ABSTRACT
Objective
To analyze the representation of access pathways to the transsexualizing process in Brazil and the main barriers faced by transgender people.
Method
A scoping review of the literature was conducted. Searches took place in January 2024, with articles and reviews that addressed access to the transsexualizing process being eligible, while books, chapters, conferences, editorial documents, and studies describing surgical procedures were excluded.
Results
A total of 776 articles were found, of which 9 were included. 66% of the studies analyzed were field research involving interviews. The findings highlight the 5 stages of the transsexualizing process: care at primary healthcare centers, referral, multidisciplinary follow-up, surgical procedure, and local care for individuals.
Conclusion
The studies focused on the barriers to accessing the transsexualizing process, rather than on the access pathways themselves, highlighting a gap in the understanding of the access itineraries to the process. rather than on the access pathways themselves, highlighting a gap in understanding the itineraries to the process.
Palabras clave
Acceso a los Servicios de Salud; Cirugía de Reasignación de Sexo; Itinerario Terapéutico; Sistema Único de Salud; Revisión de Alcance
Study contributions
Main results
Discrimination and prejudice permeate the pathways taken by trans people to access the transsexualizing process. Related studies are limited and primarily focus on the challenges rather than on the routes to access.
Implications for services
Presenting the access pathways to the transsexualizing process in the Brazilian National Health System (SUS) could contribute to more accurate and appropriate referrals within healthcare services.
Perspectives
Future research should explore the transsexualizing process in practice and support the development of public policies aimed at providing comprehensive and humane care for transgender people.
Palabras clave
Acceso a los Servicios de Salud; Cirugía de Reasignación de Sexo; Itinerario Terapéutico; Sistema Único de Salud; Revisión de Alcance
RESUMEN
Objetivo
Analizar la representación de los itinerarios de acceso al proceso de atención transexualizadora en Brasil y las principales barreras enfrentadas por las personas trans.
Método
Se realizó una revisión de alcance de la literatura. Las búsquedas se llevaron a cabo en enero de 2024, siendo elegibles los artículos y revisiones que abordaban el acceso al proceso de atención transexualizadora, mientras que se excluyeron libros, capítulos, conferencias, documentos editoriales y estudios que describían procedimientos quirúrgicos.
Resultados
Se localizaron 776 artículos, de los cuales se incluyeron 9. El 66% de los trabajos analizados fueron investigaciones de campo basadas en entrevistas. Los hallazgos evidencian las 5 etapas del proceso de atención transexualizadora: atención en unidades básicas de salud, derivación, seguimiento multidisciplinario, procedimiento quirúrgico y atención local a los individuos.
Conclusión
Los estudios se centraron en las barreras de acceso al proceso de atención transexualizadora, y no en las formas de acceso, evidenciando una brecha en la comprensión de los itinerarios de acceso al proceso.
Palabras clave
Acceso a los Servicios de Salud; Cirugía de Reasignación de Sexo; Itinerario Terapéutico; Sistema Único de Salud; Revisión de Alcance
INTRODUCTION
Historically, transsexuality has been considered as a deviation from the binary gender norm, resulting in stigmatization and denial of rights for transgender people (including transvestites, transsexuals, transgender individuals, transgender women and men).11 Romboli S. El dret a la identitat sexual en la interpretació del Tribunal Europeu de Drets Humans, entre marge d’apreciació nacional i creació de normes comunes. Rev. Catalana Dret Públic [Internet]. 2021 [cited 2024 Aug 10]; 63: 231–249. Available from: 10.2436/rcdp.i63.2021.3684,22 Hidalgo SL. Trans Rights: The Ongoing Debate in Latin American Legal Agendas. J Hum Rights Environ [Internet]. 2022 [cited 2024 mai 12];18: 163–180. Available from: 10.17561/tahrj.v18.7061 Since the beginning of the 21st century, the pathological biomedical view has been contested, with the human rights paradigm bringing greater visibility and increasing research on the topic. The current focus is on defending the legal and social rights of these people, with emphasis on violations such as difficulties in accessing healthcare, employment, education, privacy and safety.33 Rodrigues JWC, Barbosa BRSN, Silva LV. O combate à transfobia na agenda das políticas de segurança pública no Brasil: cenário atual e desafios. REI [Internet]. 2021 [cited 2024 Apr, 02]; 7: 1060–1080. Available from: 10.21783/rei.v7i3.490
