Systematic review on health care for transvestites and transsexuals in Brazil

Lima, Rafael Rodolfo Tomaz de; Flor, Taiana Brito Menêzes; Noro, Luiz Roberto Augusto

doi:10.11606/s1518-8787.2023057004693

Rafael Rodolfo Tomaz de Lima

Study design and planning, Data collection, analysis and interpretation, Preparation or revision of the manuscript, Final version approval, Public responsibility for article content

Universidade Federal do Rio Grande do Norte. Centro de Ciências da Saúde. Programa de Pós-Graduação em Saúde Coletiva. Natal, RN, Brasil

https://orcid.org/0000-0003-0647-5093

Taiana Brito Menêzes Flor

Study design and planning, Data collection, analysis and interpretation, Final version approval, Public responsibility for article content

Universidade Federal do Rio Grande do Norte. Centro de Ciências da Saúde. Programa de Pós-Graduação em Saúde Coletiva. Natal, RN, Brasil

https://orcid.org/0000-0001-5164-8446

Luiz Roberto Augusto Noro

Study design and planning, Final version approval, Public responsibility for article content

Universidade Federal do Rio Grande do Norte. Centro de Ciências da Saúde. Programa de Pós-Graduação em Saúde Coletiva. Natal, RN, Brasil

https://orcid.org/0000-0001-8244-0154

Correspondence: Rafael Rodolfo Tomaz de Lima Avenida Senador Salgado Filho, 1.787 59056-000 Natal, RN, Brasil E-mail: rafael.lima@ufrn.br

Conflict of Interests: The authors declare that there is no conflict of interest.

Database	Search strategy
SciELO	(“atenção à saúde” OR “sistema único de saúde” OR SUS OR brasil) AND (travesti OR travestilidade OR travestismo OR transexual OR transexualidade OR transexualismo OR transgênero OR “pessoas trans”)
PubMed	(“health care” OR “health systems”) AND brazil AND (“transgender persons” OR transvestism OR transsexualism)
Lilacs	(“atenção à saúde” OR “sistema único de saúde” OR SUS OR brasil) (travesti OR travestilidade OR travestismo OR transexual OR transexualidade OR transexualismo OR transgênero OR “pessoas trans”)
BVS	(“atenção à saúde” OR “sistema único de saúde” OR SUS OR brasil) (travesti* trans*)

Element	Abbreviation	Description
Participants	P	Transvestites, transgender women and men, health professionals, health managers.
Exposure	E	Health policies and programs, health services organization, health care provision.
Comparison or control	C	NA
Outcome	O	Health promotion, access to health services, responses to health demands and needs.
Types of study included	S	Original studies with a qualitative or quantitative approach.

