ABSTRACT

Objective

To describe the sociodemographic profile and access to social assistance and health services among trans people and travestis experiencing homelessness in Salvador, the capital city of Bahia state.

Methods

This was a cross-sectional study involving 24 (4.5%) participants who identified as trans people or travestis out of a total of 529 people, aged 18 or older, living in public spaces or institutional shelters included in the survey. Data were collected between 2021 and 2022, using structured questionnaires.

Results

The sample was predominantly comprised of trans women and travestis (n=18), young individuals (n=13), of Black race/skin color (n=22), single individuals (n=18) and those engaged in informal occupations (n=23), many of whom reported experiencing violence (n=17). Frequent barriers to accessing healthcare and social assistance services were found (n=15), including lack of documentation, delay in service provision and social/racial discrimination.

Conclusion

The findings highlight the heightened vulnerability of transgender people and travestis experiencing homelessness, who are subjected to multiple forms of discrimination and social exclusion.

Palabras clave
Personas en Situación de Calle; Personas Transgénero; Travestis; Vulnerabilidad Social; Encuesta Epidemiológica

Study contributions

Main results

The sample profile was comprised of young, Black, single transgender women engaged in informal employment. The primary barriers to accessing health and social assistance services were the lack of identification documents and experiences of social and racial discrimination.

Implications for services

The study addressed the disconnection and barriers faced by transgender people and travestis in accessing health and social assistance services. It emphasized the need to strengthen strategies aimed at expanding care networks and ensuring appropriate support for this population.

Perspectives

Further studies are recommended to investigate the potential increased vulnerability of transgender people and travestis to homelessness and their health needs. The urgent implementation of public policies tailored to meet the demands of this population is critical.

Palabras clave
Personas en Situación de Calle; Personas Transgénero; Travestis; Vulnerabilidad Social; Encuesta Epidemiológica

RESUMEN

Objetivo

Describir el perfil sociodemográfico y el acceso a los servicios socioasistenciales y de salud entre personas trans y travestis en situación de calle en Salvador.

Métodos

Se trata de un estudio transversal con 24 participantes (4,5%) que se autoidentificaron como personas trans o travestis, del total de 529 personas con edad igual o superior a 18 años, presentes en espacios públicos o unidades de acogida institucional incluidas en el estudio. Los datos fueron recolectados entre 2021 y 2022 mediante cuestionarios estructurados.

Resultados

La muestra estuvo compuesta mayoritariamente por mujeres trans y travestis (n=18), jóvenes (n=13), negras (n=22), solteras (n=18) y con ocupaciones informales (n=23), quienes reportaron haber sufrido violencia (n=17). Se encontraron dificultades frecuentes para acceder a los servicios de salud y socioasistenciales (n=15), principalmente debido a la falta de documentación, largas demoras en la atención y discriminación social/racial.

Conclusión

Se observa una marcada vulnerabilización de las personas trans y travestis en situación de calle, quienes están sometidas a múltiples formas de discriminación y exclusión social.

Palabras clave
Personas en Situación de Calle; Personas Transgénero; Travestis; Vulnerabilidad Social; Encuesta Epidemiológica

INTRODUCTION

The homeless population is defined as a heterogeneous group that shares the intersection of structural and personal factors, such as economic exclusion, racism, severed family ties, and the absence of regular conventional housing, relying on the streets as their primary space for social reproduction.¹1 Brasil. Decreto no 7.053, de 23 de dezembro de 2009. Institui a Política Nacional para a População em Situação de Rua e seu Comitê Intersetorial de Acompanhamento e Monitoramento, e dá outras providências. Diário Oficial da União. 24 dez. 2009; Seção 1:1.,²2 Natalino MA. A População em situação de rua nos números do Cadastro Único. Rio de Janeiro: Ipea; 2024. 57 p. (Texto para Discussão, n. 2944). Disponível em: http://dx.doi.org/10.38116/td2944-port
http://dx.doi.org/10.38116/td2944-port... The existence and growth of the homeless population are not recent phenomena. They reflect historical inequalities and macroeconomic issues that persist as consequence of systemic factors in the capitalist system.³3 Rosa AD, Cavicchioli MG, Brêtas AC. O processo saúde-doença-cuidado e a população em situação de rua. Rev Lat Am Enferm. 2005;13(4):576-82. Disponível em: https://doi.org/10.1590/s0104-11692005000400017
https://doi.org/10.1590/s0104-1169200500... -⁵5 Oliveira RJ. A segregação racial e o pensamento urbanístico no Brasil. Rev Politicas Publicas Amp Cid. 2020. Disponível em: https://doi.org/10.23900/10.23900/2359-1552v9n1-3-3-2020
https://doi.org/10.23900/10.23900/2359-1...

In Brazil, in 2023, it was estimated that over 236,000 people lacked permanent residence, living on the streets or in shelters for the homeless population. The population profile was predominantly comprised of adults aged 30 to 49 years (55%), male (87%), Black individuals (68%) and those with previous experience of employment contract (68%)^.66 Brasil. Ministério dos Direitos Humanos e da Cidadania. População em Situação de Rua: Diagnóstico com base nos dados e informações disponíveis em registros administrativos e sistemas do Governo Federal. Brasília: MDHC; 2023. 39 p. Disponível em: https://www.gov.br/mdh/pt-br/navegue-por-temas/populacao-em-situacao-de-rua/publicacoes/relat_pop_rua_digital.pdf
https://www.gov.br/mdh/pt-br/navegue-por...

