ABSTRACT

Objective

To analyze the temporal trend and characteristics of notifications of violence among the transgender population from 2015 to 2022 in Brazilian municipalities.

Methods

This was a repeated panel epidemiological study, based on violence incidents reported among the transgender population aged 20 to 59 years, available in the Notifiable Health Conditions Information System. An annual temporal trend analysis was performed by means of generalized linear regression, using the Prais-Winsten method and spatial distribution of notifying municipalities in Brazil.

Results

Notifications of violence in the transgender population decreased during the period (1.7%; β = -0.07; p = 0.010), but there was an increase in the number of notifying municipalities (45.8%), self-inflicted violence (28.9%; β = 2.21; p < 0.001) and sexual violence (β = 0.79; p < 0.001). The majority of perpetrators were male and in an affective relationship, especially with transgender women (43.4%; p < 0.001).

Conclusion

Notification of violence does not yet fully reflect the reality of this population, but it represents the first step towards visibility and addressing the issue.

Palabras clave
Personas Transgénero; Violencia de Género; Sistema de Información en Salud; Derechos Humanos; Epidemiología Descriptiva.

Study contributions

Main results

Notifications of violence against transgender people accounted for 1.7% of the total. Self-inflicted and sexual violence increased from 2015 to 2022. Almost half of Brazilian municipalities have already been reporting cases of violence against this population.

Implications for services

Continuous and high-quality notification will contribute to monitoring and understand violence in this population group, enabling the adaptation of services to meet their specific needs.

Perspectives

The development of research on the transgender population will allow for a better understand and guidance of specific health actions for this group. Information on violence against this population is crucial for informing public policies.

Palabras clave
Personas Transgénero; Violencia de Género; Sistema de Información en Salud; Derechos Humanos; Epidemiología Descriptiva.

RESUMEN

Objetivo

Analizar tendencias temporales y características de notificaciones de violencias ocurridas entre la población transgénero de 2015 a 2022, en municipios brasileños

Métodos

Estudio epidemiológico de panel repetido, basado en datos de violencia ocurridos entre población transgénero de 20-59 años, disponibles en el Sistema de Información de Enfermedades de Declaración Obligatoria. Análisis de tendencia temporal anual, se realizó mediante regresión lineal generalizada, utilizando método de Prais-Winsten y distribución espacial de municipios brasileños notificados.

Resultados

Las notificaciones de violencia entre la población trans disminuyeron en el período (1,7%; β = -0,07; p = 0,010), pero con un aumento en municípios reportados (45,8%), violencia autoinfligida (28,9%; β = 2,21; p < 0,001) y sexual (β = 0,79; p < 0,001). La mayoría de los agresores son hombres y mantienen una relación sentimental, especialmente en caso de mujeres transgénero (43,4%; p < 0,001).

Conclusión

Denunciar la violencia aún no refleja la realidad de esta población, pero es el primer paso hacia su visibilización y enfrentamiento.

Palabras clave
Personas Transgénero; Violencia de Género; Sistema de Información en Salud; Derechos Humanos; Epidemiología Descriptiva.

INTRODUCTION

Violence is a complex concept whose damage to physical and psychological health impacts not only health and safety, but also other areas of society, such as education and the economy. Therefore, it must be prioritized in public policies developed in the country.¹1 Krug EG, Dahlberg LL, Mercy JA, Zwi AB, Lozano R. Relatório mundial sobre violência e saúde [Internet]. Organização Mundial da Saúde; 2002 [citado em 5 de maio de 2022]. Disponível em: https://www.opas.org.br/relatorio-mundial-sobre-violencia-e-saude
https://www.opas.org.br/relatorio-mundia... Since 1893, death due to violence has been included in the International Classification of Diseases.²2 Laurenti R. Análise da informação em saúde: 1893-1993, cem anos da Classificação Internacional de Doenças. Rev Saúde Pública. Dezembro de 1991;25(6):407-17. However, it was not until the 1990s that the Pan American Health Organization, in response to the increasing morbidity and mortality from violence in Latin America, recommended the inclusion of violence in the intervention agenda.³3 Minayo MCDS. A difícil e lenta entrada da violência na agenda do setor saúde. Cad Saúde Pública. Junho de 2004;20(3):646-7. Subsequently, the World Health Organization recognized violence as a preventable public health problem issue, and organized the first global report containing recommendations for its management.¹1 Krug EG, Dahlberg LL, Mercy JA, Zwi AB, Lozano R. Relatório mundial sobre violência e saúde [Internet]. Organização Mundial da Saúde; 2002 [citado em 5 de maio de 2022]. Disponível em: https://www.opas.org.br/relatorio-mundial-sobre-violencia-e-saude
https://www.opas.org.br/relatorio-mundia...

