ah you are too sweet”, and gave him a kiss on the cheek and then he told me, “Jesus!” and his friend said, “God, you do everything just like a real woman, just like a real woman is supposed to do”. Sizwe identifies as MSM but uses feminine pronouns and terms to refer to herself. For Sizwe, her gender identity expression, or the way she has to navigate it, is also influenced by cultural significance associated with spaces, as she is expected as a biological male to go through traditional rites of passage and circumcision into manhood. She explained in a later interview that if she were to go through initiation that it wouldn’t be for herself. She would do it purely for cultural obedience. She explicitly stated that she wouldn’t comply with some of the post-initiation observances, like dressing in a jacket and hat. Similarly, when men get together for traditional ceremonies they will sit together in a fenced-off area called a “kraal”. Below is her reaction to the researcher in explaining her gender role amongst men in the kraal:Researcherokay and then now when you have to sit in the kraal will you sit then with other men maybe?Sizweif I am going to sit, I will arrive in the kraal, my dear, but otherwise I won’t sit long. I won’t continuously … what do I want in the kraal?Researcherit’s a man among men thereSizweI am so weak (hinting at her feminine traits)Researcheryou would have also been a man according to cultureSizweyou can see I am weak … oh no I am not a man you see me dear(November 2016)Girlie Gregory Jones and Patricia Arends are two transfeminine women who do sex work. Sex work for them is not a choice, but something they were both coerced into and stayed in as a means of survival. Their navigation of their gender identities was fraught with even more challenges and problems as they have to deal with coercive gangsters who force them into sex work, as well as clients with whom they have to navigate their gender identity.Below, Girlie expresses the confusion with which she doesn’t actively seem to have to consider whether she is a man or woman; but the realisation that she has aspects of both, even though she identifies more as a woman:I just am the way I am, see? I am a man but I like dressing like this … I know I am a man but I feel like a woman, do you see? … I just am like this.(August 2017)We found that transfeminine women use a variety of ways to express their gender identity. Although all the participants identified as women and in a feminine way, they used a variety of feminine and masculine terms/concepts to refer to themselves in different contexts, depending on spaces/places, time and who they were with. This variety was reflected in interactions in their personal lives, amongst peers, friends, family, and partners, as well as in social interactions with community members, and when accessing services and other formal processes where identification documentation is requested or required.bakla or kathoey in Thailand, Travesti in central- and south-America, Hijras in India and Waria in Indonesia for example [Globally, people who were born male but have a feminine gender identification may use a range of gender identities like ‘fairies’, ‘queens’, ‘feminine gay’, cross-dressers and transsexuals , 20. In  example , 20. A s example . Local S example –23.It is evident that gender expression is contextual to the lived reality of a transgender person. As Brumbaugh-Johnson  found, tParticipants in our study similarly used a range of terms that were contextualised in time and space. For example, participants wouldn’t use the term gay to identify themselves if their family and community members didn’t use the term, or they would not have adopted an originally denigrating term like “moffie”, if it wasn’t freely used to criticize and discriminate against them. The way that transfeminine women navigate use of terms for gender identity is, as we’ve seen with a variety of global indigenous and locally used terms, very important to how they potentially access health services and other services that require the use of their identification document. Previous research, similar to our results, have pointed to how trans people had to navigate their gender identity in private and public institutions, like home affairs, the workplace, banks, schools and more .Stabane, stuzana or gemmi ; trasi, skezonke ; Maho, magene (men who are bottoms); moffie, watermuis, tarashushu (feminine gay men).In a range of recent South African studies, HIV researchers have been interested in the liminal group of women who fit into the transgender category, like feminine-identifying MSM , 29, genWe show in a recent publication, where we used the same sample and data, that gender identity was often conflated with sexual identity for these transfeminine women in the Western Cape, South African context . In thisDespite some progress to further HIV research among transgender populations globally, very little research on the topic has been done in South Africa . From thStrengths of our study are the rich data we collected, using a wide range of data collection methods, about the lived experiences of participants, which enabled us to understand the layers of stigma and trauma transfeminine women experience, how they cope with these stresses, and how they view their gender identity. In addition, the longitudinal nature of the data allowed us to confirm information about especially sensitive topics that take time to unpack as trust was built in the research relationship. Limitations to extrapolation from our findings include: Firstly, our sample size was small. Secondly, the people identified as transfeminine in our study were difficult to find, interview, and retain. Often, transfeminine participants were socially marginalised, moving around a lot and experiencing many interruptions to their daily routines. This may mean that the experiences of participants retained in the study may not be representative of all transfeminine women in the area . However, our study draws strength from being the first exploratory study of transfeminine women in the Western Cape.In this study we found a variety of terms that South African transfeminine women use to describe their gender identity. These terms and concepts are largely contextually bound and transfeminine women in the study, even though all eight participants identified in a feminine way, often used a variety of feminine and masculine gender identifying terms depending on different contexts. These insights can be used by HIV service providers to better meet the needs of this unique population. In the context of HIV service access, this means asking about and accepting people’s gender identity and expression, instead of assuming or imposing a category, like ‘transgender’, and tailoring service delivery to the unique needs of gender fluid populations. In addition, our findings will help to inform the development of gender-responsive HIV prevention, care and treatment services to support countries in achieving the societal enabler targets and global HIV goals by 2030 .


The well-being of people living with HIV (PLHIV) remains a concern. In addition to facing discrimination in their communities, many PLHIV have family members who have a discriminatory attitude. This study analyzes the discriminatory attitude toward PLHIV in the family context using socio-economic factors and information sources in Indonesia.p-value < 0.05).A cross-sectional study design was adopted using secondary data from the 2017 Indonesian Demographic Health Survey (IDHS). A total sample of 28,879 respondents was selected using two-stage stratified cluster sampling. The study variables are information sources, sex, age, education, residence, earnings, and familial discriminatory attitude. We used the STATA 16.1 software to analyze Chi-square and binary logistics with a 95% confident interval (CI) with a significance of 5% , women , and those living in rural areas  were the least likely to have a familial discriminatory attitude. Meanwhile, the respondents aged 15–24 years  and those with a secondary level of education  were the most likely to have a familial discriminatory attitude.In the study, we found that, the younger the age and the lower the educational level of the respondent, the more likely they were to have a familial discriminatory attitude. The government may consider these factors when designing policies to tackle familial discrimination faced by PLHIV; in particular, education on HIV and AIDS should be promoted. Discrimination is an act that violates a person’s human rights, and this is no different for people living with HIV (PLHIV) . The JoiThe number of PLHIV in Indonesia in 2018 was 640,000, and the number of deaths caused by AIDS was 38,000. The latter number is an increase of 60% from 2010 . PLHIV iIn an effort to tackle and minimize discrimination against PLHIV, the Indonesian government issued Law No. 21 in 2013 concerning HIV and AIDS prevention . In the Studies in Indonesia on the factors related to discrimination against PLHIV have been conducted in the general context but not specifically in the family context. Some of the general factors include sexual orientation, gender , knowledIn its description of the discriminatory attitudes encountered by PLHIV in Indonesia, this research aims to provide information about and an understanding of the discriminative attitude among family members of PLHIV. This study adjusts the data based on socio-economic variables and information sources to investigate discriminatory attitude toward PLHIV in the family context in Indonesia.The cross-sectional design of this study was used to discover the determinants of familial discriminatory attitude toward PLHIV in Indonesia. This study used secondary data from the 2017 IDHS . To use This study used secondary data collected in December 2017. The data sets used in this study are the IDIR71FL data set for Indonesian Individuals Recode Phase 7 and the IDMR71FL data set for Indonesian Men Recode Phase 7 . The datThe independent variables in this study are information sources, sex, age, education, residence, and earnings. The information sources variable is a combination of several variables that indicate the sources of information about HIV and AIDS accessed by the respondents. These variables are “internet,” “radio,” “newspaper/magazine,” “television,” “health professionals,” “community meeting,” “seminar/counseling,” and “school/teachers.” The variables were re-coded with “yes” and “no” to standardize the information across the different sources. These variables were then combined to form the variable ‘information sources.’ This variable has three categories: “No information” , “Some information” (if “yes” was answered on 1–3 variables), and “More information” (if “yes” was answered on 4–7 variables).The sex variable in this study is a binary, namely men and women . The ageThe dependent variable in this study is familial discriminatory attitude. This variable is formed from two variables that indicate the presence of a familial discriminatory attitude. These variables are formed as questions: “Would you want the presence of HIV infection in the family to remain a secret?” and “Would you be ashamed if someone in the family had HIV?” . The varp-value < 0.05).The data in the study was analyzed using the STATA 16.1 software. Bivariate analysis was conducted using Chi-square, and multivariate analysis was conducted using binary logistics. The adjusted odds ratio (AOR) had a 95% confident interval (CI) with a significance of 5%  Findings Form ICF IRB FWA00000845. Written informed consent for each individual was performed by the IDHS. The information about ethical review is available at HS-7.htm .As shown in As shown in As shown in As shown in The results of this study show a significant relationship between the information sources, sex, age, education, and residence variables and familial discriminatory attitude toward PLHIV in Indonesia.In the study, it was found that people with more access to information are less likely to have a discriminatory attitude toward PLHIV. On average, the respondents had access to 1–3 sources of information about HIV and AIDS. The information packaged in the form of the internet and informative communication media, it can be a form of therapy for PLHIV who are depressed . With prIt was also found that women are less likely to have a familial discriminatory attitude toward PLHIV. This finding is in line with other studies that show men are more likely to discriminate due to emotional instability and misperceptions of HIV , while wFurthermore, it was found that young people (15–24 years old) are more likely to have a familial discriminatory attitude toward PLHIV. This finding is in line with other studies that show that younger people are less likely to access the correct information, which may be due to a lack of maturity when receiving information about HIV and AIDS . KeepingMoreover, it was found that people with a secondary level of education compared to other educational levels are more likely to have a familial discriminatory attitude toward PLHIV. This finding is consistent with research conducted in India, Tasmania, and Bangladesh, which shows that educational level has a highly significant relationship with discriminatory attitude towards PLHIV . In thisFinally, it was found that people living in rural areas are less likely than those in urban areas to have a familial discriminatory attitude toward PLHIV. A number of other studies have confirmed this. The reasons for this rural/urban difference could be a lack of knowledge or exposure to information about HIV in rural areas, so they do not know whether it is dangerous or not , beliefsThis study provides results that are representative of the Indonesian population. The results have been validated using several samples and internationally recognized measurement tools. However, cross-sectional studies have a number of limitations, including the inability to estimate incidence and draw conclusions about causes. Moreover, the information was gathered retroactively and was based on the respondents’ memories. Confounding factors could, therefore, emerge depending on how well the respondents remember their past. Due to data limitations in IDHS, many factors including culture, religion, and belief were not taken into account.The results of this study show that having access to information about HIV and AIDS, especially when originating from various sources, makes people less likely to discriminate against PLHIV. In addition, women are less likely than men to discriminate. People of a younger age with a lower educational level, especially when no higher than secondary, are more likely to discriminate compared to people of an older age with a higher educational level. This finding could be related to their level of knowledge and access to information. Finally, families living in rural areas are less likely to discriminate compared to those in urban areas. Based on these research findings, it is recommended that the government consider demographic characteristics to develop better policies to reduce the discriminatory attitude of communities and families toward PLHIV.10.7717/peerj.13841/supp-1Supplemental Information 1Raw data exported from the 2017 Indonesian Demographic and Health Survey with the specific variables included in the study for data analysis. Raw data can be used after received an approval from Demographic and Health Survey.Click here for additional data file.


In gender-affirming medical care (GAMC), ethical challenges in decision-making are ubiquitous. These challenges are becoming more pressing due to exponentially increasing referrals, politico-legal contestation, and divergent normative views regarding decisional roles and models. Little is known, however, about what ethical challenges related to decision-making healthcare professionals (HCPs) themselves face in their daily work in GAMC and how these relate to, for example, the subjective nature of Gender Incongruence (GI), the multidisciplinary character of GAMC and the role HCPs play in assessing GI and eligibility for interventions. Given the relevance and urgency of these questions, we conducted a qualitative study among HCPs providing GAMC to transgender adults in the Netherlands.In this qualitative research, we conducted 11 semi-structured interviews between May 2020 and February 2021 with HCPs  working in two distinct GAMC settings. We purposively sampled for professional background and years of experience in GAMC. We analyzed our interview data using thematic analysis. As some respondents were more inclined to speak about what should or ought to be done to arrive at good or right decision-making, we identified both ethical challenges and norms. Furthermore, in our analysis, we differentiated between respondents’ explicit and implicit ethical challenges and norms and ascertained the specific context in which these challenges emerged.Respondents’ ethical challenges and norms centered on (1) dividing and defining decisional roles and bounds, (2) negotiating decision-making in a (multidisciplinary) team, and (3) navigating various decision-making temporalities. These themes arose in the context of uncertainties regarding (1) GAMC’s guidelines, evidence, and outcomes, as well as (2) the boundaries and assessment of GI.This interview study provides detailed empirical insight into both the explicit and implicit ethical challenges that HCPs experience and their ethical norms regarding decision-making. It also describes how uncertainties and (implicit) normativities concerning GAMC and GI pre-structure the moral environment in which these challenges and norms manifest. We provide normative reflections and recommendations on handling these ethical challenges in a way that is sensitive to the context in which they arise. A marked increase of transgenderFirst, although the evidence base is growing, current clinical guidelines for GAMC are primarily based on expert opinion leaving many clinical questions  unanswered , 3. The The abovementioned culminates in the final theme: decision-making (Theme 6). Indeed, HCPs may face ethical challenges regarding shared decision-making with clients and how to organize (multidisciplinary) decision-making in GAMC. Examples of such challenges include: How should I share the responsibility for decision-making when a client suffers from co-occurring mental health concerns, which makes me doubt their ability to consent to treatment? Or: In a triad consisting of a surgeon, mental health professional (MHP), and client, who ought to have what kind of responsibility regarding the acceptability of risks involved with surgical treatment? This paper centers on challenges in GAMC for adult transgender clients .Ethical challenges regarding decision-making are further complicated by MHPs often playing a pivotal role in GAMC generally and decision-making specifically. According to the 7th version of the Standards of Care (SOC7)This role, however, is not without its challenges. MHPs themselves, for example, struggle with the question of to what extent they (should) have a guiding or assessing role in decision-making , 18. ConAgainst this backdrop, the paucity of empirical work investigating HCPs’ ethical challenges in decision-making regarding GAMC for adults is surprising. Much empirical literature on ethical challenges encountered by HCPs in GAMC focuses on care for trans youth –28 and sTherefore, we initiated a qualitative interview study into the ethical challenges experienced by HCPs regarding decision-making in GAMC for adult clients. We included a majority of MHPs (HCPs with a background in psychology or psychiatry) as their involvement in decision-making is central and contested. To account for the multidisciplinary nature of GAMC, we also included HCPs with other professional backgrounds . The research question was: What ethical challenges related to decision-making do HCPs face in their daily work in GAMC?This study aims to contribute to various goals, including (1) better