. 2025 Mar 17;78(Suppl 2):e20240266. doi: 10.1590/0034-7167-2024-0266

Chart 2. Strategies to facilitate access and welcoming by transgender children and adolescents to the Healthcare Network, São Paulo, São Paulo, Brazil, 2023.

BARRIERS	STRATEGIES
• Professional presumption of transgender children’s and adolescents’ sexuality, with reductionist treatments^(20,24,25); • Absence of identification of gender identity with social name and/or pronouns, such as in medical records, identification bracelets and medication administration documentation^(20,25); • Unconscious or conscious use of children’s and adolescents’ registered name, often repetitively, even after corrections by patients and/or their family ^(22,25); • Professionals are afraid of asking patients about their social name and/or pronouns and making a mistake that could cause offense⁽²⁴⁾; • Professionals use outdated and offensive language⁽¹⁸⁾; • Lack of a sense of a welcoming space for gender-related health demands, with fear that therapeutic communications would not be confidential⁽²³⁾; • Low professional knowledge, which results in unresponsive care, marked by stigmas and prejudices, with beliefs, personal values and common sense perceptions in the care of both children and adolescents and their families^(8,23,24,25); • Hostile interactions between professionals, with minimization of gender identity and association of transsexuality with a transitory stage of human development and/or a pathological view of childhood^{(22,24,25,26)}; • Absence of professionals in the multidisciplinary team who could provide welcoming care, such as mental healthcare professionals and social workers⁽²⁶⁾; • Absence of institutional protocols for welcoming and care of transsexual children and adolescents, with dependence on professional knowledge and judgment for quality care⁽²²⁾; • Reduction in health complaints among children and adolescents, which led them to seek healthcare services for transsexuality, with a lack of interest in the demand for care and gender overvaluation^(22,26); • Difficulty in accessing the RAS, due to the lack of specialized services in the region of residence or due to distance, or the perception that the RAS is not available to meet their demands⁽²³⁾; • Lack of interconnection between the RAS, especially specialized and non-specialized centers for the care of transgender children and adolescents, with pilgrimages in search of shelter, especially in cases where care is related to transsexuality^(21,22); • Limited health insurance coverage for healthcare related to transsexuality, with the absence of a service that provides care free of charge^(22,23); • Unwelcoming healthcare service environment, with structural homophobia^(20,26).	• Ask children and adolescents, from the moment they are admitted to the healthcare service, about their gender and the pronouns to be used, in a simple and respectful manner, such as: what are your pronouns? How would you like to be called? The answer should be identified in the medical record, provided that patients and family allow it so that it can be disseminated in the approaches by all professionals in care^(8,20,21,22); • In the event of unconscious use of the incorrect name and/or pronoun, it is recommended that professionals not be shy about apologizing to children and adolescents, and call them as they request⁽²⁵⁾; • Offer a space to speak to transgender children and adolescents, in a respectful manner, with active listening, without judgments and reprisals, acting with empathy, by all professionals who provide assistance, throughout the RAS^(25,26); • Training on transsexuality and care for the LGBTQIA+ population from professional graduation onwards^(21,24); • Continuing education, with constant training and updates, for all those who communicate with transgender children and adolescents in the RAS. If possible, it is recommended that training be carried out by a transgender person^{(8,20,21,24,25)}; • Efforts by healthcare professionals to respect children, adolescents and their families, regardless of gender identity⁽²⁵⁾; • Development of clear, evidence-based protocols, with an age-appropriate care plan, focusing on children, adolescents and their families⁽²²⁾; • Focus on health complaints brought by children, adolescents and families instead of gender issues, which should be addressed as a way of providing responsive and respectful care, and focused on when the complaint brought is relevant^(8,26); • Telecare as a strategy for welcoming transgender children and adolescents with health demands, regardless of where they live, without the need for transportation⁽²³⁾; • Encouraging a respectful and inclusive environment. Environmental adaptations, with posters indicating that children and adolescents are welcome in healthcare services (“This is a neutral place” or “This is a safe place”; use of LGBTQIA+ flag), using pendants on professionals’ clothing that refer to the population. In the long term, construction of neutral bathrooms and beds^(8,22,25).