In Brazil, data on the transgender population are limited. Transgender people represented 0.69% of the population and non-binary people, 1.19%, in a survey conducted in 2021, totaling nearly 3 million people.44 Spizzirri G, Eufrásio R, Lima MCP, Nunes HRC, Kreukels BP, Steensma TD, Abdo CHN. Proportion of people identified as transgender and non-binary gender in Brazil. Sci. Rep [Internet]. 2021 [cited 2024 Mai 15]; 11(1), 2240. Available from: https://doi.org/10.1038/s41598-021-81411-4
https://doi.org/10.1038/s41598-021-81411... Two-thirds were not in a relationship, and 85% of transgender men and 50% of transgender women faced challenges with gender-related body characteristics.44 Spizzirri G, Eufrásio R, Lima MCP, Nunes HRC, Kreukels BP, Steensma TD, Abdo CHN. Proportion of people identified as transgender and non-binary gender in Brazil. Sci. Rep [Internet]. 2021 [cited 2024 Mai 15]; 11(1), 2240. Available from: https://doi.org/10.1038/s41598-021-81411-4
https://doi.org/10.1038/s41598-021-81411... Nearly all had completed up to high school and 4% had higher education. Economically, 44.6% belonged to classes D and E, and 38.1% to class C, reflecting the employment challenges faced by this vulnerable population.44 Spizzirri G, Eufrásio R, Lima MCP, Nunes HRC, Kreukels BP, Steensma TD, Abdo CHN. Proportion of people identified as transgender and non-binary gender in Brazil. Sci. Rep [Internet]. 2021 [cited 2024 Mai 15]; 11(1), 2240. Available from: https://doi.org/10.1038/s41598-021-81411-4
https://doi.org/10.1038/s41598-021-81411...
Over the past seven years, the National Association of Transvestites and Transsexuals recorded 1,057 homicides of transgender people, transvestites and non-binary people in Brazil. In 2023, there were 145 homicides – an increase of 10.7% compared to 2022 (131 homicides).55 Benevides BG. Dossiê: assassinatos e violências contra travestis e transexuais brasileiras em 2023 [Internet]. ANTRA (Associação Nacional de Travestis e Transexuais) – Brasília, DF: Distrito Drag; ANTRA, 2024 [cited 2024 Feb 20]. 125p. Available from: https://antrabrasil.org/wp-content/uploads/2024/01/dossieantra2024-web.pdf
https://antrabrasil.org/wp-content/uploa... In 2023, murders of this population in Brazil increased by 150% compared to 2008. Seventy-nine percent of the victims were under 35 years old and many were engaged in sex work. The overall homicide rate decreased by 5.7%. Transvestites and transgender women are up to 32 times more likely to be murdered compared to transgender men and transmasculine individuals.55 Benevides BG. Dossiê: assassinatos e violências contra travestis e transexuais brasileiras em 2023 [Internet]. ANTRA (Associação Nacional de Travestis e Transexuais) – Brasília, DF: Distrito Drag; ANTRA, 2024 [cited 2024 Feb 20]. 125p. Available from: https://antrabrasil.org/wp-content/uploads/2024/01/dossieantra2024-web.pdf
https://antrabrasil.org/wp-content/uploa... In 2023, 94% of the murders of transgender people worldwide were of transgender women or transfeminine people.66 Fórum Brasileiro de Segurança Pública. 17º Anuário Brasileiro de Segurança Pública [Internet]. São Paulo: Fórum Brasileiro de Segurança Pública, 2023 [cited 2024 Jan 15]. ISSN: 1983-7364. Available from: https://forumseguranca.org.br/wp-content/uploads/2023/07/anuario-2023.pdf.
https://forumseguranca.org.br/wp-content...
The high murder rate may reflect both an actual increase and an increase in records. Data are underreported, many records are inadequate, and there is a lack of training among the responsible agencies.77 TMM - Trans Murder Monitoring. Trans Murder Monitoring 2023 Global Update [Internet]. 2024 [cited 2024 Feb 07]. Available from: https://transrespect.org/en/trans-murder-monitoring-2023/
https://transrespect.org/en/trans-murder... In Europe, there were 12 homicides of transgender people in the past five years, and in Africa, 18 between 2008 and 2020. In countries such as Afghanistan and Uzbekistan, where being trans is a serious crime, there was only one homicide recorded in the same period.55 Benevides BG. Dossiê: assassinatos e violências contra travestis e transexuais brasileiras em 2023 [Internet]. ANTRA (Associação Nacional de Travestis e Transexuais) – Brasília, DF: Distrito Drag; ANTRA, 2024 [cited 2024 Feb 20]. 125p. Available from: https://antrabrasil.org/wp-content/uploads/2024/01/dossieantra2024-web.pdf
https://antrabrasil.org/wp-content/uploa...