The rupture with the cis-heteronormative standard contributes significantly to social disengagement and increases the likelihood of homelessness among the LGBTQIAPN+ population, especially for trans people and travestis .⁷7 Costa AC, Pascoal BT, Salgado FM, Garcia MR, Paiva VS. Trajetória de vida e sociabilidade entre a população LGBT em situação de rua de São Paulo. Anais do I Seminário Violar. Campinas: UNICAMP; 2010. Disponível em: https://www.fe.unicamp.br/eventos/semviolar/anais/Anais-ISemViolar.pdf
https://www.fe.unicamp.br/eventos/semvio... -⁹9 Medeiros LP, Amorim AK, Nobre MT. Narrativas LGBT de pessoas em situação de rua: repensando identidades, normas e abjeções. Rev Pesqui Prat Psicossociais. 2020;15(1):16. Disponível em: https://pepsic.bvsalud.org/pdf/ppp/v15n1/07.pdf Family conflicts related to nonconformity with the binary sex-gender system, are cited as the main reason for estrangement. This reinforces discrimination based on sexual orientation and gender identity as a social determinant of health.¹⁰10 Ayres JR. Vulnerabilidade, Cuidado e integralidade: reconstruções conceituais e desafios atuais para as políticas e práticas de cuidado em HIV/Aids. Saúde Debate. 2022;46(spe7):196-206. Disponível em: https://doi.org/10.1590/0103-11042022e714
https://doi.org/10.1590/0103-11042022e71... -¹²12 Abade EAF, França JAN, Souza ES. Cuidados de enfermagem à população LGBT+. In: Rocha ESC, Toledo NN, Pina RMP, Pereira RSF, Souza ES, editores. Enfermagem no cuidado à saúde de populações em situação de vulnerabilidade. Brasília, DF: Editora ABEn; 2022. p. 93-106. Disponível em: https://doi.org/10.51234/aben.22.e11.c10
https://doi.org/10.51234/aben.22.e11.c10...

Non-cisgender people face vulnerabilities within both the family environment and on the streets, leading to lifelong exclusion and denial. These people are subjected to contexts of dehumanization and abjection, as well as a greater exposure for physical and sexual violence.⁸8 Silva RG, Bezerra WC, Queiroz SB. Os impactos das identidades transgênero na sociabilidade de travestis e mulheres transexuais. Rev Ter Ocupacional Univ São Paulo. 2015;26(3):364. Disponível em: https://doi.org/10.11606/issn.2238-6149.v26i3p364-372
https://doi.org/10.11606/issn.2238-6149.... ,⁹9 Medeiros LP, Amorim AK, Nobre MT. Narrativas LGBT de pessoas em situação de rua: repensando identidades, normas e abjeções. Rev Pesqui Prat Psicossociais. 2020;15(1):16. Disponível em: https://pepsic.bvsalud.org/pdf/ppp/v15n1/07.pdf,¹⁰10 Ayres JR. Vulnerabilidade, Cuidado e integralidade: reconstruções conceituais e desafios atuais para as políticas e práticas de cuidado em HIV/Aids. Saúde Debate. 2022;46(spe7):196-206. Disponível em: https://doi.org/10.1590/0103-11042022e714
https://doi.org/10.1590/0103-11042022e71... ,¹³13 Bento B, Pelúcio L. Despatologização do gênero: a politização das identidades abjetas. Rev Estud Fem. 2012;20(2):569-81. Disponível em: https://doi.org/10.1590/s0104-026x2012000200017
https://doi.org/10.1590/s0104-026x201200... In 2023, in Brazil, 136 cases of murders of travestis and trans women were reported, with a focus on Black women, aged 18 to 29 years, many of whom were sex workers, mainly in the Northeast and Southeast regions of the country^.1414 Benevides BG. Dossiê assassinatos e violências contra travestis e transexuais brasileiras em 2023. Brasília, DF: Distrito Drag; 2024. 125 p. Disponível em: https://antrabrasil.org/wp-content/uploads/2024/01/dossieantra2024-web.pdf
https://antrabrasil.org/wp-content/uploa... The lack of secure housing further exacerbated their vulnerability to violence.¹³13 Bento B, Pelúcio L. Despatologização do gênero: a politização das identidades abjetas. Rev Estud Fem. 2012;20(2):569-81. Disponível em: https://doi.org/10.1590/s0104-026x2012000200017
https://doi.org/10.1590/s0104-026x201200... ,¹⁵15 Glick JL, Lopez A, Pollock M, Theall KP. “Housing Insecurity Seems to Almost Go Hand in Hand with Being Trans”: Housing Stress among Transgender and Gender Non-conforming Individuals in New Orleans. J Urban Health. 2019;96(5):751-9. Disponível em: https://doi.org/10.1007/s11524-019-00384-y
https://doi.org/10.1007/s11524-019-00384...

