Lexicographic qualitative approach of nurse’s perspectives on men’s access to sexual health care in Portugal – Nature

Report on Men’s Access to Sexual Healthcare in Portugal: A Nursing Perspective

Executive Summary

This report analyses the perspectives of nurses in Portugal regarding men’s access to sexual and reproductive healthcare, a critical component of achieving Sustainable Development Goal 3 (Good Health and Well-being). A qualitative study involving focus group interviews with 15 nurses revealed significant challenges, including the political and clinical invisibility of men as recipients of sexual healthcare. Key findings indicate that care is often sought only for acute problems, healthcare settings are not inclusive, and professional training is inadequate. These barriers are reinforced by societal stereotypes of masculinity, undermining progress towards SDG 5 (Gender Equality) by perpetuating gender-based health disparities. The report concludes that advancing men’s sexual health requires a comprehensive approach, including enhanced nursing education, inclusive clinical practices, and supportive policy frameworks to ensure equitable and effective healthcare for all.

Introduction: Contextualizing Men’s Sexual Health within the Sustainable Development Goals

The Challenge to SDG 3 (Good Health and Well-being)

In Portugal, men’s sexual health needs are frequently neglected within the National Health Service, a reality that directly challenges the universal health principles of SDG 3. The World Health Organisation (WHO) defines sexual health as a state of complete physical, emotional, mental, and social well-being, not merely the absence of disease. However, the Portuguese healthcare system has historically focused on sexually transmitted infections and women’s reproductive health, rendering men largely invisible in policy, training, and clinical practice. This oversight contributes to disparities in health outcomes and longevity, where men’s life expectancy is significantly lower than women’s. Achieving Target 3.7, which calls for universal access to sexual and reproductive healthcare services, necessitates addressing the specific vulnerabilities and barriers men face.

The Gender Equality Dimension (SDG 5) and Reduced Inequalities (SDG 10)

The exclusion of men from sexual healthcare is a critical issue of gender inequality, impacting the core objectives of SDG 5. Prevailing social constructions of masculinity often discourage men from seeking help, framing illness as a sign of weakness. Healthcare services, frequently designed for and populated by women, can further alienate male patients. This systemic bias not only affects men but also hinders broader public health goals, as men’s health is integral to family and community well-being. Furthermore, this issue intersects with SDG 10 (Reduced Inequalities), as diverse groups of men, including homosexual, transgender, and older men, face compounded barriers due to intersecting vulnerabilities and a lack of culturally competent care.

Study Methodology

Research Design

A qualitative descriptive study was conducted to analyze nurses’ perspectives on men’s access to sexual healthcare in Portugal. The study utilized online Focus Group (FG) interviews to capture the diverse experiences and interactions among participants.

Participant Profile

The study involved 15 nurses from Lisbon and Coimbra, selected via a snowball sampling method to ensure diversity in gender, professional context, and experience.

• 60% of participants were women (n=9) and 40% were men (n=6).
• The average age was 48.8 years.
• The average length of professional practice was 23.5 years.
• Participants included both generalist and specialist nurses from primary and secondary healthcare settings.

Data Analysis

The transcripts from two FG interviews were compiled into a text corpus and analyzed using lexicographic analysis software (IRaMuTeQ). Descending Hierarchical Classification (DHC) and similarity analysis were employed to identify key themes and relationships within the nurses’ discourse.

Key Findings from the Lexicographic Analysis

Overview of Emergent Themes

The analysis of 487 text segments resulted in the classification of five distinct themes, which outline the primary challenges and dynamics in men’s sexual healthcare from the nursing perspective.

1. Approach Triggers Between Nurses and Men: This theme explores the circumstances that initiate healthcare interactions. Findings show that men predominantly seek care for acute health problems rather than for preventive purposes, which limits opportunities for proactive health promotion aligned with SDG 3.
2. Therapeutic Itineraries Singularities: This class details the pathways men follow when seeking care. Urologists are often the preferred first point of contact, bypassing primary care nurses and physicians. This reflects a curative rather than holistic approach to health.
3. Sexual Health as a Subject: This theme highlights the difficulties in discussing sexual health. The topic remains taboo for both patients and many healthcare professionals, with nurses’ confidence in addressing it often linked to personal investment and experience rather than formal training, a gap relevant to SDG 4 (Quality Education).
4. Issues Surrounding Men’s Sexual Health: This class covers the specific health issues that bring men into contact with the healthcare system, such as HIV, reproductive concerns within a couple, and palliative care needs. The approach is often reactive and fails to address sexuality comprehensively across the lifespan.
5. Settings for Addressing Men’s Sexual Health: This theme examines the physical and institutional environments for care. Current settings, such as “women’s health” clinics, are often exclusionary. Schools were identified as a crucial setting for foundational sexual health education, supporting the aims of SDG 4.