Progress in public policies has been slow. In 2008, the Ministry of Health issued Ordinance No. 457 authorizing the transsexualizing process within the Brazilian National Health System (Sistema Único de Saúde - SUS). In 2011, the National Policy for Comprehensive Health for Lesbians, Gays, Bisexuals, Transvestites and Transsexuals was established through Ordinance No. 2,836. In 2013, Ordinance No. 2,803 was created, revoking Ordinance No. 1,707/2008, in order to redefine and expand the transsexualizing process within the SUS. This ordinance aims to integrate care for transgender people, extending beyond just gender-affirming surgeries. It proposed interdisciplinary work, humanized and non-discriminatory care, and respect for human diversity.88 Ministério da Saúde (BR). Portaria nº 2.803, de 19 de novembro de 2013 [Internet]. Brasília: Ministério da Saúde; 2011 [cited 2024 Mar 17]. Available from: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2013/prt2803_19_11_2013.html
http://bvsms.saude.gov.br/bvs/saudelegis...
Recent legislation represents progress in ensuring the right to health for the transgender population. Monitoring for the transsexualizing process began in 2018, requiring psychiatric reports, psychological, gynecological, urological, endocrine and plastic surgery evaluations, in addition to regulating deadlines for hormonal or surgical interventions.99 Santos MCB. Aos trancos e barrancos: uma análise do processo de implementação e capilarização do processo transexualizador no Brasil [thesis on the Internet]. Rio de Janeiro: Universidade do Estado do Rio de Janeiro, 2020 [cited 2024 Mar 10], 483p. Available from: https://www.bdtd.uerj.br:8443/handle/1/18382
Transgender people face various challenges in accessing health care. Examples include discrimination, the pathologization of transsexuality, inadequate care, the requirement of surgery for name and gender change, lack of professional qualifications, absence of primary care policies and scarcity of resources.1010 Rocon PC, Wandekoken KD, Barros, MEBD, Duarte MJO, Sodré F. Acesso à saúde pela população trans no Brasil: nas entrelinhas da revisão integrativa. Trab educ e saúde [Internet]. 2019 [cited 2024 Feb 10]; 18, e0023469. Available from: https://doi.org/10.1590/1981-7746-sol00234 Many healthcare professionals impose their personal beliefs and moral values over the rights of patients.1111 Kcomt L. Profound health-care discrimination experienced by transgender people: Rapid systematic review. Soc Work Health Care [Internet]. 2019 [cited 2024 Jan 13]; 58(2), 201-219. Available from: 10.1080/00981389.2018.1532941
Despite legislation, access to services and the elimination of discrimination have not been fully achieved, as this requires a social and cultural change that recognizes diversity beyond the binary gender norm. The lack of information about the transsexualizing process remains a significant challenge.1212 Bender MS. Transnarrativas: um olhar cartográfico sobre a saúde da população trans [dissertation on the Internet]. Santa Cruz do Sul: Universidade de Santa Cruz do Sul, 2023 [cited 2024 Mar 10], 119p. Available from: https://repositorio.unisc.br/jspui/handle/11624/3702
Understanding the pathways transgender people take to access the transsexualizing process within the SUS is crucial, as it reveals their particularities and the diversity of care and social and cultural access.1313 Souza MHT, Signorelli MC, Coviello DM, Pereira PPG. Itinerários terapêuticos de travestis da região central do Rio Grande do Sul, Brasil. Cien Saude Colet [Internet]. 2014 [cited 2024 Mar 22];19(7):2277–86. Available from: https://doi.org/10.1590/1413-81232014197.10852013
https://doi.org/10.1590/1413-81232014197... This study aimed to analyze these pathways and identify the main barriers they face.
METHOD
A scoping literature review was conducted1414 Souza MTD, Silva MDD, Carvalho RD. Revisão integrativa: o que é e como fazer. Einstein [Internet]. 2010 [cited 2024 Mar 16]; 8(1):102-106. Available from: https://www.scielo.br/j/eins/a/ZQTBkVJZqcWrTT34cXLjtBx/?format=pdf&lang=pt following seven steps: elaboration of the research problem and inclusion and exclusion criteria; database search; data extraction and organization in an Excel spreadsheet; reading of titles and abstracts; reading of selected articles and assessment of methodological quality; synthesis of results; assessment of evidence and its quality; and drafting of results and discussion.1515 Galvão TF, Pereira MG. Revisões sistemáticas da literatura: passos para sua elaboração. Epidemiol Serv Saúde [Internet]. 2014 [cited 2024 Mar 18];23(1):183-4. Available from: https://doi.org/10.5123/S1679-49742014000100018
https://doi.org/10.5123/S1679-4974201400...
