Bioethical reflections on the access of transgender individuals to public health

Abstract

In Brazil, transgender individuals, those whose gender identity differs from the assigned biological sex, are marginalized by society and face difficulties in accessing the Unified Health System. This study sought to identify these difficulties by carrying out an integrative review of papers published in the SciELO, LILACS, MEDLINE, Virtual Campus for Public Health, Base de Dados de Enfermagem, and ColecionaSUS databases, in the last five years. Of the 26 articles found, only nine met the inclusion criteria. Based on their references other nine papers were included, thus totaling 18. Results point to the following difficulties encountered: hostility in care; disrespect for the social name; technical and scientific unpreparedness of professionals; difficulty of access to gender reassignment procedures; and prejudice. It is therefore of paramount importance to implement interventions to minimize segregation, and invest in further research on this topic.

Unified Health System; Transgender persons; Delivery of health care

Resumo

No Brasil os transexuais, indivíduos cuja identidade de gênero diverge do sexo biológico, são marginalizados pela sociedade e encontram dificuldades para acessar o Sistema Único de Saúde. O presente estudo buscou identificar essas dificuldades por meio de revisão integrativa de artigos publicados nos últimos cinco anos nas bases SciELO, LILACS, MEDLINE, Campus Virtual de Saúde Pública, Base de Dados de Enfermagem e ColecionaSUS. Foram obtidos 26 artigos, dos quais apenas nove satisfizeram os critérios de inclusão, e, a partir das referências destes, incluíram-se mais nove trabalhos, totalizando 18. Os resultados mostram que as dificuldades encontradas são: hostilidade no atendimento; desrespeito ao nome social; despreparo técnico-científico dos profissionais; dificuldade de acesso aos procedimentos transgenitalizadores; e preconceito. Portanto, é imprescindível aplicar intervenções para minimizar a segregação dessas pessoas, sendo necessário mais pesquisas nessa área.

Sistema Único de Saúde; Pessoas transgênero; Atenção à saúde

Resumen

En Brasil, los transexuales, individuos cuya identidad de género diverge del sexo biológico, son marginados por la sociedad y encuentran dificultades para acceder al Sistema Único de Salud. El presente estudio trató de identificar dichas dificultades por medio de la revisión integradora de artículos publicados en los últimos cinco años en las bases SciELO, LILACS, MEDLINE, Campus Virtual de Saúde Pública, Base de Dados de Enfermagem y ColecionaSUS. Se obtuvieron 26 artículos, de los cuales solo nueve cumplieron con los criterios de inclusión, y, con base en sus referencias, se incluyeron otros 9, lo que resultó en 18 trabajos. Los resultados constataron las siguientes dificultades: hostilidad en la atención; falta de respeto al nombre social; falta de preparación técnico-científica de los profesionales; dificultad de acceso a los procedimientos de transgenitalización; y prejuicio. Por lo tanto, es esencial aplicar intervenciones para minimizar la segregación de estas personas, así como para promover más investigaciones en esta área.

Sistema Unificado de Salud; Personas transgénero; Atención a la salud

Transgender individuals experience incongruence between their self-perception of gender and the one assigned at birth from biological sex, which can be manifested both socially and physically. Thus, this population is diverse, resulting in some individuals choosing to live with such incongruence, whereas others change social aspects (clothing and social name), and, still, others go through the transition process – although social stigmas discourage them from seeking health care¹ .

Until recently, the World Health Organization (WHO) listed the word “transsexualism” in its disease classification manual, which represented an idea of pathologization of transsexuality. Only in May 2019 did the WHO remove transsexuality from the International Classification of Diseases (ICD) mental illnesses list, configuring a major advance for public health and human rights² .

Despite no longer being designated as a disease by the WHO, transsexuality remains the target of much prejudice in Brazil. According to the 2019 Dossier on murders and violence against travestis and trans individuals in Brazil , published by the National Association of Travestis and Transexuals of Brazil (Antra), Brazil is the country that kills the most travestis and transsexuals in the world³ .

Thus, despite the lack of a complete impediment to the care of this population in the health field, discrimination is an important challenge to be faced. Nevertheless, social movements and new public policies contribute to the fact that in most cases prejudice is not explicit, which, even if it is not ideal, results in the provision of care that is respectful to some extent⁴ .

