HEALTH VULNERABILITIES OF TRANSGENDER SEX WORKERS: AN INTEGRATIVE REVIEW

Senhora das Graças. Recife, Pernambuco, Brasil. ABSTRACT Objective: to identify the health vulnerabilities of transgender sex workers. Method: an integrative review conducted in July 2020 in the PubMed, Web of Science, SCOPUS, CINAHL, IBECS and LILACS databases, with no language or time restrictions. The following descriptors indexed in DeCS and MESH and their respective synonyms were used: “Transgender persons”, “Sex workers” and “Health vulnerability”. The data were analyzed based on thematic analysis. Results: a total of 547 articles were retrieved and, after the selection and analysis process, 34 were included in this review. Four thematic classes emerged: “Knowledge, prevention and exposure to STIs in sex work”; “Use (and abuse) of illegal substances and alcohol”; “The social and structural dimension of vulnerabilities: from weakened support networks to violence reproduced against dissident bodies”; and “Psychosocial diseases, discrimination and challenges of transgender sex workers”. Conclusion: the health vulnerabilities experienced by transgender sex workers are marked by discrimination, social exclusion, stigma, incarceration contexts, physical, psychological and sexual violence and use of illegal substances and alcohol, in addition to difficulties in accessing essential services The integrative review study was developed in six stages: identification of the theme and guiding question; definition of inclusion and exclusion criteria; definition of the information to be extracted from the selected studies; evaluation of the studies included in the integrative review; interpretation of the results; and knowledge synthesis 14–15 .


INTRODUCTION
Health vulnerability analyses emerged in the North American context in the early 1990s, in studies on the political responses to the epidemic caused by the Human Immunodeficiency Virus (HIV) and the Acquired Immunodeficiency Syndrome (AIDS) 1 . This perspective was opposed to the epidemiological analyses of the HIV/AIDS epidemic that focused on the risk factors and risk groups 2 . Consequently, vulnerability analyses were initiated from an understanding of the totality and complexity that considered the individuals, although contextualizing them based on their social relationships and their relations with the State [3][4] .
In its origin, the vulnerability category is designated to groups or individuals who are weakened, either legally or politically, in the promotion, protection and/or guarantee of their citizenship rights 5 . Vulnerability is taken as a condition or situation that intertwines structural relations of domination or injurious forms of formation of these identities 6 . Thus, it is understood that vulnerability analyses are powerful analytical tools for understanding the case of certain social groups, such as that of transgender people 1⁕ .
The term trans people designates a set of subjects whose gender identities exert tension on the sex-gender-desire unity, typical of the cis-heteronormative logic 7 . It is evidenced that approximately 0.4% to 1.3% of the population over 15 years of age does not identify with the gender identity attributed at birth 8 .
Trans people have historically been subjected to relations of power and domination which, at the same time that they undergo processes of invisibilization, take them as abject beings. Abjection makes it impossible for these people to be intelligible from their gender performances, since they break with the hegemonic logic. In a society in which the relationships and the condition of humanity of the subjects go through the sifting of the genification processes, trans people can experience a set of vulnerabilities in their daily lives, notably those who are sex workers 8 . Experiences of physical, verbal, sexual and psychological violence, hate crimes, torture, exposure to Sexually Transmitted Infections (STIs) and greater susceptibility to the use of psychoactive substances with psychological outcomes of depression and suicide are identified. Thus, the mediatization and visibility of how the power structures -socially and historically imbricated -act on the bodies and lives that "do not matter" can contribute to the promotion and enhancement of the debate among managers, health professionals and civil society, in addition to strengthening public policies aimed at this population in Brazil, such as the Comprehensive Health Policy for Lesbians, Gays, Bisexuals and Transgenders (LGBT+) 9 .
There is evidence that trans people have poor social and community networks; they have few opportunities for formal employment, in addition to reports of transphobia that directly and indirectly interfere in the socioeconomic relationships [10][11] . Such a situation is even expressed in the low life expectancy of these individuals: 35 years old 8,12 . In addition to this, it is observed that there is a higher rate of transvestites and transsexual women who engage in sex work as a means of survival 13 . Thus, the objective was to identify the health vulnerabilities experienced by transgender sex workers. 1 ⁕ Recognizing sexual and gender diversity and trying to encompass greater representativeness when discussing the self-identification categories, during the study, we will use the term "trans people" to refer to all transgender individuals, signaling the specific identities (trans men, transvestites, trans women or non-binary people) where relevant.

