Therapeutic itinerary of transsexual people in light of human rights

Abstract

Background:

The therapeutic itinerary is not limited to the identification and availability of health services offered, but relates to the different individual searches and sociocultural and economic possibilities of each patient. In this study, we discuss the therapeutic itinerary of transsexual people seeking healthcare, from the user’s perspective.

Objective:

The aim of this study was to discuss the therapeutic itinerary of transsexual people seeking healthcare, from the user’s perspective.

Design and participants:

Individual interviews were performed with 10 transsexuals at the Trans Space of a University Hospital of Pernambuco, using the Universal Declaration of Human Rights as the theoretical reference and the Bardin’s thematic content analysis as the reference methodological framework.

Ethical considerations:

This study was approved by the Human Research Ethics Committee at the Federal University of Pernambuco under protocol no. 91284218.5.0000.5208.

Findings:

The comprehensive care for transsexual people was evidenced through four categories analyzed: low demand of transsexuals in health services; use of social name in health services; care permeated by prejudiced and discriminatory attitudes; and health system and professionals who are not able to meet transgender health issues.

Discussion:

Transsexual people are stigmatized and experience prejudice in their daily health, in a way they do not enjoy fundamental rights, as if they had fewer rights, or infringe the principle of universality of access to health. Thus, for effective and comprehensive care, the health team must keep up to date on the public policies existing in the healthcare of transsexual people and reconstruct what they understand by gender.

Conclusion:

Knowledge about the therapeutic itinerary of transgender people may support evaluation processes of health service networks to ensure the access to and reorganization of these services. Understanding this dynamic allows fostering discussions about the structure of health services at all care levels for the care of this population.

Keywords

Access to health services healthcare-seeking behavior human rights transgender people

Introduction

The understanding of the origin and “treatment” of transsexuality has been confronted throughout history from psychoanalytic and biomedical conceptions.^1,2 Both have a common axis: heteronormativity and the defense of the natural heterosexuality of bodies. Thus, a condition presented for the definition of transsexuality, among other elements, is the desire for transgenitalization surgery. On the contrary, anthropology points to a definition of transsexuality as a plural identity experience, not reduced to a universalist and pathologizing conception.³

Therefore, the first discussions on therapeutic itineraries began through social-anthropological studies, which sought, pragmatically, to understand how individuals traced their treatment choices and/or the preservation of their health. From these studies, it was possible to investigate more thoroughly how people and societies elaborated different medical conceptions about causes, symptoms, diagnoses, and treatments of diseases, as well as the search for resolutions of their sufferings and ways of behaving in these moments.^4,5

Transsexuality is conceptualized when an individual identifies with the opposite sex than that attributed to him or her in his or her birth record. In 2019, the World Health Organization (WHO) removed from the International Classification of Diseases (ICD 11) the “gender identity disorder,” which was previously considered a mental disorder.⁶ Nevertheless, society has not yet legitimized this consensus in the popular imagination and in the conception of health.

The Universal Declaration of Human Rights, in 1948, recognizes health as the inalienable right of every person and as a social value of every human life. This right has also been guaranteed in the Brazilian Federal Constitution since 1988; however, three decades after its promulgation, this right still remains far from being fully actualized, especially to social minorities.^7,8

In general, Brazil presents social and economic inequalities that directly affect the health condition of its population, in disagreement with the Unified Health System (UHS) that is in force in the country, based on the principles of universality, equity, and integrality to health promotion, protection, and recovery services.⁹ Assuming that health is a dynamic social process related to other social processes, it is understood that each individual constructs and understands his or her health.¹⁰ Transsexual people, before some health problem, usually initiate a succession of empirical practices in order to find a therapeutic outcome for their health demands.¹¹

On the health of these people, therapeutic itinerary is an incipient theme, since the available references are restricted to the deficiencies of specialized health policies to this clientele. It is important to emphasize that this itinerary is not limited to the identification and availability of the health services offered, but is related to the different individual searches and the sociocultural and economic possibilities of each person.

