ABSTRACT

We present the research findings of the master’s thesis with an integrative approach, which aimed to revisit publications with an LGBTQIA+ theme in scientific journals. By focusing on the Harm Reduction (HR) strategy, this research aimed to identify the practices conducted for the trans population and contextualize how HR can contribute to building bonds in healthcare. Data were collected in the LILACS and SciELO databases. We retrieved 110 articles published from 2005 to 2020 in Portuguese. Their summaries were read in full. Seven approaches were identified: HR as a public policy strategy; violence experienced in the transition trajectories followed by transvestites; assistance to the LGBTQIA+ population; health professionals can provide truly person-centered, humanized care, with active listening; healthcare and hormonization as a feminine construction process; social movements; education and affirmative actions for continued study and professional placement. Thus, the research contributes to expanding knowledge and understanding about LGBTQIA+ issues. The specific demands of transvestites and transsexuals in their search for care in health services are explained in order to understand how HR can be a health care strategy for the trans population.

KEYWORDS
Harm reduction; Transvestism; Transgender persons; Human rights.

Introduction

This article aims to present the results of the literature review on health care for trans and transvestite women, in the field of Harm Reduction (HR), through an integrative research approach, and briefly discuss this population’s access, comprehensiveness, equity, and proximity to health services.

The interest in this topic is related to the work of one of this article’s authors, in the territory of the north zone of Rio de Janeiro, as a harm reduction agent at the Psychosocial Care Center for Alcohol and Other Drugs (CAPS-Ad). HR as a health care strategy can reach vulnerable populations, offer access, and bring these users of alcohol and other drugs closer to and strengthen their rights as citizens.

The HR concept was built over time by people who use alcohol and other drugs, inserted in the field of social movements, against stigmas, and in the context of increasing mortality from AIDS due to contamination through sharing syringes^{11 Machado LV, Boarini ML. Políticas sobre drogas no Brasil: a estratégia de redução de danos. Psicol. Ciênc. Prof. 2013 [acesso em 2021 dez 19]; 33(3):580-595. Disponível em: https://doi.org/10.1590/S1414-98932013000300006.
https://doi.org/10.1590/S1414-9893201300...} .

We understand that, besides delivering common supplies to the service (condoms, lubricant, mask, soap, and alcohol gel), it is necessary to build a bond by listening to users and developing ways of accessing transvestites and transgender women in the territory, considering equity, one of the Unified Health System (SUS) principles. The combination of these factors are instruments that have facilitated action in territories with productive inclusion methods and attenuation of social inequalities^{22 Brasil. Ministério da Saúde, Secretaria de Gestão Estratégica e Participativa, Departamento de Apoio à Gestão Participativa. Transexualidade e travestilidade na saúde. Brasília, DF: Ministério da Saúde; 2015.}.

We also consider how HR can be a care tool given the difficulty in providing care to drug users, transvestites and trans women, and healthcare aimed at this population, characterized by very particular demands. The relevance of these studies on HR targeting the population of trans and transvestite women consists in presenting territorial actions and approaches for this specific audience, and access to public health devices and, thus, the guarantee of rights for this population^{33 Brasil. Ministério da Saúde, Secretaria Executiva, Coordenação Nacional de DST e AIDS. A Política do Ministério da Saúde para atenção integral a usuários de álcool e outras drogas. Brasília, DF: Ministério da Saúde; 2003.}.

Harm Reduction, policies, and fundamentals

The ‘war on drugs’ derives from unstructured public policies with a bias towards criminalization and repression, reduced to the scope of security and the judiciary, and not public health, producing stigma, marginalization, and violence, where more importance is assigned to the criminalization of use and less to users’ health and quality of life^{44 Passos EH, Souza TP. Redução de danos e saúde pública: construções alternativas à política global de “guerra às drogas”. Psicol. Soc. 2011 [acesso em 2021 maio 17]; 23(1):154-162. Disponível em: https://doi.org/10.1590/S0102-71822011000100017.
https://doi.org/10.1590/S0102-7182201100...} .