understanding HCPs' ethical challenges related to decision-making in the specific context of GI and GAMC; (2) informing various stakeholders about these challenges; (3) identifying barriers and facilitators for recent calls from a variety of stakeholder groups to implement shared decision-making in GAMC , 33; (4)We conducted a qualitative interview study to explore the ethical challenges of HCPs regarding decision-making in GAMC. We selected a qualitative methodology because it provides room for detail and in-depth information. It allowed us to pay attention to the fine nuances of the ethical challenges experienced and expressed by HCPs , 35.Dutch GAMC is offered by three multidisciplinary University Medical Centers (UMCs) and, increasingly, nonacademic mental healthcare centers that often work in partnership with UMCs and other somatic healthcare providers. Dutch GAMC guidelines largely follow WPATH’s SOC7  and are We included HCPs with a minimum of one year of working experience in GAMC. To meet the criterion of maximum variation, we purposively sampled for professional background and years of experience . RecruitKG conducted nine interviews, and CM and BM each conducted one semi-structured interview. In six interviews interviewer and respondent were not acquainted with each other, while in the other five, the interviewer and respondents knew each other as (in)direct colleagues. We based our interview guide on previous empirical and conceptual research , 5, the We analyzed the anonymized transcripts according to a thematic analysis approach . First, In the absence of an agreed definition, clear methodological guidelines, and consensus in social scientific and empirical ethics literature, it is challenging to identify ‘ethical challenges’ in empirical qualitative data , 36. We The research team consisted of a trained ethicist, qualitative health researcher, and Ph.D. candidate who was also a junior M.D. working in GAMC at the time data collection took place (KG), a healthcare consultant, and community advocate (CM), a senior researcher, and psychiatrist working in GAMC for adults (MB), a senior researcher in medical psychology focusing on gender identity development and (outcomes of) GAMC (BK), an expert in qualitative health research (FdB) and an ethicist and senior researcher with experience in clinical ethics support (CES) in GAMC (BM). We are a group of different genders and sexualities. To foster reflexivity, we engaged in dialogues among the research team members about how our professional and personal positionalities impact our assumptions, relationships with respondents, and research decisions . FurtherOut of the 12 HCPs we approached, 11 agreed to participate in the study, and one did not reply. We conducted 11 interviews between May 2020 and February 2021, nine of which took place via Microsoft Teams due to the COVID-19 pandemic. Information about respondent characteristics can be found in Table We identified three main themes. Respondents’ ethical challenges and norms centered on (1) how and when not to share decision-making with clients, (2) negotiating decision-making in a (multidisciplinary) team, and (3) navigating through various decision-making temporalities. These themes arose in the context of uncertainties regarding (1) GAMC’s guidelines, evidence, and outcomes, as well as (2) the boundaries and assessment of GI/GD.HCPs expressed ethical challenges and norms regarding the following aspects of the client–clinician decision-making process: (a) determining client–clinician decisional roles, (b) MHPs’ gatekeeper role, and (c) delaying or withholding treatment. The overarching ethical challenge in this theme was: How should we weigh respect for clients’ self-determination against our duty to non-maleficence?At the start of someone’s trajectory, I always tell my patients, ‘We’re a team, and as a team, we’re going to figure out how your dysphoria works for you, but especially whether medical steps will contribute to your happiness.’ I feel that whenever possible, I just want to stand by a patient’s side, form a team that works towards whatever that patient wants, but also see whether that’s sensible. Generally, HCPs strive to form a team with their clients and seek to work towards a shared goal. Some HCPs engage in a meta-conversation to discuss this explicitly. For example:Here, we see that the ideal of “forming a team,” “standing next to someone,” and “working towards the clients’ goal” has its boundaries. Indeed, Jasper also expressed an ethical obligation to assess whether the client’s goal is sensible and likely to contribute to their happiness. An implicit ethical question we identified here is: Who should define “happiness,” and what it entails for decision-making in GAMC?In our multidisciplinary team meeting this morning, we discussed a case in which, well, there were some concerns. At the same time, one of our colleagues rightly said, ‘Yes, but there’s obviously informed consent.’ And, you know, someone has to have the ability to decide for themselves and have a say in, well, what they want in terms of [medical] steps. And if someone can do that , who are we to say that we’re not going to treat? On the other side, there’s your responsibility, of course: your responsibility as a psychologist or your medical responsibility as a doctor. That can be pretty complicated when I think a patient may want something very much, but it just doesn’t sit right with me. As Maria shared, the commitment to respecting self-determination and informed consent in decision-making may come into conflict with one’s professional responsibilities:Interviewer: What isn’t black or white?Jasper: Well, the road to happiness. In this case, how sure should we be of our assessment that hormones will do this patient [with suspected co-occurring mental health concerns] good? Which obstacles and hoops should this patient jump through before we can do that? And sometimes, that’s very clear. So, you’ll say that someone has to be in mental health care, and well, they might live with their mother, so in that case, the mother has to be somewhat on board with it, too. Well, then, you know what you’re working towards. But a lot of the time, it’s more ambiguous. … How far should you go? Many MHPs described how they adapt decision-making roles and responsibilities to their clients, for example, by distinguishing between “relatively good functioning” and “complex” clients or those who are and are not able or willing to communicate. Maria shared how her role in decision-making becomes more paternalistic when confronted with clients with ‘questionable capacity’ or those unwilling to seek treatment for interfering mental health concerns. Defining one’s role and responsibilities in decision-making may also create ethical uncertainty. Consider, for example:As a clinician, you have a strange role. On the one hand, you try to stand by your patient’s side to find out, like, ‘What do you need? And what is necessary for you to take that step towards medical treatments here?’ On the other hand, you’re indicating clients for treatment and deciding when that’s happening. We can better understand Stefan’s ethical uncertainty in the context of MHPs having dual ethical obligations in decision-making. Many MHPs, like Maria, explicitly spoke of how their responsibilities regarding guidance may come into conflict with those regarding assessment, or gatekeeping:I don’t think it’s good when patients feel like I’m an obstacle they must overcome. … I want to have a position in which I’m taking them along or guiding them in their trajectory in an expert role, but with the client as a second expert or something. But at the same time, these two [roles] are at odds … because in the end, you as a clinician, well—in the context of our team-based approach, of course—have to say something about whether there is or isn’t Gender Dysphoria and whether or not we should treat. MHPs were often cognizant of the effects their gatekeeping role can have on (the possibility of) forming a client–clinician partnership in decision-making. Here is Stefan:The above can give rise to a situation in which clients—due to pragmatic motivations or mistrust—may approach their MHP instrumentally, e.g., by refraining from divulging information MHPs consider important in decision-making. Stefan, for example, recounted a client who did not tell him about a dissociative identity disorder diagnosis out of fear of being rejected for mastectomy. As Marieke emphasized, such a breach of trust in the client–clinician relationship can have serious ethical consequences for  decision-making: “When a client doesn’t trust me because he’s afraid that I’ve something to decide … I also can’t determine what’s going on or what he needs” .You know, you’ve made an oath that you want to do good and that you shouldn’t harm. Sometimes that’s... When somebody requests a treatment that I believe will do more harm than good, I’ll explain that and won’t go along. Finally, HCPs expressed ethical challenges and norms related to going against clients’ wishes by withholding or delaying treatment. Although HCPs generally considered this undesirable, many shared the normative view that one should always be able to withhold or delay treatment. To ethically justify this, clinicians often refer to the principle of non-maleficence:Yesterday, for example, I was able to explain and motivate very clearly why I didn’t refer someone to an endocrinologist. And that person understood it, was able to follow it, and got it, too. She was disappointed, but we could talk about it with each other. And she agreed with the advice [to seek mental health care] and was going to organize it. And then I think: it’s great that we could accomplish that together. HCPs expressed myriad reasons for delaying or withholding treatment, including doubt regarding the assessment of GI/GD, the conviction that co-occurring mental health concerns ought to be treated or monitored before and/or during GAMC, insufficient social and/or psychological