ABSTRACT

Objective

To investigate the prevalence of psychiatric medication use and sociodemographic factors, including gender identity, age, race/skin color, education level, formal employment, and access to Primary Health Care (PHC) centers, among individuals receiving care at a transgender outpatient clinic in Southern Brazil.

Methods

: This was a cross-sectional study using administrative data from the information systems of the Municipal Health Department of Porto Alegre, the capital city of Rio Grande do Sul state, collected between 2021 and 2022.

Results

: This study analyzed 629 records of individuals who accessed the outpatient clinic and found a 29% prevalence (95%CI 25;32) of psychiatric medication use, with the most frequent class being psychoanaleptics (45%), especially fluoxetine (31%).

Conclusion

In addition to a trend toward mixed-race race/skin color and incomplete elementary school, transgender people aged 40 to 49 years and with access to a Primary Health Care center were more likely to use psychiatric medications.

Palabras clave
Personas Transgénero; Minorías Sexuales y de Género; Salud Mental; Utilización de Medicamentos; Estudios Transversales

Study contributions

Main results

Prevalence of 29% (95%CI 25;32) of psychiatric medication use was observed, with a higher likelihood among individuals aged 40 to 49 years, with access to primary healthcare centers. Low education level and mixed-race/skin color showed significant effect sizes. The most frequently dispensed drug class was psychoanaleptics (45%), with fluoxetine (31%) standing out.

Implications for services

This study can be replicated in other transgender outpatient clinics across Brazil and should contribute to broadening the discussion on mental healthcare for the transgender population.

Perspectives

The findings highlight the importance of interdisciplinary approaches to healthcare and underscore the need to assess the effectiveness of public mental health policies for the transgender population.

Palabras clave
Personas Transgénero; Minorías Sexuales y de Género; Salud Mental; Utilización de Medicamentos; Estudios Transversales

RESUMEN

Objetivo

Investigar la prevalencia del uso de medicamentos psiquiátricos y los factores sociodemográficos, incluyendo identidad de género, edad, color de piel, nivel educativo, empleo formal y acceso a unidades de Atención Primaria de Salud (APS), entre personas atendidas en un ambulatorio trans en el sur de Brasil.

Métodos

Estudio transversal que utilizó datos administrativos de los sistemas de información de la Secretaría Municipal de Salud de Porto Alegre, recolectados entre 2021 y 2022.

Resultados

Este estudio analizó 629 registros de personas que accedieron al ambulatorio, encontró una prevalencia del 29% (IC₉₅%: 25-32) en el uso de medicamentos psiquiátricos, con mayor frecuencia en la clase psicoanaléptica (45%), destacando el uso de fluoxetina (31%).

Conclusión

Además de la tendencia relacionada al color pardo y educación primaria incompleta, las personas trans de 40 a 49 años, con acceso a una Unidad de Atención Primaria de Salud, presentaron mayor probabilidad de usar medicamentos psiquiátricos.

Palabras clave
Personas Transgénero; Minorías Sexuales y de Género; Salud Mental; Utilización de Medicamentos; Estudios Transversales

INTRODUCTION

Transgender people are those who do not identify with the sex/gender assigned to them at birth, and may identify as trans men, trans women, transvestites or non-binary, experiencing or not the man-woman gender binary.¹1 Jesus, JG. de. Orientações sobre identidade de gênero: Guia técnico sobre pessoas transexuais, travestis e demais transgêneros, para formadores de opinião. [Internet]. 2012; 2:1–42. Estimates regarding the proportion of people who identify as transgender or non-binary in the adult population vary. In the United States, 1.3 million, or 0.6% of adults, identify as transgender,²2 Herman JL, O’Neill K. Transgender population size in the United States: Updated estimates [Internet]. Los Angeles (CA): The Williams Institute, UCLA School of Law; 2022. Disponível em: https://williamsinstitute.law.ucla.edu/wp-content/uploads/Trans-Pop-Update-Jun-2022.pdf
https://williamsinstitute.law.ucla.edu/w... while in Brazil, there are 3 million, or 2% of the adult population.³3 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 Reports [Internet]. 2021;11(1):1–7. Disponível em: https://www.nature.com/articles/s41598-021- 81411-4