Articles	Checklist evaluation criteria										Risk of bias (%)^b

	1	2	3	4	5	6	7	8	9^a	10
Oliveira e Romanini ²¹21.Oliveira I, Romanini M. (Re)escrevendo roteiros (in)visíveis: a trajetória de mulheres transgênero nas políticas públicas de saúde. Saude Soc. 2020;29(1):e170961. https://doi.org/10.1590/S0104-12902020170961 https://doi.org/10.1590/S0104-1290202017...	A	A	A	A	A	B	A	A	A	A	Low (90%)
Rigolon et al. ²²22.Rigolon M, Carlos DM, Oliveira WA, Salim NJ. “A saúde não discute corpos trans”: história oral de transexuais e travestis. Rev Bras Enferm. 2020;73 Supl 6:e20190228. https://doi.org/10.1590/0034-7167-2019-0228 https://doi.org/10.1590/0034-7167-2019-0...	A	A	A	A	A	B	A	A	A	A	Low (90%)
Sousa e Iriart ²³23.Sousa D, Iriart J. “Viver dignamente”: necessidades e demandas de saúde de homens trans em Salvador, Bahia, Brasil. Cad Saude Publica. 2018;34(10):e00036318. https://doi.org/10.1590/0102-311X00036318 https://doi.org/10.1590/0102-311X0003631...	A	A	A	A	A	B	C	A	A	A	Low (80%)
Moraes e Silva ²⁴24.Moraes AND, Silva GSN. Travestis e o cuidado humanizado em saúde. Rev Abordagem Gestalt. 2020;26(2):175-87. https://doi.org/10.18065/2020v26n2.5 https://doi.org/10.18065/2020v26n2.5...	A	A	A	A	A	B	B	A	A	A	Low (80%)
Sehnem et al. ²⁵25.Sehnem GD, Rodrigues RL, Lipinski JM, Vasquez MED, Schmidt A. Health Care Assistance in Primary Care: access to care. Rev Enferm UFPE On Line. 2017;11(4):1676-84. https://doi.org/10.5205/1981-8963-v11i4a15238p1676-1684-2017 https://doi.org/10.5205/1981-8963-v11i4a...	B	A	A	A	A	B	B	A	A	A	Low (70%)
Amorim e Teixeira ²⁶26.Amorim JF, Teixeira ER. Atendimento das necessidades em saúde das travestis na atenção primária. Rev Baiana Saude Publica. 2017;41(3):759-73. https://doi.org/10.22278/2318-2660.2017.v41.n3.a2379 https://doi.org/10.22278/2318-2660.2017....	C	A	A	A	A	B	B	A	A	A	Low (70%)
Sehnem et al. ²⁷27.Sehnem GD, Rodrigues RL, Lipinski JM, Vasquez MED, Schmidt A. (Des)preparo técnico-científico para o cuidado às travestis: percepções de enfermeiras(os). Rev Enferm UFSM. 2017;7(2):236-47. https://doi.org/10.5902/2179769223649 https://doi.org/10.5902/2179769223649...	B	A	A	A	A	B	B	A	A	A	Low (70%)
Almeida et al. ²⁸28.Almeida JSM, Martins ERC, Costa CMA, Moraes PC, Ferreira GDF, Spindola T. Cuidar de pessoas transexuais na ótica dos residentes de enfermagem. Rev Enferm UERJ. 2018;26:e32030. https://doi.org/10.12957/reuerj.2018.32030 https://doi.org/10.12957/reuerj.2018.320...	B	A	A	A	A	B	B	A	A	A	Low (70%)
Souza et al. ²⁹29.Souza MHT, Signorelli MC, Coviello DM, Pereira PPG. Itinerários terapêuticos de travestis da região central do Rio Grande do Sul, Brasil. Cien Saude Colet. 2014;19(7):2277-86. https://doi.org/10.1590/1413-81232014197.10852013 https://doi.org/10.1590/1413-81232014197...	C	A	A	A	A	B	B	A	A	A	Low (70%)
Oliveira et al. ³⁰30.Oliveira BP, Silva MAS, Souza MS. O direito à saúde de pessoas trans* no Distrito Federal: entre o direito de existir e o direito à equidade. Cad Ibero Am Dir Sanit. 2019;8(1):10-25. https://doi.org/10.17566/ciads.v8i1.502 https://doi.org/10.17566/ciads.v8i1.502...	B	A	A	A	A	B	B	A	A	A	Low (70%)
Sevelius et al. ³¹31.Sevelius J, Murray LR, Fernandes NM, Veras MA, Grinsztejn B, Lippman SA. Optimising HIV programming for transgender women in Brazil. Cult Health Sex. 2019;21(5):543-58. https://doi.org/10.1080/13691058.2018.1496277 https://doi.org/10.1080/13691058.2018.14...	A	A	A	A	A	B	C	A	C	A	Low (70%)
Lovison et al. ³²32.Lovison R, Ascari TM, Zocche DAA, Durand MK, Ascari RA. Travestis e transexuais: despindo as percepções acerca do acesso e assistência em saúde. Enferm Foco. 2019;10(5):167-72. https://doi.org/10.21675/2357-707X.2019.v10.n5.2370 https://doi.org/10.21675/2357-707X.2019....	B	A	A	A	A	B	B	A	A	A	Low (70%)
Ferreira et al. ³³33.Ferreira BO, Nascimento EF, Pedrosa JIS, Monte LMI. Vivências de travestis no acesso ao SUS. Physis. 2017;27(04):1023-38. https://doi.org/10.1590/S0103-73312017000400009 https://doi.org/10.1590/S0103-7331201700...	C	A	A	A	A	B	B	A	A	A	Low (70%)
Hanauer e Hemmi ³⁴34.Hanauer OFD, Hemmi APA. Caminhos percorridos por transexuais: em busca pela transição de gênero. Saude Debate. 2019;43(Nº Espec 8):91-106. https://doi.org/10.1590/0103-11042019S807 https://doi.org/10.1590/0103-11042019S80...	A	A	A	A	A	B	C	A	C	A	Low (70%)
Silva et al. ³⁵35.Silva GWS, Sena RCF, Santos QG, Sobreira MVS, Miranda FAN. O dito e o feito: o enfermeiro e o saber/fazer saúde para travestis. Rev Enferm UFPE On Line. 2014;8(10):3347-57. https://doi.org/10.5205/1981-8963-v8i10a10066p3347-3357-2014 https://doi.org/10.5205/1981-8963-v8i10a...	B	A	A	A	A	B	B	A	A	A	Low (70%)

