ABSTRACT

The LGBT Clinic in Macaé (RJ) operates daily to provide health care for LGBTQIA+ people. This service is part of a network, including the Pedro Ernesto University Hospital and the Casa de Convivência clinic. The service has predominantly served transvestites and transgender people. This study aimed to investigate how trans people access the LGBT Clinic in Macaé. We sought to discuss gender issues, as LGBTQIA+ people have increasingly arrived at health clinics with specific demands, which creates the need for improvement for such a public. This qualitative research was conducted with thirteen users of the LGBT Clinic who self-declared transgender. As a result, several cases were confirmed in which the populations studied did not find adequate help in other health services. Furthermore, the LGBT Clinic was provenly a receptive healthcare space for trans and transvestite people in the region.

KEYWORDS
Comprehensive health care; Sexual and gender minorities; User embracement; Primary Health Care.

Introduction

Brazil ranks first place in the ranking of countries that kill the most transvestites and transsexuals in the world. According to the report by the National Association of Transvestites and Transsexuals (ANTRA), the country recorded 80 transgender people deaths in the first half of 2021. The document shows that the most violent deaths were of Black trans women/transvestites^{11 Benevides BG. Dossiê assassinatos e violências contra travestis e transexuais brasileiras em 2021. Brasília, DF: Distrito Drag, Antra; 2022.}. In 2020, the country was also in first place in the ranking, with 175 murders^{22 Benevides B, Nogueira SNB. Dossiê assassinatos e violência contra travestis e transexuais brasileiras em 2020. Brasília, DF: Antra; 2021. [acesso em 2023 mar 24]. Disponível em: https://antrabrasil.files.wordpress.com/2021/01/dossie-trans-2021-29jan2021.pdf.
https://antrabrasil.files.wordpress.com/...} . These data indicate the urgency of creating effective public policies for this group and the health sector. Currently, transphobia, that is, abuse, insults, or death of a transgender or transvestite person^{33 Ribeiro JKA. “Aonde” está a população trans na divisão sexual do trabalho? Analisando as condições da inserção para os/as trabalhadores/as travestis e transexuais no mercado de trabalho formal. Anais do 16º Encontro Nacional de Pesquisadores em Serviço Social; 2018 dez 2-7; Vitória. Vitória: Ufes; 2018. [acesso em 2023 mar 24]. Disponível em: https://periodicos.ufes.br/abepss/article/view/22307.
https://periodicos.ufes.br/abepss/articl...} has been understood as violence and can be reported in court. Bodies of people Lesbian, Gay, Bisexual, Transvestite, Transsexual and Transgender, Queer, Intersexual or Intersex, Asexual, and others (LGBTQIA+) demand the improvement of the practice of health professionals who look beyond cis-heteronormativity. It is necessary to reflect on the relationship between access to health devices by such bodies and the health effects of transphobic practices.

Transphobia, that is, disrespect for transvestite and transgender identity, is one of the most common problems mentioned in the reports of these people regarding healthcare. Due to an old conception, some health professionals do not understand that biological sex is different from gender^{44 ‌Soares LS. Cuidado em saúde e transfobia: percepções de travestis e transexuais de duas regiões do Rio de Janeiro: Maré e Cidade de Deus, sobre os serviços de saúde. [dissertação]. Rio de janeiro: Fundação Oswaldo Cruz; 2018. p. 100. [acesso em 2023 mar 24]. Disponível em: https://www.arca.fiocruz.br/bitstream/handle/icict/27920/ve_Luciano_Silveira_ENSP_2018.pdf;jsessionid=DEB728F7FD75F42CBE29C46FB029D79F?sequence=2.
https://www.arca.fiocruz.br/bitstream/ha...} , meaning that the social choice of gender is not respected or is even questioned. Institutional transphobia exists in some spaces and, in health services, imposes behavior that is part of society’s expectations regarding gender performance.