The population, intervention, comparison, outcome and context (PICOC) framework was used to define the research question: What are the pathways taken by transgender people to access the transsexualizing process within the SUS? The components of the research question are shown in Box 1.
The search terms were defined based on the main and alternative terms of the Health Sciences Descriptors and the Medical Subject Headings (MeSH). Although “transsexualizing process” is not a descriptor in the health sciences, it was included in the search as it is the official nomenclature used in Brazilian public policy. Data exportation took place on January 1, 2024, from the PubMed, Scientific Electronic Library Online (SciELO), Scopus, and Web of Science Core Collection databases.
In the Scopus and Web of Science Core Collection databases, the following search terms were used: ((“sex reassignment surgery” OR “sex reassignment procedures” OR “sexual suitability” OR “sex appropriateness” OR “gender affirming” OR “gender confirmation” OR “genital reconstruction” OR “genital reassignment” OR “sexual reassignment” OR “gender reassignment” OR “sex reassignment” OR “revitalization” OR “sex change” OR “transsexualism process”) AND (“Brazil” OR “Unified Health System” OR “ SUS”) AND “access”). The search was refined by country (Brazil) and types of documents (articles and reviews).
In PubMed , the initial searches included hundreds of articles unrelated to the study topic. Health science descriptors were used to define the terms for the searches in Web of Science and Scopus. MeSH terms were used for the search in PubMed , with the latter using the following search terms: ((“transsexualizing process” OR “sex reassignment surgery” OR “sex reassignment procedures”) AND “Brazil”). No filters were used for categories, topics, research areas, languages and year of publication. The same search terms were used for SciELO. All results were imported into Microsoft Excel to remove duplicates.
Inclusion criteria were: discussing access to the transsexualizing process; referring to the trans, transsexual or transgender population in the Brazilian context; and being either an original article or a systematic review, published on any date and in any language. An article was included by searching the references of eligible studies. The exclusion criteria included chapters, conferences, books, letters to the editor, editorial documents and clinical articles describing surgical procedures that did not undergo ethical review or failed to present consistent methodological steps, such as inadequate data collection or omission of methodological procedures.
After defining the problem, objective and scope of the research, the PRISMA Extension for Scoping Reviews (PRISMA- ScR ) was used,1616 Tricco AC, Antony J, Zarin W, Strifler L, Ghassemi M, Ivory J, et al. A scoping review of rapid review methods. BMC med [Internet]. 2015[cited 2024 Mar 16];13, 1-15. Available from: https://doi.org/10.1186/s12916-015-0465-6 and all steps were performed by two independent researchers and concomitantly, including the search process (MSB and IP), data collection (MSB and IP) and reading and classification of articles (MSB and IP). In cases where there were doubts or disagreements between the researchers, a third author was consulted to establish a consensus.
The data were summarized based on the results of the studies, divided into two categories: stages of the transsexualizing process and access barriers. No meta-analysis was performed due to the descriptive nature of the data. Drafting and discussion of the results were conducted by all authors (MSB, IP, KSB and ELG). This study was not evaluated by a research ethics committee, as it used only secondary data from published studies. As this was a scoping review, there was no bias analysis of the included studies.1717 Mattos SM, Feitosa VRC, Moreira TM. M. Protocolo de revisão de escopo: aperfeiçoamento do guia PRISMA-ScR. Rev Enferm UFPI [Internet]. 2023 [cited 2024 Mar 18]; e3062-e3062. Available from: 10.26694/reufpi.v12i1.3062 Confidence in qualitative results was not evaluated, as the focus was on the stages of the transsexualizing process.