In the health sector, significant challenges persist that hinder access to services and compromise the quality of healthcare provided. Insufficient training of professionals regarding the health needs of the LGBTQIAPN+ population, enduring social prejudice against the homeless population, in addition to the stigma associated with the human immunodeficiency virus (HIV), are among the factors that may increase this population’s vulnerability to health conditions, diseases, and unfavorable health outcomes.¹⁰10 Ayres JR. Vulnerabilidade, Cuidado e integralidade: reconstruções conceituais e desafios atuais para as políticas e práticas de cuidado em HIV/Aids. Saúde Debate. 2022;46(spe7):196-206. Disponível em: https://doi.org/10.1590/0103-11042022e714
https://doi.org/10.1590/0103-11042022e71... ,¹¹11 Brasil. Ministério da Saúde. Secretaria de Gestão Estratégica e Participativa. Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais, Travestis e Transexuais. Brasília: Ministério da Saúde; 2013. 32 p. Disponível em: https://bibliotecadigital.economia.gov.br/bitstream/123456789/387/1/politica_saude_lesbicas_gays_bissexuais_travestis.pdf
https://bibliotecadigital.economia.gov.b... ,¹⁶16 Cortes HM, Carnevalli LM, Araújo LMP, Pinho PH. O (des) acesso de pessoas transgêneras aos serviços de saúde no recôncavo baiano. Cadernos Gênero Diversidade. 2021;6(4):159-80. Disponível em: https://doi.org/10.9771/cgd.v6i4.36104
https://doi.org/10.9771/cgd.v6i4.36104... ,¹⁷17 Vieira MD, Araújo RC, Medeiros D. As dificuldades enfrentadas pela população trans no acesso aos serviços de saúde: uma revisão integrativa de literatura. Res Soc Dev. 2022;11(12):e276111235019. Disponível em: https://doi.org/10.33448/rsd-v11i12.35019
https://doi.org/10.33448/rsd-v11i12.3501... Research on the health conditions and access barriers faced by transgender individuals and travestis remains scarce, particularly in highly vulnerable contexts such as homelessness, where efforts to promote the physical and mental well-being of this population are critical.¹⁰10 Ayres JR. Vulnerabilidade, Cuidado e integralidade: reconstruções conceituais e desafios atuais para as políticas e práticas de cuidado em HIV/Aids. Saúde Debate. 2022;46(spe7):196-206. Disponível em: https://doi.org/10.1590/0103-11042022e714
https://doi.org/10.1590/0103-11042022e71... ,¹⁷17 Vieira MD, Araújo RC, Medeiros D. As dificuldades enfrentadas pela população trans no acesso aos serviços de saúde: uma revisão integrativa de literatura. Res Soc Dev. 2022;11(12):e276111235019. Disponível em: https://doi.org/10.33448/rsd-v11i12.35019
https://doi.org/10.33448/rsd-v11i12.3501...

This study aimed to contribute to the construction of knowledge on the subject. It sought to describe the sociodemographic profile and access to social assistance and health services among transgender people and travestis experiencing homelessness in Salvador, Bahia state, between 2021 and 2022.

METHODS

Study design

This work was derived from the epidemiological survey Health Conditions of the Homeless Population in Salvador – Bahia state, 2021, a cross-sectional study that included a sample of homeless people in Salvador, Bahia state.

Setting

Data collection for the survey took place between September 2021 and February 2022. Participant inclusion sites were defined after identifying institutional shelters associated with the Municipal Department of Social Promotion, Poverty Combat, Sports, and Leisure of Salvador (17 institutional shelters) and mapping public spaces (40 locations) where homeless populations concentrate and where the city’s five street clinic teams operate: Centro Histórico-Gamboa, Centro Histórico-Pelourinho, Itapuã, Itapagipe, and Brotas (Figure 1).

The institutional shelters in Salvador were categorized by types (female, male, mixed, couples, older adults and families). In order to ensure diversity among the homeless population interviewed, given their heterogeneous nature, at least one institutional shelter of each type was included in the study, selected through random sampling by subtype. Two to three institutional shelters were defined for each street clinic team, in a predetermined order.

For street-based sampling, public spaces with a concentration of homeless individuals were randomly selected for each street clinic team, with a priority order defined for conducting the survey. All identified points were visited across all street clinic areas. As the minimum number of participants was not reached during the first visit to each location, repeated visits were conducted following the prioritization protocol. Since this is a hard-to-reach population, all interested individuals present at the sites were offered participation, provided they met the predefined eligibility criteria.

Participants

The target reference population for inclusion in the survey consisted of people identified as homeless. Their characteristics corresponded to those described in the National Policy for the Homeless Population: a heterogeneous population group living in extreme poverty, with severed or weakened family ties, lacking permanent housing, and “using public spaces and degraded areas as living and livelihood spaces, temporarily or permanently, as well as shelters for temporary or provisional housing”^.11 Brasil. Decreto no 7.053, de 23 de dezembro de 2009. Institui a Política Nacional para a População em Situação de Rua e seu Comitê Intersetorial de Acompanhamento e Monitoramento, e dá outras providências. Diário Oficial da União. 24 dez. 2009; Seção 1:1.

