CARE FOR TRANSGENDER AND TRANSVESTITE PEOPLE IN PRIMARY HEALTH CARE: AN INTEGRATIVE REVIEW

Resumo

Objetivo:Relatar os obstáculos de acesso à Atenção Primária à Saúde (APS) por parte da população travesti e transexual (TT) e reconhecer as possíveis condutas dos profissionais de saúde no atendimento a essa população. Método: Trata-se de um estudo de revisão integrativa de literatura com coleta de dados nas plataformas Scielo, BVS e Lilacs. Foram selecionados artigos publicados na íntegra entre os anos de 2019 e 2022. Resultados:Os principais resultados encontrados foram a dificuldade no acolhimento desta população na APS, a rejeição pessoal dos profissionais, o fluxo inadequado da unidade, as barreiras estruturais dos serviços como a dificuldade de criar vínculo.Conclusão:Para que haja um acesso equitativo, livre de preconceitos e de discriminação faz-se necessário implementar na APSmelhoriasnas políticas públicas a fim de qualificar os profissionais no atendimentoàs necessidades e acolhimento da populaçãoTT bem como respeitá-lae protegê-la contra o preconceito.

Descritores: Travestilidade; Pessoas Transgênero; Saúde Pública.

 

Abstract
Objective:To Report Obstacles To Accessing Primary Health Care (PHC) by the transvestite and transsexual (TT) populationandtorecognizethepossibleconductofhealthprofessionals in providingcaretothispopulation. Method: Thisisanintegrativeliterature review study with data collection theScielo, BVS and Lilac platforms. Articles Published in full between 2019 and 2022 were selected. Results: The main result was found with difficulty in welcoming this population in the PHC, the personal rejection of professionals, the inadequate flow of the unit, the structural barriers of services such as the difficulty to create a bond. Conclusion: In order to have equitable access, free of prejudice and discrimination, it is necessary to implement improvements in public policies in PHC in order to qualify professionals in meeting the needs and reception of the TT population, as well as respecting and protecting them against prejudice.

Descriptors:Crossdressing – Transgender People – Public Health

 

Resumen

Objetivo: Reportar los obstáculos para acceder a laAtención Primaria de Salud (APS) por parte de lapoblación travesti y transexual (TT) y reconocerlaposibleconducta de losprofesionales de lasaludenlaatención a esapoblación. Método: Se trata de unestudio integrador de revisión bibliográfica conrecolección de datosenlas plataformas Scielo, BVS y Lilacs. Se seleccionaron artículos publicados íntegramente entre 2019 y 2022. Resultados: Los principales resultados encontrados fueronladificultad para acoger a esta poblaciónenla APS, elrechazopersonal de losprofesionales, elflujoinadecuado de launidad, lasbarrerasestructurales de losservicios como ladificultad para crearun vínculo. Conclusión: Para tenerunacceso equitativo, libre de prejuicios y discriminaciones, es necesario implementar mejorasenlaspolíticas públicas en APS conelfin de capacitar a losprofesionalesenlaatención de lasnecesidades y laacogida de lapoblación TT, así como ensurespeto y proteccióncontra elprejuicio.

Descriptores: Travestismo – Personas Transgénero – Salud Pública

 

Introduction

Society assiduously discusses gender issues and it is notable that there is great hostility behind the population's ignorance of the definitions of the terms Transvestite and Transsexual (TT). Violence and discrimination begin in childhood, the discovery phase, involving a lot of fear and shame. Despite the achievement of legal and social rights by the LGBTQIA+ public (Lesbian, Gay, Bisexual, Transgender, Queer, Intersex and Asexual) a fraction is still defenseless in the face of definitions and their approval by society. ^1,2