According to Bento, Xavier, and Sarat^{55 Bento NMJ, Xavier NR, Sarat M. Escola e infância: a transfobia rememorada. Cad Pagu. 2020 [acesso em 2023 mar 24]; (59):e205911. Disponível em: https://doi.org/10.1590/18094449202000590011.
https://doi.org/10.1590/1809444920200059...} , trans people (men or women) are expelled from their homes and have to look for shelter on the streets, as society does not accept gender transition. The course of these individuals’ lives is changed without them being able to continue their education, suffering prejudice at the time of the job interview, and even having their lives taken. These individuals become even more vulnerable on the streets, especially if no shelter or institution can accommodate them. Thus, the Macaé LGBT Clinic is vital for caring for this population, as they find a welcome that may not exist in other spaces.

The Street Clinic emerged in Macaé, state of Rio de Janeiro, in 2010 through the struggle and organization of the public network’s professionals, observing the growing number of homeless people in the city who are part of the LGBTQIA+ community. This number may show the need to expand services that cover this public, even in other areas of the country, in a consolidated manner. The Clinic connects with the Pedro Ernesto University Hospital in Rio de Janeiro, providing speech therapy, hormone therapy, and surgery services to the LGBTQIA+ population^{66 Sirelli PM, Ferreira GG, Dias ACR. Consultório LGBT: (Re)construindo narrativas de combate às violências LGBTfóbicas na saúde em Macaé Rio de Janeiro. Gênero. 2020 [acesso em 2023 mar 24]; 20(2):201-224. Disponível em: https://doi.org/10.22409/rg.v20i2.44575.
https://doi.org/10.22409/rg.v20i2.44575...} .

Compared to other cities in the North of Rio de Janeiro, Macaé still faces significant challenges in providing public health services^{77 Azevedo DC. Caracterização da pobreza em Macaé: uma abordagem multidimensional. [dissertação]. Niterói: Universidade Federal Fluminense; 2011. 166 p.}. This disparity is directly linked to the region’s lack of investment in public health policies. Given that Macaé is home to a considerable portion of a socially vulnerable population, marked by racial and gender inequalities, the lack of public health policies primarily affects the most vulnerable, such as the homeless population, sex workers, cis women, Black people, trans, and transvestites.

Despite being recognized as an oil exploration center, something that should theoretically boost local economic development, the municipality still faces a high poverty rate, which shows that the wealth generated remains concentrated and is not distributed equitably among residents, even amid economic growth. According to Azevedo^{77 Azevedo DC. Caracterização da pobreza em Macaé: uma abordagem multidimensional. [dissertação]. Niterói: Universidade Federal Fluminense; 2011. 166 p.}, more than 14% of the city’s population lives below the poverty line, with almost 5% living in destitution.

Prejudice and discrimination create institutional barriers that prevent people’s access to healthcare, especially those more vulnerable and socially fragile. The Unified Health System (SUS) continues to be relevant and essential to guarantee the health of the Brazilian population, even more so for the socially vulnerable. The Brazilian health system allows access to different healthcare levels. Primary Health Care (PHC) is the main access point for SUS services, focusing mainly on preventive care. According to Macinko and Mendonça^{88 Macinko J, Mendonça CS. Estratégia Saúde da Família, um forte modelo de Atenção Primária à Saúde que traz resultados. Saúde debate. 2018 [acesso em 2023 mar 24]; 42(esp1):18-37. Disponível em: https://doi.org/10.1590/0103-11042018S102.
https://doi.org/10.1590/0103-11042018S10...} , the importance of PHC care also lies in promoting health from a multidisciplinary team in a given territory and with its population. Furthermore, PHC principles are strengthened in the SUS based on the idea of universality, coordination, and accessibility, and PHC was defined as the gateway to the SUS in 2011.