Violence is characterized by the intentional use of force or power that may cause injury, death, deprivation, disability or psychological harm.¹1 Krug EG, Dahlberg LL, Mercy JA, Zwi AB, Lozano R. Relatório mundial sobre violência e saúde [Internet]. Organização Mundial da Saúde; 2002 [citado em 5 de maio de 2022]. Disponível em: https://www.opas.org.br/relatorio-mundial-sobre-violencia-e-saude
https://www.opas.org.br/relatorio-mundia... Self-inflicted violence refers to acts of self-harm, ranging from minor injuries to severe wounds and even suicidal behavior, while interpersonal violence involves the use of physical force, power or psychological influence to dominate or exclude another person. Interpersonal violence is subdivided into domestic and community violence. As for domestic violence, perpetrators are family members, intimate partners or individuals who share the domestic space, even occasionally, such as employees and relatives, and this type of violence can occur outside the family environment. Regarding community interpersonal violence, the perpetrators are either strangers or acquaintances, but without family or emotional ties.⁴4 BRASIL. Ministério da Saúde. Secretaria de Vigilância em Saúde. VIVA: instrutivo notificação de violência interpessoal e autoprovocada [Internet]. Brasília; 2015 [citado em 3 de janeiro de 2024]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/viva_instrutivo_violencia_interpessoal_autoprovocada_2ed.pdf
https://bvsms.saude.gov.br/bvs/publicaco...

In 2001, Brazil established the National Policy for the Reduction of Morbidity and Mortality from Accidents and Violence,⁵5 BRASIL. Ministério da Saúde. Portaria no 737 de 16 de maio de 2001. Política nacional de redução da morbimortalidade por acidentes e violências. Diário Oficial da União. maio 18, 2001. and in 2004, the National Network for Violence Prevention and Health Promotion was implmented.⁶6 BRASIL. Ministério da Saúde. Portaria no 936 de 19 de maio de 2004. Dispõe sobre a estruturação da Rede Nacional de Prevenção da Violência e Promoção da Saúde e a Implantação e Implementação de Núcleos de Prevenção à Violência em Estados e Municípios. Diário Oficial da União. 20 de maio de 2004. Since 2011, notification of self-inflicted and interpersonal violence has been part of the compulsory notifications list⁷7 BRASIL. Ministério da Saúde. Portaria no 104 de 25 de janeiro de 2011. Define as terminologias adotadas em legislação nacional, conforme disposto no Regulamento Sanitário Internacional 2005 (RSI 2005), a relação de doenças, agravos e eventos em saúde pública de notificação compulsória em todo o território nacional e estabelecer fluxo, critérios, responsabilidades e atribuições aos profissionais e serviços de saúde. Diário Oficial da União. 26 de janeiro de 2011. and has been included in the Notifiable Health Conditions Information System (Sistema de Informação de Agravos de Notificação - SINAN), allowing for records from across country, although the legislation had already incorporated notification of violence against children and adolescents, the elderly, women and suicide. In 2015, to align with the National Policy for Comprehensive Health of Lesbians, Gays, Bisexuals, Transvestites and Transgender (Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais, Travestis e Transexuais),⁸8 BRASIL. Ministério da Saúde. Secretaria de Gestão Estratégica e Participativa. Departamento de Apoio à Gestão Participativa. Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais, Travestis e Transexuais. 2013. the variables “sexual orientation” and “gender identity” were included in the notification form.⁴4 BRASIL. Ministério da Saúde. Secretaria de Vigilância em Saúde. VIVA: instrutivo notificação de violência interpessoal e autoprovocada [Internet]. Brasília; 2015 [citado em 3 de janeiro de 2024]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/viva_instrutivo_violencia_interpessoal_autoprovocada_2ed.pdf
https://bvsms.saude.gov.br/bvs/publicaco...