It is understood that receiving healthcare is still a challenge for this public because there is still a lack of understanding of the fullness of the concept of health as a state of complete physical, mental, and social well-being, and not simply the absence of diseases. Endorsing this thought, the United Nations Human Rights Council has encouraged the first international discussion involving human rights, sexual orientation, and gender identity in order to identify the scope of possible violations and preventive measures to be implemented.¹²

The estimates reveal around 25 million transgender people worldwide, and among this index, approximately 2.4 million are Brazilians.¹³ All over the country, five hospitals perform transgenitalization through the UHS (one in the state of Pernambuco) and only three perform preventive follow-up focused on children and adolescents. The state of Pernambuco currently has four outpatient care units directed at this population.

The policy for lesbians, gays, bisexuals, transvestites, and transsexuals (LGBT), arising from the struggles of social movements linked to the defense of the rights of the LGBT population, contributed to the creation of Ordinance 2836/GM/MS in December 2011, establishing, within the UHS scope, the National Comprehensive Health Policy for this group, seeking to minimize institutional violence and regulate the transsexualizing process.^14,15

Thus, the demands of the lesbian, gay, bisexual, transvestite, transsexual, transgender, queers, intersex, asexual, asexual, and more (LGBTQIA+) population, ignored and silenced throughout history, resulted in a process of marginalization and exclusion, which caused serious violations of social and human rights.¹⁶ Although questions about human sexuality are studied by different areas of knowledge, such as psychology, anthropology, education, sociology, and health sciences, the knowledge and meanings historically constructed are marked by a reductionist and biologizing view, which disregards historical and social aspects in the construction and experience of human sexuality.¹⁷ Thus, this set of knowledge still does not meet the production of pathologizing views that become socially shared meanings, leading to the concepts of deviations and perversions.

Knowing the therapeutic itinerary of transgender people involves the question of identifying the resources available and the ones people who need healthcare use, but above all understanding the meanings that guide the process of choosing care. This practice will allow health professionals to recognize how each individual faces illness, in addition to adapting their orientations so that they can be understood to be performed, considering each sociocultural reality.¹⁸ Thus, as with other health professionals, the nursing team still does not receive specific content for the care of the transsexual population in its training. The unawareness of the patient’s rights can lead the professionals to act under the strong influence of their own prejudices and to distance the user from the services for fear of embracement conditions. Thus, this study aimed to describe the therapeutic itinerary of transsexual people in search of healthcare, from the user’s perspective.

Methods

This is an exploratory, descriptive research with a qualitative approach, carried out in the Trans Space of a University Hospital of Pernambuco, accredited to the UHS. This space is currently considered a reference service in the Northeast, in health practices and care for transsexual people. It has an outpatient character, with a monthly average of 100 calls, by a multi- and interdisciplinary team, involving areas such as psychology, nursing, gynecology, endocrinology, plastic surgery, mastology, and social work, among others.

As a theoretical support, the Universal Declaration of Human Rights was used, as the UHS in Brazil was constituted by doctrinal principles based on human rights, ensuring the right to health without discrimination of any nature. The population was composed of transsexuals who attend the study site, for consultations, monthly meetings, or counseling.

The inclusion criteria were as follows: self-reported as transsexual, aged above 18 years, who regularly attends the Trans Space, which means compliance with the protocols of attendance, and participation in monthly meetings.

Semi-structured interviews were conducted, which contained sociodemographic questions and those about health needs, trajectories traveled in the health system, as well as their perceptions and possible difficulties found during this journey, guided by the following guiding questions: (1) What do you mean by health? What are the places you usually seek when you need healthcare? (2) What is your perception of the service in these locations? Why? Data collection took place in September and October 2018.

The interviews were conducted in a private environment and in the service offices, recorded on a smartphone device, and later transcribed in full in analysis grids. The data of the interviewees were encoded only by the initial “P” (participant) and enumerated according to the order of the application of the interview. The mean duration of the interview was 20–30 min, with the use of the intentional non-probabilistic sample and with sample closure by theoretical saturation.¹⁹

The sample closure by theoretical saturation is a process used to determine the closure of qualitative research in which the participants’ data are repeated. Thus, saturation was obtained after the eighth interview, with another two to confirm saturation, totaling 10 interviews.¹⁹

The data obtained were analyzed according to the method of content analysis or thematic analysis proposed by Bardin.²⁰ In this method, an objective, systematic, and quantitative description of the content of communications is possible. Thus, after the transcriptions, the participants’ discourses were analyzed and the meaning nuclei were identified, and four thematic categories on the therapeutic itinerary of transsexual people seeking healthcare were derived. The thematic categories selected were as follows: transsexuals’ low demand of health services; use of the social name in health services; care permeated by prejudiced and discriminatory attitudes; and health system and professionals not qualified for the specificities of transgender health issues.