Authors	Year	State	Research subjects	Aim	Results	Conclusions
Oliveira e Romanini ²¹21.Oliveira I, Romanini M. (Re)escrevendo roteiros (in)visíveis: a trajetória de mulheres transgênero nas políticas públicas de saúde. Saude Soc. 2020;29(1):e170961. https://doi.org/10.1590/S0104-12902020170961 https://doi.org/10.1590/S0104-1290202017...	2020	RS	6 transgender women.	To understand how the trajectories of transgender people are constructed in public health policies in a municipality in the interior of Rio Grande do Sul.	Trans women have a closer relationship with the transsexualizing outpatient clinic. However, a fragile relationship is built in this environment, as users feel constantly evaluated regarding the “truthfulness” of their transsexuality, becoming passive in the health production process due to the superiority of medical knowledge and reproduction of invisible protocols.	The journey of trans women in public health policies is guided by invisibility, leading to the construction of lines of care that do not match the real needs of this population group. It is necessary to encourage the teaching-service integration, aiming to build a dialogue between scientific knowledge about transsexuality and the experiences of trans people, to qualify health workers and, consecutively, the health care of trans women.
Rigolon et al. ²²22.Rigolon M, Carlos DM, Oliveira WA, Salim NJ. “A saúde não discute corpos trans”: história oral de transexuais e travestis. Rev Bras Enferm. 2020;73 Supl 6:e20190228. https://doi.org/10.1590/0034-7167-2019-0228 https://doi.org/10.1590/0034-7167-2019-0...	2020	SP	1 transvestite, 1 transgender woman and 2 transgender men.	To understand the life stories and journey of transvestites and transsexuals in health services.	The results were presented under two main themes: “gender and sexuality in life histories” and “trajectories in health services”. The reports reveal the challenges faced by trans people in the process of recognizing their gender identity and the dilemmas in accessing health services, keeping them away from care spaces.	The Oral History method can increase knowledge about the health needs and demands of transvestites and transsexuals. In addition, the research results can help health professionals and managers in decision-making and comprehensive care for these people.
Sousa e Iriart ²³23.Sousa D, Iriart J. “Viver dignamente”: necessidades e demandas de saúde de homens trans em Salvador, Bahia, Brasil. Cad Saude Publica. 2018;34(10):e00036318. https://doi.org/10.1590/0102-311X00036318 https://doi.org/10.1590/0102-311X0003631...	2018	BA	10 transgender men.	To understand the health needs and demands of trans men, considering this to be a first step towards enabling ways in which care strategies can be designed.	Transphobia, a structural and institutional mechanism of violence and aversion to trans people, determines care practices and the development of strategies to meet the health needs and demands of trans men. These, in turn, are presented in three categories: “de-pathologization of trans experiences”, “body modifications” and “outpatient care”.	Transphobia negatively influences the way of life of trans men, aggravating their health needs and demands. It is necessary to develop intersectoral strategies to combat transphobia and guarantee the right to health and life of trans men.
Moraes e Silva ²⁴24.Moraes AND, Silva GSN. Travestis e o cuidado humanizado em saúde. Rev Abordagem Gestalt. 2020;26(2):175-87. https://doi.org/10.18065/2020v26n2.5 https://doi.org/10.18065/2020v26n2.5...	2020	RN	7 transvestites.	To identify conceptions, desires, fears and suggestions regarding humanized health care aimed at transvestite people in the context of primary care.	Transvestites face difficulties in accessing and using health services. To overcome them and change the health care of transvestites, some suggestions are pointed out: training of health professionals, dialogue with the social movement, publicity campaigns for getting closer together with the meaning of the experience of being a transvestite.	For primary health care to be a welcoming and humanized space for transvestites, it is necessary to prioritize respect and guarantee of rights. It is necessary to rescue the promotion of care, something fundamental in health work practices, respecting differences and exercising altruism. There is an urgent need for effective changes in the training of health professionals.
