ABSTRACT

OBJECTIVE

To synthesize scientific evidence to characterize health care for transvestites and transsexuals in Brazil.

METHODS

This is a systematic review, conducted from July 2020 to January 2021 and updated in September 2021, whose protocol is registered in the International Prospective Register of Systematic Reviews (PROSPERO) platform, under code CRD42020188719. The survey of evidence was carried out in four databases and eligible articles were evaluated for methodological quality, and those with a low risk of bias were included.

RESULTS

Fifteen articles were selected and the findings were grouped into six categories according to their thematic approaches: Possibilities to transform health care; Transvestiphobia and transphobia: violations inside and outside the Brazilian Unified Health System (SUS); Professional unpreparedness to care for transvestites and transsexuals; Search for health care alternatives; Right to health for transvestites and transsexuals: utopia or reality?; The Transsexualization Process: advances and challenges.

CONCLUSIONS

There is evidence that health care for transvestites and transsexuals in Brazil is still exclusive, fragmented, centered on specialized care and guided by curative actions, resembling the care models that preceded the SUS and which have been heavily criticized since the Brazilian Sanitary Reform.

Transvestism; Transsexualism; Minority Health; Unified Health System; Systematic Review

INTRODUCTION

Transgender identities are diverse and not limited to a specific definition. However, in this study, transgender people are understood as those who have a gender identity opposite to the sex assigned at birth¹1. Jesus JG. Orientações sobre identidade de gênero: conceitos e termos: guia técnico sobre pessoas transexuais, travestis e demais transgêneros, para formadores de opinião. 2. ed. rev. ampl. Brasília, DF: Fundação Biblioteca Nacional; 2012 [cited 2021 Dec 12]. Available from: http://www.diversidadesexual.com.br/wp-content/uploads/2013/04/G%C3%8ANERO-CONCEITOS-E-TERMOS.pdf
http://www.diversidadesexual.com.br/wp-c... . In addition, the term transvestite precedes the term transsexual and is more frequent in Brazil and in other Latin American countries, designating people who experience female roles, but who do not recognize themselves as men or women¹1. Jesus JG. Orientações sobre identidade de gênero: conceitos e termos: guia técnico sobre pessoas transexuais, travestis e demais transgêneros, para formadores de opinião. 2. ed. rev. ampl. Brasília, DF: Fundação Biblioteca Nacional; 2012 [cited 2021 Dec 12]. Available from: http://www.diversidadesexual.com.br/wp-content/uploads/2013/04/G%C3%8ANERO-CONCEITOS-E-TERMOS.pdf
http://www.diversidadesexual.com.br/wp-c... .

In the global context, transvestites and transsexuals represent a small portion of the general population. However, the discrimination and social exclusion imposed on these people put them in the worst health and life conditions³3. Reisner SL, Poteat T, Keatley J, Cabral M, Mothopeng T, Dunham E, et al. Global health burden and needs of transgender populations: a review. Lancet. 2016;338(10042):412-36. https://doi.org/10.1016/S0140-6736(16)00684-X
https://doi.org/10.1016/S0140-6736(16)00... . Compared to other population groups, transvestites and transsexuals have high rates of mental suffering, including suicidal ideation and attempts, due to the discrimination and rejection they face throughout their lives and in all institutional spaces. In addition, other health problems are caused, mainly, by bodily transformations resulting from attempts to align the phenotype with gender identity. Thus, these factors end up generating a lower life expectancy and greater difficulties for these people to access health services³3. Reisner SL, Poteat T, Keatley J, Cabral M, Mothopeng T, Dunham E, et al. Global health burden and needs of transgender populations: a review. Lancet. 2016;338(10042):412-36. https://doi.org/10.1016/S0140-6736(16)00684-X
https://doi.org/10.1016/S0140-6736(16)00... , ⁴4. Narang P, Sarai SK, Aldrin S, Lippman S. Suicide among transgender and gender-nonconforming people. Prim Care Companion CNS Disord. 2018;20(3):18nr02273. https://doi.org/10.4088/PCC.18nr02273
https://doi.org/10.4088/PCC.18nr02273... .

In Brazil, similar to the reality of other countries, transvestites and transgender women are socially more vulnerable: among lesbians, gays, bisexuals, queers, intersexuals, asexuals and other categories of gender and sexuality (LGBTTQIA+), they are the main victims of violence, especially bodily injuries and homicides by firearms⁵5. Mendes WG, Silva CMFP. Homicídios da população de lésbicas, gays, bissexuais, travestis, transexuais ou transgêneros (LGBT) no Brasil: uma análise espacial. Cien Saude Colet. 2020;25(5):1709-22. https://doi.org/10.1590/1413-81232020255.33672019
https://doi.org/10.1590/1413-81232020255... , ⁶6. Mendes WG, Duarte MJO, Andrade CAF, Silva CMFP. Revisão sistemática das características dos homicídios contra a população LGBT. Cien Saude Colet. 2021;26(11):5615-28. https://doi.org/10.1590/1413-812320212611.33362020
https://doi.org/10.1590/1413-81232021261... . Given this reality, health care should not be configured only in assistance to this population’s health problems, but also in broad and concrete actions to welcome transvestites and transgender people, which help them face gender identity-based discrimination.

The Brazilian health system, regulated in 1990 and called the Unified Health System (SUS), is mostly composed of public and free health services, complemented by some services from the private network financed by the State⁷7. Paim JS. Sistema Único de Saúde (SUS) aos 30 anos. Cien Saude Colet. 2018;23(6):1723-8. https://doi.org/10.1590/1413-81232018236.09172018
https://doi.org/10.1590/1413-81232018236... . In addition, SUS is constituted by doctrinal principles (universality, equity and integrality), to which the health care model, expressed in policies, programs, services organization and care provision, must turn to, in order to recognize the social determinants of the health-disease process and health inequalities⁸8. Fertonani HP, Pires DEP, Biff D, Scherer MDA. Modelo assistencial em saúde: conceitos e desafios para a atenção básica brasileira. Cien Saude Colet. 2015;20(6):1869-78. https://doi.org/10.1590/1413-81232015206.13272014
https://doi.org/10.1590/1413-81232015206... .

Based especially on the principle of equity, health care practices should be carried out in a more fruitful way to serve the most vulnerable people, including transvestites and transgender people. Initiatives aimed at this population have been implemented in the SUS over the years, such as the National LGBT Comprehensive Health Policy, created in 2011, and the Transsexual Process Program in the SUS, created in 2008 and expanded in 2013⁹9. Rocon PC, Sodré F, Rodrigues A, Barros MEB, Wandekoken KD. Desafios enfrentados por pessoas trans para acessar o processo transexualizador do Sistema Único de Saúde. Interface (Botucatu). 2019;23:e180633. https://doi.org/10.1590/Interface.180633
https://doi.org/10.1590/Interface.180633... .