This population faces significant disparities in terms of quality of life and mental health when compared to the general population. These differences may be driven by stigma, discrimination and violence, which are motivated by prejudice, such as hate crimes based on sexual orientation or gender identity.⁴4 Tran NK, Lunn M. R, Schulkey CE, Tesfaye S, Nambiar S, Chatterjee S, et al. Prevalence of 12 Common Health Conditions in Sexual and Gender Minority Participants in the All of Us Research Program. JAMA Netw Open [Internet]. 2023;6(7):e2324969. Disponível em: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2807788 According to a report published by the National Association of Transvestites and Transsexuals (Associação Nacional de Travestis e Transexuais – ANTRA), between 2017 and 2023, it is estimated that 1,057 transgender people and transvestites were murdered in Brazil, amounting to about 13 deaths per month. Most of these victims were trans women or transvestites, sex workers, of Black race/skin color, and with low levels of education, making Brazil the country with the highest number of trans murders worldwide for the fourteenth consecutive year.⁵5 Benevides BG, organizador. Dossiê: Assassinatos e violências contra travestis e transexuais brasileiras em 2023. Brasília, DF: Distrito Drag; 2024. 132 p.

Furthermore, transgender people are considered a social minority due to historical processes of marginalization and discrimination. This results in various social disadvantages, such as minority stress, gender dysphoria, and difficulties in accessing basic rights like education, healthcare, employment, and legal recognition of gender identity. These challenges negatively impact biopsychosocial well-being and exacerbate health problems, particularly in mental health, as this population frequently experiences multiple forms of violence and prejudice, increasing the risk of mental disorders.⁶6 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 [Internet]. 2021 Out; 26:5045–56. Disponível em: https://doi.org/10.1590/1413-812320212611.3.28532019
https://doi.org/10.1590/1413-81232021261... ,⁷7 Pellicane MJ, Ciesla JA. Associations between minority stress, depression, and suicidal ideation and attempts in transgender and gender diverse (TGD) individuals: Systematic review and meta-analysis. Clin Psychol Rev. [Internet]. 2022 1; 91:102113. Disponível em: https://doi.org/10.1016/j.cpr.2021.102113
https://doi.org/10.1016/j.cpr.2021.10211...

Thus, this study aims to estimate the prevalence of psychiatric medication use and associated factors among people receiving care at a transgender outpatient clinic in a Brazilian capital city, in order to address collective mental health in the trans population.

METHODS

This is an analytical, cross-sectional, epidemiological study that followed the guidelines of the Strengthening the Reporting of Observational Studies in Epidemiology. The study was conducted using secondary data from the Transgender Outpatient Clinic and the Medication Dispensing Information System (Sistema de Informação de Dispensação de Medicamentos – DIS). in the city of Porto Alegre. Data collection was carried out using the clinic’s administrative database and the DIS. From the former, sociodemographic information was retrieved, and from the latter, data on dispensed medications were collected.

Historically, the transsexualization process in Brazil, which focused on hospital and surgical procedures, did not address the general healthcare needs of transgender people. This process involved gender affirmation surgeries and other medical procedures in specialized centers, but faced significant challenges, such as the lack of a holistic approach that considered the comprehensive health of transgender people, resulting in a fragmented care. Until 2019, the year the Transgender Outpatient Clinic was established, there were only five registered services in the country.

In 2017, the creation of the LGBT Health Technical Area and the Operational Plan represented a significant advancement in addressing the needs of the transgender population. The Trans Outpatient Clinic, integrated into the 2019-2021 II Operational Plan of the Municipal Comprehensive Health Policy for Lesbians, Gays, Bisexuals, Transvestites, Transsexuals, Queers, Intersex and Non-Binary People (PMSILGBTQI+) in Porto Alegre, was established to meet the demands of the local trans and transvestite social movement since 2018. This service was an important step in constructing a more inclusive healthcare system tailored to the specific needs of this population.

