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

Objective: To describe and analyze the national and international scientific production on Nursing care for the transgender or gender-variance population. Method: Integrative review of the literature, conducted throughout the Virtual Health Library, Cumulative Index to Nursing and Allied Health Literature, Public Medline and Web of Science databases, without pre-established periods of time and using the descriptors “Transgender AND ‘Nursing Assistance’” and “Transgender AND ‘Nursing care’”. Results: We included 11 articles, published between 2005 and 2016, broadly North American with only one Brazilian, so categorized: IFragility in the care of transgender people; II Health of the transgender population: general and specific demands; IIIPublic health policies for transgender people. Transgender people have not found yet answers to their health demands; they are victims of prejudices and violence in services and seek care in extreme cases of sickness. Final considerations: Understanding their needs is primordial to build knowledge and practices that support nursing care. Descriptors: Transgender People; Gender Identity; Nursing Care; Comprehensive Health Care; Public Health Policies. RESUMEN Objetivo: Describir y analizar la producción científica nacional e internacional sobre cuidado de enfermería a la población trans y/o con variabilidad de género. Método: La revisión de la literatura, realizada en las bases de datos Biblioteca Virtual en Salud, Cumulative Index to Nursing and Allied Health Literature, Public Medline y Web of Science, sin recorte temporal preestablecido y utilizando los descriptores “Transgénero AND ‘Cuidado de Enfermería’” y “Transgender AND ‘Nursing care’”. Resultados: Se incluyeron 11 artículos, publicados entre 2005 y 2016, predominantemente norteamericanos, apenas un brasileño, así categorizados: IFragilidades en el cuidado a las personas trans; IISalud de la población trans: demandas generales y específicas; III. Políticas públicas de salud a las personas trans. Las personas trans no han encontrado respuestas a sus demandas de salud, son víctimas de preconceptos y violencias en los servicios y buscan atención en casos extremos de enfermedad. Consideraciones finales: Comprender sus necesidades es imprescindible para construir saberes y prácticas que fundamenten el cuidado de Enfermería. Descriptores: Personas Transgénero; Identidad de Género; Cuidados de Enfermería; Cuidado Integral a la Salud; Políticas Públicas de Salud. 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 Cuidado de Enfermería a la población trans: géneros en la perspectiva de la práctica professional REVISÃO Danilo Fagundes RosaI ORCID: 0000-0003-2399-0863 Marcos Vinícius de Freitas CarvalhoI ORCID: 0000-0003-4633-413X Nayla Rodrigues PereiraI ORCID: 0000-0002-5049-0752 Natalia Tenore RochaI ORCID: 0000-0002-4482-3143 Vanessa Ribeiro NevesI ORCID: 0000-0002-2226-4723 Anderson da Silva RosaI ORCID: 0000-0003-4683-3107 I Universidade Federal de São Paulo, Escola Paulista de Enfermagem. São Paulo, Brasil. Como citar este artigo: Rosa DF, Carvalho MVF, Pereira NR, Rocha NT, Neves VR, Rosa AS. Nursing Care for the transgender population: genders from the perspective of professional practice. Rev Bras Enferm [Internet]. 2019;72(Suppl 1):299-306. [ Thematic Issue: Work and Management in Nursing]. DOI: http://dx.doi.org/10.1590/0034-7167-2017-0644 Autor Correspondente: Vanessa Ribeiro Neves E-mail: vanessa.neves@unifesp.br Submissão: 04-10-2017 Aprovação: 12-12-2017