The eligibility criteria for participating in the study included: self-identification as a homeless person, as per the aforementioned definition, absence of intellectual disability (permanent or transient), whether associated with psychoactive substance use or not, that would impair the ability to respond to the questionnaire, and absence of respiratory symptoms within the past 10 days to mitigate the risk of COVID-19 transmission to the research team. Participants with respiratory symptoms were referred for care following the municipal protocol in place at the time.

Variables

For analyses, variables were grouped into three large blocks, as follows:

1. Sociodemographic and economic variables: gender (trans woman, travesti, trans man, non-binary person), age group (18-29 years, 30-39 years, 40-49 years, ≥50 years), race/skin color (Black, White, mixed-race, Asian, Indigenous), sexual orientation (heterosexual, gay , lesbian, bisexual, asexual, pansexual), education level (complete/incomplete higher education, complete/incomplete high school, complete/incomplete elementary school, no education), can read (no; yes, without difficulty; yes, with difficulty), can write (no; yes, without difficulty; yes, with difficulty), marital status (single, legally married, in a stable union, separated or divorced, widowed), place of birth (Salvador and the Metropolitan Region of Salvador, other locations), time as a homeless person (<1 year, 1-4 years, 5-9 years, ≥10 years), monthly income (<¼ minimum wage, ¼-½ minimum wage, ½-¾ minimum wage), disability status (no, yes) and health district (Centro Histórico, Itapuã, Itapagipe, Brotas).

2. Occupational variables: currently employed (no, yes), engaged in informal work (no, yes), number of informal jobs simultaneously (1, 2, ≥3), work on the books (yes, currently; yes, in the past; never), ever barred from working (no, yes) and experienced workplace violence (no, yes).

3. Access to social assistance and health services: history of institutional sheltering (no, yes), registered in the Unified Registry (no, yes), Bolsa Família beneficiary (no, yes), difficulty accessing healthcare centers (no, yes), usual place of care (polytomous variable), barriers to accessing health services (polytomous variable), social assistance services accessed in the past year (polytomous variable), follow-up in mental health services (polytomous variable) and health care received on the street (polytomous variable).

Data sources and measurement

Data collection was performed by a team comprised of professionals from street clinics, workers from mental health, human rights services and social assistance staff, university students and volunteers. After participants’ consent, the questionnaires were administered using electronic devices (cell phones and tablets), through the Research Electronic Data Capture software (RedCap).

Study size

The final sample for this study consisted of 24 participants (4.5%) who identified as trans people or travestis, out of a total of 529 individuals included in the survey on homeless people. Inclusion in the sample was based on the question “How do you identify in terms of gender? (What is your gender identity?)”. Valid responses included: trans woman, travesti, trans man, non-binary people and others.

The minimum sample size for the survey on homeless people was calculated at 560 participants, based on an estimated 50% prevalence for multiple health outcomes, a 95% confidence level and a sampling error of 4%, without design effect adjustments.

Data analysis

A descriptive analysis of participant profiles was performed using absolute frequencies, by category. Database organization and cleaning, as well as statistical analyses, were conducted using R software, version 4.2.3 (x64). Illustrations were created by the authors, based on data from the Health Conditions of the Homeless Population in Salvador survey – Bahia state, 2021.

Ethical aspects

The study was conducted in accordance with the recommendations of Resolution No. 466/2012 of the National Health Council, and was approved by the Research Ethics Committee of the Instituto Gonçalo Moniz /Fiocruz (CAAE: 42517021.0.0000.0040), and Opinion No. 5,138,407, approved on December 1, 2021. Participants were informed about the objectives, procedures, and risks. Upon agreeing to participate in the survey, they signed and received a copy of the free informed consent form.

RESULTS

Among the 529 homeless people interviewed, 24 identified as transgender people and travestis, representing 4.5% of the total sample. The transgender and travesti population experiencing homelessness included predominantly transgender women (n=15), young adults aged 18 to 29 years (n=13), heterosexual individuals (n=12), self-identified Black and mixed-race persons (n=22), single individuals (n=18), those with an average monthly income of up to half the minimum wage (n=9), individuals from Salvador or the metropolitan region (n=20), and those without physical or mental disabilities (n=21). The majority had completed or incomplete elementary school (n=14) . Many had been homeless for less than a year (n=14) . The Centro Histórico health district concentrated the largest number of respondents (n=11) (Table 1).

More than half (n=14) of the transgender and travesti population experiencing homelessness reported having stayed in institutional shelter facilities. Fifteen people indicated registration in the Unified Registry for Social Programs. Most participants were not Bolsa Família beneficiaries (n=15). Within the 12 months prior to the survey, the most frequently accessed services included the Specialized Reference Center for the Homeless Population (n=13), followed by the Social Assistance Reference Center (n=10), the Specialized Social Assistance Reference Center (n=2) and the Social Interaction Center (n=2).

Eighteen people reported being unemployed, yet high participation in informal activities (n=23) was observed. Regarding frequency, most participants engaged in only one informal activity at a time (n=18). The majority had never held formal employment (n=20). A significant proportion (n=17) of trans people and travestis reported experiencing some type of aggression, threat or violence while performing their work activities (Table 2).