The Brazil Without Homophobia Program emerged in 2004, serving as a basis for developing a policy for the LGBTQIA+ population, establishing guidelines involving different stakeholders in different public sphere^{99 Gouvêa LF, Souza LL. Saúde e população LGBTQIA+: desafios e perspectivas da Política Nacional de Saúde Integral LGBT. Periodicus. 2021 [acesso em 2023 mar 24]; 3(16):23-42. Disponível em: https://periodicos.ufba.br/index.php/revistaperiodicus/article/view/33474.
https://periodicos.ufba.br/index.php/rev...} . From this milestone, several public conferences were held, culminating in the consolidation of the Comprehensive National Policy for Lesbians, Gays, Bisexuals, Transvestites and Transsexuals in 2011. The active participation of LGBTQIA+ members in the Health Councils highlighted the importance of recognizing these struggles^{1010 Pereira EDS. Participação social e a construção da equidade em saúde: o conselho nacional de saúde e direitos da população LGBT. [dissertação]. Brasília, DF: Universidade de Brasília; 2011. [acesso em 2023 mar 24]. Disponível em: https://www.oasisbr.ibict.br/vufind/Record/UNB_df2ba51ecdd2a444f5f2033873ed274c.
https://www.oasisbr.ibict.br/vufind/Reco...} . Representation in health systems, including the SUS, becomes crucial to guarantee the adequate reception of those seeking care.

The increase in institutional participation of LGBTQIA+ people drives the formulation of more comprehensive access policies. Specific issues related to transvestites and trans people, such as sexual reassignment surgeries, were considered due to the participation of the LGBTQIA+ movement in discussions about SUS policies. Furthermore, the health issues of these people must be understood based on the experience of this population, considering that trans and transvestites are more exposed to violence, the risks of sex work, and the possible use of psychoactive substances^{1111 Bezerra MVR, Moreno CA, Prado NMBL, et al. LGBT health policy and its invisibility in public health publications. Saúde debate. 2019 [acesso em 2023 mar 24]; 43(esp8):305-323. Disponível em: https://doi.org/10.1590/0103-11042019S822.
https://doi.org/10.1590/0103-11042019S82...} .

The research aimed to investigate access to the LGBT Clinic in Macaé, state of Rio de Janeiro, by trans and transvestite people and reflect on access, equity, and territories in health is an emerging theme in academia. The complexity of the emergence of other health challenges represents a setback for a system responsible for meeting Brazilians’ needs, such as the SUS. Therefore, it is crucial to rethink current public policies and healthcare models, considering the needs and characteristics of the different groups that occupy different territories, especially their vulnerabilities.

The Research Ethics Committee (CEP) approved the research with CAAE 57599922.6.0000.5240 and Opinion Nº 5.493.864.

Material and methods

This qualitative research was conducted at the LGBT Clinic in Macaé, in the state of Rio de Janeiro, in 2022, with face-to-face interviews combined with the snowball technique to build the purposeful sample and participant observation to understand the experiences of a specific population and social groups and their cultural and interactive issues^{1212 Medeiros M. Pesquisas de abordagem qualitativa. Rev. Eletr. Enferm. 2012 [acesso em 2023 fev 7]; 14(2):224-229. Disponível em: https://revistas.ufg.br/fen/article/view/13628.
https://revistas.ufg.br/fen/article/view...} . The interviews were combined with participant observation to improve the results. At this stage, we investigated individuals’ interactions and relationships with the environment, noting the occurrences. The participants were chosen per the list of users who are monitored at the LGBT Clinic during the research period in 2022. The snowball technique was adopted to invite more participants.

We employed semi-structured interviews with 12 questions formulated to cover the object and hypothesis of investigation: how access to healthcare is provided in Macaé and how users perceive this access. Semi-structured interviews include elaborating fundamental questions supported by relevant theories and hypotheses^{1313 Manzini EJ. Considerações sobre a elaboração de roteiro para entrevista semi-estruturada. In: Marquezine MC, Almeida MA, Omote S, organizadores. Colóquios sobre pesquisa em Educação Especial. Londrina: Eduel; 2003. p. 11-25.}. They combine open-ended and closed-ended questions, allowing the researcher to discuss the topics presented. These questions generate new hypotheses from the answers. According to Minayo^{1414 Minayo MCS, organizadora. Pesquisa Social. Teoria, método e criatividade. 18. ed. Petrópolis: Vozes; 2001.}, this technique is like a ‘purposeful dialogue’ that focuses on developing a conversation supported by a roadmap containing open or semi-structured topics.

The participants were selected under the following criteria: being users monitored at the LGBT Clinic during the research period to facilitate the collection of narratives. From the interviews, the results were analyzed based on three categories: i) access to health, ii) identity, and iii) homophobia/transphobia.