Gender identity is the way an individual perceives and expresses themselves socially, and when it differs from their biological sex, the individual is referred to as transgender.⁹9 Jesus JG. Orientações sobre a população transgênero : conceitos e termos / [Internet]. Brasília. [citado em 3 de janeiro de 2024]. 24 p. Disponível em: https://files.cercomp.ufg.br/weby/up/16/o/ORIENTAÇÕES_POPULAÇÃO_TRANS.pdf?1334065989
https://files.cercomp.ufg.br/weby/up/16/... It is estimated that 0.7% of the Brazilian adult population is transgender.¹⁰10 Spizzirri G, Eufrásio R, Lima MCP, De Carvalho Nunes HR, Kreukels BPC, Steensma TD, et al. Proportion of people identified as transgender and non-binary gender in Brazil. Sci Rep. 26 de janeiro de 2021;11(1):2240. This population is among the most vulnerable to violence, due to the great individual and institutional discrimination they experience.¹¹11 Benevides BG, Noguqira SNB. Dossiê Assassinatos e violência contra travestis e transexuais no Brasil em 2018 [Internet]. 2019. Disponível em: https://observatoriotrans.org/produ%C3%A7%C3%B5es
https://observatoriotrans.org/produ%C3%A... Brazil has the highest number of transgender people murdered, especially transvestites and transgender women, reflecting a profound intolerance toward diversity.¹²12 GRUPO GAYS DA BAHIA (GGB). Mortes violentas de LGBT+ no Brasil: relatório 2018 [Internet]. 2019 [citado em 3 de fevereiro de 2024]. Disponível em: https://observatoriomorteseviolenciaslgbtibrasil.org/wp-content/uploads/2022/05/Relatorio-2018.pdf
https://observatoriomorteseviolenciaslgb... ,¹³13 TRANSGENDER EUROPE (TGEU). TMM annual report 2016 [Internet]. 2016 [citado em 19 de fevereiro de 2024]. Disponível em: https://transrespect.org/wp-content/uploads/2016/11/TvT-PS-Vol14-2016.pdf
https://transrespect.org/wp-content/uplo...

Notification of interpersonal and self-inflicted violence among the transgender population enables the monitoring of this population health problem and informs management about necessary intervention actions to reduce and prevent it.¹⁴14 BRASIL. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância de Doenças e Agravos não Transmissíveis e Promoção da Saúde. Notificação de violências interpessoais e autoprovocadas [recurso eletrônico] [Internet]. 2017 [citado em 5 de janeiro de 2024]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/notificacao_violencias_interpessoais_autoprovocadas.pdf
https://bvsms.saude.gov.br/bvs/publicaco... This study aims to analyze the temporal trend and characteristics of notifications of violence among the transgender population between 2015 and 2022, in Brazilian municipalities.

METHOD

This was a repeated panel epidemiological study, a hybrid study combining a cross-sectional and follow-up study,¹⁵15 Klein C, Block K. Estudos Secionais. In: Medronho RA, Block KV, Luiz RR, Werneck GL. Epidemiologia. 2ª edição. São Paulo: Atheneu; 2009. 193-219 p. on self-inflicted and interpersonal violence in the transgender population aged 20 to 59 years, registered in SINAN, in the period from 2015 to 2022, with preliminary data for 2021 and 2022. The files related to the compressed anonymized microdata were downloaded from the website of the Brazilian National Health System Information Technology Department (Departamento de Informática do Sistema Único de Saúde), in the first half of December 2023.

The annual temporal trend for the period was described using the year of notification as the independent variable and the proportion of violence against transgender individuals in relation to the total number of notifications of the age group studied, as well as the proportion of the type of violence (self-inflicted, interpersonal and unknown) among transgender individuals and the proportion of each type of interpersonal violence (physical, psychological, etc.) as the dependent variable. The temporal trend analysis was performed by means of generalized linear regression, using the Prais-Winsten method. In cases where the trend showed statistical significance (p ≤ 0.05), the Durbin -Watson statistic (d) was used, considering an eight-year series, where results between 1.332 and 2.668 confirm that there is no residual autocorrelation.¹⁶16 Gujarati DN, Porter DC. Basic econometrics. 5th ed. Boston: McGraw-Hill Irwin; 2009. 922 p.