resilience, and serious concerns about a client’s ability to consent to treatment. Besides the normative view that one may only go against the wishes of the client when this is sufficiently substantiated and in their best interests, HCPs hold that they should communicate their rationale for doing so. The following quote illustrates how the latter may make shared decision-making possible even when the client’s treatment request is not (yet) granted:As in many healthcare contexts, decision-making in GAMC involves many stakeholders beyond the classic client–clinician dyad. HCPs with different disciplinary backgrounds have to relate to their clients, colleagues, teams, institutions, professional organizations (and their guidelines), and the broader socio-cultural-legal context. HCPs experienced ethical challenges, particularly in (a) determining their specific responsibility in multidisciplinary decision-making and (b) handling (multidisciplinary) decision-making dissensus.It is very different if you [as an MHP] are exploring with a patient whether a particular diagnosis fits their situation or whether you [as a somatic HCP] are discussing with someone whether we’ll perform a specific surgery. … That’s shared decision-making of a completely different caliber. .As Mike explained, decision-making in GAMC consists of different tasks or elements that are shared among various professionals and disciplines:As a [somatic] medical doctor, I feel I should only prescribe something if I can support it and believe it will benefit someone. And, the way I see things is that it’s just really great that a psychologist has already determined whether treatment is the right step for a client. And that I, based on [the MHP’s] advice combined with my endocrinological point of view, get to decide whether to start treatment. The latter entails that decision-making in GAMC encompasses a variety of multidisciplinary processes and responsibilities. Indeed, HCPs distinguish between ‘psychological’ and ‘medical/somatic’ duties in decision-making that tie into but are also distinct from each other:Tim holds that he should only initiate treatment when he agrees with it. In reaching this judgment, however, he appears to rely heavily on the MHP’s assessment, highlighting the interrelated nature of various (multidisciplinary) decision-making processes. An implicit ethical question we identified here is: How should these different (multidisciplinary) decision-making processes be integrated, and what professional/discipline should carry what responsibility?I’ll explain [to my client] that the team has to be on board. So, there can be a situation where I’ll tell a patient, ‘Yes, to me, it’s clear, but I wonder how I’m going to sell it to a team of medical doctors and psychologists who don’t know you.’ MHPs considered it crucial for the multidisciplinary team to agree with a treatment decision they reached with their clients:[T]o some extent, what I’ll share in a [multidisciplinary] team meeting, I’ll filter to what I think people want to hear. And that’s what I call the peculiar paradox of a gatekeeping model I take to my meetings. … That I guess I shouldn’t say too much. … I’m convinced that my omitting, or telling some details differently, will lead to another decision. Well, it’s not always clear-cut, but my strategizing is increasing, and I find that pretty annoying. This fragment illustrates Jasper’s anticipation of potentially differing views regarding decision-making between him and the multidisciplinary team, the implicit normative assumption being that there ought to be general support from the team for a treatment decision. This may play into a state where MHPs are reluctant to share certain case specifics with their team. As Will shared:We weren’t really on the same page about how to continue [in the case of a client with co-occurring psychiatric problems who suffered from complications following phalloplasty]. The surgeons said, ‘Well, should we even perform surgery again?’ And I understood why they found that difficult when looking at his resilience and how he dealt with his complications, especially considering that a second surgery carries the same—or perhaps an even higher—risk of complications. On the other hand, I felt that because we’ve said ‘A,’ we ought to say ‘B,’ too, because otherwise, we would’ve just left him hanging. … So, it felt tough that we didn’t try it one more time, while I really understood my colleagues' arguments. Conversely, diverging normative convictions regarding decision-making may be acknowledged, understood, and discussed:In grappling with whether performing surgery (again) is ethically permissible, Maria has to weigh her commitment to values such as trustworthiness against the surgeons’ reference to non-maleficence. In this specific case, this balancing act is made more difficult by four contextual factors, i.e., a high complication risk, the severity of suffering, the client’s co-occurring mental health concerns, and, as this MHP mentioned, his failure to understand the surgeons’ hesitance to perform surgery again. This quote also illustrates how HCPs and MHPs may engage in different decisional relationships with their clients that correspond with differing responsibilities, values, and norms. An implicit ethical challenge we identified here is: How should these diverse relationships and corresponding obligations, values, and norms be integrated into (the various steps of) the decision-making process?In the quotes above, various temporalities carry implicit or explicit normative valence in decision-making. Ethical challenges arose, particularly around (a) potential future concerns in current decision-making and (b) potential future consequences of treatment on values relevant to decision-making.Well, I always try to keep the big picture [of the client] in the back of my mind. But the way we decide about treatment, so when you’re talking about decision-making, is really step-by-step. … We approve this step, and the client can’t derive any rights for future treatment from that approval. But OK, when I know that there’s a clear wish for further treatment, I’ll consider that. I find that very complicated now and then because I’ve patients who say from the get-go, ‘Just give me those hormones, then at least I have something,’ while I worry: How are we to move forward from there? I’ve three or four [clients who have started hormone treatment] in my caseload who are still not eligible [for surgical treatments] five years down the line. GAMC encompasses a variety of potential treatment steps  that are conceptualized as separate modalities with different psychosocial and physical eligibility criteria but also function as parts of a whole. In practice, this can lead to ethical challenges, for example, regarding the ‘stepwise’ approach to decision-making:Consequently, Maria feels she has an ethical duty in decision-making to prevent clients from getting “stuck in the middle.” Hence, like Ellis, many HCPs found it “very important… that the timing of the start of treatment is right” . Yet, determining the right timing may pose challenges. Marieke, for example, shared how she experienced difficulty deciding whether a client with co-occurring mental health concerns should seek psychological care before starting GAMC and who should determine this. In handling this ethical challenge, she explicitly took into account potential future consequences of (her role in) decision-making: “What’s worse? Referring someone for hormones when you’re worried that person will become even more unstable, or postponing [hormone treatment] and having that make them unstable. That’s a really tough call sometimes” .When you take the example of a relatively young person who has always felt a great aversion towards their genitals, and they say: ‘Well, I don’t want to have sex; I want a shallow vagina ,’ then that’s possible, but I find it complicated when it concerns someone in their twenties. … Look, you can’t just deepen a vagina during a second surgery … And if you’ve had an operation that causes your aversion to subside, you may start to think differently about sex. And then you’ve decided on a situation you might not have been able to imagine. In those cases, I don’t say ‘no,’ but I give extensive information about the pros and cons, and I want someone to think it through before we decide. Look, I’m not talking about someone convinced and says, ‘I don’t want to take risks, and I’m overweight and in my sixties, and I just can’t be bothered.’ To me, that’s a different story than someone who’s 25. So, what I tend to do in these situations when someone is 25, is I’ll give them very detailed information, and I’ll say, ‘You’ll have another consultation with a surgeon, and then you’ve thought about it, and you can decide together.’ And then I don’t decide but postpone. Wietske explains how she anticipates the way time, treatment, and lived experience may change clients’ values and preferences regarding said treatment:Wietske appears to face the following ethical question: What should be the impact of potential future consequences of treatment on (my role in) decision-making in the here and now? In grappling with this question, she refers to various temporalities carrying normative valence: possible treatment outcomes, effects, calendar age, and the prospective preclusion of other surgeries. Ultimately, she handles this ethical question by thoroughly informing clients, involving more stakeholders in decision-making, and employing yet another temporality, i.e., delay.We identified how many ethical challenges and norms described arise in a context characterized by uncertainties regarding (a) GAMC and (b) GI/GD. Indeed, HCPs in GAMC have to navigate various uncertainties and corresponding contestations concerning the object of care and its treatment.We found that diverse HCPs related their ethical challenges and norms regarding decision-making to uncertainties and contestations related to GAMC, particularly its guidelines, evidence, and outcomes.Setting boundaries as a clinician is essential. You know, a BMI of 30 is a BMI of 30 and not a BMI of 30.5. When someone smokes, they have to stop, and you shouldn’t be like, ‘It’s OK; two cigarettes won’t make much of a difference.’ No, you should treat everyone the same. Don’t set a precedent, … [but] within these boundaries, there are many options. Many HCPs, like Mike, believe it is important to establish limits to decision-making through the use of guidelines, for example, through stringent criteria concerning BMI and smoking:This quote exemplifies how HCPs may invoke eligibility criteria to substantiate and solidify ethical norms regarding decision-making , marking both real and perceived boundaries of decision-making.You start to work here, and this is the guideline we use, which is, of course, European and worldwide. … [B]ut it makes me think, like, why do we take this route, and why is it a year and not nine months? Or a year and three months? Why don’t we tailor it to the client’s needs? However, other HCPs question the certainty of such guidelines, highlighting how firm boundaries may give rise to ethical uncertainties. Sara, for instance, challenges the criterion that clients are only eligible for genital surgery after a year of hormone therapy:Sara’s ethical question could be formulated as: Are current guidelines curtailing client involvement in and personalization of decision-making ethically justifiable?We don’t have any literature on these specific lab results and corresponding risks. So, I tell my client, ‘We just don’t have the evidence!’ And she asks, ‘But then, what are you basing your recommendations on?’ So, I say, ‘On our guidelines; we have to stick to our guidelines. Studies have found that long-term exposure to high [hormone] levels can lead to problems.’ And she just couldn’t do anything with that because she found it too general. She stuck to her position and said, ‘No, I’m not going to lower my dose.’ And I wondered, where does my responsibility end, and where does the patient’s begin? … What I’m leaning towards is that if I’ve clearly explained the risks, and she still decides to use more, then that’s her responsibility. Often, HCPs seek to refer to  evidence to support and justify criteria, guidelines, and treatment decisions. Although the field of trans medicine is working towards increasing its biopsychosocial knowledge base, many clinical questions remain unanswered. The latter may lead to contestation in the client–clinician decision-making relationship and ethical challenges regarding decision-making:Tim grapples with ethical questions such as: Who should carry the ethical responsibility for the potential risks of elevated hormone levels? An implicit question we identified here is: What, if any, should count as sufficient  evidence to warrant or necessitate a different approach to this decision-making disagreement?[T]he most complicated are, of course, clients that say, ‘I want to look more [gender]neutral,’ because you just can’t with these hormones. You know, you can’t choose a bit of this and a bit of that. … So, you find yourself in a difficult situation [when a client says], ‘Yes, I do want a lower voice, and then I’ll just take the increase in hair growth for granted.’ Yes, I find that really tough, like, are we doing the right thing or not? These questions point to another challenging characteristic of GAMC: the notion that the effects and outcomes of a treatment decision are—to some extent and especially on an individual level—uncertain and unpredictable. The latter can give rise to especially pressing practical and ethical challenges in the context of decision-making with non-binary clients:What makes it difficult is that it’s not a black-and-white thing. You can’t say, ‘If you’re depressed and your mother is not on board, it’s a no.’ You can only say, ‘I reckon it’s important that you do this or that first.’ Well, of course, a patient will think, like, ‘What the fuck? You think? I think differently, and it’s my decision, so leave me alone.’ Uncertain treatment outcomes may not only complicate decision-making but also lead to ethical contestation and distress in the context of the client–clinician decision-making relationship:We identified the following implicit ethical questions: In the absence of unequivocal evidence and individual predictors, should clinicians withhold or delay treatment to prevent potential adverse outcomes? How should the potential benefits of GAMC be weighed against its potential harms? How should these benefits and harms be defined? And who ought to weigh them?Furthermore, we found uncertainties regarding GI/GD to impact ethical challenges in decision-making. Many HCPs referred to GI/GD as a complex problem or phenomenon. For example: “Interviewer: If one of your clients asks you, ‘What is Gender Dysphoria?’ what would you tell them? Jasper (MHP): Gosh. I’d say, ‘What a shitty question.’” Part of what makes this such a shitty question has to do with GI/GD being ambiguous and challenging to prove. Marieke (MHP) said: “When we’re talking about decision-making, the hard thing is that it’s all based on something we can’t measure.” Indeed, HCPs are critically aware of the absence of a validated marker: “Can we scan someone and say, ‘You’ve got Gender Dysphoria?’ Well, I don’t think so, I’m inclined to say” . The notion that GI/GD is ontologically ambiguous and epistemically inaccessible has severe ramifications for the establishment of its boundaries and its assessment.When people just want a mastectomy, now they can. I’ve some clients who are non-binary and who suffer terribly from having breasts. But can you really make Gender Dysphoria out of that? For example, I have a client who says, ’75 Percent of the time I feel like a man and suffer from my breasts, but the other 25 I feel like a woman and then I don’t,’ who still wants a mastectomy. Well, I find that really complicated. Questions related to the boundaries of GI/GD mainly surfaced when clinicians spoke of non-binary clients. Indeed, the diversification of gender identity/expression and the influx of non-binary clients in GAMC gives rise to ethical challenges in decision-making. Consider the following fragments:The tricky thing is that some requests are hard to imagine … [like] patients who don’t want [their] nipples [placed back after mastectomy]. … Yes, well, maybe that’s due to my limited views and the fact that I tend to think in terms of ‘man’ and ‘woman.’ At the same time, there are no animals in nature without nipples. So, men and women have nipples. Why do you  feel the need to be different? And so, we said, we think that’s just too odd. Some people just want to be different for the sake of being different. We shouldn’t abuse a medical transition for that. … Or people who want both a phallus and a vagina. … Are these my limitations, or is that just a really strange request? And:These fragments illustrate how uncertainty and contestation as to whether HCPs can understand a particular treatment request in the context of GI/GD may give rise to feelings of ethical uncertainty regarding decision-making. Indeed, clients requesting nippleless chests or both male and female genitals confront Mike and make him reflect on his implicit binary norms and values regarding gender identity and expression.Sometimes there are people who really shouldn’t [have GAMC] but are convinced they are [gender dysphoric]; where it turns out that—in the end—it was a good decision not to start [GAMC]. People who really believe they’re gender dysphoric aren’t always. The inability to measure, visualize, or otherwise ‘prove’ GI/GD poses obvious practical and ethical challenges. One of these is that many HCPs consider GI/GD to be something that could be something else. In other words, clients may be mistaken about their condition:I find it important that people whose gender dysphoria is caused by psychiatric problems are identified quickly. It doesn’t happen often, but I’ve experienced it over the past years when it became clear that Gender Dysphoria, or alleged Gender Dysphoria, was caused by a psychotic disorder, for example. … And that’s bad because if the psychosis were to be left untreated … [GAMC] could lead to feelings of regret. MHPs mentioned “trauma,” “autism,” or “psychosis” as potential explanations for (something that at first glance may appear as) GI/GD. Many MHPs feel an ethical obligation to establish how these phenomena (inter)relate and differentiate between “authentic” or “real” GI/GD and other potential “causes.” Indeed, most MHPs held the ethical norm that as long as there is uncertainty as to whether some other phenomenon could explain GI/GD, a careful approach to decision-making is warranted. Such an approach is often anchored in the principle of non-maleficence and the corresponding norm that adverse outcomes such as regret should be prevented:Well, you know what’s difficult is that we’re talking about identity, which is challenging to classify in terms of whether it’s there or not. And, well, how someone experiences their identity is highly subjective and, by definition, true because someone feels it that way. Yet, in the diagnostic phase, we try to assess whether that’s right. That’s what I find difficult. Yet, many HCPs, like Stefan, also question the possibility of genuinely diagnosing GD:Well, I’ve spoken to many people over the years who ask me, ‘Look, what do you want to hear?’ To which I respond, ‘Well, your story,’ so to speak. And then people say, ‘No, you’re not! You say you are, but what you want to hear is that I’ve suffered from Gender Dysphoria for a long time; that I meet two out of seven DSM criteria because then I have the diagnosis; that I suffer tremendously; and that I haven’t felt like a man but a woman since years long past and I would’ve preferred to have been born a woman; and that I don’t have any problems, or at least not too many. That’s what you want to hear!’ As Will shared, the uncertainties concerning diagnosis may have consequences for the establishment of rapport and trust in the client–clinician decision-making relationship:Indeed, this fragment illustrates how uncertainties regarding GI/GD may propel (largely implicit) normative assumptions about what GI/GD is or should be and, consequently, ethical challenges related to decision-making.This qualitative interview study investigated the ethical challenges and norms regarding the decision-making of HCPs working in Dutch GAMC. These pertain to the following overarching ethical questions: (1) How should we weigh respect for clients’ self-determination against a duty to non-maleficence in decision-making? (2) How should we negotiate decision-making as a (multidisciplinary) team and (3) navigate various decision-making temporalities? We elucidated that these ethical challenges and norms arise in a context characterized by epistemic and normative uncertainties  regarding (1) GAMC’s guidelines, evidence, and outcomes and (2) the boundaries and assessment of GI/GD. Given these distinct characteristics, making and sharing decisions regarding GAMC is arguably characterized by context-specific and inherent moral and normative dimensions , 6, 7.Clients, policymakers, and professional bodies increasingly advocate the principles of shared decision-making as an ideal when more than one medically reasonable option is available, and the role of stakeholders’ values and preferences in decision-making is amplified , 40. In The first theme illustrates how decisional roles and boundaries in the client–clinician dyad may be ethically ambiguous, with HCPs having to straddle respect for clients’ self-determination with their duty to non-maleficence. In line with Dewey  our respThe above has consequences for shared decision-making in GAMC. Clark et al.  identifiThe second theme highlights how decision-making in GAMC involves stakeholders beyond the archetypal client–clinician dyad and deals with more than a single treatment decision. Today’s GAMC combines psychosocial care, hormone therapy, and gender-affirming surgeries, often provided by multidisciplinary teams . The latThe above has implications for shared decision-making in GAMC. First, HCPs should discuss multidisciplinary decisional roles, responsibilities, and processes. As GAMC is a dynamic field, it may benefit from iterative deliberation on questions such as who should introduce choices, elicit goals, and compare and weigh alternatives; in other words, who is involved in (shared) decision-making, when, and with what purpose . AnotherThe third theme foregrounds the role of time in these various decision-making processes. We may best understand decision-making in GAMC as a stepwise process comprised of multiple interconnected decisional moments . Our finThe above has implications for shared decision-making. First, shared decision-making presupposes that after the introduction of choices, comparison of alternatives, and the discussion of decisional roles, the client and HCP come to a shared decision. How should shared decision-making be adapted to a series of decisions that are also a part of an overarching decision-making process? We argue that these parts and processes should be elucidated to facilitate the iterative calibration of shared decision-making and decisional roles between the client, HCPs, and other stakeholders. A guiding question for practice could be: What should be our decisional roles in relation to this particular decision, and how do these relate to the overall decision-making process? Next, a fundamental challenge to be grappled with is the impact of potential future consequences, such as harm—particularly regret—on current decision-making. Exploring this question further in conceptual and empirical-ethics research involving diverse stakeholders could prove fruitful. How do various stakeholders define harm and/or regret? What should be the normative consequences of the possibility of harm/regret in the (shared) decision-making process?Hypotheses abound as to what underpins these various ethical challenges regarding decision-making in GAMC. These range from an inconsistent interpretation of clinical guidelines, insufficient formal education, and little institutional support for GAMC  to a lacThe growing but relatively small evidence base of GAMC and the inherently unpredictable effects and outcomes pose an obvious challenge to a core feature of shared decision-making, i.e., weighing benefits and harms. The latter, in turn, exacerbates ethical challenges concerning decision-making. We found that HCPs responded to this differently. While some acknowledged it, others appeared to mobilize implicit or explicit normativity to contain it. As Cribb notes: ethical challenges, such as ethical uncertainty, are potentially very destabilizing in medicine as they are “pervasive and because [they may be] hard to resolve” , p.22. HWe observed a similar dynamic concerning uncertainties regarding the object of care: GI/GD. The inherently subjective nature of GI/GD and corresponding uncertainty regarding its assessment, as well as uncertainty as to whether a particular set of phenomena can be understood as GI/GD, may compound ethical challenges regarding decision-making. Here, too, (implicit) normativity may be mobilized to manage ethical challenges. An example we identified in previous observational research  is the uWe concur with Cribb that (implicit) normativity “should not be lazily valorized, that is, seen automatically as either a bad thing  or as a good thing (preventing an explosion of contention)” . We descOur respondents indicated a clear need for support in recognizing and handling (shared) decision-making-related ethical challenges. CES aims to support HCPs and clients in dealing with ethical issues in clinical practice, thereby improving stakeholders' quality of care, cooperation, and moral competencies. CES may be provided through different services  with varying aims, methods, and theoretical backgrounds . Increasingly, CES is offered in GAMC in the form of ethics consultations  and MoraThis study is not without limitations. First, the semi-structured character of the interviews contributed to the depth of our findings as it allowed for the verbalization and identification of ethical challenges and norms that often remain implicit. However, although our conclusions corroborate a previously conducted focused ethnography , they caSecond, the findings of this paper provide an in-depth exploration of decision-making-related ethical challenges and norms experienced by HCPs working in Dutch institutional contexts where clinical guidelines are currently based on WPATH’s SoC7 . Qualita4Third, the double role of two authors as both researchers and MHPs in GAMC may have helped sensitize responsiveness to practice and build rapport with respondents, but it could also have increased the likelihood of interviewer/researcher bias. To attenuate the latter and enhance the credibility of our findings, we engaged in recurring reflexive dialogues among the research team and conducted member checks.Fourth, we acknowledge that the implicit ethical challenges and norms we describe are our interpretations of the data. The latter entails that they might not always be experienced or shared by our respondents or readers. By offering  transparency regarding our approach, we hope to provide space for constructive disagreement and dialogue.Fifth, we stress that this paper offers a descriptive lens on these ethical challenges and norms without the ambition to settle them normatively. The latter is in keeping with our dialogical approach to ethics which strives for moral learning through joint critical engagement and reflection rather than an outsider’s moral judgment .The discussion of what constitutes good (shared) decision-making in GAMC is in full swing. To contribute to this discussion, we elucidated the ethical challenges and norms of HCPs, particularly MHPs, regarding decision-making in GAMC. Our findings illustrate how decision-making in GAMC is ethically complex and dynamic. It is best understood as an ongoing dynamic process constantly, yet often implicitly, negotiated among and distributed across various stakeholders, places and times. The latter defies the archetypal client–clinician decision-making dyad and the notion of a single decision-making moment.The multidisciplinary and temporal structure of GAMC entails that decisional role(s), responsibilities, and values may be opaque and come into conflict. Furthermore, we expounded how the context of (shared) decision-making in GAMC is rife with uncertainties and corresponding contestations. On the one hand, clients’ and HCPs’ values and norms regarding treatment are ever-changing due to the diversification of treatment options and shifts in socio-cultural discourse concerning gender(diversity). On the other hand, the subjective and ambiguous nature of GI/GD complicates assessment and establishing its boundaries. Given these distinct characteristics, (shared) decision-making in GAMC is arguably characterized by context-specific and inherent moral and normative dimensions.Consequently, ethical challenges and normative divergence are arguably inevitable. The implications of the latter should not be underestimated: our findings indicate that—particularly underacknowledged—ethical challenges may put a significant burden on the client–clinician and clinician-team relationship, (shared) decision-making, the organization of care processes and, in the end, the quality of care. This underscores the need for more awareness of and sensitivity toward the inherent ethical challenges, normativity, and contextual uncertainties regarding decision-making. We argue that working towards good (shared) decision-making necessitates the joint identification and handling of ethical challenges and an open, reflective, and ongoing dialogue between clients and clinicians and among (multidisciplinary) teams. CES seems to offer promising means towards these ends and may consequently allow for more explicitly deliberated and justified (shared) decision-making.