In 2002, when implementing HR strategies, the Ministry of Health established that harm belongs to the social - such as marginalization, vulnerability, inequality, and social exclusion - and health fields. Ordinance Nº 1.028 of July 1, 2005, considered that the Ministry of Health should act toward social and health HR, thus reviving the citizenship of individuals in psychological distress and enhancing the effects of promoting health^{55 Brasil. Ministério da Saúde. Portaria nº 1.820, de 13 de agosto de 2009. Dispõe sobre os direitos e deveres dos usuários da saúde. Diário Oficial da União. 14 Ago 2009.}.

Evidenced as a policy, anchoring HR determines a new ethical, clinical, and public policy paradigm, which involves confronting and clashing against anti-drug policies - established when the nation endured its last military dictatorship - such as social control^{66 Brasil. Gabinete de Segurança Institucional, Conselho Nacional Antidrogas. Resolução nº3/GSIPR/CH/CONAD, de 27 de outubro de 2005. Aprova a Política Nacional Sobre Drogas. Diário Oficial da União. 28 Out 2010. [acesso em 2022 set 16]. Disponível em: http://www.obid.senad.gov.br/portais/OBID/biblioteca/documentos/Legislacao/326979.
http://www.obid.senad.gov.br/portais/OBI...} .

Through this review, we understand that an essential contribution of HR would be precisely to question the relationship between drug use and users, taking care of the existing distress or one possibly caused by use without necessarily demanding abstinence and intervening when the risk to life is assessed.

Professionals should recognize HR as a public policy strategy and care tool, understanding that it is not against abstinence but a path towards the subject’s choice if desired, and present it among many other equally ethical possibilities in which subjects can envision life from perspectives other than use.

To this end, Decree Nº 7.508 of June 28, 2011, confirms the implementation of the Psychosocial Care Network (RAPS), seeking strategies in partnership in the intersectoral services to integrate care, ensuring access to users in the entire network and enabling the HR practice, especially in the CAPS, thus consolidating the psychiatric reform^{77 Brasil. Ministério da Saúde, Secretaria de Atenção à Saúde, Departamento de Atenção Especializada e Temática. Centros de Atenção Psicossocial e Unidades de Acolhimento como lugares da atenção psicossocial nos territórios: orientação para elaboração de projetos de construção reforma e ampliação de CAPS e de UA. Brasília, DF: Ministério da Saúde; 2015.}.

With the change of Federal Government in 2019, Law Nº 13.840 was enacted and added and changed the provisions to Law Nº 11.343/2006, removing HR from the National Policy and, therefore, expanding investments in therapeutic communities, where it established the authorization of the compulsory hospitalization of people resulting from the use of alcohol and other drugs, distancing them from their families, which highlights severe human rights violations in these institutions^{88 Brasil. Lei nº 13.840, de 5 de junho de 2019. Altera as Leis nos 11.343, de 23 de agosto de 2006, 7.560, de 19 de dezembro de 1986, 9.250, de 26 de dezembro de 1995, 9.532, de 10 de dezembro de 1997, 8.981, de 20 de janeiro de 1995, 8.315, de 23 de dezembro de 1991, 8.706, de 14 de setembro de 1993, 8.069, de 13 de julho de 1990, 9.394, de 20 de dezembro de 1996, e 9.503, de 23 de setembro de 1997, os Decretos-Lei nos 4.048, de 22 de janeiro de 1942, 8.621, de 10 de janeiro de 1946, e 5.452, de 1º de maio de 1943, para dispor sobre o Sistema Nacional de Políticas Públicas sobre Drogas e as condições de atenção aos usuários ou dependentes de drogas e para tratar do financiamento das políticas sobre drogas. Diário Oficial da União. 6 Jun 2019. [acesso em 2021 nov. 7]. Disponível em: https://www.planalto.gov.br/ccivil_03/_ato2019-2022/2019/lei/l13840.htm.
https://www.planalto.gov.br/ccivil_03/_a...} .