The spatial distribution of Brazilian municipalities with and without notifications of violence (self-inflicted and interpersonal) against the transgender population aged 20 to 59 years was presented in a choropleth map, using the TabWin program version 4.1.5, for the initial year of the study series (2015), before the pandemic (2019), during the pandemic (2020) and at the end of the pandemic (2022). The proportion of municipalities in each state and region with notification was also calculated.

Furthermore, the available variables were analyzed: gender, socioeconomic characteristics (age group, race/skin color, and schooling), same municipality of residence and notification (yes; no), characteristics of the perpetrator (number, sex, and relationship), and motivation for the aggression. The percentage of each category of variables was calculated, stratifying the socioeconomic and demographic characteristics by type of notification (self-inflicted and interpersonal) and the characteristics of interpersonal violence by gender (transgender man and transgender woman, including transvestites). Pearson’s chi -square test was used to assess the existence of a statistically significant difference between the strata (p ≤ 0.05), with Yates’ correction, if necessary.

The data were analyzed using the R statistical software version 4.2.1 by means of the foreign, MASS, prais and read.dbc packages.

RESULTS

A total of 2,778,017 cases of violence were reported during the study period, with 1,535,329 occurring in the 25-59 age group (55.3%). Of these, 26,258 (1.7%) were related to the transgender population, showing a downward trend during the period (β = -0.07; p = 0.010; d = 1.71) and with the highest percentage of notification in 2016 (2.2%) (Figure 1). Among the notifications in the transgender population, the majority were related to interpersonal violence (66.6%), although this showed a decrease over the period (β = -1.94; p < 0.001; d = 2.21). However, the percentage of notifications of self-inflicted violence (28.9%), increased (β = 2.21; p < 0.001; d = 1.88), representing 35% of the notifications in 2022. On the other hand, the percentage of notifications classified as unknown regarding the type of violence remained stable (4.5%; p = 0.157).

Figure 2 shows the maps of Brazilian municipalities with notifications of violence against the transgender population in the age group studied. In 2015, 13,2% of municipalities reported violence, which increased to 18.2% in 2019 (before the pandemic), then dropped to 16.4% in 2020 (during the pandemic) and rose to 19.0% in 2022. In the period 2015 to 2022, 45.8% of municipalities reported violence against the transgender population. The Southeast region showed the highest percentage of municipalities with notifications (61.3%), with the highest proportion in the state of Rio de Janeiro (70.7%). The Northeast region had the lowest percentage of notifying municipalities (37.8%), but with a high percentage in the state of Rio Grande do Norte (79.2%), and a low percentage in the states of Sergipe (24.0%), Piauí (15.2%) and Paraíba (12.6%). Over half of the municipalities in the North region reported violence, with a high percentage in the state of Roraima (80.0%).

The notification of self-inflicted violence was proportionally higher among transgender men (22.4%; p < 0.001), those under 40 years of age (78.6%; p < 0.001) and of White race/skin color (45.9%; p < 0.001) compared to interpersonal violence (Table 1). Schooling showed a high percentage of unknown information, which was proportionally higher for notification of self-inflicted violence (31.9%; p < 0.001). Approximately 90% of notifications were made in the municipality of residence, for both self-inflicted and interpersonal violence (p = 0.094).

Multiple types of interpersonal violence were reported in 32.5% of notifications. The majority were cases of physical violence (87.5%), followed by psychological violence (35.3%), but both decreased over the period (β = -0.10; p = 0.041; d = 1.87 and β = -1.06; p = 0.003; d = 1.64, respectively) (Figure 3). Torture also showed a decrease over the period (β = -0.25; p = 0.011; d = 1.91), with the highest percentage of notification in 2015 (6.5%) and the lowest in 2021 (4.4%). Conversely, sexual violence increased (β = 0.79; p < 0.001; d = 2.04), accounting 8.5% of notifications during the period, reaching 11.5% in 2021. Notifications of sexual violence were proportionally higher for transgender men during the period (9.2%; p < 0.001) (data not shown in tables).

