Integrative review: studies on harm reduction aimed at the population of trans women and transvestites

ABSTRACT

We present the research findings of the master’s thesis with an integrative approach, which aimed to revisit publications with an LGBTQIA+ theme in scientific journals. By focusing on the Harm Reduction (HR) strategy, this research aimed to identify the practices conducted for the trans population and contextualize how HR can contribute to building bonds in healthcare. Data were collected in the LILACS and SciELO databases. We retrieved 110 articles published from 2005 to 2020 in Portuguese. Their summaries were read in full. Seven approaches were identified: HR as a public policy strategy; violence experienced in the transition trajectories followed by transvestites; assistance to the LGBTQIA+ population; health professionals can provide truly person-centered, humanized care, with active listening; healthcare and hormonization as a feminine construction process; social movements; education and affirmative actions for continued study and professional placement. Thus, the research contributes to expanding knowledge and understanding about LGBTQIA+ issues. The specific demands of transvestites and transsexuals in their search for care in health services are explained in order to understand how HR can be a health care strategy for the trans population.

KEYWORDS
Harm reduction; Transvestism; Transgender persons; Human rights.

RESUMO

Apresentam-se os achados da pesquisa da dissertação de mestrado com abordagem integrativa que objetivou revisitar as publicações com a temática LGBTQIA+ de periódicos científicos. Ao colocar, como enfoque, a estratégia de Redução de Danos (RD), a presente pesquisa objetivou identificar quais as práticas realizadas para a população trans e contextualizar como a RD pode contribuir para construção de vínculo no cuidado à saúde. Coletaram-se os dados nas bases Lilacs e SciELO. Recuperaram-se 110 artigos publicados, entre 2005 e 2020, em português. Seus resumos foram lidos na íntegra. Identificaramse sete abordagens: RD como estratégia de políticas públicas; violências vivenciadas nas trajetórias de transição percorridas pelas travestis; atendimento à população LGBTQIA+; profissionais de saúde capazes de prestar um cuidado humanizado, verdadeiramente centrado na pessoa, com escuta ativa; o cuidado a saúde e hormonização como processo de construção feminina; movimentos sociais; educação e ações afirmativas para a continuidade do estudo e colocação profissional. Assim, a pesquisa contribui para ampliar o conhecimento e a compreensão sobre a temática LGBTQIA+. As demandas específicas de travestis e transexuais em sua busca por atendimento nos serviços de saúde são explicitadas de modo a compreender como a RD pode ser estratégia de cuidado à saúde da população trans.

PALAVRAS-CHAVE
Redução do dano; Travestilidade; Pessoas transgênero; Direitos humanos.

Introduction

This article aims to present the results of the literature review on health care for trans and transvestite women, in the field of Harm Reduction (HR), through an integrative research approach, and briefly discuss this population’s access, comprehensiveness, equity, and proximity to health services.

The interest in this topic is related to the work of one of this article’s authors, in the territory of the north zone of Rio de Janeiro, as a harm reduction agent at the Psychosocial Care Center for Alcohol and Other Drugs (CAPS-Ad). HR as a health care strategy can reach vulnerable populations, offer access, and bring these users of alcohol and other drugs closer to and strengthen their rights as citizens.

The HR concept was built over time by people who use alcohol and other drugs, inserted in the field of social movements, against stigmas, and in the context of increasing mortality from AIDS due to contamination through sharing syringes¹.

We understand that, besides delivering common supplies to the service (condoms, lubricant, mask, soap, and alcohol gel), it is necessary to build a bond by listening to users and developing ways of accessing transvestites and transgender women in the territory, considering equity, one of the Unified Health System (SUS) principles. The combination of these factors are instruments that have facilitated action in territories with productive inclusion methods and attenuation of social inequalities².

We also consider how HR can be a care tool given the difficulty in providing care to drug users, transvestites and trans women, and healthcare aimed at this population, characterized by very particular demands. The relevance of these studies on HR targeting the population of trans and transvestite women consists in presenting territorial actions and approaches for this specific audience, and access to public health devices and, thus, the guarantee of rights for this population³.