Although Thailand is overtly open to diversity and promotes equality, discrimination of minorities based on gender, ethnicity, and/or certain occupations is unfortunately still prevalent. Society either obstructs their inclusion or accepts them but only under certain conditions. The objective of this study is to examine the discrimination of TGWs with intersectional identities within Thai society. A total of 19 TGW participants were recruited and underwent in-depth thematic interviews about their experiences of discrimination. Rechecking of the extracted information from the interview transcripts and the subsequent encoding process were conducted using the NVivo program. The results show that the median age was 30 years old, and the majority of the individuals with intersectional identities were ethnic minority TGWs (47%). The in-depth interviews were divided into four main themes, including discrimination at an educational institution, discrimination in the workplace, discrimination in daily life, and discrimination at a healthcare facility. Our findings reflect problems associated with multiple sources of discrimination aimed at transgender women with an intersectional identity in Thailand in every aspect, including harsh speech or physical abuse; occupational, social, and legal inequality; and healthcare provision disparity. Raising awareness about gender diversity and intersectionality, as well as enforcing anti-bullying legislation and anti-discrimination laws, should be continually pursued in order to protect the rights and improve the quality of life of transgender individuals with an intersectional identity. The lesbian, gay, bisexual, transgender, queer (LGBTQ) community is a marginalized group of people who face much discrimination around the world . AlthougThe interconnectedness of several social characteristics, such as race, gender identity, and class, is known as intersectional identity and is regarded as a contributing factor to inequalities and interrelated systems of discrimination ,12,13. IDiscrimination and experiences of mistreatment at educational institutions can be particularly challenging for LGBTQ students; their experiences include hate speech and sexual harassment from teachers and other students ,16,17,18TGWs frequently face discrimination concerning employment, such as limited access to job opportunities, being turned down by potential employers, being laid off, and being denied career training or promotion opportunities . From a A previous study by Riggs et al. 2018) revealed that transgender and nonbinary people living in Australia and the UK were more likely to be subjected to family violence than other individuals . In Thai8 revealeSome Thai Buddhists believe that homosexual people are unable to control their sexual impulses and tendencies . NeverthTGW patients are usually stereotyped and subjected to service discrimination, procrastination ,31, profThe Mplus Foundation, Chiang Mai, and the SISTERS Foundation, Chonburi, are organizations that specialize in the prevention of the spread of human immunodeficiency virus (HIV), which can lead to acquired immunodeficiency syndrome (AIDS); other sexually transmitted diseases (STDs); and sexual health, as well as advocating LGBTQ rights in Thailand. In cooperation with both foundations, a study was conducted on the issues of discrimination against diverse identities. The study is categorized into four discrimination scenarios: (1) at an educational institution, (2) in the workplace, (3) in everyday life, (4) and at a healthcare facility. The data were collected via in-depth interviews. The outcomes should reflect the problem of discrimination against TGWs with an intersectional identity and related organizations and help stakeholders to provide plans to mitigate discrimination against them in the long run.The qualitative data used in this study were collected by the Mplus Foundation in Chiang Mai and the SISTERS foundation in Chonburi, Thailand, between 1 April 2022 and 31 May 2022. Nineteen participants aged 18 years old or older with intersectional identities, including (1) ethnic minority TGWs (9), (2) TGW sex workers (6), (3) ethnic minority TGW sex workers (2), and (4) ethnic minority TGW monks (2), were included in the study . Before The interviews were carried out by an in-depth interview specialist (N.M.) who has been trained in counseling as well as mental health issues by the Mplus foundation. Since the data collection was conducted during the COVID-19 epidemic situation in Thailand, there were two methods of interviewing, in-person and by phone, which depended on what was convenient for each participant. When conducting the in-person interviews, the interviewer and the participant were in a private room, wearing masks, and staying more than 1 m apart for the entire process. This complied with the guidelines for preventing the spread of COVID-19 in Thailand. The schedule for the phone interview was arranged at the convenience of the participant and to ensure that the interviewer and participant were alone to maintain their privacy concerning personal information. The interviews with Buddhist priests were conducted over the phone and had to be formal, using religious terminology to ensure the security of the monk’s status while providing information.The participants were interviewed in Thai for between 45 and 60 min. Interviews were digitally audio recorded and then transcribed verbatim, and pseudonyms were allocated to the interviewees to preserve their anonymity. The semi-structured interviews consisted of two parts: (1) demographic information, including age, ethnicity, education, and occupation, and (2) experience of perceived discrimination. Part 2 of the semi-structured interview was a modified version of the perceived ethnic discrimination questionnaire-community version (PEDQ-CV) by using the questions in the section concerning discrimination in the past among ethnic groups living in Asia ,37.We categorized the data into four discrimination scenarios: (1) at an educational institution, (2) in the workplace, (3) in everyday life, (4) and at a healthcare facility. We rechecked the information and encoded the themes and sub-themes from the semi-structured in-depth interview transcripts using the NVivo program (release 1.3) prior to performing the statistical analysis. The descriptive statistics of the characteristics of the participants are presented as frequencies and percentages for categorical variables and medians and interquartile ranges for the age variable. Thematic analysis was used to identify patterns or themes from the interviews. A re-iterant process was used for discussing areas of agreement and disagreement.This study was approved by the Chiang Mai University Research Ethic Committee (CMUREC 65/012). Informed consent was obtained from all of the subjects involved in the study.The median age of the 19 participants was 30 years old (IQR = 28–40). The majority of the intersectional identities were ethnic minority TGWs , followed by TGW sex workers . Most of them were from the Thai Yai ethnic group , followed by Thai Yong and Thai Lue . Most of them were self-employed as sex workers  and monks . Most of them had lived in Thailand for 11 years or more  . The in-Discrimination was reported via the use of inappropriately harsh words by teachers, friends, and/or seniors at school because of having an intersectional identity, as per a TGW sex worker aged 30 years old. “Teachers tried to persuade me to transform back to being a man because society would not accept me, would bully me, and it would be difficult to find work.” (a TGW sex worker aged 27 years old); “I am from a rural community and my skin color is quite dark, and so I was often teased about being a black ladyboy.” (a TGW sex worker aged 29 years old); and “I was new to Thailand from Myanmar and couldn’t speak or write Thai, so I was often bullied for being “stupid”.” (a TGW monk from ethnic minority aged 29 years old) are some of the answers of the interviewees.Some have been discriminated against through physical violence, and some are misunderstood and judged by their outward appearance by friends and teachers at educational establishments. For example, “A third-gender friend and I were often hit, kicked, teased, and caught naked by mischievous teenagers at school.” (a TGW sex worker aged 27 years old) and “A third-gender friend and I were often subjected to anger, violence, and being spoken rudely to.” (a TGW sex worker aged 26 years old).Some have been impacted by both positive and negative discrimination at school. An example of a positive impact is “Being teased by a friend motivated me to study hard, and I received first place in the school.” (a TGW monk from ethnic minority aged 29 years old), and an example of a negative impact and unacceptable event is “The teacher told me that if they said it and I couldn’t accept it, then I should quit, and so I decided to stop studying and quit.” (a TGW sex worker aged 30 years old).An example of workplace discrimination is people refusing to work with a group of individuals with intersectional identities. For example, “When I applied for a particular job, I was rejected because they wanted a woman due to the work being delicate, and when I applied to be a security guard, the company wouldn’t accept me because it required a man.” (a TGW from an ethnic minority aged 35 years old); “My female friend applied to be a hotel worker. The hotel needed more workers but when I went to apply for a job, I was not accepted because I’m a third-gender person.” (a TGW sex worker from an ethnic minority aged 28 years old); and “In addition, the organizational restrictions are another reason why LGBTQ people are denied employment. When I went to apply for a job, the interviewer said “when you come to work, you must dress as a man and talk less. If you act as a third-gender individual at work, you will not be accepted.” (a TGW from an ethnic minority aged 29 years old).Harsh words or bullying remarks made by colleagues or even customers are other sources of discrimination at work. For example, “I’ve been accused of being homosexual and selling sex services, or some customers didn’t read my profile. When they saw me as a ladyboy, they rebuked me with harsh words.” (a TGW sex worker aged 27 years old).In addition, sex workers are at risk of physical abuse and degradation. For instance, “Customers have sometimes argued and threatened bodily harm, and have not paid or paid only half the fee when they found out I wasn’t a woman.” (a TGW sex worker aged 28 years old), and “Some customers paid me less or had sex as a prank because they saw me as a transgender woman, which I can’t accept.” (a TGW sex worker aged 26 years old).Sexist bullying words or mimicry can make someone feel despondent, especially when directed at particular minority groups. For instance, “I am often referred to as a homosexual. “ (a TGW sex worker aged 21 years old); “I’m often subjected to sexism, especially in Tai Yai society.” (a TGW from an ethnic minority aged 35 years old). Some of the participants have been humiliated by people they did not know. For example, “People looked at my dress and laughed and pointed at me. He called his friends to look at me and said loudly, “Is this a ladyboy or …?”