METHOD
The integrative review study was developed in six stages: identification of the theme and guiding question; definition of inclusion and exclusion criteria; definition of the information to be extracted from the selected studies; evaluation of the studies included in the integrative review; interpretation of the results; and knowledge synthesis [14][15] .
Initially, the theme and guiding question were identified by means of the PICo strategy 16  Subsequently, sampling was established with the definition of the inclusion and exclusion criteria: the materials included were original articles, with no time limit for the searches, published in any language, and related to the guiding question. Duplicate articles, counted once, were excluded, as well as those that addressed transgender and cisgender people in the same study without presenting the results separately; those that addressed trans people who are not sex workers; review articles; and those coming from the gray literature without scientific publishing.
The search for the articles was carried out in July 2020 through the system of the Central Library of Universidade de São Paulo and the CAPES journal, which provided access to the main databases: PubMed Central, Web of Science, SCOPUS, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Índice Bibliográfico Español en Ciencias de la Salud (IBECS) and Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS). A search strategy was used, adapted for each database according to their recognition specificities, as well as their keywords and their entry terms separated by Boolean operators OR to distinguish them and AND to associate them, in order to integrate and direct the maximum number of studies on the theme, according to Chart 1. LILACS, IBECS "Pessoas transgênero" OR "Pessoa trans" OR "Pessoas transexuais" OR "Transexual" OR "Transgênero" OR "Transgêneros" OR "personas transgénero" OR "transgender persons" OR "transgenders" OR "Person, transgender" OR "Transsexual Persons" AND "Vulnerabilidade em Saúde" OR "Vulnerabilidad en Salud" OR "Health Vulnerability" AND "Profissionais do sexo" OR "Trabajadores Sexuales" OR "Sex Workers" OR "Sex Industry" OR "Prostitution"

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In the next phase, the studies were categorized the data to be extracted were defined: after the studies were located, the results were exported to the Zotero bibliographic manager software, in order to identify and exclude duplicates. Subsequently, these were transferred to the Rayyan QCRI online platform 17 , where two independent reviewers read the titles and abstracts. When necessary, a third examiner was introduced in the selection process to settle the disagreements 18 .
Then, the subsequent stages were evaluation of the studies included with full reading of the selected studies, critical analysis and synthesis of the review results. Data extraction was obtained from a validated methodological form [19][20] , consisting of the following variables: identification of the original article, year of publication, country, methodological characteristics of the study; study sample, assessment of methodological rigor, main results, limitations and conclusions.
The level of evidence was assessed based on the proposal by Melnyk and Fineout-Overholt: 1-the evidence is the result of a systematic review, meta-analysis or clinical guidelines from systematic reviews of randomized and controlled trials; 2-evidence of at least one randomized controlled clinical trial; 3-evidence derived from well-designed clinical trials without randomization; 4-evidence from a well-designed cohort and case-control studies; 5-evidence presented from systematic reviews, descriptive and qualitative studies; 6-evidence from a single descriptive or qualitative study; 7-evidence derived from the opinion of authorities and/or experts committee opinion 21 .
In the phase of interpretation of the results, the articles included in the final sample were analyzed in a qualitative manner, based on thematic analysis 22 , which enabled categorization into 4 classes: "Knowledge, prevention and exposure to STIs in sex work"; "Use (and abuse) of illegal substances and alcohol"; "The social and structural dimension of vulnerabilities: from weakened support networks to violence reproduced against dissident bodies"; and "Psychosocial diseases, discrimination and challenges of transgender sex workers". The classes were validated by the research group based on the confrontation of theoretical knowledge, expertise and solid experience of the researchers in this type of analysis. It is noteworthy that the pre-formulated categories were previously presented to the group in question. The descriptive data of the quantitative studies were considered in the categorization of the classes.
The results, screening and selection process were presented using a flowchart in accordance with the recommendations of the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 23 and also by means of charts and in a descriptive way in order to synthesize and foster discussion on health vulnerabilities of transgender sex workers.

RESULTS
A total of 547 primary articles were identified and 34 articles were included after the selection process. The selection stages are described in Figure 1.
A total of 547 articles were obtained in the preliminary search and selection process in the databases, with 34 (100%) being included in this review, coming from research studies conducted in the United States of America (USA) -8 (23.5%); Canada -3 (8.8%); Argentina, Dominican Republic, Peru, China, Thailand, Pakistan -2 (5.8%) and Malaysia, Uruguay, Jamaica, South Africa, Brazil, Turkey, India, Holland, Puerto Rico, Guatemala and Mexico -1 (3%). All the studies (100%) are in English. As for the original databases, articles were indexed in PubMed, 32.3% (n=11); Scopus, 41.2% (n=14); Web of Science, 23.5 (n=8); and Lilacs. 3% (n=1). The description of the articles included is in Chart 2 and the thematic classes and the synthesis of health vulnerabilities in Chart 3.