Gender identity discrimination is known to influence the social determination of health and the process of suffering and illness following rejection. In this sense, in view of the principles of equity, universality, and integrality, the need to create a program to welcome this public at all hierarchy levels of the Unified Health System (SUS) was perceived. Thus, the Brazilian Ministry of Health, through Ordinance 1,707/2008⁵ , established the transsexualizing process, which integrates a set of outpatient and hospital actions to welcome those who wish to undergo gender reassignment procedures.

This process, established in the context of the Brazilian Integral Health Policy for Lesbian, Gay, Bisexual and Transgender (LGBT) Individuals, aims at comprehensive care for this population, so that health services provide humanized and respectful reception, using the social name⁶ . Thus, the beginning of the care of transsexuals and travestis occurs in primary care, a stage in which the identification and subsequent referral to specialized care takes place, including consultations and specialized examinations, surgeries, medications, prostheses, and urgent care.

However, such services are concentrated in a few Brazilian states, which is contrary to the principle of universal access to health proposed by the policy and principle of SUS. According to data from the Ministry of Health⁵ , only ten health facilities are qualified for work with the transition process, concentrated in the states of Espírito Santo, Goiás, Minas Gerais, Paraná, Pernambuco, Rio de Janeiro, Rio Grande do Sul, and São Paulo.

Moreover, this population faces other difficulties in accessing primary and further levels of care: prejudice and ignorance about the use of the social name by employees of the health system, despite being a right guaranteed by law to transgender individuals⁷ ; and the need to prove one’s transgender status, since self-diagnosis is not sufficient for these individuals to access their rights⁸ .

From this perspective, it is worth noting that such obstacles corroborate the marginalization of this population and the amplification of acceptance problems resulting from stigmatization, discrimination, and violence suffered since childhood. Thus, this population is in a context of moral vulnerability that is guided by theoretical arguments derived from cultural, religious, philosophical, and even scientific traditions. Taking a critical stance on this issue, according to the principles of bioethics, is extremely challenging given the plurality of ideological aspects⁹ .

Based on data Published by the non-governmental organization Transgender Europe, Queiroga¹⁰ notes that Brazil is the most transphobic country in the world – and it should not be different in SUS. The trajectory of transgender individuals in Brazil within the public health system is surrounded by the denial of rights and omission in care. These phenomena are mainly related to the lack of training of health professionals to meet the health demands and needs of this population⁴ .

Transgender individuals face many challenges in many aspects, from personal to social. This study sought to highlight the main difficulties experienced by this population in the context of the Brazilian public health system, focusing mainly on the difficulties of access to services offered by primary care and specialized health care.

Method

This study is quantitative in nature and consisted of an integrative review of the current medical literature. To guide the research, the following question was asked: what are the difficulties faced by transgender people in accessing primary care and the transition process offered by SUS? The following databases were searched: SciELO, LILACS, MEDLINE, Virtual Campus for Public Health, Base de Dados de Enfermagem (BDENF), and ColecionaSUS.

The inclusion criteria were: 1) articles published in Portuguese with available abstracts; 2) articles published in the last five years; and 3) empirical and/or literature review studies. Articles that, even dealing with the difficulties experienced by transgender individuals, were not related to SUS or addressed it without mentioning the difficulties experienced by the target population were excluded. The following keywords, in Portuguese, extracted from the Health Sciences Descriptors, were used: “Sistema Único de Saúde,” “pessoas transgênero,” and “atenção à saúde.”

The articles found were screened by reading the abstracts, and only those that met the three inclusion criteria were analyzed in full. The selected articles were then copied from virtual libraries and organized according to the selection order. Then, each article was read in full and the data analyzed by descriptive statistics.

Results

The search in the databases found 26 articles, of which only nine met all inclusion criteria and were considered for analysis ( Figure 1 ).

Figure 1
Flowchart of the selection of studies included in the integrative review.

After selecting the nine articles, we searched their references for studies that met the established criteria, resulting in nine new texts. Table 1 shows the 18 selected papers.

Table 1
Analysis of the works on the type of research and its respective objectives