The questions were: i) Can you identify the difficulties and facilities in accessing the health service?; ii) How is access to health units in Macaé-RJ? What health devices have you accessed?; iii) How often has this access occurred?; iv) Have you accessed the LGBT Clinic? What about the trans outpatient Clinic? Report your experience about this access; v) Gender and sexuality are categories crossed by social markers and discursive practices. How do you self-identify?; vi) Considering your gender identity, do you believe there are specific needs for care in health devices?; vii) When being treated at a health unit, how do you evaluate the professionals’ care regarding gender issues? Do you believe that your gender identity influenced this care?; viii) How do you think health professionals should conduct themselves when providing care to trans people in health units?; ix) Brazil leads the ranking for several types of violence against transvestite and transsexual bodies. Have you ever suffered transphobia/homophobia?; x) In health services, have you ever suffered any violence?; xi) Considering the various health services in Macaé, how do you perceive the possibilities of taking care of your health?; xii) Would you like to report your experience regarding health services in Macaé?

We aimed to ensure a relationship of trust with the participants to access and understand these individuals’ symbolic and subjective world. The audio was recorded to transcribe the material and previously authorized by the interlocutor based on the Informed Consent Form. The researcher’s performance also made the interlocutor feel more comfortable, bringing openness and closeness between them, favoring longer answers to questions, and allowing more complex issues to be well addressed^{1414 Minayo MCS, organizadora. Pesquisa Social. Teoria, método e criatividade. 18. ed. Petrópolis: Vozes; 2001.}.

The technique proposed by Bardin^{1515 Bardin L. Análise de conteúdo. 1. ed. São Paulo: Edições 70; 2011.} is based on the stages of pre-analysis, exploration of the material, and processing and interpretation of the results. Therefore, in the present study, pre-analysis was conducted with the systematization of ideas in order to understand the participants’ ideas; in the second phase, the material was explored by relating the ideas presented to the theoretical framework; finally, the analyzed material was described based on the categories listed above in dialogue with the bibliographic content.

Data were evaluated using the content analysis methodology framework to extract possible meanings and worldviews in the statements of the interviewed users. Conducting the interview is vital for obtaining these narratives, as it facilitates the interpretative exploration of the reports, which can be organized and systematized into themes and categories of meaning^{1616 Boni V, Quaresma SJ. Aprendendo a entrevistar: como fazer entrevistas em ciências sociais. Em tese. 2005 [acesso em 2023 fev 7]; 2(1):68-80. Disponível em: https://periodicos.ufsc.br/index.php/emtese/article/viewFile/18027/16976.
https://periodicos.ufsc.br/index.php/emt...} .

Analysis and discussion of results

Thirteen individual interviews were held with LGBT Outpatient Clinic users. Seven respondents identified themselves as trans women, ranging from 18 to 35 years. COVID-19 emerged during the research in Brazil. As a result, some health services in Macaé were closed, and professionals were relocated to other positions. The LGBT Clinic was among the discontinued services, initially located in the Casa de Convivência. Thus, there was a care shortage, and the disrupted monitoring of users served. Due to the work of one of the authors of this article on site, intense popular mobilization for the return of the service was observed after six months of non-operation. Some issues about the universe of these individuals emerged from the interviews. In this sense, trans men expressed feeling truly ‘masculine’ only after mastectomy surgery:

From this statement, we can observe that the issue of surgical intervention was still profoundly linked to self-perceived identity. Regarding body changes in trans women, they also tend to start the hormonization process early in order to modify their bodies to feel more feminine, even without professional assistance.

The friendship between service users assisted us in conducting the research, mainly using the snowball technique. One user stated that his friend had also been interviewed and that he would have enjoyed talking about the service he uses. This support was also evident in the announcement of the resumption of the LGBTQIA+ outpatient service, so several users found out through colleagues or partners who were receiving care: “We became friends as he is very communicative and receptive. So, he recommended it to me” (Respondent 5). This is a common observation of relationships in the LGBT Clinic, and it is interesting to highlight that the partnership between trans and transvestites in the health sector is highlighted by other studies^{1717 Selles BRS, Almeida PF, Ahmad AF, et al. Redes sociais de apoio às pessoas trans: ampliando a produção de cuidado. Saúde debate. 2023 [acesso em 2023 out 17]; 46(esp6):148-61. Disponível em: https://saudeemdebate.emnuvens.com.br/sed/article/view/6910.
https://saudeemdebate.emnuvens.com.br/se...} .

