Review Reports

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This topic is timely and necessary. The introduction needs to be tightened to enhance logical flow between and within paragraphs. The methods need to be more transparent e.g. a comprehensive inclusion and inclusion criteria needs to be given. What informed the choice for 11 participants? The findings need to be re-written altogether to enhance readability. The themes need to be better presented, including their naming. Separate the findings from the discussion. This is sometimes a style choice, but in its current state, it is not easy to read. This being a qualitative study, please 'tell us the story'. Make it easy for the reader to follow the story. The conclusion is too long, and some parts read like the discussion. The novelty of the study needs to be clearer, beyond additive value.  Please find this and other specific comments/suggestions in the attachment. 

Comments for author File: Comments.pdf

Comments on the Quality of English Language

An English language edit by a professional, native speaker is strongly advised.

Author Response

Please see the attachment. 

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

This is a well-written manuscript exploring, through a qualitative approach grounded in reflexive thematic analysis, how healthcare professionals from Portugal relate to the sexuality and gender identity of people with disabilities belonging to the LGBT community. The manuscript has a solid theoretical framework, uses a sound methodology, and the findings are presented and discussed properly. Consequently, I believe this piece is suitable for publication in Healthcare, pending the revisions suggested below:

 

1. Title: Please use capital P in Portuguese.

2. Grammar: Please use “it is” instead of “it’s”. Also, use consistently cis-heteronormativity (sometimes this is wrote without the hyphen).

3. Methodological section: I suggest including the footnote 7 into the manuscript’s text. Please also specify the months during which the interviews were conducted.

4. Appendix 2: The table detailing the participants’ sociodemografic characteristics could be included into the methodological section, as opposed to being appended at the end of the manuscript.

5. Societal and professional context: The most important issue of this manuscript is that it lacks a proper socio-historical context of Portuguese society and particularly its healthcare system, in relation to the prevailing conceptions regarding people with disabilities, gender, and gender minorities. I suggest authors to include a new section, before Materials and Method, in which to present the broad perspective of how these fundamental aspects are seen in Portugal, in connection to religion (Catholicism) and patriarchal social attitudes. Statistics – taken for instance from European Values Surveys, or from other large scale surveys – could help providing a better contextualized picture of the value landscape in Portugal.

Author Response

Please see the attachment. 

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

This is an interesting paper on professional's understandings of an attitudes towards LGBT identities in people with disabilities/people with functional diversity.

Overall, the paper is thorough and describes the study's findings clearly. There is a clear set of research questions identified and it is made clear how these questions have been answered.

While the methodology is well described, and the results and conclusions well supported, there are some suggestions I would make to strengthen the paper's analysis.

1. The absence of focus on the experiences of PWD - your study was about professionals, so this is not a criticism of something that cannot be changed (indeed it is clear that researching professionals' discourses and practices is well justified). There is a sense throughout the paper that people with disabilities are somewhat ‘controlled’ or ‘influenced’ by professionals. On p. 5 lines 156-162 you suggest that there is a ‘perception that sexual and gender expression and behaviors were controlled by professionals – whether by legislation, institutions’ internal policies, and/or professionals' own beliefs about what is acceptable and allowed or not.’ Professionals are framed as engaging in ‘containment’ of sexual and gender expression – so, their actions and agency are considered, but PWDs’ is absent. I think the lack of exploration of literature early on that centres on PWDs’ experiences means the article as a whole is not as critical of this perceived control as it might be. So, one suggestion I would make is that the literature review in the introduction should include an exploration of PWDs' experiences with LGBT identity, inclusion, and so on (a brief mention is made on p. 3 lines 86-87). If there is little literature here, perhaps you could comment on this. This would help orient your own study as a partial response to that literature and its insights.

2. I thought it was also interesting that the range and spectrum of disabilities the professionals may be tasked with supporting was not explained. I imagine experiences with and attitudes towards LGBT identities may vary significantly across groups. As it is, ‘people with disabilities’ or indeed ‘disabilities’ remain an uncritical monolith in the paper. I wonder if more could be done to complicate this.

3. The analysis and discussion section is shallow in places. It achieves breadth (touching on every theme and subtheme) but not depth, which is really a hallmark of qualitative research. It remains quite descriptive throughout. I wonder if there is wisdom in zeroing in on key themes/subthemes and giving a deeper, more analytical exploration, given how short on space you are.