Findings related to access to health services among trans people and travestis experiencing homelessness indicate that the emergency care units were the most common facilities sought for medical services (n=19), followed by street clinics (n=9) and primary healthcare centers and family health units (n=8), while hospitals were the least frequently accessed (n=4). There were no reports of seeking care in polyclinics or specialized units. The majority indicated encountering barriers to accessing healthcare facilities (n=12). The reported reasons for these barriers included the absence of identification documents (n=3), lack of a national health card (n=5), and long wait times for care (n=6). Social (n=4) and racial (n=1) discrimination were also identified as obstacles (Table 3).

Many participants had never accessed mental health services (n=7). An equal number (n=7) reported receiving care from psychosocial support centers specializing in alcohol and other drug use. Therapeutic communities or recovery centers related to alcohol and other drug abuse (n=5) were also used.

Street-based healthcare services most commonly involved medical or nursing consultations (n=12). Care provided by other categories of health professionals also stood out. Vaccination (n=7), rapid testing for sexually transmitted infections (n=7) and administration of medication (n=3) were among the most frequent procedures provided.

DISCUSSION

The findings of this research highlight a greater vulnerability of trans women and travestis to violence and unfavorable social outcomes, even when compared to other subgroups within the LGBTQIAPN+ population.⁷7 Costa AC, Pascoal BT, Salgado FM, Garcia MR, Paiva VS. Trajetória de vida e sociabilidade entre a população LGBT em situação de rua de São Paulo. Anais do I Seminário Violar. Campinas: UNICAMP; 2010. Disponível em: https://www.fe.unicamp.br/eventos/semviolar/anais/Anais-ISemViolar.pdf
https://www.fe.unicamp.br/eventos/semvio... ,⁸8 Silva RG, Bezerra WC, Queiroz SB. Os impactos das identidades transgênero na sociabilidade de travestis e mulheres transexuais. Rev Ter Ocupacional Univ São Paulo. 2015;26(3):364. Disponível em: https://doi.org/10.11606/issn.2238-6149.v26i3p364-372
https://doi.org/10.11606/issn.2238-6149.... ,⁹9 Medeiros LP, Amorim AK, Nobre MT. Narrativas LGBT de pessoas em situação de rua: repensando identidades, normas e abjeções. Rev Pesqui Prat Psicossociais. 2020;15(1):16. Disponível em: https://pepsic.bvsalud.org/pdf/ppp/v15n1/07.pdf,¹¹11 Brasil. Ministério da Saúde. Secretaria de Gestão Estratégica e Participativa. Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais, Travestis e Transexuais. Brasília: Ministério da Saúde; 2013. 32 p. Disponível em: https://bibliotecadigital.economia.gov.br/bitstream/123456789/387/1/politica_saude_lesbicas_gays_bissexuais_travestis.pdf
https://bibliotecadigital.economia.gov.b... ,¹⁴14 Benevides BG. Dossiê assassinatos e violências contra travestis e transexuais brasileiras em 2023. Brasília, DF: Distrito Drag; 2024. 125 p. Disponível em: https://antrabrasil.org/wp-content/uploads/2024/01/dossieantra2024-web.pdf
https://antrabrasil.org/wp-content/uploa...

It was estimated that 1.9% of the adult population of Brazil identifies as trans people or travestis ^.1818 Spizzirri G, Eufrásio RÁ, Abdo CH, Lima MC. Proportion of ALGBT adult Brazilians, sociodemographic characteristics, and self-reported violence. Sci Rep. 2022;12(1). Disponível em: https://doi.org/10.1038/s41598-022-15103-y
https://doi.org/10.1038/s41598-022-15103... The 4.5% proportion observed in this study underscores the impact of social exclusion experienced by transgender people and travestis living in street situations, a consequence of the social marginalization resulting from their divergence from cis-heteronormative expectations.⁷7 Costa AC, Pascoal BT, Salgado FM, Garcia MR, Paiva VS. Trajetória de vida e sociabilidade entre a população LGBT em situação de rua de São Paulo. Anais do I Seminário Violar. Campinas: UNICAMP; 2010. Disponível em: https://www.fe.unicamp.br/eventos/semviolar/anais/Anais-ISemViolar.pdf
https://www.fe.unicamp.br/eventos/semvio...

8 Silva RG, Bezerra WC, Queiroz SB. Os impactos das identidades transgênero na sociabilidade de travestis e mulheres transexuais. Rev Ter Ocupacional Univ São Paulo. 2015;26(3):364. Disponível em: https://doi.org/10.11606/issn.2238-6149.v26i3p364-372
https://doi.org/10.11606/issn.2238-6149.... -⁹9 Medeiros LP, Amorim AK, Nobre MT. Narrativas LGBT de pessoas em situação de rua: repensando identidades, normas e abjeções. Rev Pesqui Prat Psicossociais. 2020;15(1):16. Disponível em: https://pepsic.bvsalud.org/pdf/ppp/v15n1/07.pdf,¹¹11 Brasil. Ministério da Saúde. Secretaria de Gestão Estratégica e Participativa. Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais, Travestis e Transexuais. Brasília: Ministério da Saúde; 2013. 32 p. Disponível em: https://bibliotecadigital.economia.gov.br/bitstream/123456789/387/1/politica_saude_lesbicas_gays_bissexuais_travestis.pdf
https://bibliotecadigital.economia.gov.b... ,¹²12 Abade EAF, França JAN, Souza ES. Cuidados de enfermagem à população LGBT+. In: Rocha ESC, Toledo NN, Pina RMP, Pereira RSF, Souza ES, editores. Enfermagem no cuidado à saúde de populações em situação de vulnerabilidade. Brasília, DF: Editora ABEn; 2022. p. 93-106. Disponível em: https://doi.org/10.51234/aben.22.e11.c10
https://doi.org/10.51234/aben.22.e11.c10... ,¹⁷17 Vieira MD, Araújo RC, Medeiros D. As dificuldades enfrentadas pela população trans no acesso aos serviços de saúde: uma revisão integrativa de literatura. Res Soc Dev. 2022;11(12):e276111235019. Disponível em: https://doi.org/10.33448/rsd-v11i12.35019
https://doi.org/10.33448/rsd-v11i12.3501...