From the 1980s, the LGBTQIA+ movement gained prominence through social demonstrations in search of respect, autonomy and freedom. These mobilizations brought great positive attention to the public, which was reflected in great debates, thus sharpening the eyes of this group. The repeated concepts and prejudices experienced by citizens cooperate for a conflict in separating gender from sexual orientation. Gender identity is defined as the gender with which a being identifies, whether assigned at birth or not. Sexual orientation, on the other hand, is defined as the feeling of attraction of an individual for other people, being able to be of the same sex, of the opposite sex, of both sexes or without reference to sex or gender, and those who are not attracted to other people (asexuals). Within the Transgender group, there are transgender people who are men who create a feminine expression and transgender people who identify with the opposite sex to the one they were assigned at birth. ^{1, 3}

In June 2019, Brazil approved the criminalization of transphobia, however the law does not apply to reality and the country continues to be the country that kills the most TT people in the world, as the number of deaths skyrocketed in 2020. Worldwide, 375 murders were recorded between October 1, 2020 and September 30, 2021. Brazil is the country that records the most murders (125), followed by Mexico (65) and the United States (53). Data shows that 4,042 trans and gender diverse people were murdered between January 1, 2008 and September 30, 2021. ⁴

The Brazilian Federal Constitution of 1988 defines health as a fundamental right for all citizens and it is the duty of the State to guarantee the reduction of inequalities and install public policies aimed at this public. The civil rights implemented in the Constitution encouraged various social movements focused on the attention of the LGBTQIA+ population, which led to the approval of the National Policy for the Comprehensive Health of Lesbians, Gays, Bisexuals, Trans and Transvestites (PNSI – LGBTQIA+) in 2011 through Ordinance 2836 of the Ministry of Health,   because it generated visibility to the health requirements and brought doubts about the specific care for this public. Despite the challenges and the need for broad government commitment, the National Comprehensive Health Program (PNSI) has been helping to produce knowledge and prevent discrimination between the various instances of the Unified Health System (SUS) among health managers and workers. ^1,5,6

It is extremely important that health professionals at all levels are aware of ethical and legal issues regarding the care of TT users and their demands, thus avoiding the marginalization of health services and contributing to a good quality service, valuing humanization and reception. ¹

Primary Health Care (PHC) is the main gateway to the SUS and connects with the entire SUS Care Network, characterized by a set of individual and collective health actions, covering health promotion and protection, disease prevention, diagnosis, treatment, rehabilitation and health maintenance. ⁷

In Brazil, there is great prejudice and discrimination against TT, and it occurs because this group has a gender identity that differs from that imposed by heteronormative standards in which a man is a man and a woman is a woman, anything that deviates from this norm is seen with strangeness, which in the case of the TT translates into violence and murder. The entry of this population into the SUS requires more specific attention on how to address issues related to the health of TT, many make the abusive and indiscriminate use of different hormones, guided by other Trans, there is also the misuse of industrial liquid silicone. The HIV/AIDS disease brought the TT population a more assiduous demand for health services, given that at the beginning of the epidemic, the population was seen as a “risk group” for being more likely to become infected with the disease. Currently, the TT population more easily attends the SUS health units and is understood as a population that has other illnesses in addition to those described. ⁸

Primary care has a fundamental role in receiving and welcoming the TT public. It is up to health professionals to know the aspects of this public, to identify the personal and social suffering they are subjected to, proposing and offering actions for individual care. Welcoming is a guideline of the National Humanization Policy (PNH) which is essential in care. Its objective for the TT is to promote integral health, omitting prejudice, as well as offering the reduction of inequalities and the consolidation of the doctrines of the SUS, as a universal system, integral and equitable. Reception is not a space or a place, but an ethical posture, one of inclusion; welcoming is admitting, accepting and listening to the patient. Welcoming is a device that goes far beyond the simple reception of the user in a health unit, considering the entire care situation from his entry into the system.” ^{9, 10, 11}

This study seeks to describe the obstacles of TT in PHC and the possible changes in the attitude of health professionals in assisting the enrolled population; to report the obstacles faced by transsexuals and transvestites (TT) in Primary Health Care (PHC) and to recognize the possible substitutions of professional conduct in serving the target audience.