Most notifications of interpersonal violence involved a single perpetrator (69.0%), and was committed by males (80.7%), with cases involving more than one perpetrator and those involving perpetrators of both sexes were proportionally higher for transgender men (34.4%; p < 0.001 and 3.7%; p = 0.026, respectively) (Table 2). Regarding the relationship between the perpetrator and the victim, 41.0% involved an affective relationship – spouse, ex-spouse, boyfriend/girlfriend, ex-boyfriend/girlfriend –, being proportionally higher for transgender women (43.4%; p < 0.001); followed by strangers (20.6%), with a higher proportion for transgender men (24.7%; p < 0.001). Violence perpetrated by acquaintances and family members was also proportionally higher for transgender men (21.6% and 12.5%, respectively; p < 0.001). The majority of motives for violence was ignored (32.7%), with a higher proportion for transgender women (33.5%).

DISCUSSION

The study found that 1.7% of the notifications of self-inflicted and interpersonal violence were recorded among the transgender population, reaching 2.2% in 2016. A survey conducted between November and December 2018 estimated that the transgender population aged 18 years and older in the country was 0.7%,¹⁰10 Spizzirri G, Eufrásio R, Lima MCP, De Carvalho Nunes HR, Kreukels BPC, Steensma TD, et al. Proportion of people identified as transgender and non-binary gender in Brazil. Sci Rep. 26 de janeiro de 2021;11(1):2240. with a lower proportion only in the Midwest region (0.2%). However, it is noteworthy that the transgender population is among the most vulnerable to intolerance and discrimination; therefore, a higher proportion of notifications of violence compared to other groups is expected. In addition, the survey¹⁰10 Spizzirri G, Eufrásio R, Lima MCP, De Carvalho Nunes HR, Kreukels BPC, Steensma TD, et al. Proportion of people identified as transgender and non-binary gender in Brazil. Sci Rep. 26 de janeiro de 2021;11(1):2240. was conducted during a period of rising far-right political influence in the country, characterized by conservative moral discourse and strong criticism of “gender ideology,”¹⁷17 Miguel LF. O mito da “ideologia de gênero” no discurso da extrema direita brasileira. Cad Pagu. 2021;(62):e216216. which may have discouraged some participants from responding. However, the percentage of notifying municipalities increased during the period, reaching 19.0% in 2022, but almost half of the municipalities had already reported in the period. Furthermore, approximately 90% of notifications occurred in the municipality of residence, indicating engagement from health services. A study on notifications of interpersonal violence against women aged 20 to 59 years, conducted between 2015 and 2021, found that 31.7% of Brazilian municipalities had recorded cases involving transgender people.¹⁸18 Marinho Neto KRE, Girianelli VR. Violência interpessoal em mulheres transgêneras e cisgêneras nos municípios brasileiros: tendências e características. Cien Saude Colet. 2024;29(7):e02702024.

The proportion of notifications of self-inflicted violence has increased, and was proportionally higher among transgender men, of White race/skin color who were young compared to interpersonal violence. Similar results were found in a study based on medical records from a transgender outpatient clinic in the Federal District,¹⁹19 Corrêa FHM, Rodrigues BB, Mendonça JC, Cruz LRD. Pensamento suicida entre a população transgênero: um estudo epidemiológico. J Bras Psiquiatr. Janeiro de 2020;69(1):13-22. where suicidal ideation was more frequent among transgender men (80.5%), aged 18 to 40 years, and with incomplete high school or higher education (60.6%). A study conducted among transgender adults living in the states of São Paulo and Rio Grande do Sul found that 67.7% had suicidal ideation and 43.1% had already attempted suicide.²⁰20 Chinazzo ÍR, Lobato MIR, Nardi HC, Koller SH, Saadeh A, Costa AB. Impacto do estresse de minoria em sintomas depressivos, ideação suicida e tentativa de suicídio em pessoas trans. Ciênc Saúde Coletiva. Outubro de 2021;26(suppl 3):5045-56. A study conducted with transgender women living in São Paulo identified a history of sexual violence as a factor associated with suicidal ideation and attempts, even after adjusting for other statistically significant factors.²¹21 Reis A, Sperandei S, De Carvalho PGC, Pinheiro TF, De Moura FD, Gomez JL, et al. A cross-sectional study of mental health and suicidality among trans women in São Paulo, Brazil. BMC Psychiatry. Dezembro de 2021;21(1):557.