In the scientific literature, there has been an increase in the publication of articles on the health of the Brazilian LGBTTQIA+ population after the creation of the National LGBT Integral Health Policy¹⁰10. Prado EAJ, Sousa MF. Políticas públicas e a saúde da população LGBT: uma revisão integrativa. Tempus Actas Saude Colet. 2017;11(1):69-80. https://doi.org/10.18569/tempus.v11i1.1895
https://doi.org/10.18569/tempus.v11i1.18... , as well as theses and dissertations on transvestism, transsexuality and health, especially after the expansion of the Transsexualizing Process in the SUS¹¹11. Lima RRT, Flor TBM, Araújo PH, Noro LRA. Análise bibliométrica de teses e dissertações brasileiras sobre travestilidade, transexualidade e saúde. Trab Educ Saude. 2020;18(3):e00301131. https://doi.org/10.1590/1981-7746-sol00301
https://doi.org/10.1590/1981-7746-sol003... . Furthermore, it is possible to identify some integrative reviews on the health of the transvestite and transsexual population in Brazil, specifically on the difficulties these people face in accessing health services¹²12. Ferreira BO, Bonan C. Abrindo os armários do acesso e da qualidade: uma revisão integrativa sobre assistência à saúde das populações LGBTT. Cien Saude Colet. 2020;25(5):1765-77. https://doi.org/10.1590/1413-81232020255.34492019
https://doi.org/10.1590/1413-81232020255... , ¹³13. Rocon PC, Wandekoken KD, Barros MEB, Duarte MJO, Sodré F. Acesso à saúde pela população trans no Brasil: nas entrelinhas da revisão integrativa. Trab Educ Saude. 2020;18(1):e0023469. https://doi.org/10.1590/1981-7746-sol00234
https://doi.org/10.1590/1981-7746-sol002... . However, there are no systematic reviews that present summarized evidence on the other aspects related to health care for the Brazilian transvestite and transsexual population.

Considering that Brazil is a country of continental dimensions, with diverse and profound inequalities, especially in the realization of the universal right to health, the question is: how has health care for transvestites and transsexuals been provided within the scope of the SUS? As a result, the objective of this study is to synthesize scientific evidence to characterize health care for transvestites and transsexuals in the country.

METHODS

This is a systematic review of the scientific literature, conducted from July 2020 to January 2021 and updated in September 2021. The research protocol¹⁴14. Lima RRT, Flor TBM, Silva AB, Noro LRA. Health care for transgender people in Brazil: a systematic review protocol. Res Sq [Preprint]. 2020 [posted 2020 Sep 1; cited 2021 Dec 12]. https://doi.org/10.21203/rs.3.rs-58007/v1
https://doi.org/10.21203/rs.3.rs-58007/v... followed the recommendations of the checklist Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (Prisma-P)¹⁵15. Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev. 2015;4(1):1-9. https://doi.org/10.1186/2046-4053-4-1
https://doi.org/10.1186/2046-4053-4-1... , and is registered on the International Prospective Register of Systematic Reviews (Prospero) platform, under code CRD42020188719.

From the formulation of a well-defined problem-question and an explicit and reproducible methodology, systematic review studies are able to identify, select, evaluate and summarize already available scientific evidence¹⁶16. Galvão TF, Pereira MG. Revisões sistemáticas da literatura: passos para sua elaboração. Epidemiol Serv Saude. 2014;23(1):183-4. https://doi.org/10.5123/S1679-49742014000100018
https://doi.org/10.5123/S1679-4974201400... . Likewise, they can point out necessary changes to professional practices or recommendations for carrying out other investigations, aiming to fill gaps in knowledge.

The survey of evidence, in Portuguese and English, that integrates this systematic review was carried out from consultations to the following databases: Scientific Electronic Library Online (SciELO), US National Library of Medicine (Pubmed), Literatura Latino-Americana e do Caribe em Ciências da Saúde (Lilacs) and Biblioteca Virtual em Saúde (BVS). The BVS, a digital platform coordinated by the Centro Latino-Americano e do Caribe de Informação em Ciências da Saúde (BIREME), gathers data from different electronic databases in the health area, such as: Base Regional de Informes de Avaliação de Tecnologias em Saúde das Américas (Brisa), Littérature Scientifique in Santé (Lissa), Medical Literature Analysis and Retrieval System Online (MedLine), Sistema de Información de la Biblioteca de la Organización Mundial de la Salud (Wholis), Índice Bibliográfico Español en Ciencias de la Salud (IBECS), Base de Dados em Enfermagem (BDENF), Bibliografia Brasileira de Odontologia (BBO), among others.

To conduct the electronic search of the studies, previously defined strategies were used after different attempts, consisting of a block of health care-related descriptors in the Brazilian context and a block of keywords related to transvestites and transgender people, respecting the specificities of each database ( Box 1 ).

In the SciELO, Lilacs and BVS databases, the search strategies were composed of descriptors extracted from the vocabulary of the Descritores em Ciências da Saúde (DECS) and, for the search in PubMed, equivalent terms from the Medical Subject Headings (MESH) were used. Strategies were applied covering all indexes (title, abstract, keywords and text).

Eligibility criteria were based on the PECOS anagram¹⁶16. Galvão TF, Pereira MG. Revisões sistemáticas da literatura: passos para sua elaboração. Epidemiol Serv Saude. 2014;23(1):183-4. https://doi.org/10.5123/S1679-49742014000100018
https://doi.org/10.5123/S1679-4974201400... , with the necessary adaptations ( Box 2 ).

The adaptation in the PECOS anagram concerned the comparison or control element, not being considered for the inclusion criteria of this study. Therefore, articles resulting from original studies were included in the review, with a qualitative or quantitative approach, on aspects related to health care for the transvestite and transsexual population in Brazil, and in which the subjects were transvestites, transgender people, health professionals or health managers. Furthermore, the studies included were those published in full in scientific journals from 1990 onwards, the year of SUS regulation, regardless of language.

Studies that addressed health care for transvestites and transsexuals only in the private health system or together with aspects related to health care for other people in the LGBTTQIA+ group were excluded, as well as studies classified as abstracts published in annals, editorials, reflective articles, documentary analyses, literature reviews, technical manuals, chapters, books, monographs, dissertations and theses.

The publications were retrieved by a single researcher and subsequently coded and organized in an electronic spreadsheet for later removal of duplicates. Next, considering the inclusion and exclusion criteria adopted, screening was performed based on the reading of the titles and abstracts of the files, to select those that could be included in the systematic review and that would be read in full.

The full reading stage was carried out to elect those studies with strong potential for inclusion in the systematic review. Through manual search and in a complementary way, the reference lists of the selected articles were also consulted to identify possible misses during the electronic search.

The selected articles were read again in full so that their methodological quality could be assessed by two previously calibrated researchers, aiming to guarantee uniformity in the critical evaluation. This happened through the critical evaluation tools of the Joanna Briggs Institute (JBI), using a specific checklist for studies with a qualitative approach¹⁷17. Lockwood C, Munn Z, Porritt K. Qualitative research synthesis: methodological guidance for systematic reviewers utilizing meta-aggregation. Int J Evid Based Healthc. 2015;13(3):179-87. https://doi.org/10.1097/XEB.0000000000000062
https://doi.org/10.1097/XEB.000000000000... , since all eligible articles had this methodological approach.