INTRODUCTION
Gender is considered as a category, a social marker in which attitudes, expectations and behaviors are constructed by which society defines the values of reference and the standard of normality, valid in a given time (1) .The expected behaviors for the people, the so-called gender roles, are not inherent to the gender of birth; they are shaped by social, economic, religious and cultural demands (2) .Already the gender identity arises from the intrinsic perception of a person being a man, a woman, some alternative of gender or the combination of them, while the expression of gender is constituted by the manifestation of gender identity from physical appearance, clothes, gestures, manner of speaking to behavior patterns in interaction with other people (3)(4) .
The term "transgender" has been used to refer to all people with gender and "cisgender" variance to refer to those that correspond between the sexual designation at birth and the performed gender identity.Transgender calls a diverse group of people whose gender identities differ, to varying degrees, from the sex with which they were assigned at birth.Such definitions are loaded with ideologies, their limits are inaccurate, and are constantly changing (5) .
It is yet not possible to quantify in a precise manner the incidence of transsexuality or gender variance in the world, given the variance of gendered cultural conceptions according to place, and historical and social context.A study based on historical reports has averaged one transgender for every 45,000 people and has identified, in recent publications, an increase of this number by 10 to 100 times.It has also stressed that proper quantification is essential for the creation of policies and strategies aimed at the health of this population (6) .
What is now agreed as a transsexual person is the result of a historical context where transsexuality was considered as a pathology, which began in the 1900s and persists to the present day.Even though transsexuality is not listed, it is unique and transcends medical diagnoses (7) .In Brazil, even today the access to specialized health care has as its characteristics the use of the ICD 10 (International Classification of Diseases), F64-Gender Identity Disorders, and the need for multiprofessional follow-up to access certain procedures, such as sex reassignment surgeries (8) .
The concepts of man and woman still have a restrictive effect, despite the need to understand gender variance as a human and natural phenomenon, free from the stigmatization and pathological character that have historically been attributed to it.There is a pressing need for updating and raising the awareness of the nurse regarding sexual and gender diversity, since care for the transgender population still occurs in a logic of presumed heterosexuality, discrimination and difficulty in creating bonds (9)(10) .In addition, Brazil leads the ranking of countries that, proportionately, kill more transgender people in the world (11) ; and discrimination is present in health care practices and institutional relations in health services (12) .
Transgender or gender-variance people have specific health needs and require services that offer a multiprofessional approach, care for mental health, hormonal therapies and various surgeries (13) .In addition, they share common needs with anyone, such as the adoption of healthy living habits, disease prevention and surveillance, treatment and rehabilitation (14) .
In this context, nursing professionals play an important role in the care for transgender people and with gender variance.The nursing team is massively present in health care settings, and is often a reference from the first to the last contact in outpatient and hospital services, in addition to carrying out activities to promote health and prevent diseases at various contexts.Such professionals should be prepared to exercise ethical and quality care, respecting sexual diversity, gender and other characteristics of the people, and developing, in their specific core of knowledge and practices, the necessary skills to serve transgender people (15) .Thus, it is fundamental to expand the scientific knowledge about nursing care for the transgender people.This study intends to offer an overview of the national and international scientific production on nursing care provided to the trans or gender-variance population.Compared to other knowledge, the production of this knowledge is still incipient and presents gaps that can be converted into opportunities to carry out research on the subject.In addition, the description and analysis of this production can support new studies and the qualification of professional nursing practice in this field, little explored until then.

OBJECTIVE
We aim at describing and analyzing the national and international scientific production on nursing care for the trans or gender-variance population.