Thematic Categorization Synthesis of the health vulnerabilities of transgender sex workers
Knowledge, prevention and exposure to STIs in sex work The following was revealed: lack of knowledge about the transmission of the HIV virus and the fragile knowledge about the identification of signs and symptoms of some STIs, such as HPV warts. "Sexual agreements" favor low adherence to condom use. The performance of anal sexual practice (insertive and receptive) and ejaculation in the mouth without a condom and how the feminization of transsexual women can influence the use or not of the condom were identified. It was also possible to evidence high prevalence values of HIV, Hepatitis B and syphilis, in addition to the high-risk genotypes of HPV 9,13,26,[29][30][33][34][35][36][37]41,43,[45][46][47]53 .
Use (and abuse) of illegal substances and/or alcohol The use of drugs such as cocaine was identified, in addition to injectable and inhalation drugs during sex work. There are reports of excessive alcohol use, professional practice under the influence of alcohol and combined use of alcohol and drugs during and/or before the sexual practice, describing that "physical work is easier" 10,24,35,[42][43]47,[50][51][52] .

Thematic Categorization Synthesis of the health vulnerabilities of transgender sex workers
The social and structural dimension of vulnerabilities: from weakened support networks to violence reproduced against dissident bodies Economic and interpersonal adversities stand out, a history of home evictions, weak support networks and difficulties in employment due to gender, in addition to the exclusion that restricts access to social spaces. Insertion in sex work is considered a "norm" for young transgender women due to prejudice and difficulties in the formal job market, making it possible to identify that the population under 36 years of age was more involved in sex work. Involvement in sex work is often due to survival needs. The context of violence and harassment against transgender sex workers emerged, as well as how this prejudice is shaped by the socio-structural context, in addition to the incarceration and criminalization scenarios. In general, vulnerability is influenced by the social context and stigma, as well as access to scarce support networks and lack of support in terms of health and social programs 10

Knowledge, prevention and exposure to STIs in sex work
The health vulnerabilities of transgender sex workers identified in this study are located in several contexts of professional work which, analyzed from a macrosocial perspective, alludes to concepts such as the quality of information about self-care, the ability to incorporate preventive practices in daily life, and the level of concerns that contribute to exposure to or protection from illness 49 .
The risks of illness in the exposure of sex work are recognized due to the social conditions imposed by violence, prostitution, and use of drugs and alcohol 50 . It was possible to identify how the negotiation of the sex work prices aiming at sexual practices without a condom, in addition to the fulfillment of sexual desires related to fetishization of the body and the exploitation of people considered abject 39 , result in sexual commercialization associated with physical and psychological aggression to the detriment of health and lives that "do not matter" 7,30,41 .
Ignorance of the risks and of certain diseases may be involved, in some scenarios, with the denial of access to education and to the socioeconomic status that conditions trans people to disinformation regarding the transmission and infection by several STIs. It is possible to observe that transgender sex workers are at a higher risk of being infected by HIV, in addition to the estimate that 27.3% of the transgender sex workers worldwide have HIV 55-57 . Logie et al (2020) suggest that trans women who are sex workers have nine times higher rates of HIV infections compared to trans women who are not sex workers 10,[13][14]37,[39][40] .
In a study carried out in Malaysia, it is observed that 28.3% of the transgender sex workers have syphilis, as well as significant rates of gonorrhea. All of these data suggest that misinformation can be linked, to some extent, with the infection and transmission of some of these diseases, such as HIV, syphilis and gonorrhea 43 . In a study carried out in Portugal with transvestites who are sex workers, it was observed in an ethnography that knowledge about the prevention of HIV and of other STIs was permeated by non-scientific and common sense knowledge, such as ointments, receiving Chart 3 -Cont.