Based on the checklist presented by Lockwood et al.¹⁷17. Lockwood C, Munn Z, Porritt K. Qualitative research synthesis: methodological guidance for systematic reviewers utilizing meta-aggregation. Int J Evid Based Healthc. 2015;13(3):179-87. https://doi.org/10.1097/XEB.0000000000000062
https://doi.org/10.1097/XEB.000000000000... , as well as the classification proposed by Almeida et al.¹⁸18. Almeida GM, Oliveira KHD, Monteiro JS, Medeiros MAT, Recine EGIG. Educational training of nutritionists in public health nutrition: a systematic review. Rev Nutr. 2018;31(1):97-117. https://doi.org/10.1590/1678-98652018000100009
https://doi.org/10.1590/1678-98652018000... , the risk of bias in the articles was rated as high (with up to 49% of affirmative responses), moderate (affirmative responses between 50% and 69%) and low (70% or more of affirmative responses). In this review study, the final synthesis was composed only of articles with low risk of bias.

The entire process of screening, eligibility and assessment of the methodological quality of the articles was carried out by two independent researchers. In case of doubt or disagreement, the researchers met virtually to discuss and establish a consensus.

The synthesis of the findings was carried out through the formal narrative and by preparing tables containing some data of the articles: title, authorship, year of publication, objective, sample/target audience, place of study (Federative Unit of Brazil, i.e., state), type of study, methodological approach, results and conclusions.

The results of the studies included in the systematic review were grouped categorically, according to their thematic approaches, and interpreted with the support of the scientific literature that deals with the issue investigated here. Finally, the final writing of this manuscript followed the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-analyses checklist (Prisma)¹⁹19. Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLoS Med. 2009;6(7):e1000097. https://doi.org/10.1371/journal.pmed.1000097
https://doi.org/10.1371/journal.pmed.100... .

RESULTS

By searching the databases of interest for this systematic review, it was possible to retrieve 1,164 titles. After removing duplicates, screening after reading titles and abstracts, including other publications by checking the references of the screened articles, and updating the search, 45 articles were submitted to full reading. Of these, 24 were submitted to methodological quality assessment and 15 were included in the results synthesis, with 14 articles published in Portuguese and one article published in English ( Figure 1 ).

The 15 articles included in this systematic review do not meet the sixth criterion of the checklist used to guide the assessment of methodological quality¹⁷17. Lockwood C, Munn Z, Porritt K. Qualitative research synthesis: methodological guidance for systematic reviewers utilizing meta-aggregation. Int J Evid Based Healthc. 2015;13(3):179-87. https://doi.org/10.1097/XEB.0000000000000062
https://doi.org/10.1097/XEB.000000000000... , that is, they do not present explicit information about the researchers’ cultural or theoretical location and its possible influence on the study ( Box 3 ).

In studies with qualitative approaches, researchers’ beliefs and values, as well as their theoretical orientations, can influence the conduct of the research, from data collection to results dissemination. Therefore, it is important that articles that value methodological rigor explain the possible influences of the researchers in the study, or the strategies adopted to reduce these potential influences¹⁷17. Lockwood C, Munn Z, Porritt K. Qualitative research synthesis: methodological guidance for systematic reviewers utilizing meta-aggregation. Int J Evid Based Healthc. 2015;13(3):179-87. https://doi.org/10.1097/XEB.0000000000000062
https://doi.org/10.1097/XEB.000000000000... .

The synthesis of the included studies ( Box 4 ) reveals that 10 articles, i.e., the majority, were published between 2017 and 2019. The research that originated these articles was developed in the South and Southeast of Brazil, five of them in each region. Therefore, articles resulting from studies carried out in the North region were not included.

In their entirety, the articles have a qualitative approach as the only methodological characteristic. In addition, six of the articles had transvestites and transgender women as research subjects and three were developed with health professionals, specifically nurses, focusing on their perception of health care for transvestites and transsexuals.

According to the summary contained in Box 4 , eight articles (the majority) have as their focus of analysis the access of transvestites and transsexuals to health services and the care offered to this public. From the thematic approaches identified in the results of the articles, the findings of this review were grouped into six categories, presented below.

Possibilities to Transform Health Care

With regard to health care for transvestites and transsexuals in Brazil, the articles reveal, almost unanimously, the existing difficulties for implementing the basic principles of the SUS. In view of the diagnosis of these difficulties, which will be addressed in the following categories, possibilities are pointed out to transform this health care model, such as: development of intersectoral strategies to combat discrimination against transvestites and transsexuals, including in health services²³23. Sousa D, Iriart J. “Viver dignamente”: necessidades e demandas de saúde de homens trans em Salvador, Bahia, Brasil. Cad Saude Publica. 2018;34(10):e00036318. https://doi.org/10.1590/0102-311X00036318
https://doi.org/10.1590/0102-311X0003631... , ³³33. Ferreira BO, Nascimento EF, Pedrosa JIS, Monte LMI. Vivências de travestis no acesso ao SUS. Physis. 2017;27(04):1023-38. https://doi.org/10.1590/S0103-73312017000400009
https://doi.org/10.1590/S0103-7331201700... ; constant dialogue between SUS management and the social segments that represent transvestites and transgender people, with a view to understanding and respecting the health specificities of this part of the population²⁴24. Moraes AND, Silva GSN. Travestis e o cuidado humanizado em saúde. Rev Abordagem Gestalt. 2020;26(2):175-87. https://doi.org/10.18065/2020v26n2.5
https://doi.org/10.18065/2020v26n2.5...

25. Sehnem GD, Rodrigues RL, Lipinski JM, Vasquez MED, Schmidt A. Health Care Assistance in Primary Care: access to care. Rev Enferm UFPE On Line. 2017;11(4):1676-84. https://doi.org/10.5205/1981-8963-v11i4a15238p1676-1684-2017
https://doi.org/10.5205/1981-8963-v11i4a... - ²⁶26. Amorim JF, Teixeira ER. Atendimento das necessidades em saúde das travestis na atenção primária. Rev Baiana Saude Publica. 2017;41(3):759-73. https://doi.org/10.22278/2318-2660.2017.v41.n3.a2379
https://doi.org/10.22278/2318-2660.2017.... , ³⁰30. Oliveira BP, Silva MAS, Souza MS. O direito à saúde de pessoas trans* no Distrito Federal: entre o direito de existir e o direito à equidade. Cad Ibero Am Dir Sanit. 2019;8(1):10-25. https://doi.org/10.17566/ciads.v8i1.502
https://doi.org/10.17566/ciads.v8i1.502... , ³³33. Ferreira BO, Nascimento EF, Pedrosa JIS, Monte LMI. Vivências de travestis no acesso ao SUS. Physis. 2017;27(04):1023-38. https://doi.org/10.1590/S0103-73312017000400009
https://doi.org/10.1590/S0103-7331201700... ; implementation of the National LGBT Comprehensive Health Policy, guaranteeing access for transvestites and transsexuals to the different establishments of the SUS²⁵25. Sehnem GD, Rodrigues RL, Lipinski JM, Vasquez MED, Schmidt A. Health Care Assistance in Primary Care: access to care. Rev Enferm UFPE On Line. 2017;11(4):1676-84. https://doi.org/10.5205/1981-8963-v11i4a15238p1676-1684-2017
https://doi.org/10.5205/1981-8963-v11i4a...