The Trans Outpatient Clinic was inaugurated in 2019 as a fully funded service by the Brazilian National Health System (Sistema Único de Saúde – SUS) and operating on an “open door” basis. Initially, it was implemented without the necessary funding, specific staff or adequate infrastructure, a situation that persisted until the service was relocated, allowing for a reorganization and improvements in care. Following the relocation, the outpatient clinic began offering individual and group consultations, as well as medical and nursing procedures. Aimed at transgender people and transvestites living in Porto Alegre, its services are equivalent to those provided by a primary health care (PHC) center, offering comprehensive and inclusive care. In addition, it is serves as a field of practice for multi-professional residency programs in mental health, family and community health, and public health.

This context highlights the importance of health policies that address the specific needs of the transgender population, integrating specialized care with a broad and inclusive approach. While national policies are essential, their local implementation is crucial in transforming reality. Although national policies provide framework for dialogue, local initiatives, such as the Transgender Outpatient Clinic, are key to significant progress and more effective, accessible care for transgender people.⁸8 Thomazi GL, Avila S, Teixeira LB. Ambulatório T da Atenção Primária à Saúde de Porto Alegre: política pública de inclusão e garantia de direito à saúde de pessoas trans. Sex, Salud Soc (Rio J) [Internet]. 2022; (38):e22302. Disponível em: https://doi.org/10.1590/1984-6487.sess.2022.38.e22302.a

The DIS is an electronic system implemented in Porto Alegre to manage the medication dispensing, containing general identification information about users, such as name, SUS card, date of birth, mother’s name, and taxpayer identification number (Cadastro de Pessoa Física – CPF). At the time of data collection, information on race/skin color, gender identity, or sexual orientation was not included.

To collect outcome data, the registry from the Transgender Outpatient Clinic was used to perform individual searches in the DIS system using the SUS card number and/or CPF. Additionally, the 2023 Municipal List of Essential Medicines (Relação Municipal de Medicamentos Essenciais – REMUME) was used to classify and identify medications subject to special control.

Population and data analysis

A total of 629 records of people who accessed the Transgender Outpatient Clinic between 2021 and 2022, were aged 18 years or older and resided in the municipality. The study outcome considered the use of psychiatric medication as measured by the dispensing recorded in the DIS. Independent variables included sociodemographic characteristics and healthcare access, such as gender identity, age, race/skin color, education level, formal employment and access to a PHC center.

Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS®), version 18.0. For the analysis of sample distribution and prevalence of psychiatric medication use according to independent variables, the Mann-Whitney U test, Pearson’s chi-square test, and Fisher’s exact test were used, with a significant level of 20%. To estimate the crude and adjusted prevalence ratios (PR) of psychiatric medication use based on sociodemographic variables, a backward Poisson regression approach was used, with robust variance, with a 5% significance level. Medications were classified according to their pharmacological class, based on the Anatomical Therapeutic Chemical (ATC).

Ethical considerations

The project was submitted to the Research Ethics Committee of the Municipal Health Department of Porto Alegre, Opinion No. 6,460,330.

As this study used secondary data, the Free and Informed Consent Form was replaced by the data confidentiality agreement regarding data handling.

RESULTS

A total of 263 (41.9%) trans men, 227 (36.1%) trans women, 101 (16.1%) non-binary people, 16 (2.6%) transvestites and 21 (3.3%) individuals categorized as “other”, as they did not identify with any of the gender categories presented when they first started receiving care at the service. Regarding race/skin color, 436 (72.7%) individuals self-identified as White; 69 (11.5%), mixed-race; 86 (14.3%), Black; 2 (0.3%), Indigenous; and 7 (1.2%), Asian. As for age, the median age was 26 years [IQ 22; 32], with a minimum age of 18 years and a maximum of 71 years. With regard to education, 29 (5.2%) people had incomplete elementary school; 20 (3.6%), had complete elementary school; 14 (18.7%), incomplete high school; 191 (34.4%), complete high school; 142 (25.6%), incomplete higher education; and 69 (12.4%), complete higher education.

Regarding social name rectification, 118 (19.1%) people had their name legally changed and 499 (80.9%) had not rectified their name. Furthermore, regarding formal employment, 182 (34%) individuals reported having a formal job and 354 (66%) were not formally employed. Concerning access to PHC centers, 298 (47.4%) individuals reported attending their reference healthcare center, while 330 (52.6%) had not accessed it.