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oral sex without a condom, using "hot baths" or unprotected sexual practices when the client was physically fit 58 .
It was observed that anal and oral sex with ejaculation in the mouth proved to be a routine practice in the daily life of the target population, thus constituting relevant risk factors, motivating these practices by the clients' "eccentric" desires 36,38 . Infection by HPV, for example, can be the result of sexual practices with multiple partners, of the failure to identify anal warts and of the practice of anal sex without a condom, factors that are linked to denial and to the difficulty of access to education and health. In addition to this, various studies were found in which there is an association and evidence of the prevalence of HIV with transgender sex workers; however, this population is also exposed to syphilis and chlamydia, showing the need for articulation not only in the prevention of HIV/AIDS but also of other STIs 31,[36][37][38] .
Vulnerabilizing relationships permeate the lives of transgender individuals and impact on the health-disease process. In several contexts, the successful experiences result from activism in the face of these people's social and health difficulties; however, they are still insufficient and demand the participation of the social actors in the fight against transphobia, in the defense of life and in solidarity. Nursing plays a plural role in care; consequently, nurses can provide services in a singular manner, listen to and actively participate in the health promotion actions and in the prevention of diseases and health problems, offer basic and specialized assistance in an interdisciplinary fashion and with inclusion of the social movements in decision-making and permanent education spaces.

Use (and abuse) of illegal substances and/or alcohol
The night experience of transgender people in places of prostitution was sometimes associated with the use and abuse of legal and illegal drugs offered by clients and socialized, occasionally, by the professionals. It is estimated that 77% of these individuals use drugs, either due to client imposition or to addiction 31,40 . It is stated that drug use is often initiated since leaving the parents' home and remains in the daily lives of trans people, especially in the prostitution spaces, which can culminate in contexts of incarceration, criminalization and violence 40 .
It can be inferred that experiencing certain contexts of the sexual profession enhances the use and association of psychoactive substances in sex work or outside of it, even allowing for the commercialization of these substances such as cocaine and injectable drugs. The association of the use of illicit drugs in sex work is also reported, showing itself as one of the reasons for non-adherence to condoms and as a way to "escape" from the reality that produces contexts of distress 40,43 . The use of psychoactive substances in sex work spaces is also characterized by the ease of access in the sexual practice with the client or due to addiction 46 .
Both the consumption of alcoholic beverages and illicit drugs was shown to be intense in the studies identified since, in some way, it is part of the daily routine of trans sex workers. Another factor to be considered is the associated use of alcohol and illicit drugs, requiring guidelines on the risks of this combination, for example: the harmful effects caused by the simultaneous use of crack and alcohol. However, the importance of not associating the experiences and experiences of trans people with the use of drugs is emphasized, given that such process reasserts the prejudice that is based on the structural relations of power, the stigma, and the negative representations of these people present in society 59 .
The importance of the role of managers and health professionals in assisting trans sex workers who use and abuse illicit drugs is also emphasized. Free of value judgments, the support provided by these trained professionals can enable the creation of a network of actions aimed, above all, at screening, discussion of harm reduction, rehabilitation and prevention of complications.

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The social and structural dimension of vulnerabilities: from weakened support networks to violence reproduced against dissident bodies The recognition, by the health sector, of the importance of identifying the influence of macrosocial processes on the lives of people dissenting from the norm takes place based on the consideration and interaction of the contexts of the social actors in vulnerabilizing situations. However, this recognition is not, by itself, sufficient to resolve unequal contexts and social injustices, as is the case with trans sex workers. In the family network itself, for example, the population in question is the target of physical, verbal and psychological violence 10,38 where they cannot express their gender identity, resorting to friends or colleagues who can assist in this phase 38,52 .
The family network is the main pillar of affection and support and the denial of this base weakens the protection alliances, culminating in the expulsion of transgender youths from their homes. When that link weakens, trans people hardly have access to school and other social services, being forced to live on the street and to initiate strategies that can assist in their survival 26,29 .
The survival context can be linked to transphobia, which impacts on the exercise of the right to citizenship of transgender sex workers, guaranteed by laws and advocated worldwide 12,15,25,27 . Social exclusion is configured as a complex process and grounded on material and political dimensions, a way that involves people and their relationships with each other, being asserted from different perspectives: cultural and ethnic, economic, sexual, gender and pathological 44 . in addition to this, it is observed that the gender relationship of transvestites and/or trans women with society -and here the power structures and hierarchies taken from the logic of heterosexual and cisgender hegemony are mentioned -will, to this extent, enhance not only social exclusion, but an entire chain of inferiorization, even evidencing problems such as violence and the experience of vulnerable contexts 60 .
The association between stigma and social exclusion results in violence that impacts on the life expectancy of trans people, which does not exceed 35 years old 12 . In the TGEU report, released in 2017, the following is observed: 11% of the transgender people murdered between January 1 st , 2008 and December 31 st , 2017 were under the age of 20; 46% were between 20 and 29 years old; 29%, between 30 and 39 years old; 11%, between 40 and 49 years old; 3%, between 50 and 59 years; and 1% was over 60 years old 8,16 .
What is shaped in the social thinking of the figure of transsexual women, for example, is situated in the common sense of social breakdown, in which trans people and the prostitution scene are linked, in addition to poverty, incarceration and trafficking. This representation emerges from a system that has cis-heterosexuality as a device for the production of distress and that locates people dissenting from the norm in a social and existence periphery. It is necessary to understand that the vulnerabilities in this population are not only in the access to the public policies, but to education, leisure, work and their right to exercise their citizenship. Therefore, the health vulnerabilities of transgender sex workers are due not only to the form of the risks that sex work imposes, but also to the strengthening of structural processes that legitimize "which lives matter". In addition to this, not only the individual aspects within the context of vulnerability should be considered, as this would be simplistic and inductive to blaming the subjects.