.” (a TGW from an ethnic minority aged 29 years old).Even though perpetrators think of it as a prank, it is actually a type of sexual harassment. For instance, “I was touched on my butt, chest, or genitals.” (a TGW from an ethnic minority aged 30 years old). During the Songkran festival, this group is often subjected to physical violence. For example, “I went to a Songkran festival with my friends when I was a teenager. People threw shoes and water bowls, and even placed a bucket of water on my head.” (a TGW sex worker aged 28 years old).Being rejected by family and local people is another form of discrimination experienced in daily life. Some forms are related to religion and/or traditional beliefs. For instance, “People in the community say, “Why not be a man?”, “Why do you want to be a woman?”, or “It’s a sin”. It’s a sin that will fall on us and we will need to make merit to atone for it. They frequently comment about it even though the truth is not related.” (a TGW sex worker aged 27 years old), and “People in the community say they don’t like me and don’t want anything to do with me. They spoke specific words concerning hermaphrodites.” (a TGW from an ethnic minority aged 36 years old).In addition, people with conflicting identities have restricted access, such as when they want to use public restrooms. This group of people often encounter problems in their daily lives, such as “When I need to go to the public restroom, I am always confused about whether I should go to the men’s or women’s. If I go to the women’s bathroom, the women will be angry and resentful. If I go to the men’s bathroom, men look at me.” (a TGW from an ethnic minority aged 52 years old); “Including rights that I should have access to but are restricted due to them only being available for Thai nationals and people with characteristics that match their birth gender only. This causes obstacles and restrictions for people with intersectional identities. For traveling outside the area or across the province, we need to apply for a permit for leaving the area at the district level, which causes inconvenience and hassle.” (a TGW from an ethnic minority aged 36 years old). Other examples are as follows: “My friend and I encountered difficulties with our name title prefix when traveling abroad. The interviewer asked us more questions than the others and often asked us if we are going to sell sex services?” (a TGW sex worker aged 26 years old). In addition, there are restrictions on marriage registration in Thailand that can make life as a couple difficult. For example, “My partner with whom I live in Thailand has questions about various lifestyles. There is no law to certify same-sex marriage, which makes living together here quite difficult. In his country, there is a law that allows same-sex marriage.” (a TGW sex worker aged 26 years old).TGWs are often discriminated against at healthcare facilities because their name and title prefix do not match how they dress. For example, “I went to the hospital and was called Mr.... and I had to walk past other people who looked at me and laughed, embarrassing me like I was a clown, and so I didn’t want to receive healthcare services.” (a TGW from an ethnic minority aged 40 years old). Discrimination against TGW sex workers with intersectional identities, especially those working in brothels, is prevalent. They are asked to undergo additional health checks that are not related to their symptoms. When seeking treatment for a panic disorder, one participant was asked to consent to a blood test to check for thyroid functionality and questioned about taking hormones despite seeking treatment for an unrelated condition: “I went for treatment for a panic disorder. The additional blood test or unrelated health checks are just because I’m a transgender woman. This made my treatment cost much higher than for others.” (a TGW sex worker aged 26 years old).Another important issue concerning discrimination at healthcare facilities is restricting the right to medical treatment. For instance, “I went to the hospital for treatment. I don’t have the right to medical care or personal health insurance, and so I had to pay all my expenses because I’m from an ethnic minority.” (a TGW from an ethnic minority aged 35 years old). When they want to help others by donating blood, their offer to help others is usually refused because they are LGBTQ. For example, “When I donated my blood, the staff saw me as a third-gender person and didn’t accept my blood even though I have no comorbid diseases.” (a TGW sex worker aged 30 years old).Most TGW participants  have experienced discrimination related to refusing them employment at certain workplaces, followed by being rejected by their family and local people in their daily lives  and verbal bullying in their daily lives . Compared to the other intersectional identity groups, TGWs from ethnic minorities have experienced fewer forms of discrimination (1–5), whereas TGW sex workers have experienced more (3–7). Moreover, the number of discrimination forms is not related to the number of intersectional identities .The findings from our study through in-depth interviews with 19 people revealed discrimination experienced by the intersectional identities group at school, at work, in daily life, and/or at a healthcare facility. The major discriminatory actions toward transgender people at school were insulting speech and/or even physical abuse. As well as being subjected to these, the intersectional identity groups had been insulted for belonging to an ethnic group, which had an impact on both positive and undesirable outcomes. The positive impact was that it encouraged them to study harder, whereas the negative impact forced them out of the school system. Likewise, in previous studies, these individuals are less likely than others to have a bachelor’s degree ,40,41,42We found no evidence to support that a higher number of intersectional identities affects the higher forms of discrimination against TGWs with intersectional identities. However, those in some categories of intersectional identity (such as TGW sex workers) experienced more forms of discrimination than others. Whether they belong or do not belong to an ethnic minority, most of them  reported that they had experienced discrimination when seeking employment. This might be one of the reasons that made them decide to become sex workers, even though they faced a higher risk of discrimination in their work and daily lives. This is consistent with the findings from a previous report in that the high amount of compensation and acceptance of their gender identity has enticed some TGWs in Thailand to enter the sex industry .When considering employment discrimination, TGWs not only have limited access to employment but also experience conflict with colleagues and supervisors. Some employers require employees to dress according to their birth-assigned gender and also interfere with their chances of promotion . For thoAs an example of discrimination against individuals with an intersectional identity according to race, a research group from the US reported that 11.3% of LGBTQI employees of color experienced unfair treatment at work compared to 6.5% of white LGBTQI employees . Anti-diBecause they have been rejected by society and unappreciated by their families and communities, they often relocate from home to try and avoid discrimination. In addition, the main religion in Thailand is Buddhism, and most Buddhists believe that sin or karma is to blame for a person’s desire to have a different gender assignment from that given at birth . This miOur findings suggest that intersectional people experience worse healthcare outcomes, which is supported by previous study outcomes. For instance, LGBTQ people in the UK have less favorable healthcare experiences than cisgender people . One of As can be seen from our study outcomes, intersectional identity groups are stigmatized and discriminated against in every aspect of their lives with harsh words or sexual violence, at school or work, in everyday life or in healthcare settings. Even though school is supposed to be a safe and equitable environment free of discrimination for all students, it fosters violence and stigma against TGWs or minority students. Furthermore, some teachers aggravate rather than help the situation, causing some of them to drop out. The compulsory education level in Thailand is grade 9 in high school. Meanwhile, the job market is extremely competitive, and a good career is impossible to achieve without adequate education. Thai society only accepts transgender people conditionally, provided that they are beautiful, wealthy, and successful. At the other end of the spectrum, job security is extremely limited for anyone who engages in sex work. Their daily lives are difficult, and a lack of basic rights and sufficient healthcare prevents them from living normal lives. Moreover, a sex worker having an intersectional identity makes the situation even worse .Although this is a small sample size interview with intersectional identities, the results of these in-depth interviews are extremely valuable since the participants with intersectional identities cannot be easily contacted. The study’s strength is that there has not been as much research published on intersectional identities as there is on transgender groups.Although transgender identity is socially acceptable in Thailand to a certain degree, stigma and discrimination are still important issues, especially for transgender women with an intersectional identity. The outcomes of this qualitative in-depth interview study reflect the problems associated with multiple sources of discrimination aimed at transgender women with an intersectional identity in Thailand, including harsh speech or physical abuse; occupational, social, and legal inequality; and healthcare provision disparities. Raising awareness about gender diversity and intersectionality, as well as enforcing anti-bullying legislation and anti-discrimination laws, should be continually pursued in order to protect the rights and improve the quality of life of transgender individuals with an intersectional identity. In addition, enabling the rights of transgender people by allowing changes in gender assignment and same-sex marriages, as well as providing better welfare, will reduce the inequality between the cisgender and transgender populations.