Ethical considerations

Data collection was performed in a reserved room, located in the Trans space, with guaranteed privacy. After proper clarification about the purpose of the study and clarifying all doubts, the Informed Consent Form was signed and a copy was left with the participant. All ethical aspects contained in resolution 466/2012 of the National Health Council were respected, safeguarding the confidentiality, secrecy, and privacy of the participants. The research was approved by the Human Research Ethics Committee at the Federal University of Pernambuco under protocol no. 91284218.5.0000.5208.

Results and discussion

In this research, we obtained participation from 10 users, all with follow-up in the process of transsexualization in an outpatient clinic. As a sociodemographic profile, out of the total 10 participants, we found seven (70%) females and three (30%) males; the mean age was 29–39 years (50%); origin—seven (70%) were from Recife and the metropolitan region and three (30%) were from the inland state. Regarding the marital status, five (50%) reported being unmarried; on the race/color question, six (60%) self-reported as brown; concerning schooling, three (30%) had incomplete primary education, and six (60%) were own-account workers.

Theme 1: transsexuals’ low demand of health services

All participants of the research reported that they have already avoided or still avoid health services because they have already gone through embarrassing situations or are afraid to experience such situations:

I have always had this my head, when I start to have a certain significant change, where people start to see who I am, I keep staring at them, you know? So I have always lived in that expectation, waiting, let us wait, let us wait to be able to face. (P1)

Sometimes, when I am sick I go and ask my mother to buy medicine just to avoid going and having this impact on care. (P5)

The reduced flow of transsexuals to health services is worrisome, especially to primary care, which is the gateway to the system and space of greater permanence of the user in the network. This social group directly goes to specialized services only for the transsexualizing process, as they are places that supposedly have professionals trained to deal with gender issues.^21,22 However, this population should not seek health services only during the process of sexual reassignment. Also, for those who do not intend to perform the surgery, where and by whom will they be cared for?

…when we get sick we try everything at home, take medication, self-medicate. But not today, I come to the Space, then I see the importance of having a follow-up of professionals. (P7)

This is a worrying reality, as it implies that access to health is not universal, being necessary to understand that not all people seek health services for the same interventions. In addition, the transsexual population is quite heterogeneous and has several characteristics regarding sexual orientation, age, race, religion, and socioeconomic status. Thus, they belong to various care areas, such as women’s health, men’s health, workers’ health, and elder health, among others, requiring an integral health that is offered by other instances of the system from which they feel excluded.²³

The reference centers for the transsexualizing process are of paramount importance for this process to be carried out adequately; however, the health of transsexual people should be seen in an integral way and exceed their gender identity, which is only a component of all their biopsychosocial demands.²⁴ There is also a discourse of individual blaming for social representations, in which failure is attributed to the transsexual subject for the degradation of his or her health. This situation corroborates several studies that justify the small demand for health services by these people, which is not simply an irresponsibility or lack of self-care.^25,26

Pathologization and discrimination are the greatest challenges faced by the transsexual population for access to health, as they cause severe individual damage and have repercussions in situations of abandonment of treatments in progress and resistance to seek healthcare when necessary.²⁴ The disrespect for the social name in health services is responsible for several types of violence such as “derision” and humiliation, among other situations, which reflects the worsening of their health conditions.²⁶

Transsexual people are stigmatized and experience prejudice in daily health, as they do not enjoy fundamental rights, as if they had fewer rights, or violate the principle of universal access to health.²⁵ Thus, barriers are formed by the difficult communication with health professionals, leading to exclusion and marginalization of health services and, consequently, to reduced care and search for assistance by this clientele.