From the included studies, a thematic network was generated, consisting of a keyword co-occurrence network. The network was generated using the VosViewer program,1818 Van Eck N, Waltman L. Software survey: VOSviewer, a computer program for bibliometric mapping. Scientometrics [Internet]. 2010 [cited 2024 Mar 12], 84(2), 523-538. Available from: https://doi.org/10.1007/s11192-009-0146-3
https://doi.org/10.1007/s11192-009-0146-... in which spheres represent the themes that stood out most in the field of study. The size of the sphere (theme) was proportional to the number of associated documents, and the lines represented the relationships between the themes. The more lines originating from a theme, the greater the centrality of that theme in the field of study.1818 Van Eck N, Waltman L. Software survey: VOSviewer, a computer program for bibliometric mapping. Scientometrics [Internet]. 2010 [cited 2024 Mar 12], 84(2), 523-538. Available from: https://doi.org/10.1007/s11192-009-0146-3
https://doi.org/10.1007/s11192-009-0146-... The themes were grouped by colors. with clusters representing the association and co-occurrence of themes over time.1818 Van Eck N, Waltman L. Software survey: VOSviewer, a computer program for bibliometric mapping. Scientometrics [Internet]. 2010 [cited 2024 Mar 12], 84(2), 523-538. Available from: https://doi.org/10.1007/s11192-009-0146-3
https://doi.org/10.1007/s11192-009-0146-...
RESULTS
A total of 776 publications were identified, including 84 in PubMed, 13 in Scopus and 679 in Web of Science (Figure 1). Nine studies were included in the descriptive synthesis (Table 1). Supplementary Table 1 provides additional data, such as the objective of the articles analyzed and the barriers and difficulties in accessing the transsexualizing process, limitations and recommendations.
The most prominent themes were “transgender people” and “SUS”, representing the core focus of the research. The “transgender people” network was related to HIV, discrimination, sexual reassignment and therapy, among others, highlighting the most addressed topics in the studies (Figure 2). The relationship between transgender people and SUS revealed themes such as healthcare access, integrated care, care delivery, and minorities.
The identification of the main themes (Figure 2) helped in understanding the development of the subject and to determine which topics are more advanced or require further research. The narrative synthesis showed the results of the thematic network and the interfaces between the themes. The barriers to access the transsexualizing process and the need for a multidisciplinary approach in gender identity studies were highlighted. Through this analysis, it was possible to identify the itinerary of the transsexualizing process. Figure 3 presents and describes the stages of this process. It begins with the primary healthcare centers (stage 1) which initiate the process and refer people (stage 2) for multidisciplinary follow-up within SUS (stage 3). After two years of follow-up, stage 4 can be initiated, which consists of the request for surgical procedures. Stage 5 refers to the place of care for individuals.
Access pathways to the transsexualization process within the Brazilian National Health System
Studies report that, in order to implement the transsexualizing process within the SUS, it is not enough to establish guidelines for care, but rather to reclaim the principles of comprehensiveness and universality of the SUS. The goal is to have a set of actions that ensure the right to healthcare, especially in the context of specialized care.1919 Popadiuk G, Oliveira DC, Signorelli MC. A Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais e Transgêneros (LGBT) e o acesso ao Processo Transexualizador no Sistema Único de Saúde (SUS): avanços e desafios. Cien Saude Colet [Internet]. 2017[cited 2024 Mar 24];22(5):1509–20. Available from: https://doi.org/10.1590/1413-81232017225.32782016
https://doi.org/10.1590/1413-81232017225... The implementation of the transsexualizing process within the SUS represents a significant advancement in promoting the health of transgender people.2020 Lima RRT, Flor TBM, Noro LR. A. Systematic review on health care for transvestites and transsexuals in Brazil. Rev Saúde Pública [Internet]. 2023 [cited 2024 Mar 08];57:19. Available from: https://doi.org/10.11606/s1518-8787.2023057004693
https://doi.org/10.11606/s1518-8787.2023...
DISCUSSION
The findings of this study, based on the literature analyzed, present the five stages of the SUS transsexualizing process: primary healthcare services, referral, multidisciplinary follow-up, surgery request, and local healthcare provision. Disrespect for the use of the social name, ridicule and discrimination faced by transgender people in health services were also observed in the studies,2121 Costa AB, Rosa Filho HT, Pase PF, Fontanari AMV, Catelan RF, Mueller A, et al. Healthcare Needs of and Access Barriers for Brazilian Transgender and Gender Diverse People. J Immigr Minor Health [Internet]. 2018[cited 2024 Mar 02];20(1):115-123. Available from: 10.1007/s10903-016-0527-7.,2525 Silva RCD, Silva ABB, Alves, FC, Ferreira KG, Nascimento LDV, Alves MF, et al. Reflexões bioéticas sobre o acesso de transexuais à saúde pública. Rev. Bioét [Internet]. 2022 [cited 2024 Mar 19]; 30(1):195–204. Available from: 10.1590/1983-80422022301519PT advocating the need for specific training for healthcare professionals, aiming to combat discrimination and improve care delivery.1919 Popadiuk G, Oliveira DC, Signorelli MC. A Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais e Transgêneros (LGBT) e o acesso ao Processo Transexualizador no Sistema Único de Saúde (SUS): avanços e desafios. Cien Saude Colet [Internet]. 2017[cited 2024 Mar 24];22(5):1509–20. Available from: https://doi.org/10.1590/1413-81232017225.32782016
https://doi.org/10.1590/1413-81232017225... ,2121 Costa AB, Rosa Filho HT, Pase PF, Fontanari AMV, Catelan RF, Mueller A, et al. Healthcare Needs of and Access Barriers for Brazilian Transgender and Gender Diverse People. J Immigr Minor Health [Internet]. 2018[cited 2024 Mar 02];20(1):115-123. Available from: 10.1007/s10903-016-0527-7.