From gestation to the moment they express their identity and challenge the sex-gender system and its associated behavioral expectations, transgender people and travestis are rendered invisible, perceived as “the other,” “the stranger,” or “the abject,” existing solely to be erased^.1313 Bento B, Pelúcio L. Despatologização do gênero: a politização das identidades abjetas. Rev Estud Fem. 2012;20(2):569-81. Disponível em: https://doi.org/10.1590/s0104-026x2012000200017
https://doi.org/10.1590/s0104-026x201200... “It is a process of granting life, through discourse, only to extinguish it immediately”^.1919 Bento B. Na escola se aprende que a diferença faz a diferença. Rev Estud Fem. 2011;19(2):549-59. Disponível em: https://doi.org/10.1590/s0104-026x2011000200016
https://doi.org/10.1590/s0104-026x201100...

Most trans people and travestis identified as Black, predominantly Black people. This data reflected the historical composition of the homeless population, referring to former enslaved individuals. Following the abolition of slavery, these people were left without legal or reparative support and turned to public spaces, particularly urban areas, for residence.⁴4 Almeida MD. Pessoas em situação de rua e relações familiares: uma visão a partir dos sujeitos do Movimento População de Rua da Bahia [Trabalho de Conclusão de Curso]. Salvador: Universidade Federal da Bahia; 2016. Disponível em: https://ips.ufba.br/sites/ips.ufba.br/files/mariana-dornelas_23-11-2016_tcc-final-2016.1.pdf,⁵5 Oliveira RJ. A segregação racial e o pensamento urbanístico no Brasil. Rev Politicas Publicas Amp Cid. 2020. Disponível em: https://doi.org/10.23900/10.23900/2359-1552v9n1-3-3-2020
https://doi.org/10.23900/10.23900/2359-1... Although being part of the Black population is a shared inequity across all homeless individuals, non-conforming gender identities serve as a significant intersectional factor, exposing Black transgender people and travestis to violence and social exclusion driven by both racial and gender-based discrimination^.88 Silva RG, Bezerra WC, Queiroz SB. Os impactos das identidades transgênero na sociabilidade de travestis e mulheres transexuais. Rev Ter Ocupacional Univ São Paulo. 2015;26(3):364. Disponível em: https://doi.org/10.11606/issn.2238-6149.v26i3p364-372
https://doi.org/10.11606/issn.2238-6149....

The majority of trans people and travestis reported being unemployed, although many engaged in some form of informal paid activity. Most had never held formal employment. Their labor context was predominantly characterized by self-employment, underemployment and informal work or complete exclusion from the labor market.⁸8 Silva RG, Bezerra WC, Queiroz SB. Os impactos das identidades transgênero na sociabilidade de travestis e mulheres transexuais. Rev Ter Ocupacional Univ São Paulo. 2015;26(3):364. Disponível em: https://doi.org/10.11606/issn.2238-6149.v26i3p364-372
https://doi.org/10.11606/issn.2238-6149.... ,²⁰20 Paniza MD, Moresco MC. À margem da gestão da diversidade? Travestis, transexuais e o mundo do trabalho. Rev Adm Empresas. 2022;62(3):e2021-0031. Disponível em: https://doi.org/10.1590/S0034-759020220305
https://doi.org/10.1590/S0034-7590202203...

The most common informal activities included prostitution and collecting and selling recyclable materials, often performed simultaneously.

These activities reflect the challenges faced in securing formal employment, which frequently push transgender people and travestis into more accepting sectors such as compulsory sex work, beauty, entertainment, and the arts.⁸8 Silva RG, Bezerra WC, Queiroz SB. Os impactos das identidades transgênero na sociabilidade de travestis e mulheres transexuais. Rev Ter Ocupacional Univ São Paulo. 2015;26(3):364. Disponível em: https://doi.org/10.11606/issn.2238-6149.v26i3p364-372
https://doi.org/10.11606/issn.2238-6149.... ,²⁰20 Paniza MD, Moresco MC. À margem da gestão da diversidade? Travestis, transexuais e o mundo do trabalho. Rev Adm Empresas. 2022;62(3):e2021-0031. Disponível em: https://doi.org/10.1590/S0034-759020220305
https://doi.org/10.1590/S0034-7590202203... The streets, whether as a venue for sex work or artistic performances, constituted a significant social space in their trajectories, including their political organization to advocate against violence.⁹9 Medeiros LP, Amorim AK, Nobre MT. Narrativas LGBT de pessoas em situação de rua: repensando identidades, normas e abjeções. Rev Pesqui Prat Psicossociais. 2020;15(1):16. Disponível em: https://pepsic.bvsalud.org/pdf/ppp/v15n1/07.pdf,²¹21 Carrijo GG, Simpson K, Rasera EF, Prado MA, Teixeira FB. Movimentos emaranhados: travestis, movimentos sociais e práticas acadêmicas. Rev Estud Fem. 2019;27(2). Disponível em: https://doi.org/10.1590/1806-9584-2019v27n254503
https://doi.org/10.1590/1806-9584-2019v2... ,²²22 Silva JC. Bajubá Odara: resumo histórico do nascimento do movimento social de travestis e transexuais do Brasil. Picos: Piauí; 2021.