In Article XXI, the text of item 2 of the Human Rights Charter clarifies that “Everyone has the right to equal access to public service in his country.” This guarantee is explained in Articles 196–200 regarding the right to health of the Federal Constitution of 1988, since it recognizes health as a universal right and duty of the State, guaranteed through social and economic policies aimed at reducing the risk of disease and other complications.⁸

Therefore, universal and equal access to actions and services for health promotion, protection, and recovery should be a priority; thus, the analysis of the relationships between health and rights of transgender people requires several reflections on the practical effects of laws, on the daily lives of institutions, in the care of professionals, as well as in the experiences lived by these people.²⁷

Theme 2: use of the social name in health services

Regarding the embracement and promotion of access to health by transgender people, the disrespect for the right to use the name chosen by them is configured as violence and embarrassment and distances them from healthcare.²¹ Furthermore, respect for the social name is inherent to the right of their identity, considered as the personality structure of the individual, basing the recognition of the value of his or her dignity. Therefore, Article VI of the Universal Charter of Human Rights considers that “Everyone has the right to recognition everywhere as a person before the law.”²⁸

The name carries along with the body the multiple senses of femininity and masculinity that operate as a constituent of gender.^21,29 Thus, it is possible to perceive attitudes of prejudice and discrimination, pointed out as important access obstacles of this social segment to prevention and care services, as evidenced in the following excerpt:

I found it a bit hard because of that UHS issue, of the UHS card. So, as we go through this process of transsexuality, we do not want to be exposed in any way on the female side, right? So, while I had none, I had kept distance from health services. (P9)

On 13 August 2009, the Ministry of Health published the UHS Users’ Rights Charter, through ordinance no. 1820, making it mandatory that all identification documents of users, such as medical records and National Health Card, among others, contain a place to be filled with the name that the user wishes to be called.^28,30 This document states that every citizen has the right to humanized, welcoming, and discrimination-free service. Therefore, the National Policy of Integral LGBT Health aims to reinforce comprehensive care, eliminating discrimination and institutional prejudice, standardizing the use of the social name according to the UHS Users’ Rights Charter.^14,30

Despite the various regulations that aim to guarantee the right to the social name in the care of health services, the interviews evidence the insistence and disrespect of health professionals regarding its use:

We need to have this card and, despite still undergoing the transition process, despite the possibility, she read my name there, because, so far I had not rectified in the hospital yet, but now it is rectified, had not rectified, had the civil name and below the social name, she did not respect my social name. So there was a whole boring situation, I believe she could have avoided it, but it happened anyway. (P6)

The respect for the social name and the proper use of pronouns are essential for the construction of therapeutic bond, indispensable for the treatment and permanence of the user in the service.²¹ The disrespect for the social name is the beginning of trans/transvestite phobia in health services and is one of the main impediments to universal, integral, and equitable access. However, it was possible to observe that the user, feeling understood and respected regarding his or her gender identity, accesses health services and enjoys his or her rights in a comfortable way, as can be seen in P5’s speech:

I sought the health center near my house because I was taking some shots. Then the girl asked normally, “what name do you want me to put here?.” I mean, and I had never told her I was trans, I had never asked her to put the social name on and at first I was like “wow, someone thought I was a trans person, saw a male name and looked at me.” So I asked her to put my name on it and I was happy, right? (P5)

Theme 3: care permeated by prejudiced and discriminatory attitudes

Transsexuality is marked by suffering, of the understanding of not belonging to the so-called biological sex, but mainly by the non-acceptance of this condition by society.^16,17 In the foreword of the universal charter of human rights,³⁰ “whereas recognition of the inherent dignity and of the equal and inalienable rights of all members of the human family is the foundation of freedom, justice and peace in the world.” In this sense, the performance of health services is compromised when there are discriminatory processes involved in care.

Nevertheless, prejudice and discrimination are explicitly present in health services, expressed in small gestures or behaviors performed by health professionals, making clear the size of invisibility and transphobia. Regardless of how they occur, situations of prejudice and discrimination cannot be neglected, since such situations represent important repercussions on the health conditions of the individual:^15,31

Prejudice is in the eye, in the gesture, not only in violence, in the verbal. Sometimes a look hurts more than a “get out of here.” (P3)

Human rights violations create situations of risk for people with disabilities, indigenous populations, sex workers, drugs users, children and adolescents, transgender people, and others discriminated, whether by gender, sexuality, race/ethnicity, or religious choice. Therefore, discrimination can produce three types of repercussions on these people’s lives: the first would be the feeling of decreased well-being, causing symptoms of anxiety and depression; the second is the use of psychotropic drugs caused by discriminatory experience, as well as chronic production of hormones related to stress, increased heart rate, and hypertension. Finally, they may imply the patient’ abandonment of the proposed treatment.³² These repercussions are evident in the communication of interviewee P8:

…it is an ansiogenic factor, it is a sick factor because it ends up making the person sick. Falling ill in various ways, for not having to expose oneself, not having to go through this embarrassment, either for the question of not going and ending up really getting sick, or aggravating what one already has. (P8)

Most health professionals receive training for their exercise with the imposed character of hetero-cis-normativity, defined as the only and socially acceptable rule of being heterosexual and recognizing themselves according to the sex of birth, not being able to meet the population that does not meet this parameter.³³ This is a subject that is little seen, or unseen, in academic training, reflecting the lack of preparation of health professionals before a population that differs from the gender patterns imposed by society.^11,34

Theme 4: health system and professionals not qualified for the specificities of transgender health issues

The meaning of health is considered as a human right; thus, professionals and states must ensure quality, adequate, acceptable, and accessible healthcare. Therefore, to place professionals in specific care sectors, their internal availability and preparation for humanized embracement must be taken into account in order to avoid situations such as that described in P4’s speech:

Oh, I am unable to treat you! You treat me like everyone else, I am a human being just like you! (P4)

This population needs a quality embracement, with qualified professionals capable of referring them to specific services according to the need presented, ensuring an equitable, democratic, humanized, and comprehensive service. Nevertheless, many health professionals still associate transsexuality with a psychopathology related to gender identity.²²

However, there is need to understand that the transsexual individual faces several obstacles when assuming his or her identity, which invariably causes intense suffering and can affect his or her mental health.¹⁷ The recognition of the expression of this suffering by health professionals should contemplate the therapeutic itinerary of these individuals, leading them to a better acceptance in the process of characterization of their personal experiences.

Thus, for effective and comprehensive care, the health team must keep up to date on the existing public policies in the healthcare of transgender people and reconstruct their understanding about gender.^21,34 It is also important to understand that this need should not only be a demand for specialized services for this population, so one should consider the universal access of the individual to health services and maintain the implicit respect in the doctrinal principles of the UHS.

This study presented limitations because it was performed in only a specialized service in the state of Pernambuco and with a small number of participants. Only 11 cities in Brazil have these services. There is need for further studies to give visibility to this population and consolidate the findings in order to contribute consistently with public policies of access to health services by all citizens.

Conclusion

After analyzing the statements, it is possible to observe that transsexual people live daily with the violation of human rights, especially the right to access to health services, and often fear being victims of prejudice, choosing not to enjoy this right.

Access to health services in some cases becomes so embarrassing that the existence of a specialized service becomes the only safe option, free of prejudice. Therefore, the Declaration of Human Rights is a milestone in the discussion of the fundamental rights of each individual and in the legal order of each country, and should be binding on all governments since each person has the right to be recognized in his or her difference and diversity, which is constitutive to him or her, as an indivisible whole.

Thus, health professionals and managers should act as facilitators in the process of respecting human rights because no one can subtract them; however, many of these professionals are not prepared to meet the specificities of transsexual people, due to either lack of training or prejudice.

The knowledge produced here about the transsexual population is expected to contribute to the recognition of health as a human right that should be accessible equally to all. For this, the permanent education of health professionals is an essential premise, and these professionals are responsible for attention and embracement of all people, without discriminatory judgments or values, so that the professional posture does not interfere in the therapeutic itinerary of people negatively.

Knowledge about the therapeutic itinerary of transsexual people may support evaluation processes of health service networks to ensure access to and reorganization of these services. Understanding this dynamic allows fostering discussions about the structure of health services at all care levels for the care of this population.

For good nursing practices, investing in this theme is a cross-cultural need, as it enables understanding diversities in human care, which requires ethical, technical, and humanistic articulation before the health needs of the transsexual population.

Footnotes

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Elizandra Cassia da Silva Oliveira

Raphael Alves da Silva

References

Rocon

Sodré

Zamboni

, et al.

O que esperam pessoas trans do Sistema Único de Saúde? [What trans people expect of the Brazilian National Health System?]

Interface (Botucatu) 2018; 22(64): 43–53.

Ferreira

Silva

. Caminhos do cuidado: itinerários de pessoas que convivem com HIV [Routes to care the itineraries of people living with HIV]. Cienc Saúde Colet 2017; 11(17): 3087–3098.