26. Amorim JF, Teixeira ER. Atendimento das necessidades em saúde das travestis na atenção primária. Rev Baiana Saude Publica. 2017;41(3):759-73. https://doi.org/10.22278/2318-2660.2017.v41.n3.a2379
https://doi.org/10.22278/2318-2660.2017.... - ²⁷27. Sehnem GD, Rodrigues RL, Lipinski JM, Vasquez MED, Schmidt A. (Des)preparo técnico-científico para o cuidado às travestis: percepções de enfermeiras(os). Rev Enferm UFSM. 2017;7(2):236-47. https://doi.org/10.5902/2179769223649
https://doi.org/10.5902/2179769223649... ; strategies to disseminate the meaning of being a transvestite or transsexual to the community in general, aiming to assert subjectivities and respect these people’s needs²⁴24. Moraes AND, Silva GSN. Travestis e o cuidado humanizado em saúde. Rev Abordagem Gestalt. 2020;26(2):175-87. https://doi.org/10.18065/2020v26n2.5
https://doi.org/10.18065/2020v26n2.5... , ³¹31. Sevelius J, Murray LR, Fernandes NM, Veras MA, Grinsztejn B, Lippman SA. Optimising HIV programming for transgender women in Brazil. Cult Health Sex. 2019;21(5):543-58. https://doi.org/10.1080/13691058.2018.1496277
https://doi.org/10.1080/13691058.2018.14... ; review of work practices in health, involving the rescue of the promotion of care, altruism by health professionals, development of autonomy for transvestites and transsexuals and inclusion of transsexual workers in health teams²⁴24. Moraes AND, Silva GSN. Travestis e o cuidado humanizado em saúde. Rev Abordagem Gestalt. 2020;26(2):175-87. https://doi.org/10.18065/2020v26n2.5
https://doi.org/10.18065/2020v26n2.5... , ²⁵25. Sehnem GD, Rodrigues RL, Lipinski JM, Vasquez MED, Schmidt A. Health Care Assistance in Primary Care: access to care. Rev Enferm UFPE On Line. 2017;11(4):1676-84. https://doi.org/10.5205/1981-8963-v11i4a15238p1676-1684-2017
https://doi.org/10.5205/1981-8963-v11i4a... , ³¹31. Sevelius J, Murray LR, Fernandes NM, Veras MA, Grinsztejn B, Lippman SA. Optimising HIV programming for transgender women in Brazil. Cult Health Sex. 2019;21(5):543-58. https://doi.org/10.1080/13691058.2018.1496277
https://doi.org/10.1080/13691058.2018.14... ; and changes in professional training in health, encouraging the integration of teaching-service-community, the inclusion of content on gender and sexuality in the curricula of courses in the health area and the development of permanent education actions regarding humanized care for transvestites and transsexuals to SUS workers²¹21. Oliveira I, Romanini M. (Re)escrevendo roteiros (in)visíveis: a trajetória de mulheres transgênero nas políticas públicas de saúde. Saude Soc. 2020;29(1):e170961. https://doi.org/10.1590/S0104-12902020170961
https://doi.org/10.1590/S0104-1290202017... , ²⁴24. Moraes AND, Silva GSN. Travestis e o cuidado humanizado em saúde. Rev Abordagem Gestalt. 2020;26(2):175-87. https://doi.org/10.18065/2020v26n2.5
https://doi.org/10.18065/2020v26n2.5... .

Transvestiphobia and Transphobia: Violations Inside and Outside the SUS

In the course of their lives, transvestites as well as transgender women and men are victims of prejudiced attitudes, a reflection of structural violence (transvestiphobia and transphobia) caused by the simple fact that it is a group that breaks with the hegemonic pattern, which tries to define the gender only by the anatomy of genital organs.

This aversion soon emerges within the family, when transvestites and transsexuals in search of recognition of their gender identities are not accepted by the family itself. This non-acceptance also occurs on the part of people from social circles²²22. Rigolon M, Carlos DM, Oliveira WA, Salim NJ. “A saúde não discute corpos trans”: história oral de transexuais e travestis. Rev Bras Enferm. 2020;73 Supl 6:e20190228. https://doi.org/10.1590/0034-7167-2019-0228
https://doi.org/10.1590/0034-7167-2019-0... , ³⁴34. Hanauer OFD, Hemmi APA. Caminhos percorridos por transexuais: em busca pela transição de gênero. Saude Debate. 2019;43(Nº Espec 8):91-106. https://doi.org/10.1590/0103-11042019S807
https://doi.org/10.1590/0103-11042019S80... . In addition, more than structural, transvestitephobia and transphobia are also institutional violence, that is, they are present in institutions such as the SUS.

Therefore, recognizing the violence suffered by transvestites and transsexuals must be part of the work process in the health area, in order to try to welcome and support the victims. However, discriminatory acts, such as disrespect for the social name and lack of understanding about transvestism and transsexuality on the part of health professionals and managers³¹31. Sevelius J, Murray LR, Fernandes NM, Veras MA, Grinsztejn B, Lippman SA. Optimising HIV programming for transgender women in Brazil. Cult Health Sex. 2019;21(5):543-58. https://doi.org/10.1080/13691058.2018.1496277
https://doi.org/10.1080/13691058.2018.14... , ³⁴34. Hanauer OFD, Hemmi APA. Caminhos percorridos por transexuais: em busca pela transição de gênero. Saude Debate. 2019;43(Nº Espec 8):91-106. https://doi.org/10.1590/0103-11042019S807
https://doi.org/10.1590/0103-11042019S80... , negatively influence health care practices for this specific public.

As a result, transvestites and transsexuals feel insecure when using health services³³33. Ferreira BO, Nascimento EF, Pedrosa JIS, Monte LMI. Vivências de travestis no acesso ao SUS. Physis. 2017;27(04):1023-38. https://doi.org/10.1590/S0103-73312017000400009
https://doi.org/10.1590/S0103-7331201700... , ³⁴34. Hanauer OFD, Hemmi APA. Caminhos percorridos por transexuais: em busca pela transição de gênero. Saude Debate. 2019;43(Nº Espec 8):91-106. https://doi.org/10.1590/0103-11042019S807
https://doi.org/10.1590/0103-11042019S80... , even avoiding them²²22. Rigolon M, Carlos DM, Oliveira WA, Salim NJ. “A saúde não discute corpos trans”: história oral de transexuais e travestis. Rev Bras Enferm. 2020;73 Supl 6:e20190228. https://doi.org/10.1590/0034-7167-2019-0228
https://doi.org/10.1590/0034-7167-2019-0... , ²⁹29. Souza MHT, Signorelli MC, Coviello DM, Pereira PPG. Itinerários terapêuticos de travestis da região central do Rio Grande do Sul, Brasil. Cien Saude Colet. 2014;19(7):2277-86. https://doi.org/10.1590/1413-81232014197.10852013
https://doi.org/10.1590/1413-81232014197... . In the case of transsexual men, as reported by Sousa and Iriart²³23. Sousa D, Iriart J. “Viver dignamente”: necessidades e demandas de saúde de homens trans em Salvador, Bahia, Brasil. Cad Saude Publica. 2018;34(10):e00036318. https://doi.org/10.1590/0102-311X00036318
https://doi.org/10.1590/0102-311X0003631... based on a study carried out in Salvador, Bahia, institutional transphobia prevents their access to health services that meet their specific needs and demands, including hormonal monitoring for body modifications.