We should debate public investments without oversight in these primarily private and religious entities based on exclusion and social hygiene. In contrast, HR is a practice built by people belonging to the vulnerable population, who made their demands heard, and by professionals who use it to build bonds, guaranteeing access to care and health. Thus, the importance of having people from the population acting as health agents^{99 Petuco DRS. Redução de Danos: das técnicas à ética do cuidado. In: Ramminger T, Silva M, organizadores. Mais substâncias para o trabalho em saúde com usuários de drogas. Bis. 2014 [acesso em 2022 maio 17]; 21(2):94-103. Disponível em: https://doi.org/10.52753/bis.2020.v21.34622.
https://doi.org/10.52753/bis.2020.v21.34...} stands out in the care strategy and health promotion processes^{99 Petuco DRS. Redução de Danos: das técnicas à ética do cuidado. In: Ramminger T, Silva M, organizadores. Mais substâncias para o trabalho em saúde com usuários de drogas. Bis. 2014 [acesso em 2022 maio 17]; 21(2):94-103. Disponível em: https://doi.org/10.52753/bis.2020.v21.34622.
https://doi.org/10.52753/bis.2020.v21.34...} .

Methods

Hearing “We are not guinea pigs to be studied and left behind” at the beginning of my HR work in the night action impressed me. Later, upon entering academia, as a cisgender woman, I decided to develop integrative review research to collect, systematize, and analyze data that could support new studies and public policies targeting trans and transvestite women in the field of HR.

Through an integrative review^{1010 Roos CM. Ações de redução de danos voltadas para usuários de drogas: uma revisão integrativa. [dissertação]. Porto Alegre: Universidade Federal do Rio Grande do Sul; 2011. [acesso em 2022 jun 18]. Disponível em: http://hdl.handle.net/10183/31126.
http://hdl.handle.net/10183/31126...} , we accessed the main scientific works already produced on the topic, in field research and HR experiences focused on transvestites and transsexual women developed in Brazil - and of great importance in presenting current and relevant data between 2005 and 2020.

Data were collected in specific databases, based on descriptors, exclusion and inclusion criteria for articles, searching for publications via the internet, in the Latin American Health Literature (LILACS), Scientific Electronic Library Online (SciELO), and Medical Literature Analysis and Retrieval System Online (MEDLINE).

During this process, we aimed to understand HR as a strategy for building bonds and healthcare for transvestites and trans women based on the mapping of scientific products on HR experiences conducted in Brazil and those contextualized by the territory where the actions occur.

First, we carefully read the works to fully grasp the contents described containing information to be developed in this integrative work on the topic. The integrative review’s guiding question, essential for data collection for this study, began with the search for common HR practices offered to the population of Lesbians, Gays, Bisexuals, Transsexuals, Transvestites, Transgenders, Queer, Intersex or Intersex, Asexual and other possibilities of existence (LGBTQIA+), more specifically for female transvestites and trans women, published in scientific literature, selected from specific databases, using descriptors, inclusion and exclusion criteria for articles, through internet search, in March 2022.

The inclusion criteria were free online articles published from 2005 to 2020 that covered the theme from the theoretical, political, or practical aspects. The exclusion criteria were articles not covering the proposed theme or published outside the indicated period. Based on these methodological brackets, the research started with data capture in the abovementioned databases.

Results

Our search was performed within the theme, considering its relevance and the material’s informative value, studies with the following descriptors presented here, namely, harm reduction, transvestite, transgender people and human rights, combined and shown in table 1. Based on the works’ reading, I call them approaches to situate features presented in the collected articles^{1111 Ribas SM. Redução de danos como estratégia de cuidado à saúde: um estudo sobre atendimento a mulheres transexuais e travestis. [dissertação]. Rio de janeiro: Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz; 2022.}.

Table 1 below, prepared from my master’s thesis, displays the contents of the integrative review studies. In the first column, I list the main search approaches; in the second, I include a summary of the research content; and in the third, the number of articles read.