Harm Reduction, policies, and fundamentals

The ‘war on drugs’ derives from unstructured public policies with a bias towards criminalization and repression, reduced to the scope of security and the judiciary, and not public health, producing stigma, marginalization, and violence, where more importance is assigned to the criminalization of use and less to users’ health and quality of life⁴.

In 2002, when implementing HR strategies, the Ministry of Health established that harm belongs to the social - such as marginalization, vulnerability, inequality, and social exclusion - and health fields. Ordinance Nº 1.028 of July 1, 2005, considered that the Ministry of Health should act toward social and health HR, thus reviving the citizenship of individuals in psychological distress and enhancing the effects of promoting health⁵.

Evidenced as a policy, anchoring HR determines a new ethical, clinical, and public policy paradigm, which involves confronting and clashing against anti-drug policies - established when the nation endured its last military dictatorship - such as social control⁶.

Through this review, we understand that an essential contribution of HR would be precisely to question the relationship between drug use and users, taking care of the existing distress or one possibly caused by use without necessarily demanding abstinence and intervening when the risk to life is assessed.

Professionals should recognize HR as a public policy strategy and care tool, understanding that it is not against abstinence but a path towards the subject’s choice if desired, and present it among many other equally ethical possibilities in which subjects can envision life from perspectives other than use.

To this end, Decree Nº 7.508 of June 28, 2011, confirms the implementation of the Psychosocial Care Network (RAPS), seeking strategies in partnership in the intersectoral services to integrate care, ensuring access to users in the entire network and enabling the HR practice, especially in the CAPS, thus consolidating the psychiatric reform⁷.

With the change of Federal Government in 2019, Law Nº 13.840 was enacted and added and changed the provisions to Law Nº 11.343/2006, removing HR from the National Policy and, therefore, expanding investments in therapeutic communities, where it established the authorization of the compulsory hospitalization of people resulting from the use of alcohol and other drugs, distancing them from their families, which highlights severe human rights violations in these institutions⁸.

We should debate public investments without oversight in these primarily private and religious entities based on exclusion and social hygiene. In contrast, HR is a practice built by people belonging to the vulnerable population, who made their demands heard, and by professionals who use it to build bonds, guaranteeing access to care and health. Thus, the importance of having people from the population acting as health agents⁹ stands out in the care strategy and health promotion processes⁹.

Methods

Hearing “We are not guinea pigs to be studied and left behind” at the beginning of my HR work in the night action impressed me. Later, upon entering academia, as a cisgender woman, I decided to develop integrative review research to collect, systematize, and analyze data that could support new studies and public policies targeting trans and transvestite women in the field of HR.

Through an integrative review¹⁰, we accessed the main scientific works already produced on the topic, in field research and HR experiences focused on transvestites and transsexual women developed in Brazil - and of great importance in presenting current and relevant data between 2005 and 2020.

Data were collected in specific databases, based on descriptors, exclusion and inclusion criteria for articles, searching for publications via the internet, in the Latin American Health Literature (LILACS), Scientific Electronic Library Online (SciELO), and Medical Literature Analysis and Retrieval System Online (MEDLINE).

During this process, we aimed to understand HR as a strategy for building bonds and healthcare for transvestites and trans women based on the mapping of scientific products on HR experiences conducted in Brazil and those contextualized by the territory where the actions occur.

First, we carefully read the works to fully grasp the contents described containing information to be developed in this integrative work on the topic. The integrative review’s guiding question, essential for data collection for this study, began with the search for common HR practices offered to the population of Lesbians, Gays, Bisexuals, Transsexuals, Transvestites, Transgenders, Queer, Intersex or Intersex, Asexual and other possibilities of existence (LGBTQIA+), more specifically for female transvestites and trans women, published in scientific literature, selected from specific databases, using descriptors, inclusion and exclusion criteria for articles, through internet search, in March 2022.

The inclusion criteria were free online articles published from 2005 to 2020 that covered the theme from the theoretical, political, or practical aspects. The exclusion criteria were articles not covering the proposed theme or published outside the indicated period. Based on these methodological brackets, the research started with data capture in the abovementioned databases.