Title	Authors	Type of study	Objective
“Experiências de acesso de mulheres trans/travestis aos serviços de saúde: avanços, limites e tensões”4	Monteiro and Brigeiro	Qualitative study	Discuss the discrimination of access of trans women /travestis to the health system and their difficulties
“Dificuldades vividas por pessoas trans no acesso ao Sistema Único de Saúde”11	Rocon and collaborators	Qualitative study	Discuss the difficulties of trans people living in the metropolitan region of Vitória, Espírito Santo to access health services in SUS
“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”12	Popadiuk, Oliveira and Signorelli	Qualitative and quantitative study	Qualitatively and quantitatively study SUS and the ways of implementing the transition process in the health system
“O que esperam pessoas trans do Sistema Único de Saúde”13	Rocon and collaborators	Qualitative research	Address interviews by trans individuals about the need for body transformations and access to the health system
“Implicações bioéticas no atendimento de saúde ao público LGBTT”14	Santos and collaborators	Study design	Analyze academic publications regarding LGBTT health care actions by focusing on principialist bioethics
“Outness, stigma, and primary health care utilization among rural LGBT populations”15	Whitehead, Shaver, and Stephenson	Qualitative and quantitative study	Analyze the impact of stigma specifically for rural LGBT populations
“Addressing gaps in physician knowledge regarding transgender health and healthcare through medical education”16	McPhail, Rountree-James and Wheltter	Qualitative study	Analyze the denial of care to trans individuals due to lack of medical knowledge and transphobia
“Perceived barriers and facilitators to health care utilization in the United States for transgender people: a review of recent literature”17	Lerner and Robles	Literature review	Identify barriers to health care for trans individuals: negative experiences in the health system; lack of knowledge of the provider on identity issues and transgender health issues
Percepções de usuários transexuais sobre o cuidado na Estratégia de Saúde da Família: o desafio do reconhecimento e do rompimento da invisibilidade 18	Gomes	Master’s thesis: qualitative, descriptive, and exploratory study.	Understand the reality experienced by transgender individuals from their perceptions about the care provided to them in the family health strategy
O processo transexualizador no SUS e a saúde mental de travestis e transexuais 19	Ferreira	Term paper: exploratory research of qualitative approach.	Analyze the perception of trans patients regarding the care they receive considering the promotion of their mental health in the transition process offered by SUS
“Removing transgender identity from the classification of mental disorders: a Mexican field study for ICD-11”20	Robles and collaborators	Qualitative study	Compare the diagnostic elements proposed for gender incongruity of ICD-11, gender dysphoria of DSM-5 and transsexualism of the ICD-10 category with the self-reported experience by trans individuals
“Uso do nome social no Sistema Único de Saúde: elementos para o debate sobre a assistência prestada a travestis e transexuais”21	Silva and collaborators	Essay	Analyze the use of the social name in SUS as a way of access and integrality of travestis and transgender people
“Factors impacting transgender patients’ discomfort with their family physicians: a respondent-driven sampling survey”22	Bauer and collaborators	Qualitative study	Analyze how trans patients feel uncomfortable and may avoid health care in primary care
“I am your trans patient”23	Lewis and collaborators	Case report	Share the experiences of the transgender population in health care and an important message that doctors would like to know
“Barriers to care among transgender and gender nonconforming adults”24	Gonzales and Henning-Smith	–	Examine trans individual’s health and access to health
“Guidelines for the primary and gender-affirming care of transgender and gender nonbinary people”25	Deutsch	Manual	Empower the health services and system with instruments and knowledge to achieve the health needs of the transgender population and patients with gender dysphoria
“How should physicians refer when referral options are limited for transgender patients?”26	Dietz and Halem	Case report	Examine the care scenario from the perspective of a patient whose experiences with specialists were negative
“O acesso das pessoas transexuais e travestis à atenção primária à saúde: uma revisão integrativa”27	Pereira and Chazan	Literature review	Present the results of an integrative review on the access of trans individuals to primary health care services

Discussion

Access to health services

Transgender, travesti, and transsexual individuals are the most susceptible to prejudice, discrimination, and several types of violence – physical and psychological¹² . Thus, the difficulty of access to health is not restricted to infrastructure problems, since it also results from normalized heterosexuality, misogyny, and intolerance to the “different,” on the part of society and of health professionals¹⁴ . Considering this population as a minority and understanding that Brazilian society is not ready to deal with them at multiprofessional level, we should pay attention to the role of SUS in the inclusion of transgender individuals in the universal health system¹³ .

The difficulties in accessing health can be explained by stigmas suffered by transgender individuals, that is, pre-established judgments that lead the individual not to seek their rights¹⁵ . They can occur in three spheres:

1. Anticipated stigma: concern about possible discrimination;

2. Internalized stigma: devaluation of the self, based on sexual orientation or gender identity, by non-heteronormativity; and

3. Promulgated stigma: real cases of discrimination.

This reality is not only Brazilian, but global; a Canadian study conducted in Winnipeg, Manitoba, with 30 transgender individuals and 11 health professionals showed that the scientific knowledge of physicians presents gaps, since they have doubts about hormonal application (endocrinology), gynecology, and psychiatry¹⁶ . The physicians interviewed described gaps in their education regarding the approach to this condition¹⁶ - ¹⁷ .