This study has limitations, such as the restricted databases and the small sample size, which prevent the generalization of the results. The observational nature does not allow for determining causality or performing statistical analyses, and the scoping review method offers a descriptive view without meta-analytic generalizations. Despite the independent analysis by two researchers, there is a risk of bias, especially in qualitative studies. In addition, it was identified that many of the studies analyzed do not offer practical solutions for transgender people, failing to fulfill the role of science in disseminating applicable and relevant knowledge for all.
Although the transsexualizing process has been in place for 10 years, information about the access pathways remains limited. In general, studies focus on the challenges, rather than access pathways.
The therapeutic itinerary for transgender people included two components: primary care and specialized care. Primary care serves as the gateway to the health system, responsible for providing care and referrals to specialists. Specialized care includes outpatient care (hormone therapy and psychotherapeutic follow-up) and hospital care (sexual reassignment surgeries and pre- and post-operative care).2828 Benevides B. Como acessar o SUS para questões de transição? [Internet]. Direitos e Política, Saúde. ANTRA. 2020 [cited 2024 Jan. 25]. Available from: https://antrabrasil.org/2020/07/27/como-acessar-o-sus-para-questoes-de-transicao/
https://antrabrasil.org/2020/07/27/como-...
Outpatient care in Brazil is provided by six specialized outpatient clinics for the care of the transgender population within the SUS: Research and Support Center for Transvestites and Transsexuals of Curitiba, Instituto Estadual de Diabetes e Endocrinologia Luiz Capriglione do Rio de Janeiro, Hospital Universitário Professor Edgard Santos de Salvador, Centro de Referência e Treinamento DST/AIDS de São Paulo, ambulatório do Hospital das Clínicas de Uberlândia e Hospital Universitário Cassiano Antônio de Moraes de Vitória. There are also state outpatient clinics.2929 Granada A, Grünheidt P. O guia da disforia de gênero [Internet]. 2021 [cited 2024 Fev 05]. Available from: https://disforiadegenero.com.br/introducao/
https://disforiadegenero.com.br/introduc...
In the fourth stage of the transsexualizing process, which involves surgical procedures, hospital care must be provided at one of the five hospitals accredited to perform the transsexualizing process, namely: Hospital das Clínicas da Universidade Federal de Goiás, Hospital de Clínicas de Porto Alegre, Hospital das Clínicas da Universidade Federal de Pernambuco, Hospital Universitário Pedro Ernesto do Rio de Janeiro e Hospital de Clínicas da Universidade de São Paulo.2828 Benevides B. Como acessar o SUS para questões de transição? [Internet]. Direitos e Política, Saúde. ANTRA. 2020 [cited 2024 Jan. 25]. Available from: https://antrabrasil.org/2020/07/27/como-acessar-o-sus-para-questoes-de-transicao/
https://antrabrasil.org/2020/07/27/como-...
Breast implants and genital surgery are the most sought-after procedures by transgender women and transvestites. Transgender men most frequently seek mastectomy (breast removal for masculinization) and hysterectomy (removal of the uterus). Phalloplasty surgery is still performed experimentally in Brazil.2828 Benevides B. Como acessar o SUS para questões de transição? [Internet]. Direitos e Política, Saúde. ANTRA. 2020 [cited 2024 Jan. 25]. Available from: https://antrabrasil.org/2020/07/27/como-acessar-o-sus-para-questoes-de-transicao/
https://antrabrasil.org/2020/07/27/como-... Sexual reassignment surgery is positioned at the end of a long healthcare journey through public services.