Simoes

Carrara

. O campo de estudos socioantropológicos sobre diversidade sexual e de gênero no Brasil: ensaio sobre sujeitos, temas e abordagens [The field of socio-anthropological studies on sexual and gender diversity in Brazil: an essay on subjects, themes and approaches]. Cad Pagu 2014; 42: 75–98.

Braz

. Vidas que esperam? Itinerários do acesso a serviços de saúde para homens trans no Brasil e na Argentina. [Lives on hold? Itineraries in access by trans men to health services in Brazil and Argentina]. Cad Saúde Pública 2019; 35(4): e00110518.

Soares

Santos

Arruda

. Itinerários terapêuticos de pessoas com câncer: produção científica no Brasil [Therapeutic itineraries of people with cancer: scientific production in Brazil]. Revista Aps 2017; 1(20): 118–129.

Organização Pan-Americana da Saúde.Organização Mundial da Saúde. Perguntas e respostas: revisão da Classificação Internacional de Doenças (CID), 2018 [Pan American Health Organization. World Health Organization. Questions and Answers: Review of Classificac International Disease (CID), 2018]. http://www.paho.org/bra/index.php?option=com_content&view=article&id=5574:perguntase-respostas-revisao-da-classificacao-internacional-de-doencas-cid&Itemid=875

Organização das Nações Unidas (ONU). declaração universal dos direitos humanos [Organization of the United Nations (UN). Universal Declaration of Human Rights]. 1948, available at: http://www.dudh.org.br/wp-content/uploads/2014/12/dudh.pdf

BRASIL. Constituição da República Federativa do Brasil. Diário Oficial da União, 5 de outubro de 1988 [Constitution of the Federative Republic of Brazil. Official Gazette of the Union, October 5, 1988 ].

Duarte

Eble

Garcia

. 30 anos do Sistema Único de Saúde [30 years of the Brazilian National Health System]. Epidemiol Serv Saúde 2018; 27(1): e00100018.

10.

Rocha

David

HMSL

. Determinação ou Determinantes? Uma discussão com base na Teoria da Produção Social da Saúde [Determination or determinants? A debate based on the Theory on the Social Production of Health]. Ver Esc Enferm USP 2015; 49(1): 129–135.

11.

Coelho

Campos

LML

. Diversidade sexual e ensino de ciências: buscando sentidos [Sexual diversity and science teaching: seeking senses]. Ciênceducbauru 2015; 21(4): 893–910.

12.

Nagamine

RRVK

. Os direitos das pessoas LGBT na ONU (2000-2016) [The rights of LGBT people in the UN (2000-2016)]. Sex Salud Soc (Rio J.) 2019; 31: 28–56.

13.

Winter

Diamond

Green

, et al. Transgender people: health at the margins of society. Lancet 2016; 388(10042): 390–400.

14.

Brasil. Ministério da Saúde (MS). Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais, Travestis e Transexuais—LGBT [National Poli'tica Health Integral Lesbian, Gay, Bisexual, and Transgender LGBT] . Brasília, Brazil: MS, 2008.

15.

Popadiuk

Oliveira

Signorelli

. A Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais e Transgêneros (LGBT) e o acesso ao Processo Transexualizador no Sistema Único de Saúde (SUS): avanços e desafios [The National Policy for Comprehensive Health of Lesbians, Gays, Bisexuals and Transgender (LGBT) and access to the Sex Reassignment Process in the Brazilian Unified Health System (SUS): progress and challenges]. Ciênc. Saúde Coletiva 2017; 22(5): 1509–1520.

16.

Tagliamento

. Direitos Humanos e a Saúde: a efetivação de políticas públicas voltadas à saúde integral da população trans [Human Rights and Health: the implementation of public policies aimed at the integral health of the trans population]. Ministério da Saúde (BR). Secretaria de Gestão Estratégica e Participativa. Departamento de Apoio à Gestão Participativa. Transexualidade e travestilidade na saúde. Brasília, Brazil: Ministério da Saúde, 2015, pp. 65–79.

17.

Grade

Gross

Ubessi

. Patologização da transexualidade a partir de uma revisão integrativa [Transsexuality pathologization from an integrative review]. Psic Saúde & Doenças 2019; 20(2): 435–451.

18.