METHOD
This is an integrative review of the literature.It is a method that, in a systematic, orderly and comprehensive manner, allows synthesizing research results, obtaining information about a certain subject, in order to provide an overview of the knowledge produced, to identify gaps and to make feasible the analysis of criticism by using and incorporating of this information by professionals in practice settings (16)(17) .The present study was elaborated through six steps: 1. identification of the theme and selection of the hypothesis or question of research; 2. establishment of inclusion and exclusion criteria of studies/sampling or search in the literature; 3. definition of the information to be extracted from the selected studies/categorization of the studies; 4. evaluation of included studies; 5. interpretation of results; 6. presentation of knowledge review/synthesis (17) .
To answer the research question "What is the national and international scientific production on nursing care for the transgender people?" the Virtual Health Library (VHL), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Public Medline (PubMed) and Web of Science (WoS) databases were consulted in May 2017, using the descriptors "Transgender" and "Nursing Assistance" from the Health Sciences Descriptors (DeCS), and their correspondents in the English language "Transgender" and "Nursing Care", from Medical Subject Headings (MeSH).These terms were combined using the Boolean operator AND in both languages.
As for the selection criteria of the publications, it was established that articles would be included in the Portuguese, English and Spanish languages, which were available electronically and approached the topic under study.Duplicate articles and those that did not deal directly with the proposed topic or whose focus was not on the transgender population were excluded.We also chose not to establish a period of time for the searches, in order to increase the scope of the research.
Initially, 42 publications were found in the VHL, 22 in CINAHL, 21 in Pubmed and 10 in WoS, totaling 95 records.The analysis, performed through the reading of the records by the authors, led to the selection of 11 articles, as shown in Figure 1.
Selected articles, variables, title, author, year of publication, country of origin, journal title, objectives, main findings, and conclusions were organized into a Microsoft Office Excel 2010® software spreadsheet, which was the study database.The articles were then grouped by similarity and theme relevance, originating categories that were presented, analyzed and discussed in light of the available literature on the theme.

RESULTS
The 11 selected studies were published between August 2005 and October 2016, with one per year in 2005 (18) , 2010 (19) , 2011 (20) , 2012 (21) and 2013 (22) , and two in 2014 (23 -24) , 2015 (25)(26) and 2016 (27- 28) .We identified 19 authors and none of them wrote more than one of the articles found.Ten journals published these articles, with emphasis on the English journal Nursing Standard, which included two of these studies (23,28) .Six countries came from the United States (18)(19)(20)(21)(22)25) , two from the United Kingdom (23,28) , two from Canada (24,27) and one from Brazil (26) with predominance of the English language, expressed in ten articles (18)(19)(20)(21)(22)(23)(24)(25)(27)(28) , and the presence of the Portuguese language in a publication (26) .No articles were found in the Spanish language.The objectives, main results and conclusions of these researches can be discussed in Chart 1. The incease in content related to gender diversity in nursing curricula assists in the inclusion and acceptance of gender diversity in professional practice.
Transgender identity and health care Implications for psychosocial and physical evaluation (20) Alegria, 2011 USA

Journal of the American Academy of Nurse Practitioners
To instruct nurses about the definition and scope of transgender, social influences on transgender people and health care for them.
It presents barriers built by patients who are afraid of being ridiculed by health professionals, and by care providers who are not aware of the proper way to care for these patients, in which interfere with the care of transgender people.
Transsexual people remain marginalized and may remain reclusive, with the possibility of negative psychological and psychosocial consequences.To offer holistic care, Nursing professionals need to be aware of the influence of the social context on the lives of transgender people and their health needs.
Providing culturally proficient care for transgender (25) Wichinski, 2015 USA Nursing To discuss myths and conceptions about transgender individuals and address appropriate terminologies to improve nursing care.
Even with a high demand for care, transgender people are more impacted by factors that prevent access to health care.Nurses are responsible for providing a safe and biased environment.
Many myths arise from a lack of understanding and instruction about the transgender population, and nurses must understand all the nuances of transgender people in order to reduce their stigma.
Question of gender (23) Deschamps, 2014 United Kingdom Nursing Standard To discuss the need for instruction for nurses and physicians about the transgender population.
About 60% of patients felt the need for better instruction of health professionals regarding transgenerism.
It is necessary to raise standards of care for the transgender population, so that they can be welcomed and integrated into health services.Most health professionals do not adequately serve transgender people, and often end up psychologically assaulting their patient.
It is necessary to improve the training of health professionals to meet the transgender population, so that caregivers will know how to deal with and respect this group.
Transgender women and the Gender Reassignment Process: subjection experiences, suffering and pleasure in body adaptation (26) Petrya, 2015 Brazil Revista Gaúcha de Enfermagem To understand the experiences of transsexual women regarding hormone therapy and sex reassignment surgery, which constitute the Transsexual Process.
Within the process of transformation to construct the female body, there are several behavioral, medicinal and surgical factors that can subject the person to the pleasures and sufferings.
The discussion that involves the Transsexual Process brings Nursing subsidies regarding the corporal modifications experienced by transsexual women.
Creating environments of care with transgender communities (19) Thornhill et al., 2010 USA