The stages of the transsexualizing process within the SUS are permeated by ignorance, neglect, exclusion and prejudice.2121 Costa AB, Rosa Filho HT, Pase PF, Fontanari AMV, Catelan RF, Mueller A, et al. Healthcare Needs of and Access Barriers for Brazilian Transgender and Gender Diverse People. J Immigr Minor Health [Internet]. 2018[cited 2024 Mar 02];20(1):115-123. Available from: 10.1007/s10903-016-0527-7. The main obstacles to accessing the transsexualizing process are bureaucracy, long waiting times,2222 Monteiro S, Brigeiro M. Experiências de acesso de mulheres trans/travestis aos serviços de saúde: avanços, limites e tensões. Cad Saúde Pública [Internet]. 2019[cited 2024 Mar 09];35(4):e00111318. Available from: https://doi.org/10.1590/0102-311X00111318
https://doi.org/10.1590/0102-311X0011131... the centralization of specialized services in large urban centers, which makes the geographic issue a social marker of difference,2323 Mattos MH, Zambenedetti G. Itinerários terapêuticos de homens trans em transição de gênero. Psicol. Soc [Internet]. 2021 [cited 2024 Mar 06]; 33: e240732. Available from: https://doi.org/10.1590/1807-0310/2021v33240732
https://doi.org/10.1590/1807-0310/2021v3... ,2424 Rocon PC, Sodré F, Rodrigues A, Barros MEB de, Wandekoken KD. Desafios enfrentados por pessoas trans para acessar o processo transexualizador do Sistema Único de Saúde. Interface (Botucatu) [Internet]. 2019 [cited 2024 Mar 12];23:e180633. Available from: https://doi.org/10.1590/Interface.180633
https://doi.org/10.1590/Interface.180633... the pathologization demonstrated by healthcare professionals and the requirement for a gender identity disorder diagnosis.2525 Silva RCD, Silva ABB, Alves, FC, Ferreira KG, Nascimento LDV, Alves MF, et al. Reflexões bioéticas sobre o acesso de transexuais à saúde pública. Rev. Bioét [Internet]. 2022 [cited 2024 Mar 19]; 30(1):195–204. Available from: 10.1590/1983-80422022301519PT
However, access barriers often lead transgender individuals to develop self-care and self-medication strategies that can put them at risk.2121 Costa AB, Rosa Filho HT, Pase PF, Fontanari AMV, Catelan RF, Mueller A, et al. Healthcare Needs of and Access Barriers for Brazilian Transgender and Gender Diverse People. J Immigr Minor Health [Internet]. 2018[cited 2024 Mar 02];20(1):115-123. Available from: 10.1007/s10903-016-0527-7.
22 Monteiro S, Brigeiro M. Experiências de acesso de mulheres trans/travestis aos serviços de saúde: avanços, limites e tensões. Cad Saúde Pública [Internet]. 2019[cited 2024 Mar 09];35(4):e00111318. Available from: https://doi.org/10.1590/0102-311X00111318
https://doi.org/10.1590/0102-311X0011131... -2323 Mattos MH, Zambenedetti G. Itinerários terapêuticos de homens trans em transição de gênero. Psicol. Soc [Internet]. 2021 [cited 2024 Mar 06]; 33: e240732. Available from: https://doi.org/10.1590/1807-0310/2021v33240732
https://doi.org/10.1590/1807-0310/2021v3... When seeking for hormone therapy, transgender people face resistance from some professionals and healthcare services. The reasons for this are the lack of specialization, a failure to understand different gender identities, and denial of the referred identity. These experiences keep transgender people away from institutionalized health services.2626 Santos MOF, Olivar JMN. Muros, frestas e atalhos: agenciamentos de pessoas transmasculinas para hormonização no Processo Transexualizador na cidade de São Paulo. Saúde e Soc [Internet]. 2023 [cited 2024 Mar 16];32(2):e220589pt. Available from: https://doi.org/10.1590/S0104-12902023220589pt
https://doi.org/10.1590/S0104-1290202322...