The prevalence of psychiatric medication use of 29% (95%CI 25;32) was observed among people registered at the Transgender Outpatient Clinic. Significant frequencies for psychiatric medication use were observed among individuals with a median age of 27 years [IQR 23; 38], those identifying as mixed-race (44%), those with incomplete elementary school (45%), and those who had accessed a PHC center (40%), as shown in Table 1.

A total of 391 psychiatric medication dispensations were performed during the study period, with the highest proportion dispensed for the psychotropic category (45%), notably fluoxetine (31%), followed by psycholeptic category (36%), with chlorpromazine being the most common (12%). On the other hand, the lowest frequencies were observed in the antiepileptic and anti-parkinsonian categories, with 17% and 1%, respectively, valproic acid (9%) being the most used antiepileptic treatment (Table 2).

As for the multivariate analysis of the data, the results of the effect between sociodemographic and access factors with the use of psychiatric medication in people receiving care at the Transgender Outpatient Clinic indicate that, after adjusting for variables using the elimination method, the factors “age group” and “access to a healthcare center” were associated with a higher likelihood of psychiatric medication use. Therefore, it could be seen that people aged 40 to 49 years were 2,06 (IC₉₅% 1,55;2,73) times more likely to use psychiatric medications when compared to younger age groups. On the other hand, the lack of access to a PHC center showed a protective factor of 0.46 (95%CI 0.35;0.60), when compared to those with access. Although the variables “education level” and “race/skin color” lost statistical significance in the adjusted model, they showed an association trend in the bivariate analysis (Table 3). Individuals with incomplete elementary school showed the highest adjusted PR, of 1.39 (95%CI 0.91;2.12), and those identifying as mixed-race had the highest adjusted PR of 1.33 (95%CI 0.97;1.81). The “Indigenous” category was not included in the multivariable analysis due to equal distribution (50%) between groups, preventing precise estimation of statistical effects.

DISCUSSION

This study presented results that showed a prevalence of psychiatric medication dispensing in 29% of the sample. Being a person of Black race/skin color and having incomplete elementary school were observed as risk factors in the bivariate analysis. Furthermore, characteristics such as being an adult and having access to a PHC center remained associated in the adjusted model.

It is worth highlighting that the lack of official data on transgender people and transvestites in Brazil, a serious issue that hampers the implementation and improvement of public policies. The Census and the National Health Policy (Política Nacional de Saúde – PNS) do not contain fields that refer to gender identity. As such, the data available in Brazil are primarily obtained from academic research and surveys conducted by non-governmental organizations led by transgender people, such as ANTRA.⁵5 Benevides BG, organizador. Dossiê: Assassinatos e violências contra travestis e transexuais brasileiras em 2023. Brasília, DF: Distrito Drag; 2024. 132 p.

According to the World Health Organization, the global prevalence of mental disorders in the population is 13%; however, this occurrence may vary based on different population characteristics.⁹9 WHO. World mental health report: transforming mental health for all. Geneva; 2022. In Brazil, no comprehensive estimate for all common mental disorders has been found in the literature. However, according to the 2019 National Health Survey, approximately 10% of the population reported having received a diagnosis of depression from a mental health professional.¹⁰10 IBGE. Pesquisa nacional de saúde: 2019: ciclos de vida: Brasil. Rio de Janeiro: IBGE; 2021. 139 p. Ministério da Saúde. Disponível em: https://www.pns.icict.fiocruz.br/wp-content/uploads/2021/12/liv101846.pdf
https://www.pns.icict.fiocruz.br/wp-cont... Regarding the use of psychiatric medications, we found only one systematic review addressing the Brazilian population. However, this study is limited to the prevalence of the use of a specific class of drugs – antidepressants – and reported an overall proportion of 4% across the studies reviewed.¹¹11 Tiguman GMB, Hoefler R, Silva MT, Lima VG, Ribeiro-Vaz I, Galvão TF. Prevalence of antidepressant use in Brazil: a systematic review with meta-analysis. Braz J Psychiatry [Internet]. 2024; 46: e20233095. Disponível em: https://doi.org/10.47626/1516-4446-2023-3095
https://doi.org/10.47626/1516-4446-2023-... In our study, it could be seen that the frequency for fluoxetine was 31.5%, and for amitriptyline was 10.7%. Taking into consideration that transgender people and transvestites are more exposed to various types of violence and experience greater social vulnerability, they are at higher risk of developing mental health problems compared to the general population. This risk is still evident among transgender people, and varies depending on factors such as age, race/skin color, place of residence, education level and economic situation.¹²12 Vance SR, Boyer CB, Glidden DV, Sevelius J. Mental Health and Psychosocial Risk and Protective Factors Among Black and Latinx Transgender Youth Compared With Peers. JAMA network open [Internet]. 2021. 2021 Mar 1;4(3):e213256. doi: 10.1001/jamanetworkopen.2021.3256. Disponível em: https://doi.org/10.1001/jamanetworkopen.2021.3256
https://doi.org/10.1001/jamanetworkopen.... ,¹³13 Nogueira FJ de S, Leitão ES de F, Silva ECS da. Interseccionalidades na Experiência de Pessoas Trans nos Serviços de Saúde. PSSA [Internet]. 17 de novembro de 2021; 13(3):35-49. Disponível em: https://pssa.ucdb.br/pssa/article/view/1243