 

Methods

An integrative literature review was carried out on the care of transgender and transvestite people in primary health care, with data collection on the Scielo, VHL and Lilacs platforms according to the PICO strategy. The description of the PICO strategy is composed of four components, which are P- Patient or Problem, which can be a single patient or a group with a particular condition, I- Intervention of interest, which may be therapeutic, preventive, diagnostic, prognostic, administrative or related to economic matters, C- Control or Comparison which is defined as a standard intervention, being the most used or having none, and O- Outcome/outcome represents the expected results. Thus, the PICO strategy guides the construction of the question and helps in the bibliographic search, allowing the researcher to quickly and easily locate the best available scientific information. ¹²

Articles published in full between the years 2019 and 2022 were selected. In the search strategy, the following terms were used according to the Health Sciences Descriptors (DeCS): Travestility, Transgender People, Public Health. To perform the crossing between terms, Boolean logic AND and OR were used in order to obtain the greatest possible number of results.

Articles selected from the provided databases were established as inclusion criteria, using the descriptors considered for the study; articles were included that address the theme “Assistance to the transsexual population”; in Portuguese, English and Spanish, available online in full. It was decided to exclude bibliographic review articles and articles that do not match the theme, year and language of publication. As this is an integrative review study, approval by the Research Ethics Committee (CEP) was waived in accordance with Resolutions 466/12 and 510/16 of the National Health Council.

Thus, the guiding question of the present study is: What are the obstacles faced by the TT population in the Primary Health Care (PHC) service? What are the possible transformations that can be carried out in the conduct of professionals in assisting the enrolled population?

Results

72 articles were selected from the Scielo, VHL and Lilacs databases, remaining after analysis and exclusion, a total of 15 articles published in Portuguese and Spanish (Chart 1).

Table 1: Selected articles, 2022.

