Table 3.

Thematic extraction of findings, based on the socio-ecological model. (specific to people who identify as trans and non-binary in italics)

Main themes	Sub themes: Barriers	Sub themes: Enablers
Intra-personal Intersecting disadvantage of marginalised groups Knowledge and awareness, and behaviourPsychological factor Competing priorities	Age. Sexuality. Physical appearance. Gender. Gender identity. Immigration status. Language. Cultural group. Racial and ethnic groups. Linguistic ability. Colonial legacy. Level of education. Income. Level of deprivation of area of residence. Area of residence (rurality). Unstable housing. Living with HIV. Sex work. Selling drugs. Previous incarceration. Accuracy, depth and breadth. Use inadequate indicators to assess STI status of partners, for example, demeanour, appearance. Difficulty in differentiating between credible and non-credible information. Internet deemed a confusing medium. Brochures and videos not specific enough and fail to address intensity of symptoms. Repetition of learned unhelpful behaviour, for example, only using condoms if worried about pregnancy. Learned fear: older women have seen women who left the community to get help not returning. Lack of familiarity with condoms. Lack of access to advice for younger women-older relatives are dead/cannot remember/will not talk about menopause. Depression. Loneliness. Poor self-esteem. Self-silencing. Low levels of sexual assertiveness. Felt defensive. Fear. Worry. Embarrassment. Less self-efficacy meant less likely to seek help from HCPs. Prioritising of intimacy over risk. Feelings of intimacy falsely associated with feelings of safety from STIs. Vulnerability of relationship transitions. New lack of desire felt as a relief. Sense of freedom linked with feeling young, resulting in more risk taking. Impact of traumaPhysical changes. Comorbidities (impact of physical and mental health and perceived health status). Stage of the menopause. Fear of side-effects and contra-indications to treatments. Concerned about effect of condoms on erectile dysfunction. Prioritised gender-affirming therapy. Lack of time. Care-giving responsibilities.	Age. Level of education. More likely to use condoms compared to when younger. Multi-format educational material, for example, consumer decision aids, seminars, pamphlets, documentaries, storytelling programmes, adverts, newspapers/magazines, comprehensive website. In-person options. Support groups. Need for specific information about sexual health during menopause. Peer out-reach. Making accessing services a habitual behaviour, for example, regular smear tests. Mobile health, for example, with podcasts, videos, virtual reality, mindfulness, expert blogs (anonymous, quick to access, evidence-based). No longer felt like sexual objects. Renewed sense of autonomy. Growth In sexual expression and awareness of own needs. Renewed interest in sex. New lack of desire sometimes felt as a loss (prompting help-seeking). Impact of trauma (prompting help-seeking). Stage of the menopause (severity of symptoms may prompt utilisation of other SHSW services).
Intra-personal Interactions with providers Women’s perceptions of HCPs HCP Knowledge and Beliefs Representation in healthcare	Made to feel dismissed. Ageist. Sexist. Heterosexist. Transphobic. Racist. Embarrassed. HCPs influenced by social taboos. More training required. HCPs reticent to initiate conversations. Uncertainty as to which HCPs could best answer their questions. Descriptions of physicians who make unilateral decisions. Need for better training. Prioritise general over sexual health. Do not ask about sexual well-being even if patients have conditions affecting sex life. Question whether menopause an issue for immigrant women. HCPs prefer women to enter consultations clear and informed about what they want. Women’s Initiative study.	Knowledgeable, approachable physicians. Supportive and trustworthy. Caring relationships. Holistic care. Personalised. Preventive care. Multi-skilled HCPs. HCPs who broach sexual health topics. HCPs normalise age-related changes. Honest and direct communication. Non-judgemental and do not make assumptions. Appetite for better training. Women should oversee decisions. Women who consulted HCPs found them useful. Decision aids could enable discussions More women. Better cultural and minority group representation.
Organisation factors Perception of HC systems Format of HC systems	Institutional distrust. Sceptical of system’s ability to meet needs.	Integrated educational and emotional support. Interdisciplinary clinics. Organisations incorporating many different services: One-stop, Gender-affirming. STI services incorporated into other healthcare service. Self-testing. Self-service. Women-only clinics. Multiple options of healthcare education. Culturally competent systems. Anonymous locations. Policy change to allow HCPs other than physicians to prescribe HRT. Trans-positive hospital policies.
Community factors Cultural factors Social connection Intergenerational factors	Stigma. Social norms (age and sex), for example age-gender barriers to accessing condoms in shops/pharmacies. Women view help-seeking appropriate only up to a certain age. Normalisation of condomless sex. ‘Othering’ those at risk of STIs. Paying for sex. Older people should ‘know better’-ashamed to seek help. Normalisation of violence. Mainly women’s responsibilities. Women socialised to minimise discomforts. ‘Couple culture’ – pressure to re-couple. Workplace expectations, minimisation by employees and colleagues. Reluctance to talk about sex with partner prevents help-seeking. Lack of understanding from partner. Sex less pleasurable due to partner or relationship characteristics, for example, partner’s inability to perform, unhappiness in relationship. Lack of recognition and awareness at work about menopause. Without awareness, women felt uncertain of the validity of their own experiences, often questioning themselves and their concerns. Distancing from young people’s risky behaviour yet pressure to adjust to new sexual culture fast. Ageist assumptions from younger men, for example, expectation that midlife women are lower risk so can have condomless sex. Fast progression to sex in new relationships. Condoms associated with youth. Mothers not discussing details of menopause with daughters.	Social norms: sex as a work-out, sex as beneficial to women’s health. Reconnecting with world. Educating others in community. Interdependence between their sexual experiences and important people in life. More likely to seek help if partnered. Gender-age dynamics on sexual risk negotiation: influence of young relatives on understanding of sexual safety. Fighting against stereotypes of older women not being sexually active.
Public policy Public health messages Material barriers/enablers	Disconnection from safe sex messaging. Sensationalised media coverage. Excluded by adverts. Cost of services. Transport options. Shortage of appropriate HCPs. Shortage of HCP time. Poor treatment options/lack of research.	Greater public discussion about sexuality and more positive mid-life representation. PrEP should be advertised all over the city, on the buses, metro stations (subways), on doors everywhere, in doctors’ offices, social media-everywhere possible, with phone numbers to contact, particularly on streets and public places because ‘I learn my information from the street’. Create identifying profile markers to improve focus of strategies. Focus on predictors of risk behaviour rather than predictors of risk status. Country-specific approach required. Facilities closer to home. Insurance coverage. Expertise and skills and range of tests available outside sexual health services. Recall-based screening systems. Incentives (financial) to meet basic needs. Mobile technology, for example, Apps.

The barriers and enablers to accessing sexual health and well-being services for midlife women (aged 40–65 years) in high-income countries: A mixed-methods systematic review. HC, healthcare; HCP, healthcare professionals; PrEP, pre-exposure prophylaxis; SHSW, sexual health and sexual well-being; STI, sexually transmitted infection.