Souza

MHT

Signorelli

Coviello

, et al. Therapeutic itineraries of transvestites from the central region of the state of Rio Grande do Sul, Brazil. Cien Saude Colet 2014; 19(7): 2277–2286.

19.

Minayo

Maria

. Amostragem e saturação em pesquisa qualitativa: consensos e controvérsias [Sampling and saturation in qualitative research: consensuses and controversies]. Qualitative Research Journal 2017; 5(7): 1–12.

20.

Bardin

. Análise de conteúdo [Content analysis]. 2011. São Paulo: Edições 70.

21.

Silva

LKM

Silva

ALMA

Coelho

, et al. Uso do nome social no Sistema Único de Saúde: elementos para o debate sobre a assistência prestada a travestis e transexuais [Use of the social name in the Brazilian Public Health System: elements for the debate on assistance provided to transvestites and transsexuals]. Physis 2017; 27(3): 835–846.

22.

Melo

Perilo

Braz

. Políticas de saúde para lésbicas, gays, bissexuais, travestis e transexuais no Brasil: em busca de universalidade, integralidade e equidade [Health policies for lesbians, gays, bisexuals, transsexuals and travestis in Brazil: the pursuit of universality, integrality and equity]. Sex Salud Soc 2011; 9: 7–28.

23.

Rocon

Wandekoken

de Barros

, et al. Acesso à saúde pela população trans no brasil: nas entrelinhas da revisão integrativa [Access to health by the transsexual population in brazil: between the lines of the integrative review]. Trab Educ Saúde 2020; 18(1): e0023469.

24.

Rocon

Silva

Sodré

. Diversidade de gênero e Sistema Único de Saúde: uma problematização sobre o processo transexualizador [Diversity in gender and unified health system: a critical analysis about access to health care]. SER Social 2018; 30(43): 432–448.

25.

Ferreira

Nascimento

Pedrosa

, et al. Vivências de travestis no acesso ao SUS [Transvestitess experiences in access to SUS]. Physis Revista De Saúde Coletiva 2017; 27(4): 1023–1038.

26.

Souza

MHT

Pereira

PPG

. Cuidado com saúde: as travestis de Santa Maria, Rio Grande do Sul. [Health care: the transvestites of Santa Maria, Rio Grande Do Sul, Brazil]. Texto & Contexto Enfermagem 2015; 24(1): 146–153.

27.

Monteiro

Brigeiro

Barbosa

. Saúde e direitos da população trans [Transgender health and rights]. Cad Saúde Pública 2019; 35(4): e00047119.

28.

Brasil. Ministério da Saúde (MS). Carta dos Direitos dos Usuários da Saúde [Charter of rights of users of healthy]. Brasília: MS; 2006. (Série F. Comunicação e Educação em Saúde).

29.

Rocon

Rodrigues

Zamboni

, et al. Dificuldades vividas por pessoas trans no acesso ao Sistema Único de Saúde [Difficulties experienced by trans people in accessing the Unified Health System]. Cien Saude Colet 2016; 21(8): 2517–2525.

30.

Brasil. Portaria nº1.820 de 13 de agosto de 2009. Dispõe sobre os direitos e deveres dos usuários da saúde [Disposal on the rights and duties of users of Sa’ud]. Diário Oficial da União 2009.

31.

Borba

. Sobre os obstáculos discursivos para a atenção integral e humanizada à saúde de pessoas transexuais [On the discursive obstacles to comprehensive and humanized health care for people Transsexuals]. Sex Salud Soc (Rio J) 2014; 17: 66–97.

32.

Bastos

Faertein

. Discriminação e saúde: perspectivas e métodos [Discrimination and health: perspectives and methods ]. Rio de Janeiro, Brazil: Editora Fiocruz, 2012.

33.

Vitali

Castro ACJSoratto

. “Homem é homem e mulher é mulher, o resto, sem-vergonhice”: representações sociais da transexualidade sobre comentários da internet [“A man is a man and a woman is a woman; everything else is hanky-panky”: social representations of transsexuality on internet comments]. Saudesoc 2019; 28(4): 243–254.

34.

Rosa

. Assistência de Enfermagem à população trans: gêneros na perspectiva da prática profissional [Nursing Care for the transgender population: genders from the perspective of professional practice]. Rev Bras Enferm 2019; 72(Suppl. 1): 299–206.