The majority of the transgender and travesti population experiencing homelessness reported having been sheltered in institutional housing facilities, which serve as temporary residences. Despite the high number of registrations in the Unified Registry, the majority of this population were not Bolsa Família beneficiaries, the main federal cash transfer program. According to the information on monthly income provided by trans people and travestis participating in the study, two of them were eligible for Bolsa Família Program (up to ¼ of the minimum wage)^.2323 Fontes LF, Jacinto PD, França MT. Programas de transferência de renda e migração interna: evidências do programa bolsa família. Anal Econ. 2019;37(72). Disponível em: https://doi.org/10.22456/2176-5456.70805
https://doi.org/10.22456/2176-5456.70805... The reasons for the absence of this benefit were not specified, but may include lack of documentation, social discrimination and lack of knowledge about their rights. Bureaucratic barriers, such as the mismatch of gender identity in official documents and insufficient training of service professionals, further contributed to the exclusion and marginalization of this group in accessing social assistance services.⁸8 Silva RG, Bezerra WC, Queiroz SB. Os impactos das identidades transgênero na sociabilidade de travestis e mulheres transexuais. Rev Ter Ocupacional Univ São Paulo. 2015;26(3):364. Disponível em: https://doi.org/10.11606/issn.2238-6149.v26i3p364-372
https://doi.org/10.11606/issn.2238-6149.... ,¹⁶16 Cortes HM, Carnevalli LM, Araújo LMP, Pinho PH. O (des) acesso de pessoas transgêneras aos serviços de saúde no recôncavo baiano. Cadernos Gênero Diversidade. 2021;6(4):159-80. Disponível em: https://doi.org/10.9771/cgd.v6i4.36104
https://doi.org/10.9771/cgd.v6i4.36104...

The homeless transgender and travesti population faced challenges in accessing health services, relying primarily on emergency care facilities (n=19), such as emergency rooms. This pattern reflects a tendency to seek care only in acute or life-threatening situations.¹⁶16 Cortes HM, Carnevalli LM, Araújo LMP, Pinho PH. O (des) acesso de pessoas transgêneras aos serviços de saúde no recôncavo baiano. Cadernos Gênero Diversidade. 2021;6(4):159-80. Disponível em: https://doi.org/10.9771/cgd.v6i4.36104
https://doi.org/10.9771/cgd.v6i4.36104... ,²⁴24 Aguiar MM, Iriart JA. Significados e práticas de saúde e doença entre a população em situação de rua em Salvador, Bahia, Brasil. Cad Saude Publica. 2012;28(1):115-24. Disponível em: https://doi.org/10.1590/s0102-311x2012000100012
https://doi.org/10.1590/s0102-311x201200... ,²⁵25 Carneiro Jr N, Silveira C. Organização das práticas de atenção primária em saúde no contexto dos processos de exclusão/inclusão social. Cad Saude Publica. 2003;19(6):1827-35. Disponível em: https://doi.org/10.1590/s0102-311x2003000600026
https://doi.org/10.1590/s0102-311x200300... A lack of understanding about primary healthcare as part of the emergency care network was evident, likely due to the breakdown in service provision at primary health centers and family health units, along with the misconception that primary care is limited to scheduled consultations.¹⁶16 Cortes HM, Carnevalli LM, Araújo LMP, Pinho PH. O (des) acesso de pessoas transgêneras aos serviços de saúde no recôncavo baiano. Cadernos Gênero Diversidade. 2021;6(4):159-80. Disponível em: https://doi.org/10.9771/cgd.v6i4.36104
https://doi.org/10.9771/cgd.v6i4.36104... ,¹⁷17 Vieira MD, Araújo RC, Medeiros D. As dificuldades enfrentadas pela população trans no acesso aos serviços de saúde: uma revisão integrativa de literatura. Res Soc Dev. 2022;11(12):e276111235019. Disponível em: https://doi.org/10.33448/rsd-v11i12.35019
https://doi.org/10.33448/rsd-v11i12.3501...