Regarding the median age in the study for dispensing psychiatric medication, it could be seen that older people had a higher prevalence of medication withdrawal, and those aged 40 to 49 years had the highest adjusted PR. This phenomenon can be partially explained by the fact that these individuals grew up and lived in a society that considered sexual orientation and gender identity as mental disorders.¹⁴14 Alvares J, Penna MN, Garcia LDM, Falcke D. Saúde mental de pessoas transgênero: revisão integrativa de literatura. PSIUNISC [Internet]. 6 de setembro de 2022; 6(2):139-57. Disponível em: https://online.unisc.br/seer/index.php/psi/article/view/17227 Thus, only in 2019, transgender was removed from the category of mental health disorders and included in the category of conditions related to sexual health, in the International Classification of Diseases. Studies have shown that the depathologization of transgender identity, gender affirmation processes, the use of the social name and self-declared gender were associated with the reduction of symptoms of anxiety and depression, leading to a sense of belonging, improved social integration, greater engagement of transgender people to healthcare services and improved quality of life.¹⁵15 Fontanari AMV, Vilanova F, Schneider MA, Chinazzo I, Soll BM, Schwarz K, Lobato MIR, Brandelli Costa A. Gender Affirmation Is Associated with Transgender and Gender Nonbinary Youth Mental Health Improvement. LGBT Health. [Internet]. 2020 Jul;7(5):237-247. doi: 10.1089/lgbt.2019.0046. Disponível em: https://doi.org/10.1089/lgbt.2019.0046
https://doi.org/10.1089/lgbt.2019.0046... ,¹⁶16 Turban JL, King D, Kobe J, Reisner SL, Keuroghlian AS. Access to gender- affirming hormones during adolescence and mental health outcomes among transgender adults. PLoS One [Internet]. 2022. 17(1): e0261039. doi: https://doi.org/10.1371/journal.pone.0261039 Disponível em: https://doi.org/10.1371/journal.pone.0261039
https://doi.org/https://doi.org/10.1371/...

The dispensing of psychiatric medications was more prevalent among individuals self-identified as Black and mixed-race with lower levels of education, despite greater access to outpatient services being observed among. White individuals with higher level of education. Given that, studies show that self-declared Black transgender people, who face more discrimination and violence, have a lower level of education, are more likely to be employed in underpaid jobs, experience worse socioeconomic conditions and have lower life expectancy, resulting in a significantly higher risk of developing health problems and psychological distress.¹⁷17 O’Brien R, Neman T, Seltzer N, Evans L, Venkataramani A. Structural racism, economic opportunity and racial health disparities: Evidence from U.S. counties. SSM – Popul Heal [Internet]. 2020 Mar 9; 11:100564. doi: 10.1016/j.ssmph.2020.100564. Disponível em: https://doi.org/10.1016/j.ssmph.2020.100564
https://doi.org/10.1016/j.ssmph.2020.100... ,¹⁸18 Biello KB, Hughto JMW. Measuring intersectional stigma among racially and ethnically diverse transgender women: Challenges and opportunities. Am J Public Health [Internet]. 2021 Mar; 111(3):344-346. doi: 10.2105/AJPH.2020.306141. Disponível em: https://ajph.aphapublications.org/doi/10.2105/AJPH.2020.306141
https://doi.org/10.2105/AJPH.2020.306141... According to a survey conducted by Antra , entre 2017 e 2023, approximately 17 78,7% of transgender people murdered were Black, and 57% were sex workers.⁵5 Benevides BG, organizador. Dossiê: Assassinatos e violências contra travestis e transexuais brasileiras em 2023. Brasília, DF: Distrito Drag; 2024. 132 p. Given that, the concept of intersectionality allows us to better understand this result, as it analyzes the multiple forms of discrimination that a person can experience, which more pronounced among transgender, Black people and people belonging to social classes with lower purchasing power.¹⁸18 Biello KB, Hughto JMW. Measuring intersectional stigma among racially and ethnically diverse transgender women: Challenges and opportunities. Am J Public Health [Internet]. 2021 Mar; 111(3):344-346. doi: 10.2105/AJPH.2020.306141. Disponível em: https://ajph.aphapublications.org/doi/10.2105/AJPH.2020.306141
https://doi.org/10.2105/AJPH.2020.306141...