REFERENCE	OBJECTIVE	METHOD	MAIN RESULT	CONCLUSION
Baccarim & Tagliamento (2020).13	Discussion about care and the right to comprehensive health for transvestites and transsexuals, men or women.	Qualitative research. Interviews were conducted with public health professionals from Curitiba/PR, addressing knowledge about transsexuality and transvestitism. For the analysis of the data, the analysis of the discursive practices of the professionals was used through the categories: acceptability, accessibility, quality and availability.	It was observed that gender regulatory norms affect the practice of policies and care for transgender people, making it difficult for them to access public health services.	As observed in the discourses of health professionals, technical ignorance – and perceptible indifference – of public health policies for transgender people, and barriers related to acceptance, either of policies or even of people, directly imply accessibility to health services, which was also observed in the research.
Reis, et al (2021).14	Understanding the meanings produced by nurses about the reception of transvestites and transgender people in primary care.	Qualitative study, carried out with four nurses who work in a Basic Health Unit in the South West Zone of Manaus. Data were collected from May to June 2016. Socio-anthropological studies were used for data analysis and discussion, with field research as a methodological reference.	The meanings produced by nurses about welcoming transvestites and transgender people in primary care are based on issues such as embarrassment, neutrality and lack of knowledge regarding gender issues beyond gender binarism.	There is a dominant biomedical-based training, and nursing care does not consider the sociocultural and political aspects of people, their bodies and their health.
Ferreira &Bonan (2021).15	To analyze reports of professionals in assisting the LGBT+ population in the Family Health Strategy (Fhs).	Research with a qualitative approach, in which the method applied was the study of oral reports, in the city of Teresina, Piauí, with professionals from the Family Health Team.	It is possible to perceive a lack of recognition of the LGBT population, a poor distribution of resources in health units and a weak representation of minorities.	Primary care, which should be one of those responsible for community health actions, which prioritizes health promotion and prevention, is the same that has offered denial, violence, and negligence in caring for LGBTT people. Therefore, listening is one of the keys to respect for sexual and gender diversity, so that these people are recognized as FHS users.
Valenzuela & Velásquez (2021).16	Describe the characteristics of the Service and Referral Protocol for trans users.	Analysis of experience, framed in a research with a qualitative approach.	The 1st group of categories is found that are antecedents of the need for depathologization and good treatment. From this category, they transmit activism and the empowerment and openness of professionals, which together with Chilean legislation lead to dialogue and social participation. Thanks to work between the trans community and healthcare providers, the protocol emerges.	The Care Protocol for trans people implemented by the Talcahuano Health Service is considered a pioneer in the country, and is positively valued by the trans national community, a fact that makes it valid. For this reason, ways to reproduce this work in other health services should be sought.
Rocon, et al (2022).17	To analyze recognition and public appearance as determinants for the health of transsexual women.	Qualitative approach with narrative interviews recorded in digital audio with 9 transgender women who underwent sex reassignment surgery in the state of Espírito Santo.	The reports show the permanence of the reality of discrimination experienced by the trans population in health services.	The conditions of appearing or not publicly produce different possibilities of accessing or not accessing health services, as well as experiencing health and disease processes.
Lucena, et al (2022).18	To report the experience of creating a Gender Identity Ambulatory (AMIG) service in a Hospital.	Documentary, qualitative, descriptive research. 25 minutes were collected from meetings on LGBTQIA+ topics, conversations between infectologists, family and community medicine and the multidisciplinary team.	The general lines of the trajectory were drawn from the idealization of the project until the inauguration of the Gender Identity Ambulatory (AMIG) of the Hospitalar Conceição Group (GHC).	Strengthening the service itself and the health care network for this population will require continued training of professionals, as well as encouragement from the institutions involved in this process. The formalization of the project, the expansion of popular participation and social movements and the encouragement of educational and training actions are perspectives to be considered in the next steps of this trajectory.
Parente, et al (2021).19	To analyze, in the light of principialist bioethics, the experience of LGBTQA+ in accessing health services.	Cross-sectional research, with a qualitative approach, carried out in 2018, in the municipality of Iguatu/CE, Brazil, with 26 lesbian, gay, bisexual and transgender people, who participated in focus groups with semi-structured interviews.	The results point to serious violations of the basic principles of the principialist current, with institutional violence of a psychological nature, disrespect for dignity, refusal of blood donation, non-acceptance of social name, lack of reception and humanization of care.	It was possible to identify severe violations of the principles of principialist bioethics. Government strategies, including the PNSI-LGBT+ and the political and social advances achieved, although important, have proved to be insufficient in view of the systemic nature of LGBTphobia.