Sehnem et al. ²⁵25.Sehnem GD, Rodrigues RL, Lipinski JM, Vasquez MED, Schmidt A. Health Care Assistance in Primary Care: access to care. Rev Enferm UFPE On Line. 2017;11(4):1676-84. https://doi.org/10.5205/1981-8963-v11i4a15238p1676-1684-2017 https://doi.org/10.5205/1981-8963-v11i4a...	2017	RS	10 nurses.	To get to know health care for transvestites, from the perspective of nurses, in primary care.	Two thematic categories emerged: “weaknesses in meeting the demands of transvestites in primary health care” and “welcoming as an integrating practice in primary health care”. Nurses do not feel prepared to welcome transvestites and believe that they do not seek Basic Health Units for fear of being embarrassed.	The few health actions aimed at transvestites occurred in an isolated and fragmented way. To overcome the challenges, it is recommended the implementation of the LGBT health policy in the SUS, the permanent education of health workers and the strengthening of reception to enhance the bond between professionals and transvestite users.
Amorim e Teixeira ²⁶26.Amorim JF, Teixeira ER. Atendimento das necessidades em saúde das travestis na atenção primária. Rev Baiana Saude Publica. 2017;41(3):759-73. https://doi.org/10.22278/2318-2660.2017.v41.n3.a2379 https://doi.org/10.22278/2318-2660.2017....	2017	RJ	5 transvestites.	To discuss meeting transvestites’ health needs in primary health care services.	For the interviewees, the health condition is linked to health promotion actions. In the search for body modifications, transvestites make use of female hormones without monitoring, leading to the emergence of other demands, such as cardiovascular complications. When seeking the Basic Health Units (UBS), transvestites face disrespect for their social name and other violations, which distance them from these health services, bringing them closer to alternative or clandestine practices for self-care.	Primary care is still fragile to meet transvestites’ health needs and demands. It is recommended to implement a public health policy that considers transvestites’ specific health issues to promote comprehensive health care; include content on the care of transvestites in health area courses and develop permanent educational actions, on reception and humanization, for health professionals working in primary care.
Sehnem et al. ²⁷27.Sehnem GD, Rodrigues RL, Lipinski JM, Vasquez MED, Schmidt A. (Des)preparo técnico-científico para o cuidado às travestis: percepções de enfermeiras(os). Rev Enferm UFSM. 2017;7(2):236-47. https://doi.org/10.5902/2179769223649 https://doi.org/10.5902/2179769223649...	2017	RS	10 nurses.	To know the nurses’ perceptions about transvestites and the technical-scientific preparation to assist them.	Data were presented in two thematic categories: “transvestite: meanings constructed from the perspective of nurses” and “(lack of) technical-scientific preparation: repercussions on the care provided to transvestites”. Nurses are unaware of the meaning of being a transvestite and public policies aimed at the LGBT population, one of the reasons given for this lack of knowledge being the fragile approach to gender and sexuality issues during academic training.	For the care of transvestites, it is necessary to rethink public health policies for this part of the population, guarantee access and reception in health services, in addition to qualifying the technical-scientific preparation of health professionals on gender and sexuality issues.
Almeida et al. ²⁸28.Almeida JSM, Martins ERC, Costa CMA, Moraes PC, Ferreira GDF, Spindola T. Cuidar de pessoas transexuais na ótica dos residentes de enfermagem. Rev Enferm UERJ. 2018;26:e32030. https://doi.org/10.12957/reuerj.2018.32030 https://doi.org/10.12957/reuerj.2018.320...	2018	RJ	13 nurses.	To identify the training of resident nurses for the qualified care of transgender people and to analyze the process of nursing care for this clientele, from the perspective of the nursing resident.	The testimonies were presented in two categories: “nurse education and care for transgender people” and “the process of nursing care from the resident’s perspective”. In the residents’ view, the training of nursing professionals is not aware of the particularities of different gender identities, including those of transgender people. Thus, the unpreparedness of these professionals to provide qualified care, given the needs of transgender people, will be perpetuated.	The unpreparedness of nursing professionals to meet the social and health demands of the transsexual population was evidenced, justified, above all, by the absence of curricular content on transsexuality during professional training.