Journal of the association of nurses in AIDS Care
To know the needs of transgender people about the HIV perspective and analyzing how links between multiprofessional team and transgender patients interfere with compliance with the treatment and assimilation of HIV information.
Transgender people and community health nurses together have led to a greater understanding of HIV prevention and treatment needs, improved individual health outcomes and recognition of the need for institutional change to address this population.
Best practices may make transgender-specific care services less necessary because all Primary Care providers and health institutions would be empowered to care for this population.In order to respond to persistent health disparities experienced by transgender individuals, establishing strategic partnerships with community members is an essential tool.

Female-to-Male Transmasculine Adult
Health A Mixed-Methods Community-Based Needs Assessment (22) Reisner et al., 2013 USA

Journal of the American Psychiatric Nurses Association
To identify the health conditions and needs perceived by adult transgender men.
There were four groups of health indicators: depression, alcohol use, smoking, physical inactivity and overweight.In addition to personal health needs, community needs and resilience and protection factors were identified.Transphobia was perceived both in care and in prevention actions.
The findings filled an important gap in the health of the male transgender community and pointed to the need for public health efforts that holistically addressed concomitant health problems.
Transgender Patients Implications for Emergency Department Policy and Practice (18)

DISCUSSION
As of 2010, there is an annual recurrence of publications on nursing care for the transgender people, but the incipient volume of articles indicates the need to devise and disseminate more studies on the subject, especially in Brazil, the country of origin of only one of the eleven articles found.USA researchers were the authors of most studies, as was the predominance of the English language, which indicates the importance of the domain of this language by professionals who wish to acquire or update their theoretical knowledge on the subject.
With the reading and organization of the information of the selected studies, it was possible to categorize them in three themes: I -Fragility in care for transgender people; II -Transgender population health: general and specific demands; and III -Public health policies for transgender people.
Nursing Care for the transgender population: genders from the perspective of professional practice Rosa DF, Carvalho MVF, Pereira NR, Rocha NT, Neves VR, Rosa AS.

I -Fragility in care for transgender people
Transgenderism is present in different historical, geographical and social contexts.There have always been people challenging and confronting the social roles imposed by the biological gender, but nowadays this group is gradually earning space in society and thus health professionals are dealing more often with trans and/or gender-based patients (12) .The creation of normative barriers (27,29) and the lack of knowledge about the transgender population on the part of the nurses entails the invisibility of the health needs of this population and also causes damages to the nursing care that must be provided to it (20,24,30) .
In order to offer the transgender person complete care, it is necessary to know their social context and their health needs (24)(25) , as well as other intersectionalities that influence their life (31) .The team of professionals who work in the hospital needs to be better prepared (23,32) , as it has the responsibility of providing a safe environment free of prejudice, understanding the nuances involving gender identity and reducing its stigmatization (25) .However, it has been observed that a minority of nurses feel able to meet the needs of these people (28) .
There is a lack of instruction, knowledge and competence in nurses' dialogue with transgender people and to deal with gender diversity in the professional practice (20)(21)(23)(24)(25)27,32) , and it is necessary to raise the standards of care (23) , which will only be achieved with the of content related to gender diversity in nursing curricula (27,(33)(34) . It is imprative for nurses and other health professionals to know the needs of transgender people (35) , to listen to what they have to say, to share knowledge about their own understandings, perceptions of care, and what is health for them and thus provide more appropriate care for this population.
In addition, in view of the increasing movement of standardization of nursing care, attention should be paid to the risks of hardening professional practice, the reproduction of prejudices and naturalized violence in society, and the assumption of homogenizing profiles that exclude diversity of gender, religion, habits, customs, etc.In short, the challenge is to maintain and extend the benefits of standardization, but without losing the plasticity of adapting to the dynamic process of social transformation without excluding any possibility of living.