This disengagement was further exacerbated by institutional transphobia perpetuated by healthcare professionals, ranging from failure to acknowledge gender identity to disrespecting social names, undermining the quality of care for the specific health needs of transgender people and travestis .¹⁶16 Cortes HM, Carnevalli LM, Araújo LMP, Pinho PH. O (des) acesso de pessoas transgêneras aos serviços de saúde no recôncavo baiano. Cadernos Gênero Diversidade. 2021;6(4):159-80. Disponível em: https://doi.org/10.9771/cgd.v6i4.36104
https://doi.org/10.9771/cgd.v6i4.36104... ,¹⁷17 Vieira MD, Araújo RC, Medeiros D. As dificuldades enfrentadas pela população trans no acesso aos serviços de saúde: uma revisão integrativa de literatura. Res Soc Dev. 2022;11(12):e276111235019. Disponível em: https://doi.org/10.33448/rsd-v11i12.35019
https://doi.org/10.33448/rsd-v11i12.3501... ,²⁶26 Abade EA, Chaves SC, Silva GC. Saúde da população LGBT: uma análise dos agentes, dos objetos de interesse e das disputas de um espaço de produção científica emergente. Physis. 2020;30(4). Disponível em: https://doi.org/10.1590/s0103-73312020300418
https://doi.org/10.1590/s0103-7331202030... -²⁸28 Rocon PC, Sodré F, Rodrigues A, Barros ME, Wandekoken KD. Desafios enfrentados por pessoas trans para acessar o processo transexualizador do Sistema Único de Saúde. Interface Comun Saude Educ. 2019;23. Disponível em: https://doi.org/10.1590/interface.180
https://doi.org/10.1590/interface.180...

The use of specialized mental health services was observed among trans people and travestis, particularly in psychosocial care center for alcohol and other drug use. This result corroborated the high rates of negative mental health outcomes, including substance use^.2929 Chinazzo ÍR, Lobato MI, 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. Cienc Saude Coletiva. 2021;26(suppl 3):5045-56. Disponível em: https://doi.org/10.1590/1413-812320212611.3.28532019
https://doi.org/10.1590/1413-81232021261... It further emphasizes their detachment from health promotion and disease prevention initiatives offered by primary care services^.3030 Dultra LS. Acesso da população em situação de rua na Atenção Básica: uma análise das práticas instituídas pela Saúde da Família no Centro Histórico de Salvador [Dissertação]. Salvador: Universidade Federal da Bahia; 2021. Disponível em: https://repositorio.ufba.br/bitstream/ri/34309/1/Disserta%c3%a7%c3%a3o_Lua_S%c3%a1-Dultra-2018.pdf

Although homelessness itself exposes individuals to numerous rights violations, being transgender adds a layer of vulnerability, manifesting even before homelessness occurs and intensifying with this new condition. It is essential to adopt a political commitment to recognize the resilience of trans people and travestis in the face of marginalization, as expressed through their identity affirmation, organization, and social participation in rights advocacy.

Selection bias was a limiting factor in this study. The sample was obtained through convenience sampling, a common practice in similar studies due to the challenges in reaching the homeless population. Despite this limitation, the study stands out for its singular focus on the trans and travesti population in the context of homelessness, exploring a wide set of variables related to the sociodemographic profile and access to social assistance and health services. The sample of trans people and travesti (n=24) did not allow for statistical analyses of association.

This study aims to contribute to the understanding of the trans and travesti population experiencing homelessness, addressing a gap that has been little explored in the international and national literature. The findings emphasize the need to improve specific public policies aimed at ensuring the basic rights of transgender people and travestis, such as healthcare, housing, and employment, to facilitate their transition out of homelessness. It is expected that these data will stimulate further debate on this topic and guide future research to provide more detailed information and robust data analyses on factors associated with morbidity and mortality in this population.

Combining quantitative and qualitative approaches is critical to understanding the personal, social, and contextual experiences contributing to the vulnerabilities faced by homeless transgender people and travestis. Ongoing education for health and social service professionals, grounded in scientific evidence and social movement guidelines, is essential. Reducing institutional violence, particularly barriers to access, and improving the quality of care for this population are key objectives.

In conclusion, the findings of this study reveal the profound vulnerability of homeless transgender people and travestis, who are subjected to multiple forms of discrimination and social exclusion. The intersection of social class, gender, and race exacerbates this situation, limiting access to essential services such as healthcare and employment. These results highlight the urgent need for specific public policies to safeguard basic rights, promote social inclusion, and combat transphobia. Future research should delve deeper into the lived experiences of these individuals to develop more effective interventions.

ACKNOWLEDGMENTS

We extend our gratitude to all collaborators from institutions and support involved in the implementation of the Health Conditions of the Homeless Population in Salvador Project – Bahia, 2021: National Movement for the Homeless Population, Street Clinic teams Instituto de Saúde Coletiva/Universidade Federal da Bahia, Instituto Gonçalo Moniz/Fundação Oswaldo Cruz, Associação de Pais e Amigos dos Excepcionais, Defensoria Pública do Estado da Bahia, Fórum de Catadores e de Catadoras de Rua e em Situação de Rua da Bahia, S3 Gestão em Saúde, Programa Corra Pro Abraço, Cata Rua, Centro de Atenção Psicossocial Álcool e Drogas Gregório de Matos, Obras Sociais Irmã Dulce, Secretaria Municipal de Promoção Social, Combate à Pobreza, Esportes e Lazer e Secretaria Municipal de Saúde de Salvador. To George Gonçalves, for creating the map of sanitary district coverage, points of concentration of the homeless population, and institutional shelter units.

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