Results

Our search was performed within the theme, considering its relevance and the material’s informative value, studies with the following descriptors presented here, namely, harm reduction, transvestite, transgender people and human rights, combined and shown in table 1. Based on the works’ reading, I call them approaches to situate features presented in the collected articles¹¹.

Table 1
Summary from reading the abstracts

Approach	Summary	Nº of papers
Social movements	Discussion for visibility of the topic addressed, the right to health, and access to health actions and services.	8
Assistance to the LGBTQIA+ population	Focusing only on physical diagnosis or treatment, differentiation in treatment, and multiple constraints	20
Harm reduction as a public policy strategy	Presentation of public policy as a health work tool, which proposes access to health for people	25
Education and affirmative actions for continued study and professional placement	Debates on gender and sexuality that focus on transsexuals and transvestites who may have difficulty accessing primary education, higher education, and work	3
Healthcare and hormonization as a feminine construction process	Studies that aim to understand the demands of this population, the hormone use process, and even transsexualization	15
Health professionals can provide truly person-centered, humanized care, with active listening	Presenting discussions that highlight the difficulty or ineptitude of professionals who disrespect, discriminate, and produce stigma	17
Violence experienced in the transition trajectories followed by transvestites	Publications that highlight of violence and distress experiences during the transition	22

¹¹

One hundred eighteen articles were found in the total selection, using the first and second reading of their respective abstracts, with eight articles removed from the selection due to duplicates in the databases. Fifty-eight were found in SCIELO, 47 in LILACS, and five in MEDLINE. Thus, in the end, we analyzed 110 abstracts that included the guiding questions and descriptors¹¹⁽³⁹⁾.

Table 1 below, prepared from my master’s thesis, displays the contents of the integrative review studies. In the first column, I list the main search approaches; in the second, I include a summary of the research content; and in the third, the number of articles read.

Table 1 above shows that there may be barriers to accessing health and rights and issues of violence, discrimination, and stigma; and that transvestites and trans women are exposed to health vulnerabilities and immersed in obstacles and social inequalities. I set these questions as a provocation regarding the need to i) promote access to health care for vulnerable populations, especially trans and LGBTQIA+ women; ii) enhance the quality of care provided by health professionals; and iii) consolidate the concept that health services need to adapt to the needs of the LGBTQIA+ population.

Approximately 52.73% of the articles were found in SciELO; LILACS returned 42.73%; and MEDLINE 4.55%, and these numbers for the approaches are presented as follows: harm reduction as a public policy strategy (22%); violence experienced in the transition trajectories followed by transvestites (20%); service to the LGBT population (18.18%); health professionals who can provide humanized, truly person-centered care, with active listening (15.45%); healthcare and hormonization as a feminine construction process (13.64%); social movements (7.27%); education and affirmative actions for continuing study and professional placement (2.73%)¹¹⁽⁴⁰⁾.

Adopting the social name in written or oral form, when not respected, as shown in this research, exposes transvestites and transsexuals to embarrassment, does not respect their rights, and causes significant psychological impacts, such as depression, among other aggravations in mental health, with the possibility of breaking the minimum existing bond, besides the consequent discontinuity in the search for health services¹².

Female hormones, used to obtain the feminine contour desired by trans and transvestite women, provide a form of care presented as a demand in care, requiring medical monitoring. Many do not do so, as they want a quick change in their body since the dosage they use is much higher in order to achieve the desired appearance, which implies even more attention to this population. It is necessary to offer comprehensive care¹³ as a HR strategy.

The lack of access to the training of some health professionals in the topic of care for the LGBTQIA+ population probably corroborates the problematic reception and lack of preparation at work, concomitantly with the lack of adequate public policies, which can produce a service full of discrimination when this population seeks health facilities, especially if we consider that transvestites and trans women care demands exceed biological health issues, as they have other specific issues and require a broader perspective from the health professionals.

Research portrays excerpts from interviews that characterize feelings of mental distress, such as sadness, anguish, and discrimination experienced in health services, resulting in the abandonment of treatments that were initiated. In other words, the place where they should be received becomes a space of discriminatory relationships, distancing the LGBTQIA+ population from public health environments, which worsens their health conditions¹⁴, given this situation.