BARRIERS

STRATEGIES

• Professional presumption of transgender children’s and adolescents’ sexuality, with reductionist treatments^(20,24,25);

• Absence of identification of gender identity with social name and/or pronouns, such as in medical records, identification bracelets and medication administration documentation^(20,25);

• Unconscious or conscious use of children’s and adolescents’ registered name, often repetitively, even after corrections by patients and/or their family ^(22,25);

• Professionals are afraid of asking patients about their social name and/or pronouns and making a mistake that could cause offense⁽²⁴⁾;

• Professionals use outdated and offensive language⁽¹⁸⁾;

• Lack of a sense of a welcoming space for gender-related health demands, with fear that therapeutic communications would not be confidential⁽²³⁾;

• Low professional knowledge, which results in unresponsive care, marked by stigmas and prejudices, with beliefs, personal values and common sense perceptions in the care of both children and adolescents and their families^(8,23,24,25);

• Hostile interactions between professionals, with minimization of gender identity and association of transsexuality with a transitory stage of human development and/or a pathological view of childhood^{(22,24,25,26)};

• Absence of professionals in the multidisciplinary team who could provide welcoming care, such as mental healthcare professionals and social workers⁽²⁶⁾;

• Absence of institutional protocols for welcoming and care of transsexual children and adolescents, with dependence on professional knowledge and judgment for quality care⁽²²⁾;

• Reduction in health complaints among children and adolescents, which led them to seek healthcare services for transsexuality, with a lack of interest in the demand for care and gender overvaluation^(22,26);

• Difficulty in accessing the RAS, due to the lack of specialized services in the region of residence or due to distance, or the perception that the RAS is not available to meet their demands⁽²³⁾;

• Lack of interconnection between the RAS, especially specialized and non-specialized centers for the care of transgender children and adolescents, with pilgrimages in search of shelter, especially in cases where care is related to transsexuality^(21,22);

• Limited health insurance coverage for healthcare related to transsexuality, with the absence of a service that provides care free of charge^(22,23);

• Unwelcoming healthcare service environment, with structural homophobia^(20,26).

• Ask children and adolescents, from the moment they are admitted to the healthcare service, about their gender and the pronouns to be used, in a simple and respectful manner, such as: what are your pronouns? How would you like to be called? The answer should be identified in the medical record, provided that patients and family allow it so that it can be disseminated in the approaches by all professionals in care^(8,20,21,22);

• In the event of unconscious use of the incorrect name and/or pronoun, it is recommended that professionals not be shy about apologizing to children and adolescents, and call them as they request⁽²⁵⁾;

• Offer a space to speak to transgender children and adolescents, in a respectful manner, with active listening, without judgments and reprisals, acting with empathy, by all professionals who provide assistance, throughout the RAS^(25,26);

• Training on transsexuality and care for the LGBTQIA+ population from professional graduation onwards^(21,24);

• Continuing education, with constant training and updates, for all those who communicate with transgender children and adolescents in the RAS. If possible, it is recommended that training be carried out by a transgender person^{(8,20,21,24,25)};

• Efforts by healthcare professionals to respect children, adolescents and their families, regardless of gender identity⁽²⁵⁾;

• Development of clear, evidence-based protocols, with an age-appropriate care plan, focusing on children, adolescents and their families⁽²²⁾;

• Focus on health complaints brought by children, adolescents and families instead of gender issues, which should be addressed as a way of providing responsive and respectful care, and focused on when the complaint brought is relevant^(8,26);

• Telecare as a strategy for welcoming transgender children and adolescents with health demands, regardless of where they live, without the need for transportation⁽²³⁾;

• Encouraging a respectful and inclusive environment. Environmental adaptations, with posters indicating that children and adolescents are welcome in healthcare services (“This is a neutral place” or “This is a safe place”; use of LGBTQIA+ flag), using pendants on professionals’ clothing that refer to the population. In the long term, construction of neutral bathrooms and beds^(8,22,25).