Souza et al. ²⁹29.Souza MHT, Signorelli MC, Coviello DM, Pereira PPG. Itinerários terapêuticos de travestis da região central do Rio Grande do Sul, Brasil. Cien Saude Colet. 2014;19(7):2277-86. https://doi.org/10.1590/1413-81232014197.10852013 https://doi.org/10.1590/1413-81232014197...	2014	RS	49 transvestites.	To present the therapeutic itineraries of transvestites residing in Santa Maria, a municipality in the central region of Rio Grande do Sul.	It was found that transvestites seek multiple ways to obtain health care, including outside institutionalized health services. For a better understanding of the transvestites’ therapeutic itineraries, the results of the study were presented in four categories: “the trajectory of the transvestite construction”, “the itinerary of care in the spaces covered by transvestites”, “the itinerary in public health services” and “the itinerary in the Afro religion, the batuque ”.	The study revealed that transvestites avoid public health services, because when they seek them they are always victims of discrimination. Such health services are not prepared to meet their needs and demands. Therefore, the therapeutic itineraries of the transvestites in Santa Maria, Rio Grande do Sul, are constituted by other scenarios and health practices, in addition to the institutional spaces of the SUS, such as living spaces, prostitution points, in public spaces and religious meeting places ( casas de santo ).
Oliveira et al. ³⁰30.Oliveira BP, Silva MAS, Souza MS. O direito à saúde de pessoas trans* no Distrito Federal: entre o direito de existir e o direito à equidade. Cad Ibero Am Dir Sanit. 2019;8(1):10-25. https://doi.org/10.17566/ciads.v8i1.502 https://doi.org/10.17566/ciads.v8i1.502...	2019	DF	2 transgender people.	To understand how trans social movements in the Federal District understand the right to health.	It is understood that the right to health is related to three thematic units: “right to exist”, such as the search for basic human rights (use and respect for the social name); “right to equity”, since health services must be prepared to meet the specific needs of the trans population; and “implementation of the trans clinic and social participation”, highlighting the importance of social control for the realization of the right to health.	The fight for recognition of the specific needs of the trans population and the winning of social equipment to satisfactorily serve this population, such as the trans outpatient clinic, are initiatives that can provide a permanent dialogue between trans people and health professionals for the production of specific and qualified care, reverberating in the realization of the right to health and citizenship.
Sevelius et al. ³¹31.Sevelius J, Murray LR, Fernandes NM, Veras MA, Grinsztejn B, Lippman SA. Optimising HIV programming for transgender women in Brazil. Cult Health Sex. 2019;21(5):543-58. https://doi.org/10.1080/13691058.2018.1496277 https://doi.org/10.1080/13691058.2018.14...	2019	RJ	36 transgender women.	To explore how the social context of stigma and transphobia affect Brazilian trans women’s access and their preferences for HIV prevention method and care programming guided by the Gender Affirmation Model.	The results portray discrimination in health services, from disrespecting the social name to the prior conception that these users are people living with HIV. Transgender women are uncertain about the effectiveness and delivery of Pre-Exposure Prophylaxis (PrEP), and are not emotionally prepared to face a possible positive HIV result. Group activities can explore other issues, in addition to HIV, ensuring the possibility of coexistence between seropositive and non-seropositive people. The interviewees demonstrate a feeling of confidence when faced with health services that have transsexual workers in the team.	The data strongly support a gender-affirming approach to transgender health, in which HIV programming for transgender women is not limited to individual and biomedical strategies such as increased PrEP intake or increased testing rates. There is a need to affirm the diverse subjectivities of transgender women and support their autonomy as they cultivate health and empowerment, both for themselves and their communities.