Data from a study with Brazilian transsexual women reveal that health professionals’ previous conception that they would live with the Human Immunodeficiency Virus (HIV), among other Sexually Transmitted Infections (STIs), causes these users to stop seeking SUS services, considered discriminatory by these women³¹31. Sevelius J, Murray LR, Fernandes NM, Veras MA, Grinsztejn B, Lippman SA. Optimising HIV programming for transgender women in Brazil. Cult Health Sex. 2019;21(5):543-58. https://doi.org/10.1080/13691058.2018.1496277
https://doi.org/10.1080/13691058.2018.14... . In addition, the prejudice and stigma of health professionals related to them ends up keeping them away from access to combined HIV prevention strategies, such as the use of PrEP³¹31. Sevelius J, Murray LR, Fernandes NM, Veras MA, Grinsztejn B, Lippman SA. Optimising HIV programming for transgender women in Brazil. Cult Health Sex. 2019;21(5):543-58. https://doi.org/10.1080/13691058.2018.1496277
https://doi.org/10.1080/13691058.2018.14... .

Professional Unpreparedness to Care for Transvestites and Transsexuals

The findings reveal that health professionals, especially nursing professionals, are not properly qualified to welcome and care for transvestites and transgender people in health services²⁵25. Sehnem GD, Rodrigues RL, Lipinski JM, Vasquez MED, Schmidt A. Health Care Assistance in Primary Care: access to care. Rev Enferm UFPE On Line. 2017;11(4):1676-84. https://doi.org/10.5205/1981-8963-v11i4a15238p1676-1684-2017
https://doi.org/10.5205/1981-8963-v11i4a... , ²⁷27. Sehnem GD, Rodrigues RL, Lipinski JM, Vasquez MED, Schmidt A. (Des)preparo técnico-científico para o cuidado às travestis: percepções de enfermeiras(os). Rev Enferm UFSM. 2017;7(2):236-47. https://doi.org/10.5902/2179769223649
https://doi.org/10.5902/2179769223649... , ²⁸28. Almeida JSM, Martins ERC, Costa CMA, Moraes PC, Ferreira GDF, Spindola T. Cuidar de pessoas transexuais na ótica dos residentes de enfermagem. Rev Enferm UERJ. 2018;26:e32030. https://doi.org/10.12957/reuerj.2018.32030
https://doi.org/10.12957/reuerj.2018.320... , ³⁵35. Silva GWS, Sena RCF, Santos QG, Sobreira MVS, Miranda FAN. O dito e o feito: o enfermeiro e o saber/fazer saúde para travestis. Rev Enferm UFPE On Line. 2014;8(10):3347-57. https://doi.org/10.5205/1981-8963-v8i10a10066p3347-3357-2014
https://doi.org/10.5205/1981-8963-v8i10a... . In their view, the unpreparedness for health care for this specific public is due to the fragile approach to questions about gender diversity and sexuality during the professional training process²⁷27. Sehnem GD, Rodrigues RL, Lipinski JM, Vasquez MED, Schmidt A. (Des)preparo técnico-científico para o cuidado às travestis: percepções de enfermeiras(os). Rev Enferm UFSM. 2017;7(2):236-47. https://doi.org/10.5902/2179769223649
https://doi.org/10.5902/2179769223649... .

As a result, some nurses are unaware of the subjectivities of a transvestite or transsexual person and their health needs and demands²⁷27. Sehnem GD, Rodrigues RL, Lipinski JM, Vasquez MED, Schmidt A. (Des)preparo técnico-científico para o cuidado às travestis: percepções de enfermeiras(os). Rev Enferm UFSM. 2017;7(2):236-47. https://doi.org/10.5902/2179769223649
https://doi.org/10.5902/2179769223649... , ²⁸28. Almeida JSM, Martins ERC, Costa CMA, Moraes PC, Ferreira GDF, Spindola T. Cuidar de pessoas transexuais na ótica dos residentes de enfermagem. Rev Enferm UERJ. 2018;26:e32030. https://doi.org/10.12957/reuerj.2018.32030
https://doi.org/10.12957/reuerj.2018.320... . In addition, the absence of permanent educational actions, which disseminate the guidelines of the National Policy for Integral LGBT Health and which qualify the care for transvestites and transsexuals in the SUS, makes nursing professionals perpetuate stigmas and continue to limit care for these people, disrespecting them and basing their care practices only on curative actions³⁵35. Silva GWS, Sena RCF, Santos QG, Sobreira MVS, Miranda FAN. O dito e o feito: o enfermeiro e o saber/fazer saúde para travestis. Rev Enferm UFPE On Line. 2014;8(10):3347-57. https://doi.org/10.5205/1981-8963-v8i10a10066p3347-3357-2014
https://doi.org/10.5205/1981-8963-v8i10a... .

Search for Health Care Alternatives

Due to professional unpreparedness, and the discriminatory acts experienced within SUS establishments already pointed out in the results of this article, transvestites and transsexuals avoid seeking care in these institutional spaces²²22. Rigolon M, Carlos DM, Oliveira WA, Salim NJ. “A saúde não discute corpos trans”: história oral de transexuais e travestis. Rev Bras Enferm. 2020;73 Supl 6:e20190228. https://doi.org/10.1590/0034-7167-2019-0228
https://doi.org/10.1590/0034-7167-2019-0... , ²⁹29. Souza MHT, Signorelli MC, Coviello DM, Pereira PPG. Itinerários terapêuticos de travestis da região central do Rio Grande do Sul, Brasil. Cien Saude Colet. 2014;19(7):2277-86. https://doi.org/10.1590/1413-81232014197.10852013
https://doi.org/10.1590/1413-81232014197... , ³²32. Lovison R, Ascari TM, Zocche DAA, Durand MK, Ascari RA. Travestis e transexuais: despindo as percepções acerca do acesso e assistência em saúde. Enferm Foco. 2019;10(5):167-72. https://doi.org/10.21675/2357-707X.2019.v10.n5.2370
https://doi.org/10.21675/2357-707X.2019....

33. Ferreira BO, Nascimento EF, Pedrosa JIS, Monte LMI. Vivências de travestis no acesso ao SUS. Physis. 2017;27(04):1023-38. https://doi.org/10.1590/S0103-73312017000400009
https://doi.org/10.1590/S0103-7331201700... - ³⁴34. Hanauer OFD, Hemmi APA. Caminhos percorridos por transexuais: em busca pela transição de gênero. Saude Debate. 2019;43(Nº Espec 8):91-106. https://doi.org/10.1590/0103-11042019S807
https://doi.org/10.1590/0103-11042019S80... . Faced with these violations, a minority of transvestites and transsexuals opt for private assistance, but most cannot afford a health plan, becoming dependent on alternative self-care practices, on the support of people in the social network or religious spaces of African origin, or body transformations without proper professional follow-up²⁶26. Amorim JF, Teixeira ER. Atendimento das necessidades em saúde das travestis na atenção primária. Rev Baiana Saude Publica. 2017;41(3):759-73. https://doi.org/10.22278/2318-2660.2017.v41.n3.a2379
https://doi.org/10.22278/2318-2660.2017.... , ²⁹29. Souza MHT, Signorelli MC, Coviello DM, Pereira PPG. Itinerários terapêuticos de travestis da região central do Rio Grande do Sul, Brasil. Cien Saude Colet. 2014;19(7):2277-86. https://doi.org/10.1590/1413-81232014197.10852013
https://doi.org/10.1590/1413-81232014197... , ³²32. Lovison R, Ascari TM, Zocche DAA, Durand MK, Ascari RA. Travestis e transexuais: despindo as percepções acerca do acesso e assistência em saúde. Enferm Foco. 2019;10(5):167-72. https://doi.org/10.21675/2357-707X.2019.v10.n5.2370
https://doi.org/10.21675/2357-707X.2019.... .