Lima, et al (2019).20	Introduce the family and community doctor as an important professional in the area of health for the LGBT+ population.	Case report carried out in the city of Rio de Janeiro, through ecomap and genogram analysis, illustrating clinical encounter and use of family and community medicine tools.	The team manages to develop a common project for the management of the problems of this population, having factors that can cause illness: the prejudice they go through in the mere act of going out into the street, the pressure from family members dissatisfied with their diversity, sexual or gender, the person's psychological difficulty in getting rid of their own taboos and prejudices to allow themselves to accept new identities.	The health care provided to the lesbian, gay, bisexual, transvestite and transgender population in the Family Health Strategy requires paradigm changes that range from the theoretical-organizational sphere to care relationships.
Oliveira &Bonan (2021).21	To analyze experiences narrated by primary care professionals in health care for LGBT populations in Teresina, Piauí.	This is a qualitative research carried out with 32 professionals who worked in the Basic Health Unit. The analysis was based on three dimensions - relational, organizational and contextual.	It was observed that primary care should be one of those responsible for community health actions, which prioritizes health promotion and prevention, is the same that has offered denials, violence and negligence in the care of LGBT people.	Listening is one of the keys to respecting sexual and gender diversity, so that these people are recognized as FHS users.
Paulino, et al (2019).22	Identify discourses on access to and quality of comprehensive health care for the Lesbian, Gay, Bisexual, Transvestite and Transgender (LGBT) population among doctors of the Family Health Strategy and reflect on how these discourses can impact the health care of the LGBT population.	Fifteen physicians participated in Uberlândia and Belo Horizonte, Minas Gerais, Brazil. The analysis of the interviews followed the theoretical assumptions of Social Constructionism. Three categories of analysis were constructed: “Discourse of non-difference”, “Discourse of not knowing” and “Discourse of not wanting”.	It was possible to understand how these discourses enhance the silencing of issues involving the health conditions of the LGBT population, distancing them from comprehensive, equitable and universal healthcare.	The best care for this population depends on changes in the performance of health professionals, with urgent training and qualification for comprehensive LGBT health.
Sauthier, et al (2022).23	Identify and discuss the reasons that hinder or restrict the accessibility of transsexuals to basic health services.	Original research with a qualitative approach. Twelve semi-structured interviews were carried out with transsexuals between December 2018 and March 2019 in the West Zone of Rio de Janeiro.	The following thematic categories emerged from the data analysis: Low resolution and multiple barriers to access to health.	The non-recognition of the transsexual as a citizen with rights to access to health, the abjection of the transsexual body, prejudice and loss of value are presented as restrictive factors of this population to the health system. This difficulty reverberates in an important challenge to be overcome by the transsexual in the search for qualified assistance.
Silva, et al (2020). 24	Reflect on the implementation process and improve the health conditions of the LGBT population.	It is a qualitative approach involving four focus groups with 48 participants, including SUS managers, the Paraná State Health Department, professionals from the intersectoral network and representatives of LGBT social movements. Four axes of analysis were defined: access of the LGBT population to comprehensive health care; health promotion and surveillance actions; permanent education and popular health education; and monitoring and evaluation of health actions.	Health services for LGBT in Paraná are permeated by situations of stigma, which hinder LGBT access and permanence in SUS services. There is a need to promote tools to improve work processes and change professional practices towards the LGBT public.	There are gaps in policy implementation at the three levels of health care for the LGBT population.
Oliveira, et al (2022). 25	To analyze, from the perspective of Family Health Team professionals, the access of Lesbians, Gays, Bisexuals and Transvestites/Transsexuals to Basic Family Health Units.	This is a quantitative, qualitative, field, exploratory and descriptive study. The sample was composed by the snowball technique with 54 professionals, using a semi-structured interview script questionnaire in the urban area of the city of Cajazeiras, in the State of Paraíba.	The generated classes emerged, determined by subcategories: Equality in the care of LGBT people, Attitudes and behaviors of the LGBT population that hinder the search for the health service,    Prejudice and restriction on LGBT person's access to health and LGBT person's right to access health services.	Professionals perceive LGBT people as human beings who deserve equal access to the spaces of the ESF, so much so that they have access to serological tests, rapid tests, consultations and supplies for the prevention of STIs.
Cruz, et al (2021). 26	To analyze professional performance in the Primary Health Care network, and describe the production of care with the LGBTQIA+ population based on reflections on nursing work.	Qualitative study, carried out with 18 nurses who worked in Primary Health Care in a municipality in Bahia, Brazil.	The scenario of production and nursing care in Primary Care aimed at the population was permeated by weaknesses in the recognition of this population in clinical care and recognition.	There are fragility and barriers in the health care of the LGBTQIA+ population, both professionally and administratively in Primary Care. This scenario provokes the maintenance of inequalities and inequities in health that need to be overcome.
Shihadeh, et al (2021).27	To investigate how health services can make service to the LGBTQIA+ public unfeasible.	Qualitative research was carried out via intentional sampling, where interviews were conducted with eleven members of the LGBTQIA+ community.	It is evident that there are barriers in relation to the access of the LGBTQIA+ population in the search for health care, with reception being the most impaired moment in the interaction between prison services and users.	It is detected that health services still do not have the structure and/or trained professionals to work with sexual diversity as a whole. There is a need for training, dialogue and respect for laws that support health care in an expanded way.