The majority of notifications of violence in the transgender population concerned women, with 82.0% of cases of interpersonal violence and 77.6% of cases of self-inflicted violence. A study conducted between 2016 and 2020, using data from TabNet on interpersonal violence in the city of São Paulo, also found a higher percentage of notifications among transgender women.²²22 Fernandes H, Bertini PVR, Hino P, Taminato M, Silva LCPD, Adriani PA, et al. Violência interpessoal contra homossexuais, bissexuais e transgêneros. Acta Paul Enferm. 12 de agosto de 2022;35:eAPE01486.

The proportion of notifications of interpersonal violence among the transgender population decreased over the period, but there was an increase in sexual violence, which was higher among men. However notifications of sexual violence have been higher for cisgender women than for transgender women.¹⁸18 Marinho Neto KRE, Girianelli VR. Violência interpessoal em mulheres transgêneras e cisgêneras nos municípios brasileiros: tendências e características. Cien Saude Colet. 2024;29(7):e02702024. Corrective rape, intended to force the individual to change their sexuality to conform to heteronormativity,²³23 Costa L dos S d’Utra. A prática delitiva do estupro corretivo e a heteronormatividade compulsória: um estudo acerca da correlação entre crime e patriarcado. Revista Direito e Sexualidade. Junho de 2021;2(1):50-65. is a form of violence that has been reported among cisgender lesbian women, but transgender men also susceptible to this type of violence. Corrective and collective rape now carry aggravated penalties under the Penal Code.²⁴24 Brasil. Lei no 13.718, de 24 de setembro de 2018. Altera o Decreto-Lei no 2.848, de 7 de dezembro de 1940 (Código Penal), para tipificar os crimes de importunação sexual e de divulgação de cena de estupro, tornar pública incondicionada a natureza da ação penal dos crimes contra a liberdade sexual e dos crimes sexuais contra vulnerável, estabelecer causas de aumento de pena para esses crimes e definir como causas de aumento de pena o estupro coletivo e o estupro corretivo; e revoga dispositivo do Decreto-Lei no 3.688, de 3 de outubro de 1941 (Lei das Contravenções Penais) [Internet]. 2018. Disponível em: https://www.planalto.gov.br/ccivil_03/_Ato2015-2018/2018/Lei/L13718.htm
https://www.planalto.gov.br/ccivil_03/_A...

Physical violence remains the most reported type of violence, but it decreased from 2019 to 2021, which may be related to the difficulty in accessing health services due to the COVID-19 epidemic. The classification of offensive, prejudiced and violence acts against LGBTQIAPN+ people as equivalent to the crime of racism in 2019,²⁵25 Supremo Tribunal Federal (BR). STF enquadra homofobia e transfobia como crimes de racismo ao reconhecer omissão legislativa [Internet]. 2019a. Disponível em: https://portal.stf.jus.br/noticias/verNoticiaDetalhe.asp?idConteudo=414010 Acesso em 10 Jan 2024
https://portal.stf.jus.br/noticias/verNo... may also have influenced the reduction in notifications. The decrease in notifications does not necessarily mean a reduction in violent practices among the transgender population, whose resurgence of physical violence in 2022 nearly returned to the levels seen at the beginning of the series (2015). A study that analyzed violence against women found a higher proportion of notifications of physical violence against transgender women .¹⁸18 Marinho Neto KRE, Girianelli VR. Violência interpessoal em mulheres transgêneras e cisgêneras nos municípios brasileiros: tendências e características. Cien Saude Colet. 2024;29(7):e02702024.