In this context, body transformations, such as inappropriate hormone therapy, industrial silicone grafting and breast self-mutilation, can cause other health problems, such as cardiovascular and aesthetic complications. This clearly characterizes another risk factor for the lives of transvestites and transgender people²⁶26. Amorim JF, Teixeira ER. Atendimento das necessidades em saúde das travestis na atenção primária. Rev Baiana Saude Publica. 2017;41(3):759-73. https://doi.org/10.22278/2318-2660.2017.v41.n3.a2379
https://doi.org/10.22278/2318-2660.2017.... .

Right to Health for Transvestites and Transsexuals: Utopia or Reality?

According to the Federal Constitution of Brazil, access to health is a basic right for all people, guaranteed through public policies aimed at reducing the risk of diseases and injuries, as well as allowing universal and equal access to health actions and services³⁶36. Brasil. Constituição da República Federativa do Brasil. Brasília, DF: Presidência da República; 1988 [cited 2021 Dec 20]. Available from: http://www.planalto.gov.br/ccivil_03/constituicao/constituicao.htm
http://www.planalto.gov.br/ccivil_03/con... . However, for Brazilian social minorities, such as transvestites and transsexuals, this fundamental right has not been real.

The right to health for transvestites and transsexuals, or the lack of it, can be understood by three aspects: the right to exist, considering that these people still struggle to have their social names respected, including in the SUS; right to equity, as health services are not yet prepared to assist transvestites and transsexuals; and social participation, because transvestites and transsexuals need to exercise social control to access and remain in health services, and to demand the creation of specific services to offer transsexualizing procedures³⁰30. Oliveira BP, Silva MAS, Souza MS. O direito à saúde de pessoas trans* no Distrito Federal: entre o direito de existir e o direito à equidade. Cad Ibero Am Dir Sanit. 2019;8(1):10-25. https://doi.org/10.17566/ciads.v8i1.502
https://doi.org/10.17566/ciads.v8i1.502... , ³²32. Lovison R, Ascari TM, Zocche DAA, Durand MK, Ascari RA. Travestis e transexuais: despindo as percepções acerca do acesso e assistência em saúde. Enferm Foco. 2019;10(5):167-72. https://doi.org/10.21675/2357-707X.2019.v10.n5.2370
https://doi.org/10.21675/2357-707X.2019.... , ³⁴34. Hanauer OFD, Hemmi APA. Caminhos percorridos por transexuais: em busca pela transição de gênero. Saude Debate. 2019;43(Nº Espec 8):91-106. https://doi.org/10.1590/0103-11042019S807
https://doi.org/10.1590/0103-11042019S80... .

The Transsexualization Process: Advances and Challenges

In Brazil, the transgender procedures, on an experimental basis, have been authorized by the Federal Council of Medicine (CFM) since 1997, being incorporated into the SUS in 2008, when the Ministry of Health founded the Transsexualizing Process program and formally recognized that body transformations are also health needs of the transvestite and transsexual population⁹9. Rocon PC, Sodré F, Rodrigues A, Barros MEB, Wandekoken KD. Desafios enfrentados por pessoas trans para acessar o processo transexualizador do Sistema Único de Saúde. Interface (Botucatu). 2019;23:e180633. https://doi.org/10.1590/Interface.180633
https://doi.org/10.1590/Interface.180633... . Such procedures, as well as the creation of qualified services to offer them, represent a step forward in promoting the health of transvestites and transsexuals.

Therefore, it is expected that the services enabled to offer the procedures provided for in the Transsexualization Process are welcoming, discrimination-free environments, as they are made up of multidisciplinary teams duly qualified to care for transvestites and transsexuals in a humane way³³33. Ferreira BO, Nascimento EF, Pedrosa JIS, Monte LMI. Vivências de travestis no acesso ao SUS. Physis. 2017;27(04):1023-38. https://doi.org/10.1590/S0103-73312017000400009
https://doi.org/10.1590/S0103-7331201700... . However, there is a fragile bond between health professionals and users, especially with trans women²¹21. Oliveira I, Romanini M. (Re)escrevendo roteiros (in)visíveis: a trajetória de mulheres transgênero nas políticas públicas de saúde. Saude Soc. 2020;29(1):e170961. https://doi.org/10.1590/S0104-12902020170961
https://doi.org/10.1590/S0104-1290202017... .

According to Oliveira and Romanini²¹21. Oliveira I, Romanini M. (Re)escrevendo roteiros (in)visíveis: a trajetória de mulheres transgênero nas políticas públicas de saúde. Saude Soc. 2020;29(1):e170961. https://doi.org/10.1590/S0104-12902020170961
https://doi.org/10.1590/S0104-1290202017... , this situation can be explained by the existence of medical superiority and a care protocol, lasting two years, which treats gender identity transition as a disorder, making this diagnosis a condition for access to specific health services for this part of the population. As a result, in these services, transvestites and transsexuals are constantly asked about the veracity of their gender identities and intentions, not allowing them autonomy in the production of care.

DISCUSSION

The health care model consists of a set of knowledge and combinations of resources (financial, technological, human, etc.) to meet individual and collective health needs³⁷37. Gil CRR, Maeda ST. Modelos de Atenção à Saúde no Brasil. In: Soares CB, Campos CMS, organizadores. Fundamentos de Saúde Coletiva e o Cuidado de Enfermagem. Barueri, SP: Manole; 2013. p. 325-48. . Therefore, analyzing the health care model, whether for the general population or for specific groups, such as the group of transvestites and transgender people, implies understanding what public health policies exist to mitigate or nullify inequities and how these policies reflected in programs, actions, services and research for this purpose³⁸38. Paim JS. Modelos de Atenção à Saúde no Brasil. In: Giovanella L, Escorel S, Lobato LVC, Noronha JC, Carvalho AI, organizadores. Políticas e Sistema de Saúde no Brasil. 3. ed. Rio de Janeiro: FIOCRUZ; 2017. p. 547-73. .

In view of the results of this systematic review, it is clear that health care for transvestites and transsexuals in Brazil is still exclusionary, fragmented, centered on specialized care and guided by curative actions, resembling the care models that preceded the SUS and which have been strongly criticized since the 1970s, from the Brazilian Sanitary Reform movement. At the time, the critics highlighted the importance of profound changes not only in the health system, so that care was humanized, equitable and comprehensive, guaranteeing universal access to all men and women³⁸38. Paim JS. Modelos de Atenção à Saúde no Brasil. In: Giovanella L, Escorel S, Lobato LVC, Noronha JC, Carvalho AI, organizadores. Políticas e Sistema de Saúde no Brasil. 3. ed. Rio de Janeiro: FIOCRUZ; 2017. p. 547-73. .