Furthermore, two respondents (trans men) recognized that the support group is larger among trans men than among trans women or transvestites, reflecting what happens in the cis-heteronormative universe, as there is also greater support among groups of men than among female groups, with rivalry between women being encouraged, hindering mutual help in female environments. This perception about gender, even in a trans group, is similar. In other words, trans men also support each other more than trans women support each other:

We noted that trans women suffer more violence than trans men:

In Brazil, transvestites and transsexuals face a lack of professional qualifications and a lack of opportunities in the formal job market, where many find a source of income in prostitution, further increasing the risk of violence. According to Benevides and Nogueira^{22 Benevides B, Nogueira SNB. Dossiê assassinatos e violência contra travestis e transexuais brasileiras em 2020. Brasília, DF: Antra; 2021. [acesso em 2023 mar 24]. Disponível em: https://antrabrasil.files.wordpress.com/2021/01/dossie-trans-2021-29jan2021.pdf.
https://antrabrasil.files.wordpress.com/...} , 124 transgender or transvestite people were murdered in 2019, and violence was also racialized: most were Black in this group. Furthermore, the number of homicides increased by 40% from January 2020 to April 2020 against the same period in 2019.

Research on the territorialization of violence against transvestites and transgender people compared the relationship between occupation, spatiality, and death, showing that the primary fatal victims were transvestites and trans people, especially sex workers^{1818 Silva GWS, Souza EFL, Sena RCF, et al. Situações de violência contra travestis e transexuais em um município do nordeste brasileiro. Rev. Gaúcha Enferm. 2016 [acesso em 2023 out 17]; 37(2):e56407. Disponível em: https://doi.org/10.1590/1983-1447.2016.02.56407.
https://doi.org/10.1590/1983-1447.2016.0...} . Considering this, the LGBT Clinic should offer a safe, receptive space, with reports confirming that the place offers the necessary care in the psychology and psychiatry services provided.

Regarding professionals who work in PHC, the research revealed that it is vital to familiarize with transvestites and trans people who live in the region and their vulnerabilities in the health-disease process. Health professionals should be prepared to understand these issues, and health devices should promote a bond with the user to favor continuing monitoring.

Violence against trans people occurs in the most different spaces. In this study, the streets were the violence venue. However, this violence also occurs at home, schools, health services, and other settings. Regarding violence’s spatiality, we noticed that violence on the streets is a common fact in the daily lives of trans people^{1818 Silva GWS, Souza EFL, Sena RCF, et al. Situações de violência contra travestis e transexuais em um município do nordeste brasileiro. Rev. Gaúcha Enferm. 2016 [acesso em 2023 out 17]; 37(2):e56407. Disponível em: https://doi.org/10.1590/1983-1447.2016.02.56407.
https://doi.org/10.1590/1983-1447.2016.0...} , confirming the research results.

Gender violence involves social structures, especially patriarchy, machismo, and capitalism, controlling the bodies and lives of the subordinates. With the exploitation of the cis female body, patriarchy also encourages violence against trans women and transvestites, besides the LGBTphobia they endure because, alongside the similar physical appearance, trans and transvestites share female spaces - for example, being hairdressers, manicurists, in the domestic environment, being domestic worker, just like cis women^{1717 Selles BRS, Almeida PF, Ahmad AF, et al. Redes sociais de apoio às pessoas trans: ampliando a produção de cuidado. Saúde debate. 2023 [acesso em 2023 out 17]; 46(esp6):148-61. Disponível em: https://saudeemdebate.emnuvens.com.br/sed/article/view/6910.
https://saudeemdebate.emnuvens.com.br/se...} .

The experiences of trans and transvestites are also permeated by class prejudice, as many face poverty. Furthermore, it is common for the idea of a transvestite to be related to prostitution, a reality in Brazil, given that this population does not have significant economic power and certainly often has to resort to this type of activity^{1919 Marilac L, Queiroz N. Eu, Travesti: memórias de Luísa Marilac. Rio de Janeiro: Record; 2019.}.