Table 1 above shows that there may be barriers to accessing health and rights and issues of violence, discrimination, and stigma; and that transvestites and trans women are exposed to health vulnerabilities and immersed in obstacles and social inequalities. I set these questions as a provocation regarding the need to i) promote access to health care for vulnerable populations, especially trans and LGBTQIA+ women; ii) enhance the quality of care provided by health professionals; and iii) consolidate the concept that health services need to adapt to the needs of the LGBTQIA+ population.

Adopting the social name in written or oral form, when not respected, as shown in this research, exposes transvestites and transsexuals to embarrassment, does not respect their rights, and causes significant psychological impacts, such as depression, among other aggravations in mental health, with the possibility of breaking the minimum existing bond, besides the consequent discontinuity in the search for health services^{1212 Souza MHT, Malvasi P, Signorelli MC, et al. Violência e sofrimento social no itinerário de travestis de Santa Maria. Cad. Saúde Pública. 2015 [acesso em 2022 mar 22]; 31(4):767-776. Disponível em: https://doi.org/10.1590/0102-311X00077514.
https://doi.org/10.1590/0102-311X0007751...} .

Female hormones, used to obtain the feminine contour desired by trans and transvestite women, provide a form of care presented as a demand in care, requiring medical monitoring. Many do not do so, as they want a quick change in their body since the dosage they use is much higher in order to achieve the desired appearance, which implies even more attention to this population. It is necessary to offer comprehensive care^{1313 Jesus JG. Orientações sobre identidade de gênero: conceitos e termos. Brasília, DF: EDA/FBN; 2012.} as a HR strategy.

The lack of access to the training of some health professionals in the topic of care for the LGBTQIA+ population probably corroborates the problematic reception and lack of preparation at work, concomitantly with the lack of adequate public policies, which can produce a service full of discrimination when this population seeks health facilities, especially if we consider that transvestites and trans women care demands exceed biological health issues, as they have other specific issues and require a broader perspective from the health professionals.

Research portrays excerpts from interviews that characterize feelings of mental distress, such as sadness, anguish, and discrimination experienced in health services, resulting in the abandonment of treatments that were initiated. In other words, the place where they should be received becomes a space of discriminatory relationships, distancing the LGBTQIA+ population from public health environments, which worsens their health conditions^{1414 Carrara S, Hernandez JG, Uziel AP, et al. Body Construction and Heath itineraries: a survey among travestis and trans people in Rio de Janeiro, Brazil. Cad. Saúde Pública. 2019 [acesso em 2022 jul. 27]; 35(4):e00110618. Disponível em: https://doi.org/10.1590/0102-311X00110618.
https://doi.org/10.1590/0102-311X0011061...} , given this situation.

Among the LGBTQIA+ population, trans people face the most significant difficulties in seeking health services due to specific demands and access to transsexualizing services. Trans/transvestiphobia episodes in the daily routine of healthcare facilities lead to recommendations for reducing discriminatory processes towards this population and an understanding of diversity regarding sexuality to seek respect for the uniqueness of subjects^{1010 Roos CM. Ações de redução de danos voltadas para usuários de drogas: uma revisão integrativa. [dissertação]. Porto Alegre: Universidade Federal do Rio Grande do Sul; 2011. [acesso em 2022 jun 18]. Disponível em: http://hdl.handle.net/10183/31126.
http://hdl.handle.net/10183/31126...} .

Although the Ministry of Health assumes essential initiatives, such as publishing ordinances and establishing specific health services for this population, we can understand that, even so, this segment faces the most difficulties in accessing health services, from primary to high-complexity care. Therefore, the scarce resources and the lack of policies and programs to combat discrimination tend to take on a leading role as a barrier to access to healthcare for transvestites and trans women^{1111 Ribas SM. Redução de danos como estratégia de cuidado à saúde: um estudo sobre atendimento a mulheres transexuais e travestis. [dissertação]. Rio de janeiro: Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz; 2022.}.

Therefore, the results of this research corroborate the measurements of Querino et al.^{1212 Souza MHT, Malvasi P, Signorelli MC, et al. Violência e sofrimento social no itinerário de travestis de Santa Maria. Cad. Saúde Pública. 2015 [acesso em 2022 mar 22]; 31(4):767-776. Disponível em: https://doi.org/10.1590/0102-311X00077514.
https://doi.org/10.1590/0102-311X0007751...} , who state how the promotion of health services, programs, and actions for the LGBTQIA+ population indicates greater equity, completeness, and universality proposed by the Brazilian health reform.