According to Arán et al.³⁹39. Arán M, Murta D, Lionço T. Transexualidade e saúde pública no Brasil. Cien Saude Colet. 2009;14(4):1141-9. https://doi.org/10.1590/S1413-81232009000400020
https://doi.org/10.1590/S1413-8123200900... , despite transsexuality being a phenomenon recognized since the late 19th century, issues related to transgender identities in the Brazilian public health began to be visible only after 1979, with the possibility of medical interventions, when the CFM was consulted for the first time on mammoplasty in transgender people.

Going forward in time, and acknowledging the existence of numerous debates that took place on the subject, including in the legal field, in 1997 – as already discussed in this article – the reassignment procedures were authorized by the CFM and incorporated into the SUS 11 years later⁹9. Rocon PC, Sodré F, Rodrigues A, Barros MEB, Wandekoken KD. Desafios enfrentados por pessoas trans para acessar o processo transexualizador do Sistema Único de Saúde. Interface (Botucatu). 2019;23:e180633. https://doi.org/10.1590/Interface.180633
https://doi.org/10.1590/Interface.180633... . It should be noted that the existence of these procedures in the SUS is a fundamental initiative not only to meet a need for transvestites and transsexuals, but also to assist in the construction of subjectivities and identities neglected by society and the State.

However, criticisms are made of the care protocols established by the Ministry of Health, through regulations⁴⁰40. Ministério da Saúde (BR), Secretaria de Atenção à Saúde. Portaria Nº 457, de 19 de agosto de 2008. Aprova a regulamentação do Processo Transexualizador no âmbito do Sistema Único de Saúde (SUS). Brasília, DF; 2008 [cited 2022 May 9]. Available from: https://bvsms.saude.gov.br/bvs/saudelegis/sas/2008/prt0457_19_08_2008.html
https://bvsms.saude.gov.br/bvs/saudelegi... , ⁴¹41. Ministério da Saúde (BR). Portaria Nº 2.803, de 19 de novembro de 2013. Redefine e amplia o Processo Transexualizador no Sistema Único de Saúde (SUS). Brasília, DF; 2013 [cited 2022 May 9]. Available from: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2013/prt2803_19_11_2013.html
https://bvsms.saude.gov.br/bvs/saudelegi... , so that transvestites and transsexuals can benefit from these specialized health services, especially psychiatric follow-up for at least two years in order to confirm the diagnosis of transsexuality. While this diagnosis represents the winning of the right to health for transvestites and transsexuals, it also contributes to the permanence of the stigma on these people, as it does not consider the personal and historical issues of each subject, assigning the recognition of gender identity to a psychiatric and normalizing procedure³⁹39. Arán M, Murta D, Lionço T. Transexualidade e saúde pública no Brasil. Cien Saude Colet. 2009;14(4):1141-9. https://doi.org/10.1590/S1413-81232009000400020
https://doi.org/10.1590/S1413-8123200900... .

Furthermore, access to reassignment procedures is not the only health need for transvestites and transsexuals in Brazil. In addition to access to these procedures, it is necessary to promote the fight against discrimination based on gender identity so that transvestites and transsexuals can access any space with dignity, such as health promotion spaces, without being victims of violence²⁶26. Amorim JF, Teixeira ER. Atendimento das necessidades em saúde das travestis na atenção primária. Rev Baiana Saude Publica. 2017;41(3):759-73. https://doi.org/10.22278/2318-2660.2017.v41.n3.a2379
https://doi.org/10.22278/2318-2660.2017.... .

If access to gender reassignment procedures were the only health need of Brazilian transvestites and transsexuals, it would be very unequal and far from being met, since in the country there are only ten services authorized by the Ministry of Health to offer the procedures provided for in the Transsexualizing Process program, most of them located in the Southeast and none in the North⁹9. Rocon PC, Sodré F, Rodrigues A, Barros MEB, Wandekoken KD. Desafios enfrentados por pessoas trans para acessar o processo transexualizador do Sistema Único de Saúde. Interface (Botucatu). 2019;23:e180633. https://doi.org/10.1590/Interface.180633
https://doi.org/10.1590/Interface.180633... .

The findings of this systematic review also reveal possible ways to transform the current health care model for transvestites and transsexuals in the SUS: it would be interesting to develop intersectoral strategies to combat discrimination against transvestites and transsexuals²³23. Sousa D, Iriart J. “Viver dignamente”: necessidades e demandas de saúde de homens trans em Salvador, Bahia, Brasil. Cad Saude Publica. 2018;34(10):e00036318. https://doi.org/10.1590/0102-311X00036318
https://doi.org/10.1590/0102-311X0003631... , ³³33. Ferreira BO, Nascimento EF, Pedrosa JIS, Monte LMI. Vivências de travestis no acesso ao SUS. Physis. 2017;27(04):1023-38. https://doi.org/10.1590/S0103-73312017000400009
https://doi.org/10.1590/S0103-7331201700... , constant dialogue between SUS management and the social segments that represent transvestites and transsexual people ²⁴24. Moraes AND, Silva GSN. Travestis e o cuidado humanizado em saúde. Rev Abordagem Gestalt. 2020;26(2):175-87. https://doi.org/10.18065/2020v26n2.5
https://doi.org/10.18065/2020v26n2.5...

25. Sehnem GD, Rodrigues RL, Lipinski JM, Vasquez MED, Schmidt A. Health Care Assistance in Primary Care: access to care. Rev Enferm UFPE On Line. 2017;11(4):1676-84. https://doi.org/10.5205/1981-8963-v11i4a15238p1676-1684-2017
https://doi.org/10.5205/1981-8963-v11i4a... - ²⁶26. Amorim JF, Teixeira ER. Atendimento das necessidades em saúde das travestis na atenção primária. Rev Baiana Saude Publica. 2017;41(3):759-73. https://doi.org/10.22278/2318-2660.2017.v41.n3.a2379
https://doi.org/10.22278/2318-2660.2017.... , ³⁰30. Oliveira BP, Silva MAS, Souza MS. O direito à saúde de pessoas trans* no Distrito Federal: entre o direito de existir e o direito à equidade. Cad Ibero Am Dir Sanit. 2019;8(1):10-25. https://doi.org/10.17566/ciads.v8i1.502
https://doi.org/10.17566/ciads.v8i1.502... , ³³33. Ferreira BO, Nascimento EF, Pedrosa JIS, Monte LMI. Vivências de travestis no acesso ao SUS. Physis. 2017;27(04):1023-38. https://doi.org/10.1590/S0103-73312017000400009
https://doi.org/10.1590/S0103-7331201700... , the implementation of the National LGBT Comprehensive Health Policy²⁵25. Sehnem GD, Rodrigues RL, Lipinski JM, Vasquez MED, Schmidt A. Health Care Assistance in Primary Care: access to care. Rev Enferm UFPE On Line. 2017;11(4):1676-84. https://doi.org/10.5205/1981-8963-v11i4a15238p1676-1684-2017
https://doi.org/10.5205/1981-8963-v11i4a... , strategies to disseminate the meaning of being a transvestite or transsexual to the community in general²⁴24. Moraes AND, Silva GSN. Travestis e o cuidado humanizado em saúde. Rev Abordagem Gestalt. 2020;26(2):175-87. https://doi.org/10.18065/2020v26n2.5
https://doi.org/10.18065/2020v26n2.5... , ³¹31. Sevelius J, Murray LR, Fernandes NM, Veras MA, Grinsztejn B, Lippman SA. Optimising HIV programming for transgender women in Brazil. Cult Health Sex. 2019;21(5):543-58. https://doi.org/10.1080/13691058.2018.1496277
https://doi.org/10.1080/13691058.2018.14... , review of work practices in health²⁴24. Moraes AND, Silva GSN. Travestis e o cuidado humanizado em saúde. Rev Abordagem Gestalt. 2020;26(2):175-87. https://doi.org/10.18065/2020v26n2.5
https://doi.org/10.18065/2020v26n2.5... , ²⁵25. Sehnem GD, Rodrigues RL, Lipinski JM, Vasquez MED, Schmidt A. Health Care Assistance in Primary Care: access to care. Rev Enferm UFPE On Line. 2017;11(4):1676-84. https://doi.org/10.5205/1981-8963-v11i4a15238p1676-1684-2017
https://doi.org/10.5205/1981-8963-v11i4a... , ³¹31. Sevelius J, Murray LR, Fernandes NM, Veras MA, Grinsztejn B, Lippman SA. Optimising HIV programming for transgender women in Brazil. Cult Health Sex. 2019;21(5):543-58. https://doi.org/10.1080/13691058.2018.1496277
https://doi.org/10.1080/13691058.2018.14... and changes in professional training in health²¹21. Oliveira I, Romanini M. (Re)escrevendo roteiros (in)visíveis: a trajetória de mulheres transgênero nas políticas públicas de saúde. Saude Soc. 2020;29(1):e170961. https://doi.org/10.1590/S0104-12902020170961
https://doi.org/10.1590/S0104-1290202017... , ²⁴24. Moraes AND, Silva GSN. Travestis e o cuidado humanizado em saúde. Rev Abordagem Gestalt. 2020;26(2):175-87. https://doi.org/10.18065/2020v26n2.5
https://doi.org/10.18065/2020v26n2.5... .