Violence is not always recognized as an object of intervention in health professions and is instead merely viewed as some judicial/police matter. However, the health sector can play a role in guiding and supporting victims of violence and instructing patients on care measures. In this sense, approaches to combat violence against trans and transvestites must be implemented horizontally in the health policy, also focusing on the experiences of trans and transvestites^{2020 Condé LB. As medidas protetivas de urgência e a lei de feminicídio em face ao combate à violência doméstica: um estudo de caso. [monografia]. Brasília, DF: UniCEUB; 2020. [acesso em 2023 out 17]. Disponível em: https://repositorio.uniceub.br/jspui/handle/prefix/14853.
https://repositorio.uniceub.br/jspui/han...} .

We observed unpreparedness and a lack of sensitivity in some of the health services in Macaé, in those that are not explicitly designed to serve the LGBTQIA+ population. When telling the story of a friend who suffered an attack and needed to go to the hospital, Respondent 9 revealed this lack of preparation:

The reports coincided with the excellent treatment in health services specific to the LGBTQIA+ population, such as the LGBT Clinic: “At the trans clinic [...] I went there four times, and was always treated very well” (Respondent 7). Several users treated at the LGBT outpatient clinic first access the Adolescent Reference Center (CRA), where a multidisciplinary care team is available. The reports highlight the name of the CRA social worker to remember the excellent service, defining her as a ‘mother’. The category of ‘father’ is given to the doctor who works at the LGBT outpatient clinic, defined as an observant and caring human being with patients.

Respondents mentioned psychological issues, such as depression and anxiety. They reported that the psychology and psychiatry services at the LGBT Clinic were adequate. Professionals from other services should be adequately trained to perceive patients’ possible trauma or distress during care, even if the initial search was not for mental health treatment. Evaluating care in health services depends on several factors, such as respect for gender identity and preparation for care. Health service employees had to respect their social names, which not everyone fulfills. However, we observed that several professionals lacked information on LGBTQIA+ issues, causing them to take erroneous attitudes toward these patients. The positive part was related to respect for the social name, good service, listening within the Clinic, and the services offered: “Not only trans people and LGBT people in general can take tests; everything is ready here. We have an endocrinologist; we have everything. It’s super great here” (Respondent 12).

Passability, that is, being socially recognized in the gender to which one understands oneself belonging, was also a topic raised: “It was much easier when I was a girl”, said Respondent 3, who also reported that she avoids “saying she is a trans man so as not to suffer prejudice”, facilitated his ‘passability’. At the Macaé LGBT Clinic, Respondent 1 revealed that the employees were careful and respected his name’s choice, avoiding calling him by his given name: “I think it’s caring because if people are somehow trying to understand or improving, I think it’s caring”.

When starting the transition process, deciding on one’s name is something thought about. It is part of the experience of trans and transvestite people. Respect for the name change, as shown by Respondent 1, is like a demonstration of care. Having your name disrespected, called by the incorrect gender, or by the ‘dead’ name can psychologically affect those who suffer this violence, which is also why rectification at a notary’s office is so relevant, as there is no longer any possibility of the ‘dead’ name being brought to light. However, rectification is not simple. According to Respondent 9:

We should underscore that Brazil does not provide this service free of charge even though it is a social right. Waiting time can be a problem for those users who do not have the financial means to pay for surgery or hormonal treatment through the private network. Respondent 3 reported that some people wait around seven years for surgery. This search outside the public network was reported by Respondent 6, evidencing the relevance of having specific services for the LGBT+ population:

Many users seek care in Rio de Janeiro, as they understand that the supply is still low in Macaé. Arraial do Cabo was also mentioned. It was also reported that one went to the south of Brazil in order to undergo silicone implant surgery. Respondent 7 reports that, after sexual reassignment surgery, doctors usually ask her to be naked in the office, frequently being observed by medical students, and indicates that

As something positive regarding the service, the respondents underscored the work of the professionals at the outpatient Clinic and the LGBT Clinic, that is, doctors, nurses, social workers, and receptionists. They perceived that the employees of the LGBT Clinic were experts: “I think they are prepared for this; they treat us very well” (Respondent 13). They also highlighted that monitoring at health centers for hormone treatment means establishing a positive relationship between employees and the patient, exchanging experiences and conversations, and providing a pleasant environment.