Lovison et al. ³²32.Lovison R, Ascari TM, Zocche DAA, Durand MK, Ascari RA. Travestis e transexuais: despindo as percepções acerca do acesso e assistência em saúde. Enferm Foco. 2019;10(5):167-72. https://doi.org/10.21675/2357-707X.2019.v10.n5.2370 https://doi.org/10.21675/2357-707X.2019....	2019	SC	4 transgender women and 1 transvestite.	To know the perception of transvestites and transsexuals living in Chapecó, Santa Catarina, regarding access and health care.	The search for care in public health services is not a priority for the interviewees. They end up opting for self-medication or paying the costs of private assistance. This stems from the discriminatory acts they face in these services, mainly disrespect for the social name and lack of knowledge on the part of health professionals about health policies and programs for this specific population.	Access and health care are limited and fragmented due to the small number of professionals and health services that meet the general demands of the population of the municipality of Chapecó, and the lack of preparation of the municipal health system to meet the specific demands of the trans population. Trans women do not have basic rights met, such as the right to health; they do not receive information about health processes and procedures and are discriminated against by health professionals and other users within health services.
Ferreira et al. ³³33.Ferreira BO, Nascimento EF, Pedrosa JIS, Monte LMI. Vivências de travestis no acesso ao SUS. Physis. 2017;27(04):1023-38. https://doi.org/10.1590/S0103-73312017000400009 https://doi.org/10.1590/S0103-7331201700...	2017	IP	6 transvestites.	To analyze and understand transvestites’ experiences regarding health care in the SUS in Teresina, Piauí.	Two thematic categories emerged: “weaknesses in transvestite care” and “specialization in transvestite care “. The first category reveals situations of prejudice in health services due to body changes, generating insecurity on the part of this population when using services. The second category suggests that the creation of specific services for transvestites could minimize situations of embarrassment.	It was evident that there is a need for greater integration between the different social segments and health services, the qualification of professionals to guarantee the reception of transvestites and urgent reflection on the discriminatory nature of the specialized services implemented by SUS, even though it is a door for transvestites to enter the health system.
Hanauer e Hemmi ³⁴34.Hanauer OFD, Hemmi APA. Caminhos percorridos por transexuais: em busca pela transição de gênero. Saude Debate. 2019;43(Nº Espec 8):91-106. https://doi.org/10.1590/0103-11042019S807 https://doi.org/10.1590/0103-11042019S80...	2019	MG	4 transgender men and 3 transgender women.	To describe the paths traversed by transsexuals, aiming to know their itineraries in the search for meeting their health needs and demands.	The different paths presented are related to the process of identifying as a transsexual person and the influence of social networks, as well as the health services in this path. Health care networks were recognized as central in the lives of trans people interviewed, especially with regard to access to body modifications.	The search for the desired gender identity is crossed by numerous difficulties, such as family and social non-acceptance and denial of the right to health when seeking SUS services. Transsexuality seems to be misunderstood by people in social life and by professionals and managers of health care networks.
Silva et al. ³⁵35.Silva GWS, Sena RCF, Santos QG, Sobreira MVS, Miranda FAN. O dito e o feito: o enfermeiro e o saber/fazer saúde para travestis. Rev Enferm UFPE On Line. 2014;8(10):3347-57. https://doi.org/10.5205/1981-8963-v8i10a10066p3347-3357-2014 https://doi.org/10.5205/1981-8963-v8i10a...	2014	RN	12 nurses.	To analyze the practice and knowledge of nurses from the Family Health Strategy (ESF) regarding care to the transvestite population.	The results of the study are presented from three discursive axes. The first axis concerns the construction of the transvestite identity, how the interviewed professionals understand this gender identity and how they develop nursing practices for this population group. In the second axis, the nurses reveal that they have not treated transvestites in primary care or that they do not know how to identify them. The third axis presents initiatives by some professionals to better welcome and assist transvestites, such as respect for the social name.	Nurses demonstrated that practice and knowledge in assisting transvestites are limited, failing to identify them by gender of choice, judging them only by their physical and apparent characteristics. Due to this invisibility, they only perform a curative service, without considering the transvestites’ subjectivities and respect for the social name, disqualifying the care for this specific public.

[1] Correspondence: Rafael Rodolfo Tomaz de Lima Avenida Senador Salgado Filho, 1.787 59056-000 Natal, RN, Brasil E-mail: rafael.lima@ufrn.br

Brasil

Brasil

Systematic review on health care for transvestites and transsexuals in Brazil

ABSTRACT

OBJECTIVE

METHODS

RESULTS

CONCLUSIONS