Regarding healthcare access, recognizing the vulnerability of the transgender population and its historical detachment from the SUS, the PNSILGBT was launched to ensure universal access to healthcare for this population. It establishes guidelines for inclusive care and comprehensive prevention and health promotion. However, when attempting to access healthcare services, transgender people face several barriers, such as the pathologization of their identities, institutional prejudice and discrimination by healthcare professionals, resistance to the use of their social name and appropriate pronouns, and lack of support.¹⁹19 Oliveira PHL de, Galvão JR, Rocha KS, Santos AM dos. Itinerário terapêutico de pessoas transgênero: assistência despersonalizada e produtora de iniquidades. Physis [Internet]. 2022;32(2):e320209. Disponível em: https://doi.org/10.1590/S0103-73312022320209
https://doi.org/10.1590/S0103-7331202232... ,²⁰20 Lima RRT de, Flor TBM, Noro LRA. Revisão sistemática sobre a atenção à saúde para travestis e transexuais no Brasil. Rev. saúde pública [Internet]. 30 de março de 2023;57(1):19. Disponível em: https://www.revistas.usp.br/rsp/article/view/210288 These barriers contribute to delays in seeking preventive care, increasing the risk of developing chronic diseases and worsening mental health problems.

Historical discrimination imposed by heteronormative, sexist, racist and classist society, can lead to social and institutional marginalization of the transgender population, contributing to increasing the risk of developing mental health problems, high-risk behavior for sexually transmitted infections and substance abuse.⁴4 Tran NK, Lunn M. R, Schulkey CE, Tesfaye S, Nambiar S, Chatterjee S, et al. Prevalence of 12 Common Health Conditions in Sexual and Gender Minority Participants in the All of Us Research Program. JAMA Netw Open [Internet]. 2023;6(7):e2324969. Disponível em: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2807788,⁶6 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 [Internet]. 2021 Out; 26:5045–56. Disponível em: https://doi.org/10.1590/1413-812320212611.3.28532019
https://doi.org/10.1590/1413-81232021261... ,⁷7 Pellicane MJ, Ciesla JA. Associations between minority stress, depression, and suicidal ideation and attempts in transgender and gender diverse (TGD) individuals: Systematic review and meta-analysis. Clin Psychol Rev. [Internet]. 2022 1; 91:102113. Disponível em: https://doi.org/10.1016/j.cpr.2021.102113
https://doi.org/10.1016/j.cpr.2021.10211... In this study, the medications most frequently dispensed included fluoxetine, followed by chlorpromazine, lithium carbonate, amitriptyline and valproic acid. Although we present the frequency of medications dispensing according to the ATC classification, we use the perspective of the therapeutic approach and recommendation of the use of medications in our discussion, to expand the understanding of their use in mental health care.