Discussion: Implications for Sustainable Development

Overcoming Barriers to Achieve SDG 3 and SDG 5

The findings illustrate how deeply ingrained gender norms and institutional biases create significant barriers to achieving both good health (SDG 3) and gender equality (SDG 5). Services characterized as heteronormative and “tailored for women” exclude men, while a lack of professional training leaves nurses ill-equipped to provide competent care. To advance these goals, healthcare systems must deconstruct simplistic notions of masculinity and redesign services to be inclusive and responsive to men’s diverse needs.

The Role of Institutions and Policy (SDG 16)

The study highlights systemic weaknesses in Portuguese health policy, which contributes to men’s invisibility in sexual healthcare. This points to a need for stronger, more accountable, and inclusive institutions, as called for by SDG 16. Effective policy must move beyond a narrow reproductive focus to embrace a comprehensive definition of sexual health that includes men as active participants and beneficiaries. This requires clear political guidelines and institutional investment in training and program development.

Reducing Health Inequalities (SDG 10)

To ensure no one is left behind, it is essential to adopt an intersectional approach that recognizes the unique barriers faced by different groups of men. The fear of confidentiality breaches among homosexual couples, the asexualization of older men, and cultural barriers for diverse populations all represent inequalities in access and outcome. Fulfilling the mandate of SDG 10 requires targeted strategies that address these specific needs and promote health equity for all.

Conclusions and Recommendations for Policy and Practice

Summary of Conclusions

Nurses in Portugal recognize the importance of sexuality to men’s health but face significant challenges in providing proactive and holistic care. Interventions are largely reactive, and systemic barriers—rooted in social stereotypes, inadequate training, and exclusionary healthcare settings—persist. Addressing these issues is fundamental to making meaningful progress on the Sustainable Development Goals, particularly those related to health, gender equality, and reduced inequalities.

Recommendations Aligned with the SDGs

Based on the findings, the following actions are recommended to create a more equitable and effective healthcare system:

1. Enhance Professional Education (SDG 4): Integrate comprehensive content on men’s sexual health, cultural competence, and gender diversity into undergraduate and postgraduate nursing curricula to equip professionals with the necessary competencies.
2. Develop Inclusive Clinical Programs (SDG 3): Invest in targeted male sexual health programs that are integrated into broader health surveillance initiatives across the lifespan. These programs should promote sexual health literacy and proactive care.
3. Strengthen Policy and Governance (SDG 16): Formulate clear national and international guidelines to support healthcare professionals and decision-makers in implementing best practices. Policies should explicitly recognize men as subjects of sexual and reproductive healthcare.
4. Promote Inclusive and Safe Environments (SDG 5 & 10): Redesign healthcare spaces to be private, safe, and welcoming to all men. Facilitate community dialogues and provide accessible resources to promote positive sexuality and dismantle harmful stereotypes.

Analysis of Sustainable Development Goals in the Article

1. Which SDGs are addressed or connected to the issues highlighted in the article?

The article on men’s sexual healthcare access in Portugal connects to several Sustainable Development Goals (SDGs) by highlighting systemic issues in health, education, and gender equality. The primary SDGs addressed are:

• SDG 3: Good Health and Well-being: This is the most central SDG, as the article’s entire focus is on sexual and reproductive health, a key component of overall health. It discusses barriers to healthcare access, the quality of care, and health outcomes for men.
• SDG 5: Gender Equality: The article explicitly frames the lack of men’s sexual healthcare as a gender issue. It points out that sexual health services are traditionally “tailored for women,” rendering men politically and clinically “invisible.” It also discusses how social norms and stereotypes about masculinity create barriers to care, which is a core concern of gender equality.
• SDG 4: Quality Education: The need for better education and training for healthcare professionals is a recurring theme. The article states that “in Portuguese nurses’ education… sexual health, and specifically men’s sexual health, is not deepened” and recommends that “nursing education curricula should include dedicated content on men’s sexual health.” This directly links the problem to the quality of professional education.
• SDG 10: Reduced Inequalities: The article addresses health inequalities based on gender. The fact that men have lower life expectancy and face specific barriers to accessing a universal healthcare system points to an inequality of outcome and opportunity. It also touches upon intersecting vulnerabilities, noting that “homosexual couples rarely use public services” due to fears about confidentiality, highlighting inequalities within the male population.
• SDG 16: Peace, Justice and Strong Institutions: The article calls for policy-level changes and stronger institutional frameworks. It mentions the need for “political guidelines” and the development of “national and international programs” to support healthcare professionals. This relates to building effective, accountable, and inclusive institutions that can deliver equitable healthcare.