4. The concept of 'discourse', although it is in the title, seemed to slip away in the body of the paper. In the methodology section could you make clearer what you mean by 'discourse' - or perhaps there is another term you want to foreground?
5. Page 4 line 138 and footnote 8 – interesting that theoretical saturation was reached with so few participants in heterogenous roles – I wonder if there’s more to reflect on here. For example, might data collection have ended here for additional reasons – some might be practical? I am mindful of the danger of proclaiming to have reached theoretical saturation without demonstrating how this has been achieved, and of defining saturation purely as ‘no new information’ emerging – I’ve found Jacqueline Low’s 2019 paper on this useful (‘A Pragmatic Definition of the Concept of Theoretical Saturation’)

As well as these more substantial critiques, there were some much smaller comments I wanted to also bring your attention to:

1. line 35 – ‘LGBT population with disability’ should read ‘with disabilities’
2. Page 4 – Participants – interesting that sexuality was not an identity category listed – any reason for this?
3. Page 5 – Analysis and discussion – line 156 – ‘We emerged’ does not make grammatical sense – Perhaps the themes emerged from the data, or ‘we identified’ themes in the data
4. Page 9 line 346-7 – should that not be ‘Professionals' reluctance to address LGBT issues can perpetuate cis-heteronormativity OR treat service users as sexless’ – as cis-heteronormativity and treating services users are sexless are almost the opposite

Overall, this was a really interesting paper that offers some useful insights. I hope my comments provide some constructive avenues to make it as strong as possible.

Author Response

Please see the attachment. 

Author Response File: Author Response.pdf

Reviewer 4 Report

Comments and Suggestions for Authors

The manuscript addresses the interesting association between LGBT identities and disability. However, the authors need to address the following comments to improve the manuscript.

The main findings of the manuscript are lack of training, cis-heteronormativity, need for inclusive practices, and they are already well documented repeatedly in international literature. Plus the study does not clearly articulate how its findings extend, refine, or challenge existing theories related to disability studies, queer studies, or professional practice. The authors claim novelty based on the Portuguese context. However, I think contextual novelty alone is insufficient for publication in an international journal.

Participants come from heterogeneous professional backgrounds (psychologists, occupational therapists, personal assistants), yet no analytic differentiation between these roles is provided. Plus nearly half of participants report no direct professional experience with LGBT PWD, meaning much of the data reflects hypothetical reasoning rather than lived practice. In addition, the absence of LGBT people with disabilities themselves is a major flaw, given the study’s stated focus on their needs and rights.

The authors used RTA, but absence of clear researchers’ positionality and reflexive engagement, which is a core requirement of RTA, is a concern. And I think insufficient details are provided to understand how themes were generated, refined, and validated.

The analysis introduces a strong organizing concept, “practices of sexual and gender expression containment”, which implies structural, institutionalized mechanisms of control. This claim is far stronger than what the data can support. Much of the evidence reflects uncertainty, lack of confidence, or absence of guidance, which could alternatively be interpreted as organizational ambiguity rather than active containment. Plus the manuscript frequently collapses individual attitudes, institutional gaps, and structural oppression into a single explanatory frame without sufficient analytic differentiation.

In the discussion section, the manuscript often uses citations to compensate for thin data rather than using literature to deepen interpretation. This creates a pattern in which findings appear pre-known and interviews serve primarily as illustrative validation. Plus statements regarding institutional responsibility, rights enforcement, and systemic reform are not directly derived from the data but extrapolated from broader ethical frameworks.

Author Response

Please see the attachment. 

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Please find in the attached document a few points for your consideration. 

Comments for author File: Comments.pdf

Comments on the Quality of English Language

An English language edit by a professional, native speaker is strongly advised.

Author Response

Please see the attachment for the reviewed document with comments.

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

I think the revisions have improved the paper and have addressed my comments. It was a pleasure to read.

Author Response

We appreciate your careful review of our paper and the valuable insights you provided

Reviewer 4 Report

Comments and Suggestions for Authors

The authors have addressed the comments, and the manuscript has been improved sufficiently fot its possible publication. Thanks the authors for their work on this manuscript.

Author Response

We appreciate your careful review of our paper and the valuable insights you provided.