Overall, studies indicate high prevalence of mental disorders, such as depression, anxiety and suicide behavior among transgender people, as a result of daily transphobic violence.²¹21 Lund EM, Burgess CM. Sexual and Gender Minority Health Care Disparities: Barriers to Care and Strategies to Bridge the Gap. Prim Care Clin Off Pract. [Internet]. 2021;48(2):179–89. Disponível em: https://doi.org/10.1016/j.pop.2021.02.007
https://doi.org/10.1016/j.pop.2021.02.00... The data presented in this study corroborate the scientific literature regarding the mental suffering of this population, with approximately 70% of the 659 people in the study diagnosed with depression and anxiety, and a significant portion reporting suicidal thoughts.²²22 Kattari SK, Kattari L, Johnson I, Lacombe-Duncan A, Misiolek BA. Differential Experiences of Mental Health among Trans/Gender Diverse Adults in Michigan. Int J Environ Res Public Health. [Internet]. 2020 Sep 18;17(18):6805. doi: 10.3390/ijerph17186805. Disponível em: https://doi.org/10.3390/ijerph17186805
https://doi.org/10.3390/ijerph17186805. ... In addition, they were more likely to be prescribed for antidepressants and anxiolytics and to be hospitalized following suicide attempts.²³23 Bränström R, Pachankis JE. Reduction in Mental Health Treatment Utilization Among Transgender Individuals After Gender-Affirming Surgeries: A Total Population Study. American Journal of Psychiatry [Internet]. 2020 Aug 1;177(8):727–34. Disponível em: 10.1176/appi.ajp.2019.19010080 In our study, we observed prevalence in the dispensing of fluoxetine, amitriptyline, clonazepam and diazepam, medications typically used in the treatment of depression and anxiety, contributing to reducing symptoms.

The mental health disparities among transgender people can be associated with minority stress, as both daily stressors and specific stressors negatively impact mental health indicators and quality of life of this population.²⁴24 Hoy-Ellis CP. Minority Stress and Mental Health: A Review of the Literature. J Homosex. [Internet]. 2023 Apr 16;70(5):806-830. doi: 10.1080/00918369.2021.2004794. Disponível em: https://pubmed.ncbi.nlm.nih.gov/34812698/
https://doi.org/10.1080/00918369.2021.20... A study conducted in Chicago, which used a population cohort of young people from sexual and gender minorities, associated family rejection, among transgender people, with increased symptoms of depression and social isolation associated with suicidal ideation. This study also compared social, family and friend support, between transgender youth and minority cisgender youth, identifying lower levels of support among transgender youth in their relationships.²⁵25 Newcomb ME, Hill R, Buehler K, Ryan DT, Whitton SW, Mustanski B. High Burden of Mental Health Problems, Substance Use, Violence, and Related Psychosocial Factors in Transgender, Non-Binary, and Gender Diverse Youth and Young Adults. Arch Sex Behav. [Internet]. 2020. Feb;49(2):645-659. doi: 10.1007/s10508-019-01533-9. Disponível em: https://doi.org/10.1007/s10508-019-01533-9
https://doi.org/10.1007/s10508-019-01533... This finding is in line with other studies that found a strong correlation between stigmatization, discrimination and severe depression.²⁶26 Lin Y, Xie H, Huang Z, Zhang Q, Wilson A, Hou J, et al. The mental health of transgender and gender non-conforming people in China: a systematic review. Lancet Public Health [Internet]. 2021;6(9):e591–e592. Disponível em: http://www.thelancet.com/article/S246826672100236X/fulltext

The literature also suggests that the excessive burden of social stressors associated with low levels of education, informal access to the labor market, and fragile social support is linked to early use of psychoactive substances and a higher risk of substance abuse.²⁷27 Souza IC de, Tavares TMCL, Beserra G de L, Araújo Júnior AJL de, Sousa WMA, Ribeiro SG, et al. Drug use and perceived social support in a sexual minority. Rev Gaúcha Enferm [Internet]. 2022;43:e20210151. Disponível em: https://doi.org/10.1590/1983-1447.2022.20210151.en
https://doi.org/10.1590/1983-1447.2022.2... ,²⁸28 Cotaina M, Peraire M, Boscá M, Echeverria I, Benito A, Haro G. Substance Use in the Transgender Population: A Meta-Analysis. Brain Sci. 2022;12(3):366. [Internet]. 2022 Mar 10. doi:10.3390/brainsci12030366. Disponível em: https://doi.org/10.3390/brainsci12030366
https://doi.org/10.3390/brainsci12030366... Furthermore, it is worth highlighting that mental suffering is not only due to gender identity, but rather arises from the intersection between gender, race, territory, and educational level, with specific segments of this population (Black and impoverished people) being exposed to greater survival risks.⁵5 Benevides BG, organizador. Dossiê: Assassinatos e violências contra travestis e transexuais brasileiras em 2023. Brasília, DF: Distrito Drag; 2024. 132 p.