II -Transgender population health: general and specific demands
Transgender people are often kept out of traditional means of support, such as family, school, health services, religious community and local community, because of prejudices, mistreatment and violence (15,36) .Many transgender people report having difficulties with the service of public and private health institutions, as there is a moral judgment evidenced by the resistance of professionals to use social names, as well as gestures, glances and discriminatory statements that come from those who should be offering health care to them (37) .
The good service to the user must come from all the employees and service providers of the health institution, in order to assure a respectful and welcoming environment (15) .However, many professionals have a negative attitude towards transgender people, creating a hostile environment and offering discriminatory and prejudiced care, far from the necessary empathy (35) .Such actions can be traumatic (21) and make many transsexuals only seek care services in extreme cases of sickness (27) .
It is necessary to improve the training of health professionals to care for the transgender population, which is the first step to deal respectfully with this group that is so vulnerable (32,34,38) .Thus, it would be possible to deconstruct the prejudices and misunderstandings responsible for the inadequate and often violent treatment that is provided to these people (21) .
The transition process carried out by the transgender person is complex and can be mitigated or worsened by intersectionality with socioeconomic conditions, schooling, race and social ties, as well as barriers to access health, which requires resilience and determination of those who decide to face it (31,39) .For the construction of a body that asserts its gender, it may be necessary to adjust behavior, posture, voice, use of hormones, face surgical complications, among other factors that may inflict pleasures and suffering on those who undergo these changes.Such paths are as diverse as the possibilities of gender identity, so that the individuality of each person's transition process must be respected (40) and probably will not fit into the rigidity of "treatment" protocols.
It is important to establish bonds and empathy for the person to whom care is provided, the partnership of transgender individuals with nurses leads to a better understanding of needs (19,35,39) .In this way, the possibilities of building knowledge, solutions and practices of care and self-care that are adequate to the expectations of transgender people and health teams are expanded.
In spite of the expressive scientific production in the literature on the specific needs of transgender people, such as surgeries for sex reassignment, breast and uterine removal, reconstructive mammary plastics (including silicone prostheses), vocal folds extension for voice change, all of which are assisted by the Brazilian Unified Health System (SUS) (4) .There is a great number of people who avoid using the public health service, because they report being humiliated and ill-treated in these places and give preference to private services, where they can demand better care because they are paying directly for the desired procedures (37) .It should be noted that despite this scientific production and the range of procedures offered to transgender people, Nursing has not developed specific knowledge and skills in these areas (39) .
Besides specific health needs, there are general demands to anyone, such as the prevention of diseases due to alcoholism, overweight, smoking and physical inactivity (22) , among others.However, transgender people commonly seek other care routes than traditional health services, since they replicate violence rather than providing adequate support, which leads to unguided self-care, self-medication (37,41) , and exposure to several risks in clandestine services and practices of handling of the body.
Although health in Brazil is a universal right and duty of the State, and that the transgender population has conquered a set of laws and public policies specific to their demands (22) , there remains a need to act against discrimination in care practices and relationships institutional in health, produce knowledge and strategies to meet the demands of the transition process, and ensure, in practice, the transgender people to have full access to the health care they need (22,42) .