Psychological violence was the second most frequent type of violence, indicating its recognition by both victims and professionals. However, unlike physical violence, it continued to decline in 2022. Psychological violence usually emerges at the beginning of the cycle of aggression, especially in intimate relationships, and therefore tends to be less visible. It is more frequently revealed in interview-based studies,²⁶26 Leite FMC, Amorim MHC, Wehrmeister FC, Gigante DP. Violence against women, Espírito Santo, Brazil. Rev Saúde Pública [Internet]. 2017 [citado em 28 de fevereiro de 2024];51(0). Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-89102017000100223&lng=en&tlng=en physical and sexual violence in women victims of intimate partner violence assisted in the primary care services. METHODS This is a cross-sectional study, conducted in 26 health units in Vitória, State of Espírito Santo, from March to September 2014. We interviewed 991 women aged 20-59 years. To classify the psychological, physical and sexual violence, the World Health Organization instrument on violence against women was used and a questionnaire to investigate the sociodemographic, behavioral characteristics, and the women’s family and life history was developed. The statistical analyzes used were Poisson regression, Fisher’s exact test and Chi-square. RESULTS The prevalence we observed were psychological 25.3% (95%CI 22.6–28.2and can often only be identified by the interviewer.

Most perpetrators were biologically male (80.7%) and had an intimate relationship with the victim (41.0%), with a higher proportion of cases involving transgender women (p < 0.001). A study focused on violence against women found that aggression from people with an emotional bond to the victim was higher among transgender women.¹⁸18 Marinho Neto KRE, Girianelli VR. Violência interpessoal em mulheres transgêneras e cisgêneras nos municípios brasileiros: tendências e características. Cien Saude Colet. 2024;29(7):e02702024. A systematic review and meta-analysis on intimate partner violence in the transgender population²⁷27 Peitzmeier SM, Malik M, Kattari SK, Marrow E, Stephenson R, Agénor M, et al. Intimate Partner Violence in Transgender Populations: Systematic Review and Meta-analysis of Prevalence and Correlates. Am J Public Health. Setembro de 2020;110(9):e1-14.CINAHL found a lifetime prevalence of 37.5% for this type of violence, with transgender people being more likely to experience intimate partner violence compared to the cisgender population. This study included 74 articles from various countries published up to 2019, two of which were Brazilian, although the main focus was on HIV.

The motive for the violence was not recorded in 32.7% of the notifications, making it impossible to identify the main causes of aggression. The notification of violence perpetrated due to gender identity (transphobia), sometimes assumed by the aggressor in relation to the victim, is crucial for informing public policies aimed at combating this discrimination. Schooling also showed a high percentage of missing data, which has been observed in studies based on information systems.

The low completion of some fields in the notification form is one of the limitations of the study, as well as the potential for data entry errors, given that some concepts may still be unfamiliar to health professionals, as evidenced by some studies.²⁸28 Girianelli VR, Ferreira AP, Vianna MB, Teles N, Erthal RMDC, Oliveira MHBD. Qualidade das notificações de violências interpessoal e autoprovocada no Estado do Rio de Janeiro, Brasil, 2009-2016. Cad Saúde Coletiva. 17 de setembro de 2018;26(3):318-26. ,²⁹29 Ministério da Saúde (BR). Qualidade dos dados de notificação de violência interpessoal e autoprovocada, Brasil [Internet]. Brasília: Ministério da Saúde [Internet]; 2016 [citado em 2 de fevereiro de 2024]. Disponível em: https://www.saude.ba.gov.br/wp-content/uploads/2019/03/Qualidade-dos-dados-de-notifica%C3%A7%C3%A3o-de-viol%C3%AAncia-interpessoal-e-autoprovocada-Brasil-%E2%80%93-2016-Relat%C3%B3rio-de-Qualidade.pdf
https://www.saude.ba.gov.br/wp-content/u... The lack of information on gender identity in the demographic census also hinders the estimation of the prevalence of violence in the transgender population, which is essential information for supporting public policies. Existing estimates, despite efforts at representativity, include a small sample size and tend to focus on large urban centers.

Additionally, the likely underreporting is expected to be higher in this type of harm, as it depends on recognition by both the victim and the health professional, a situation that is not always perceived by both. Partnerships with non-governmental organizations, including notification, as provided by law, could help minimize existing underreporting, improve the quality of information and better direct services to meet the needs of this population.

Further research that includes surveys to estimate the size of the transgender population is essential until such data is incorporated into the demographic census, as well as the development of more in-depth studies on self-inflicted and sexual violence, which have increased in this population.

Despite the limitations identified, it is expected that the study can raise awareness of the characteristics of the notifications of violence in the transgender population – which has evolved over the eight years following the inclusion of this population in the notification form – and thus contribute to supporting public policies aimed at addressing this issue.

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