Among the LGBTQIA+ population, trans people face the most significant difficulties in seeking health services due to specific demands and access to transsexualizing services. Trans/transvestiphobia episodes in the daily routine of healthcare facilities lead to recommendations for reducing discriminatory processes towards this population and an understanding of diversity regarding sexuality to seek respect for the uniqueness of subjects¹⁰.

Although the Ministry of Health assumes essential initiatives, such as publishing ordinances and establishing specific health services for this population, we can understand that, even so, this segment faces the most difficulties in accessing health services, from primary to high-complexity care. Therefore, the scarce resources and the lack of policies and programs to combat discrimination tend to take on a leading role as a barrier to access to healthcare for transvestites and trans women¹¹.

In this integrative research, mention was found in the literature about the publication of the National Comprehensive Health Policy for LGBT people, which advocates access to health without discrimination and with the right and respect for the social name [...]⁸⁽⁴²⁾.

Therefore, the results of this research corroborate the measurements of Querino et al.¹², who state how the promotion of health services, programs, and actions for the LGBTQIA+ population indicates greater equity, completeness, and universality proposed by the Brazilian health reform.

Discussion

Based on reading the works, I name approaches to highlight characteristics presented in the collected articles and indicate, as a result, that it is crucial to build and form networks with other sectors, monitor mental health in the territory, and establish specific actions.

Care is in constant production within routine contexts and experiences. It is interesting to reflect that in CAPS, those who receive the subjects are multidisciplinary professionals with mental health training or specialization, supported by a doctor to define and include the International Classification of Diseases (ICD) code, understanding that users’ protagonism and autonomy can move in a rather individual direction towards a collective one, where the care of oneself permeates the care of others, understanding that this depends on the service that users start to integrate¹¹⁽⁴²⁾.

It is vital to highlight affirmative policies, considering that the high rate of school dropout, low schooling, and lack of access to technical and professional training in the lives of transvestites and trans women can lead to vulnerability and marginalization of this population and hinder their incorporation into the job market¹³.

We highlight here the issue of the search for the body’s femininity, a need that overlaps with fear of the existing risk, resulting in the lack of a health system that supports such demands, in the administration of excessive doses of hormones, and even in the application of industrial silicone¹⁴.

Final considerations: the importance of inclusive public policies for trans and transvestite women

Still thinking specifically about the case of trans and transvestite women, this integrative review research allows us to elaborate within the limits of the data described here that discrimination and stigmatization in health services and equipment - a clear expression of institutional transphobia -, for example, disrespect for the social name, are evidence of an access barrier that culminates in distress and illness¹⁵.

I defend and propose disseminating the current legislation on care for the LGBTQIA+ population to improve care for these people and their access to health. Furthermore, it is essential to include content in health professional training that addresses specific care for trans and transvestite women in health course subjects¹⁶.

Permanent or continuing education aimed at working professionals is extremely relevant, and the training of health professionals should be articulated with the needs and demands of the target population. Besides health policies, it is necessary to produce scientific knowledge so that new actions can help face the ongoing challenges.

I highlight here the consolidation of CAPS as a substitutive service that derives from the Psychiatric Reform, a movement with its distinct complexity, as this is an expansion of processes that involve social struggles to care for mentally distressed subjects and care production strategy, an institutional arrangement created through a network of actions performed beyond the walls of the service^11(30-31).

Due to its dynamics, some strategy changes may occur when operating in the territory. As a result, adjustments and strategy changes can occur in light of the territory’s responses. We thus have health as a social production and action mode in the daily lives of these services¹⁷.

Built with many dynamics, HR practices look at the substance and the subject from a macro perspective, their relationship with the drug and the world. Therefore, it is necessary to expand its actions to other objectives, such as guaranteeing citizenship and human rights. Considering the debate that this article proposes, one conclusion stands out: the need to confront transphobia in the SUS remains. Such confrontation is fundamental and includes guaranteeing access to public health services and the quality of care for the LGBTQIA+ population.

• Financial support: non-existent

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Edited by

Responsible editor: Vania Reis Girianelli

Publication Dates

• Publication in this collection
  28 June 2024
• Date of issue
  Dec 2023

History

• Received
  23 Oct 2023
• Accepted
  03 Dec 2023