III -Public health policies for transgender people
Unnecessary exposures, improper care, and other situations of patient vulnerability led to a debate in the United States in 2005 about the right to quality care and the lack of policies to care for transgender people (18) .
In Brazil, only in 2009, was possible for SUS users to use their social name in care units, a right assured by the Carta dos Direitos dos Usuários da Saúde (43) .In 2011, the Ministry of Health instituted the implementation of the Política Nacional de Saúde Integral LGBT (National Policy for Comprehensive Health of LGBT people), in which gender identity and sexual orientation are considered social determinants of health, aiming at a quality and equitable treatment of LGBT people in general (4) .
It should be noted that Nursing is not part of the multiprofessional team of the ordinance 2.803/2013, which redefines and expands the Transexualization Process in Brazil (8) .This fact may be related to the results of this study, showing that Brazilian Nursing has not systematically produced knowledge and practices to act on the specificities of this population.However, in 2015, the Universidade Aberta do SUS (UNA-SUS) made available the online course "Políticas de Saúde LGBT" (LGBT Health Policies) so that health professionals, especially from the SUS, knew them and put them into practice (44) .In the first three offers, nursing professionals were the ones who sought the most (45) , which, despite coming from the largest professional category in health, may denote in training and interest in the subject.
Specifically for transgender care, the Ministry of Health published in 2016 the book "Transexualidade e Travestilidade na Saúde", which aims to contribute to the elimination of discrimination and institutional prejudice, aiming at structuring a line of care, since the Primary Care to specialized, free of discrimination at all levels of care (12) .
In 2012, the World Professional Association for Transgender Health (WPATH) published the Standards for the Health Care of Transgender and Gender-Variance People with the objective of providing a clinical orientation for health professionals to help transgender and gender-variance people to travel on safe and effective ways to achieve personal and lasting comfort with their gender identities in order to maximize their overall health, their psychological well-being and their personal fulfillment (13) .
With the knowledge of gender diversity and the application of existing norms and policies, public and private institutions providing care can reduce the negative effect of unprepared services and health professionals to deal with transgender people.In the general context, building a more inclusive, non-violent society that respects all ways of life must be based on laws and public policies, but the full achievement of such goals will only be reached when the diversity of human existence does not need to be affirmed and protected by the State, but it is a commitment of all the people who make up the nation.

Study limitations
This integrative review comprised only electronic studies in selected databases and in English, Portuguese and Spanish, which may lead to the omission of studies that consider other inclusion criteria related to the descriptors used.The choice of the descriptor, Nursing Care, was intentional and justified; however, it is possible to have knowledge about nursing care, produced in the logic of multiprofessional and interdisciplinary approaches that were not located.

Contributions to the sectors of Nursing, Health and Public Policies
The paths of technical and scientific development of Nursing need to be socially referenced.Advances in the human rights of transgender or gender-variance people, the recognition of their specific health needs, the creation of public policies to meet them, as well as the rampant indicators of prejudice, violence and discrimination, require that the area of knowledge and practices responsible to this situation.
This article presents the international scientific production on nursing care for transgender, at the same time as it reveals the importance of Brazilian Nursing to commit to this issue.Its content points to the urgency of studies on the health needs and the processes of sickness of the transgender population; the construction and systematization of care practices and self-care for specific issues; the implementation and improvement of public policies for this population; the incorporation of Nursing in the composition of the multiprofessional team for the Transsexual Process, foreseen in the Brazilian legislation; and the strengthening of the human and social sciences applied to health in the training of nursing professionals.

FINAL CONSIDERATIONS
The articles analyzed in this literature review revealed the national and international overview of nursing care for the transgender population and showed the lack of preparation of the health professionals and services to act considering the gender diversity of the users.
These publications have shown the unhappiness of transgender people with the care they have received in the health services, because they often do not find answers to the general and specific health demands that they have and are victims of the reproduction of prejudices, discrimination and violence on the part of those, who should offer care, making them only seek care in extreme cases of sickness.
The reversal of this setting will necessarily happen through Nursing, given its massive presence in services and the high degree of interaction professionals have with users.Ethical and efficient care goes beyond respect and empathy, and demands the construction of knowledge and practices capable of serving the transgender people as unique and full, without restricting them only to the dimensions of gender.
In the general context, there are recent advances with the creation of specific public policies and assurances of rights to this population in Brazil.However, much remains to be done to build a more inclusive, non-violent society that respects all possibilities of gender and life.

Figure 1 -
Figure 1 -Flowchart of the selection of publications

Chart 1 -
Distribution of studies included in the integrative review according to title, author, year, country, objective, main results and conclusion, São Paulo State, Brazil, 2017

Nursing Care for the transgender population: genders from the perspective of professional practice
Rosa DF, Carvalho MVF, Pereira NR, Rocha NT, Neves VR, Rosa AS.