Source: prepared by the authors, 2022.

Discussion

Results of studies indicate that one of the facts considered as a barrier to entry to health services refers to the association of TT with HIV/AIDS, since during the epidemic this group was strongly associated with the spread of the virus, strengthening social stigmatization. Professionals make a distinction when caring for transvestites and transsexuals, deciding to wear gloves after finding out, relating them to people with infectious diseases.^13,28

Again, misinformation and ignorance about the population ends up labeling trans people, strengthening the devaluation, inequality and abandonment of their health. Studies emphasize the discourse of "treating everyone the same" when asked about the need for professional qualification, since the 2008 National Policy on Comprehensive Health for Lesbians, Gays, Bisexuals, Transvestites and Transsexuals determines: to include the issue of confronting gender discrimination, sexual orientation, race, color and territory in the continuing education processes of managers, health workers and members of Health Councils. ^13,28

The "strangeness" that occurs in the daily lives of professionals with this public is directly linked to the withdrawal and illness of TT regarding health services, points out Tagliamento & Baccarim (2020). ¹³

Keeping this aspect, Ferreira & Bonan (2021) interviewed 32 professionals who work in the Family Health Strategy (ESF) in the state of Piauí, the study revealed that those responsible for welcoming the population, they are the same ones that offer denials, violence, and negligence in care. A statement distorts the SUS principle of equity, revealing. ¹⁵

This report exemplifies the deviation of concepts, clashing with the principle of Universality, where everyone has the right and access to health, however each one with their particularities and specific needs. ¹⁵

Ferreira & Bonan (2021) point out listening as the key to respect, recognition of LGBTQIA+ needs and bodies as active users. In addition to welcoming, listening, respecting their expressions, their desires, identities and differences. ¹⁵

An original, qualitative descriptive study carried out at Family Clinics in the West Zone of the state of Rio de Janeiro, highlighted the importance of the public service focused on PHC, which should be the user's gateway to the SUS, and noted important obstacles such as: few inputs for treatment, difficult access due to prejudice and unpreparedness of professionals during reception. In this sense, the authors highlight prejudice and social stigma, reflecting that Policies aimed at LGBTQIA+ need to be implemented more efficiently within primary care institutions. ²³

Studies claim that, in addition to the prejudice coming from professionals, the testimonies bring a perception of invisibility from the users themselves, where they claim to exclude themselves from the system due to a feeling of social invalidity and not belonging to the SUS. Strengthening this feeling, the user often chooses to look for ways that are not safe for their health. ^23,29

Research claims that the right to health for the TT population is not being guaranteed, contradicting the policies and principles of SUS health, which does not allow exclusion of any kind and has a duty to promote equity, it is of paramount importance to embrace this population , the result of the inequalities of a misogynistic world, which relegates bodies to inhumanity, and can be replaced by an implementation of the promotion of a life without exclusions. ^27,29

 

Conclusion

Prejudice and discrimination against TT are still high, as the gender identity of this group is different from that imposed by heteronormative standards, which translates into violence and murder. The APS is the main gateway to the SUS, connecting the entire SUS Care network, covering health promotion and protection, disease prevention, diagnosis, treatment, rehabilitation and health maintenance. This population that enters the SUS needs a more specific focus on how to address issues related to the health of the TT, such as the self-medication process, knowing that they will be discriminated against in the service. Access to PHC, through the target audience of the research, is outdated, impersonal and prejudiced, thus demonstrating the need for discussion of this topic. Professionals are not trained and few understand the existing protocols, generating embarrassing calls for both when they have contact with TT users.

It was verified that there is a rejection of the professional to this theme, with lack of knowledge of the social name, dehumanization, lack of specific approach, low professional qualification, ignorance about the subject and lack of continuing education. To recognize the possible substitutions of professional conduct in the service to the public described, the analysis of the study led to the conclusion that better public policies should be implemented, effectively informing professionals about this population and their needs through continuing education and addressing acts of prejudice.

With this, the hypothesis raised, that the assistance to transgender and transvestite people in Primary Health Care involves prejudice confirms, because professionals make a distinction when providing care to the TT population, deciding to put on gloves after finding out, relating them to people with infectious and contagious diseases. In addition to the prejudice coming from the professionals, the testimonies bring a perception of invisibility of the users themselves where they claim to exclude themselves from the system due to a feeling of social invalidity and not belonging to the SUS.

It can be concluded that implementing better public policies, listening more, respecting more, qualifying reception better, informing professionals more about this population and their needs through continuing education and addressing acts of prejudice and cutting, can replace the professional conduct in serving the described public.

 

References

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