Psychosocial diseases, discrimination and challenges of transgender sex workers
When discussing the existence of trans people in society, this is permeated by a set of mechanisms that have social control as a way to regulate actions instituted against people who exert tension on the norm, being characterized by operations that will favor the experience of social stigmas and discrimination 61 .

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Discrimination against transgender sex workers is present in different spheres: it occurs in the family, resulting in expulsion of the family; in formal institutions, such as school and work, corroborating school evasion and entry into precarious activities and linked to subordination, with prostitution being the most recurrent practice; in access to the health services, which does not meet the demands of this population, as well as it does not respect the use of the social name and has services intertwined in coercive and transphobic practices [62][63] . Such situations produce contexts that will potentiate the emergence of psychosocial diseases and reassert a location in society that involves the system of social stratification and hierarchy 64 .
The social, economic and psychological context in which transgender sex workers are inserted is, within the macrosocial context to which these individuals are configured, situated in a social map perspective 64 . Thus, it is pointed out that social discrimination can result in illness and distress, with the possibility of presenting itself in different types of violence. The stigmatization experiences suffered by this population contribute to the emergence of mental and psychological distress in trans people. Depression, anxiety, mood disorders and self-inflicted violence were identified in people who suffer discrimination, being accentuated when the reason for prejudice is associated with gender issues [61][62] .
Therefore, discrimination is materialized by social exclusion, violence and stigma, as well as by the stereotypes reproduced by society, by the family and even by the very clients of the professionals. The psychological state is weakened due to the rejection and insecurity experienced and influenced by such a context of sex work, leading to suicidal 32 and depressive ideas, as shown by a study from Argentina 65 , in which it is made explicit that at least one third of the participating sex workers reported attempted suicide resulting from the social context experienced by the population in question 62 .
The implications of the results evidenced can enhance the discussion about the vulnerable processes and how these structures act in the context of trans sex workers. Such results can also aid the understanding by health professionals, managers and the Nursing team to comprehend and develop strategies that may be able to dialog with the needs of transgender sex workers and that understand the socio-cultural dynamics established from of the way of life, promoting problematizations and dialogs that favor the reception, access and resolution of the demands of the target population.
Thematic categorization performed in the analysis is pointed out as a study limitation, since the same study could fall into different categories, but not at the same predominance levels. Thus, it was decided to allocate the study to the thematic classes that were related and which not necessarily addressed only a specific theme. In addition to this, the chosen databases are highlighted, which may have limited, to some extent, the identification of other studies and the predominant levels of evidence VI and V of the studies included in the final sample.

CONCLUSION
The analyzed publications showed that the health vulnerabilities experienced by transgender sex workers are marked by discrimination, social exclusion and stigma, linked to gender dissent and enhanced by sex work. In addition to this, the following were identified as social inequalities: difficulty in accessing essential services such as health, education and leisure; incarceration; and neglect to provide health services, resulting from processes based on structures of social power and regulation. In this aspect, it is possible to reflect on the need for articulation of processes that can give visibility to the demands and existence of these people, for the recognition of their specificities in different spheres; as well as on the need for an equitable, holistic service that understands the social and historical context without inferring value judgments or reproducing prejudices and violence.
In addition to this, knowledge gaps were identified, even in the context of trans sex workers, such as the absence of studies that addressed aspects outside the logic centered solely on HIV infection, but also by other contexts that can produce vulnerability scenarios and that will, to some 12/17 extent, enhance their entry into the sex work market. Therefore, it is suggested to formulate and conduct empirical studies -either in Health Sciences or in Human Sciences -that may foster debates on this gap identified.