YouTube and Facebook and WhatsApp groups have proven to be the main sources of recommendations on medications, procedures and services for transgender people, as well as for information about transgender identity and possible body changes. The search for information online is a common feature of the therapeutic pathway for the majority of this population.2727 Hanauer OFD, Hemmi APA. Caminhos percorridos por transexuais: em busca pela transição de gênero. Saúde Debate, [Internet]. 2019 [cited 2024 Jan. 16];43(spe8):91–106. Available from: https://doi.org/10.1590/0103-11042019S807 Regional discrepancies in access to SUS services are another significant issue in the transsexualizing process. Previous studies have heavily criticized the geographical concentration and limitation of healthcare services.2424 Rocon PC, Sodré F, Rodrigues A, Barros MEB de, Wandekoken KD. Desafios enfrentados por pessoas trans para acessar o processo transexualizador do Sistema Único de Saúde. Interface (Botucatu) [Internet]. 2019 [cited 2024 Mar 12];23:e180633. Available from: https://doi.org/10.1590/Interface.180633
https://doi.org/10.1590/Interface.180633... ,2525 Silva RCD, Silva ABB, Alves, FC, Ferreira KG, Nascimento LDV, Alves MF, et al. Reflexões bioéticas sobre o acesso de transexuais à saúde pública. Rev. Bioét [Internet]. 2022 [cited 2024 Mar 19]; 30(1):195–204. Available from: 10.1590/1983-80422022301519PT
The concentration of specialized services in a few metropolitan regions violates the principle of universality of the SUS and creates geographic inequalities.2525 Silva RCD, Silva ABB, Alves, FC, Ferreira KG, Nascimento LDV, Alves MF, et al. Reflexões bioéticas sobre o acesso de transexuais à saúde pública. Rev. Bioét [Internet]. 2022 [cited 2024 Mar 19]; 30(1):195–204. Available from: 10.1590/1983-80422022301519PT Transgender individuals living in peripheral or rural areas face barriers to access and lack the financial resources for transportation. This prevents equitable access to health care for the most disadvantaged.
The persistence of barriers to accessing the transsexualizing process is partly due to the lack of adequate training for healthcare professionals2222 Monteiro S, Brigeiro M. Experiências de acesso de mulheres trans/travestis aos serviços de saúde: avanços, limites e tensões. Cad Saúde Pública [Internet]. 2019[cited 2024 Mar 09];35(4):e00111318. Available from: https://doi.org/10.1590/0102-311X00111318
https://doi.org/10.1590/0102-311X0011131... ,2626 Santos MOF, Olivar JMN. Muros, frestas e atalhos: agenciamentos de pessoas transmasculinas para hormonização no Processo Transexualizador na cidade de São Paulo. Saúde e Soc [Internet]. 2023 [cited 2024 Mar 16];32(2):e220589pt. Available from: https://doi.org/10.1590/S0104-12902023220589pt
https://doi.org/10.1590/S0104-1290202322... The lack of continuing education on gender diversity perpetuates these barriers. This undermines the application of the principles of comprehensiveness and universality in the SUS.
This reality drives transgender people away from services and contributes to additional barriers, such as the pathologization of transgender identities and the requirement for gender identity disorder diagnoses as part of the transsexualizing process.1010 Rocon PC, Wandekoken KD, Barros, MEBD, Duarte MJO, Sodré F. Acesso à saúde pela população trans no Brasil: nas entrelinhas da revisão integrativa. Trab educ e saúde [Internet]. 2019 [cited 2024 Feb 10]; 18, e0023469. Available from: https://doi.org/10.1590/1981-7746-sol00234 Despite the progress represented by the transsexualizing process,2828 Benevides B. Como acessar o SUS para questões de transição? [Internet]. Direitos e Política, Saúde. ANTRA. 2020 [cited 2024 Jan. 25]. Available from: https://antrabrasil.org/2020/07/27/como-acessar-o-sus-para-questoes-de-transicao/
https://antrabrasil.org/2020/07/27/como-... limitations such as the implementation of inclusive public policies and inadequate dissemination of access pathways hinder its reach and effectiveness. The lack of direct involvement of the transgender population in policy formulation may also contribute to the persistence of these barriers.
This study contributes to the understanding of the transsexualizing process and suggests updating legislation and dissemination strategies, addressing an important gap. This makes it easier for transgender people to access their rights and provides guidance to healthcare professionals. It is crucial to adopt approaches committed to human rights and equity in healthcare delivery. The collection of sociodemographic data should include transgender people to avoid their invisibility. In addition, it is essential that transgender people participate in the formulation and reformulation of policies related to them, as they are most familiar with their own needs and particularities.
Future research should consider other databases and larger samples in an attempt to produce generalizable results. A longitudinal analysis could be conducted to explore the relationship between specific interventions and health outcomes for the transgender population. Empirical studies, such as case studies and observational studies, are suggested to understand the transsexualizing process in practice. This could involve analyses of SUS facilities, such as primary healthcare centers, as well as issues related to individuals starting the transsexualizing process. Other studies could delve deeper into the formulation of public policies aimed at reducing the challenges and difficulties associated with the process.
The stages of the transsexualizing process within the SUS lack transparency to provide humane care to individuals. Although the transsexualizing process consists of five defined stages, both healthcare professionals and patients have doubts about the process, which reinforces the importance of adequate professional training and the dissemination of information about the available services.
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