Considering these possibilities, the relevance of the participation of social movements representing this segment in the formulation and conduction of public health policies, through the exercise of citizenship and social control, is highlighted here. In the process of building the SUS and its health policies, joining the social struggle for the country’s re-democratization, the LGBTTQIA+ movement played an important role, placing sexual and gender diversity on the agenda as social markers and structural determinants of the health-disease process⁴²42. Macrae E. A construção da igualdade: política e identidade homossexual no Brasil da “abertura”. Salvador, BA: EDUFBA; 2018. , ⁴³43. Galvão ALM, Oliveira E, Germani ACCG, Luiz OC. Determinantes estruturais da saúde, raça, gênero e classe social: uma revisão de escopo. Saude Soc. 2021;30(2):e200743. https://doi.org/10.1590/S0104-12902021200743
https://doi.org/10.1590/S0104-1290202120... .

As a result of the work of LGBTTQIA+ social movements in health, we highlight the creation of the Brazil without Homophobia Program and the Technical Committee on Health of the LGBT Population at the Ministry of Health in 2004, the holding of the 1st National Seminar on Health of the LGBT Population in 2007, the institution of the Transsexualizing Process in the SUS in 2008, the regulation of the use of the social name of transvestites and transsexuals in the SUS in 2009, the formulation of the National Policy for Integral LGBT Health, etc.⁴⁴44. Sena AGN, Souto KMB. Avanços e desafios na implementação da Política Nacional de Saúde Integral LGBT. Tempus Actas Saude Colet. 2017;11(1):9-28. https://doi.org/10.18569/tempus.v11i1.1923
https://doi.org/10.18569/tempus.v11i1.19...

In conclusion, health care for transvestites and transsexuals in Brazil does not correspond to the health care model advocated in the legal-legal framework of SUS. Therefore, it is necessary to develop strategies to deal with specific issues of transvestites and transsexuals, with emphasis on the vulnerabilities that permeate these people’s lives.

In addition to guaranteeing health care, it is necessary to provide opportunities for access to education, employment, housing, food, etc. These actions should not only come from transvestites and transsexuals, but from those who believe in the potential of the SUS and in an egalitarian and democratic society.

With regard to the actions of health professionals in relation to transvestites and transsexuals, this analysis focused on nursing professionals, as the studies retrieved and included in this review addressed only this professional category. In order not to induce that the professional lack of preparation for the health care of transvestites and transgender people in the Brazilian health system is a specificity of nursing professionals, and considering that the work in the SUS must be interprofessional and collaborative, further studies are recommended that investigate the way in which other health professionals deal with transvestites and transgender people.

At the same time that criticisms are made, it is important to highlight that this analysis about the work of nurses, in favor of care for transvestites and transsexuals, may result from advances in research on gender diversity in the field of nursing. However, as shown in the results presented here, it is still necessary to change work practices, allowing a significant transformation in the daily life of health care spaces for transvestites and transsexuals.

As limitations of the study, we point out the possibility that some articles do not use the descriptors adopted in the search strategies of this review and the existence of other articles indexed in databases not consulted. However, to bypass this possible situation, manual searches were performed.

In addition, other limitations refer to the non-inclusion of studies developed in the North region of Brazil, considering that the SUS is present throughout the national territory, and to the authors’ choice to exclude from the systematic review articles that analyzed health care for transvestites and transsexuals together with aspects related to health care for other people in the LGBTTQIA+ group.

The non-inclusion of articles that deal with health care for transvestites and transsexuals in states in the North region is justified by the fact that existing studies did not meet the inclusion criteria adopted in the systematic review, or did not have a low risk of bias, according to the checklist used to assess the methodological quality of the articles¹⁷17. Lockwood C, Munn Z, Porritt K. Qualitative research synthesis: methodological guidance for systematic reviewers utilizing meta-aggregation. Int J Evid Based Healthc. 2015;13(3):179-87. https://doi.org/10.1097/XEB.0000000000000062
https://doi.org/10.1097/XEB.000000000000... .

The choice to exclude articles that addressed health care for transvestites and transsexuals together with health care for other people in the LGBTTQIA+ group is justified by virtue of the National Policy for LGBT Integral Health, which partially recognizes the specific needs and identities of transvestites and transsexuals, because, despite the existence of intersections between gender and sexuality issues, they demand different analyses and investments.

In this sense, it would be important to put in place new policies and specific programs for the health of transvestites and transsexuals, prioritizing coping with the vulnerabilities faced by these people¹¹11. Lima RRT, Flor TBM, Araújo PH, Noro LRA. Análise bibliométrica de teses e dissertações brasileiras sobre travestilidade, transexualidade e saúde. Trab Educ Saude. 2020;18(3):e00301131. https://doi.org/10.1590/1981-7746-sol00301
https://doi.org/10.1590/1981-7746-sol003... , ⁴⁵45. Bagagli BP. O reconhecimento das identidades trans nas políticas públicas para além da cisnormatividade. In: Oliveira AD, Pinto CRB, organizadores. Transpolíticas públicas. Campinas, SP: Papel Social; 2017. p. 31-47 . However, these decisions may have limited the results of the systematic review, as it is expected that aspects about transvestites and transsexuals will be addressed together with those related to lesbian, gay, bisexual, non-binary people, etc., due to the existence of a single health policy for the entire LGBTTQIA+ population in Brazil.

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