In our study, the results of the PR on the use of psychiatric medication contribute to the discussion in the field of health policies aimed at the transgender population. It should be noted that, despite the efforts represented by the implementation of the PNSILGBT, there remains a challenge in ensuring that this population has equitable access to health care. Given the results of this study, it is clear that inequalities in access to health services intensify the historical vulnerabilities and disparities experienced by these people. Transgender people do not suffer solely because they are transgender, but because of society’s lack of acceptance and the prejudice they encounter, which negatively impacts various aspects of their lives, such as education, employment, relationships, and health.

It is essential to recognize that, when administered safely and appropriately, medication can control and alleviate the symptoms of mental disorders. However, psychiatric medication use remains stigmatized due to misconceptions about mental disorders and their treatment. The decision to prescribe psychotropic medications must consider the patient’s diagnosis, medical history, age, comorbidities, and the concurrent use of other medications or substances. On the one hand, we discuss whether the prevalence of psychiatric medication use may be an intermediary for the high occurrence of mental disorders among the transgender population; on the other hand, we acknowledge the importance of equity and guaranteeing access to pharmacological technologies.

Access to medications should be viewed as an essential part of mental health care, particularly given the numerous barriers transgender individuals face when accessing healthcare services. The lack of mental health services within the SUS exacerbates this situation, resulting in limited access to psychiatric medications and psychotherapies for this population. Therefore, improving safe and adequate access to medications is crucial to addressing the mental health needs of these vulnerable groups.

Furthermore, when accessing health services, transgender people face complex and multifaceted organizational barriers related to discrimination, pathologization, inadequate reception and sociodemographic factors, which result in healthcare avoidance.²⁹29 Kcomt L, Gorey KM, Barrett BJ, McCabe SE. Healthcare avoidance due to anticipated discrimination among transgender people: A call to create trans-affirmative environments. SSM Popul Health. [Internet]. 2020 May 28; 11:100608. Disponível em: https://doi.org/10.1016/j.ssmph.2020.100608
https://doi.org/10.1016/j.ssmph.2020.100... It is important to recognize that a successful model of equitable and comprehensive healthcare requires acknowledging the specific needs of each group. A strategy to overcome these barriers and fully implement the policy includes the training of healthcare professionals and support staff to improve the reception and care for this population.³⁰30 Miskolci R, Signorelli MC, Canavese D, Teixeira F do B, Polidoro M, Moretti-Pires RO, et al. Desafios da saúde da população LGBTI+ no Brasil: uma análise do cenário por triangulação de métodos. Ciênc saúde coletiva [Internet]. 2022 Oct;27(10):3815–24. Disponível em: https://doi.org/10.1590/1413-812320222710.06602022
https://doi.org/10.1590/1413-81232022271...

The limitations of this study include its cross-sectional design, which hinders inferences about changes in exposure over time. Additionally, the scarcity of studies addressing medication use among the transgender population highlights the need for further research on this topic so that effective public policies can be restructured, recognizing that the high prevalence of medication use may reflect mental suffering due to health inequities. We believe that the frequency of medication use was underestimated, as we relied solely on dispensing data as a secondary collection instrument. Therefore, the use of psychometric scales through validated questionnaires should be encouraged. Another limiting factor is the issue of access to treatment and, consequently, to medications, which may have contributed to underestimating the problem.

This study estimated the prevalence of psychiatric medication dispensing and associated factors among individuals receiving care at the Transgender Outpatient Clinic in a capital city in Southern Brazil. The results show that 29% of individuals registered with the service collected one or more medications used to treat mental disorders, with age and lack of access to a PHC center being factors associated with the outcome. Although education and race/skin color, did not remain in the adjusted model, they showed moderate effect measures in the adjusted analysis. Based on these findings, we discuss how stigma and discrimination are vulnerability factors that expose the transgender population to high levels of mental suffering, which is increased when associated with gender, race/skin color, education, and social class.

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