When discussing the transition process, the perception of having a body different from the one assigned at birth begins in childhood. In the interviews, the difficulty of starting to transition was reported, primarily due to the coercive power of social institutions that restrict this freedom, such as family and religion. Respondent 3 said:

The sociability of the trans or transvestite person is also modified when they decide to transition. In this context, prejudice in the selection processes was felt by Respondent 12:

The ‘conditions’ would be her recognition as a trans woman, removing her right to occupy a position in which she had the necessary competence.

Final considerations

Although the research results are limited, as the interviews could only encompass a small part of the region’s LGBTQIA+ population, we offered an insight into the experience of this population in the context of Macaé, Rio de Janeiro. The Macaé LGBT Clinic was provenly a place where users felt well and comfortable receiving care. Many positive reports were directed to local health professionals, social workers, and attendants. This experience, then, should be expanded nationwide. In this sense, there is a need to investigate in more depth how access is provided in other parts of the national territory, as there have been complaints about services outside the LGBT Clinic, such as in the Airport emergency room.

The participants’ reports confirmed several cases where the populations studied did not find adequate help and sought other health services to meet this demand. The value judgments and judgments expressed in the actions of some health professionals suggest that their discriminatory attitudes towards transvestites and transsexuals have historically manifested themselves in different social spaces. The need for interaction in public health services designed to meet health needs and provide care for the cisheteronormative masses is widespread.

Trans and transvestites’ access to healthcare often exposes health professionals’ intolerance and low understanding of issues related to gender identity and their uniqueness, leading to prejudice and institutional discrimination. Considering health for this population may mean that professionals need to move away from prejudiced values to give way to broader views of sexual and gender diversity. We also noted the need to verify, through further research, how care is provided in other health facilities in that municipality.

The statements show that these individuals carry stories of suffering and stigmatization surrounding this experience of what it means to be trans or transvestite in Brazil. Therefore, more research must be conducted to make evident the need to receive this population, both by health devices, with more LGBT Clinics throughout Brazil, and by health professionals having access to these narratives since their inception in training processes, to know how to address the differences and demands that arrive in an office, an emergency room, or a clinic.

For transvestites and transgender people, the act of presenting documents at the reception of health services can be somewhat anxiety-provoking, as disrespect for the chosen gender identity is still common in services not specific to the LGBTQIA+ public. This prejudice against social names can play a decisive role in the continuity of an individual’s treatment. All healthcare settings should consider the specific needs of trans or transvestite people, even if it is not a specific place to care for the LGBTQIA+ population. The following can be considered specific needs of this population: the careful evaluation of the indication of gynecological tests in trans men, respect for the name, and patient’s body care after surgery.

The denial of the social rights of trans and transvestites involves neoliberal logic, in which it is necessary for some populations to be placed on the margins, like other groups, for example, Black and impoverished people. In the case of Macaé, a city that is advancing industrially, there is no financial return to expand policies that involve the LGBTQIA+ population, even though the LGBT Clinic has proven to be effective in caring for these people, which shows that the LGBTQIA+ population is not a priority in the power of the State and the private sector regarding their demands.

Preserving a capitalist society requires winners and losers. That being said, trans and transvestites would be left over because they are not the standard of the dominant class, occupying a socially despicable place, shown by the lack of public policies, healthcare, and acceptance and rejection of fundamental needs.

The interview reports point to the need to expand health facilities that receive the LGBTQIA+ population, as it was evident that users felt more accepted at the LGBT Clinic than in other health facilities, such as the Airport emergency room.

Therefore, debating dominant narratives centered on cis-heteronormativity is vital to guaranteeing and realizing the rights of the LGBTQIA+ population, which can be modified with public inclusion policies, such as the assistance of social workers to help these people seek citizenship by obtaining documents and financial assistance. Furthermore, shelters such as Casa Florescer and visit places such as the LGBT Clinic in Macaé are other examples of how trans and transvestite people can gain acceptance and exercise their citizenship.

References

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History