2. What specific targets under those SDGs can be identified based on the article’s content?

Based on the issues discussed, several specific SDG targets can be identified:

1. SDG 3: Good Health and Well-being

   • Target 3.7: “By 2030, ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes.” The article’s core argument is that men in Portugal lack this universal access, as services are primarily focused on women’s reproductive health and STI prevention, neglecting a holistic approach to men’s sexual well-being.
   • Target 3.8: “Achieve universal health coverage… access to quality essential health-care services…” Although Portugal has a universal system, the article demonstrates that coverage is not effectively universal for men in this specific area. Nurses’ perspectives reveal that men are not seen as “legitimate recipients of such care,” indicating a gap in quality and accessibility.
   • Target 3.3: “By 2030, end the epidemics of AIDS… and other communicable diseases.” The article mentions that in Portugal, sexual health has been reduced to “sexually transmitted infections prevention and diagnosis” and that there has been a “significant increase in STIs” among men, linking the issue directly to communicable disease control.

2. SDG 5: Gender Equality

   • Target 5.6: “Ensure universal access to sexual and reproductive health and reproductive rights…” This target is reinforced from a gender equality perspective. The article highlights that men’s “political invisibility in this area” and the framing of sexual health as a “women’s issue” prevent men from fully exercising their right to sexual health.

3. SDG 4: Quality Education

   • Target 4.7: “By 2030, ensure that all learners acquire the knowledge and skills needed to promote sustainable development, including… gender equality…” The article’s conclusion strongly advocates for including “dedicated content on men’s sexual health” in nursing curricula to equip them with the necessary competencies. This lack of training is identified as a key barrier, as nurses “feel uncomfortable talking to patients about it and therefore avoid it.”

4. SDG 10: Reduced Inequalities

   • Target 10.2: “By 2030, empower and promote the social, economic and political inclusion of all, irrespective of… sex…” The article directly addresses the exclusion of men from sexual healthcare policies and services, calling for a “comprehensive and inclusive approach” to overcome their “political invisibility.”
   • Target 10.3: “Ensure equal opportunity and reduce inequalities of outcome…” The article points to a significant inequality of outcome, noting that in Portugal, “life expectancy for men is 6.1 years less than for women.” It suggests that unequal access to healthcare contributes to this gap.

5. SDG 16: Peace, Justice and Strong Institutions

   • Target 16.7: “Ensure responsive, inclusive, participatory and representative decision-making at all levels.” The call for “political guidelines” and “national and international programs” reflects a need for more inclusive institutional decision-making that recognizes and incorporates the health needs of men.

3. Are there any indicators mentioned or implied in the article that can be used to measure progress towards the identified targets?

The article mentions or implies several qualitative and quantitative indicators that could measure progress:

1. Indicators for SDG 3 (Good Health and Well-being)

   • Life expectancy gap between men and women: The article explicitly states this gap is “6.1 years” in Portugal. A reduction in this gap would indicate improved health outcomes for men.
   • Rate of men’s access to sexual health services: The article implies this is low, stating men’s access is triggered by “acute health conditions” rather than prevention. An increase in routine or preventative visits would be a positive indicator.
   • Incidence of STIs in men: The article notes a “significant increase in STIs” among men. Tracking these rates would be a direct measure of sexual health outcomes.

2. Indicators for SDG 5 (Gender Equality)

   • Qualitative assessment of gender stereotypes in healthcare: The study itself serves as a baseline, identifying nurses’ perceptions and the impact of “hegemonic masculinity” as barriers. Follow-up studies could measure changes in these perceptions.
   • Inclusion of men in sexual and reproductive health policies: The article notes that policies focus on “women’s reproductive health.” An indicator would be the number and scope of national health policies that explicitly address men’s sexual health.

3. Indicators for SDG 4 (Quality Education)

   • Proportion of nursing curricula including men’s sexual health: The article states this content is currently lacking. An indicator would be the percentage of undergraduate and postgraduate nursing programs that have integrated this topic.
   • Nurses’ self-reported confidence: The study notes that nurses “feel uncomfortable” and lack confidence. Surveys measuring nurses’ confidence and competence in addressing men’s sexual health could track improvements resulting from better training.

4. Indicators for SDG 10 (Reduced Inequalities)

   • Healthcare utilization rates by different male populations: The article implies lower access for homosexual men. An indicator would be disaggregated data on healthcare access by sexual orientation to ensure equitable service delivery.

5. Indicators for SDG 16 (Strong Institutions)

   • Existence of national guidelines on men’s sexual health: The article calls for the “development of national and international programs and guidelines.” The creation and implementation of such documents would be a clear indicator of institutional progress.

4. Summary Table of SDGs, Targets, and Indicators

Source: nature.com