Discussion

Based on reading the works, I name approaches to highlight characteristics presented in the collected articles and indicate, as a result, that it is crucial to build and form networks with other sectors, monitor mental health in the territory, and establish specific actions.

It is vital to highlight affirmative policies, considering that the high rate of school dropout, low schooling, and lack of access to technical and professional training in the lives of transvestites and trans women can lead to vulnerability and marginalization of this population and hinder their incorporation into the job market^{1313 Jesus JG. Orientações sobre identidade de gênero: conceitos e termos. Brasília, DF: EDA/FBN; 2012.}.

We highlight here the issue of the search for the body’s femininity, a need that overlaps with fear of the existing risk, resulting in the lack of a health system that supports such demands, in the administration of excessive doses of hormones, and even in the application of industrial silicone^{1414 Carrara S, Hernandez JG, Uziel AP, et al. Body Construction and Heath itineraries: a survey among travestis and trans people in Rio de Janeiro, Brazil. Cad. Saúde Pública. 2019 [acesso em 2022 jul. 27]; 35(4):e00110618. Disponível em: https://doi.org/10.1590/0102-311X00110618.
https://doi.org/10.1590/0102-311X0011061...} .

Final considerations: the importance of inclusive public policies for trans and transvestite women

Still thinking specifically about the case of trans and transvestite women, this integrative review research allows us to elaborate within the limits of the data described here that discrimination and stigmatization in health services and equipment - a clear expression of institutional transphobia -, for example, disrespect for the social name, are evidence of an access barrier that culminates in distress and illness^{1515 Rocon PC, Wandekoken KD, Barros MEB, et al. Acesso à saúde pela população trans no Brasil: nas entrelinhas da revisão integrativa. Trab. Educ. Saúde. 2020 [acesso em 2022 jun. 16]; 18(1):e0023469. Disponível em: https://doi.org/10.1590/1981-7746-sol00234.
https://doi.org/10.1590/1981-7746-sol002...} .

I defend and propose disseminating the current legislation on care for the LGBTQIA+ population to improve care for these people and their access to health. Furthermore, it is essential to include content in health professional training that addresses specific care for trans and transvestite women in health course subjects^{1616 Fernandes FMB, Moreira MR. Considerações metodológicas sobre as possibilidades de aplicação da técnica de observação participante na Saúde Coletiva. Physis. 2013 [acesso em 2021 ago 22]; 23(2):511-529. Disponível em: https://doi.org/10.1590/S0103-73312013000200010.
https://doi.org/10.1590/S0103-7331201300...} .

Permanent or continuing education aimed at working professionals is extremely relevant, and the training of health professionals should be articulated with the needs and demands of the target population. Besides health policies, it is necessary to produce scientific knowledge so that new actions can help face the ongoing challenges.

Due to its dynamics, some strategy changes may occur when operating in the territory. As a result, adjustments and strategy changes can occur in light of the territory’s responses. We thus have health as a social production and action mode in the daily lives of these services^{1717 Cezar MA, Melo W. Centro de Atenção Psicossocial e território: espaço humano, comunicação e interdisciplinaridade. Hist., Ciênc. Saúde-Manguinhos. 2018 [acesso em 2022 ago 22]; 25(1):127-142. Disponível em: https://doi.org/10.1590/S0104-59702018000100008.
https://doi.org/10.1590/S0104-5970201800...} .

Built with many dynamics, HR practices look at the substance and the subject from a macro perspective, their relationship with the drug and the world. Therefore, it is necessary to expand its actions to other objectives, such as guaranteeing citizenship and human rights. Considering the debate that this article proposes, one conclusion stands out: the need to confront transphobia in the SUS remains. Such confrontation is fundamental and includes guaranteeing access to public health services and the quality of care for the LGBTQIA+ population.

References

Publication Dates

History