Thus, understanding the stigma and pathologization of the trans experience is one of the roles of health professionals in promoting humanized welcoming and changing social reality. In this sense, a qualitative, descriptive, and exploratory research conducted with 12 SUS users who defined themselves as transsexuals in the state of Rio de Janeiro showed that all participants reported having already sought the public health service. However, the interviewees affirm that seeking SUS is always a last recourse, since the weariness of humiliation and the neglect to which they are often subjected keeps this population away from medical services¹⁸ .

This social vulnerability related to LGBT health, with a focus on transgender individuals, is an indispensable topic of discussion for bioethics. This problem is mainly related to the inadequate and non-humanized reception provided to this population, contradicting the ethical principles of SUS, which propose equity as a basis for solving distortions in the distribution of health, enabling universal access.

Therefore, health professional should be sensitive when approaching a patient’s life history, talking about gender identity keeping the environment safe and pleasant. This relationship of trust based on respect enables quality care²⁸ .

Pathologization of the trans experience

In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), of the American Psychiatric Association, the term “disorder” was replaced by “dysphoria,” which, however, is still characterized as a disease¹⁹ . And in the ICD-11, adopted by the WHO in May 2019, the terminology about trans individuals were inserted in the area of sexuality, being referred to as “gender incongruence”² .

The need to identify in the ambivalence of body and gender causes transgender individuals to seek bodily changes that put their lives at risk²⁰ . Some examples of this are industrial silicone administration, use of hormones without medical follow-up and clandestine plastic surgeries. These procedures may present adverse effects, causing irreversible sequelae and even death.

Most of the time, the individuals undergo such interventions due to the marginalization to which they are submitted, so that, in the face of the desire to perform body modification, they are unaware of the risks involved. Physicians should thus not blame patients in these conditions¹² .

Transition process

Considering that Brazil faces the problem of the stigma of travesti individuals, in a micro- and macrostructural sphere, we must think of the access of the trans population to SUS from the discovery of gender identity. The transition process is a right of trans individuals and comprises the respect for one’s social name, hormone therapy accompanied by a doctor and reassignment surgeries. Therefore, it must be considered holistically⁴ .

The guarantee of the right to the transition process offered by SUS represents a great advance for the promotion of health of trans individuals, since it recognizes that phenotypic changes are necessary for both physical and mental health. However, even with these achievements, the trans population finds it difficult to perform the procedures given the association of the transgender experience with illness. Thus, the pathologization demonstrated by low-skilled professionals leads to the diagnosis of “transsexualism,” which makes access to the services offered by the system even more selective¹³ .

Gender-affirming surgery is standardized by CFM Resolution 1,955/2010²⁹ , requiring rigorous evaluation with a multidisciplinary team, which includes psychiatric follow-up for a minimum of two years to confirm the diagnosis of gender dysphoria. However, a study conducted in 2018 in an outpatient clinic of a reference unit specialized in special parasitic infectious diseases in the state of Pará showed that some health teams do not have psychiatrists, thus, the responsibility falls on psychologists¹⁹ .

Social name

Language produces meanings and significations that characterize the being as a whole. In this sense, the social name is an important acquired right, since it implies respect for the way the trans person sees themselves, according to their male or female appearance¹³ . Therefore, the refusal to adopt the social name of trans patients in health facilities is a form of prejudice (both transphobia and against travesties) that constitutes an important barrier to the health promotion of this population²¹ .

The social name promotes access to health, since transsexuals and travestis feel more welcomed, which improves physician-patient interactions²¹ . Thus, by being included as the person they recognize themselves as, patients feel comfortable to access the services and enjoy their health rights, which is crucial to care since it affects patient satisfaction and results²² .

From an ethical point of view, health professionals should refrain from moral and religious judgments in the care of the LGBT population. These values incite stigmatization and, alongside pseudo-neutrality supposedly based on science, may result in the unrestricted association of trans individuals with sexually transmitted infections (STIs), especially HIV. Thus, professional practice based on patterns of heteronormativity is presented as a limiting factor in the quality of care, and even associated with illness, the reason for which also it should be considered as the starting point of ethical dilemmas ³⁰ .

The following citation materializes the importance of primarily respecting the social name of trans individuals in health environments to promote their inclusion:

You probably aren’t an expert in trans issues – that’s OK. You don’t need to be an expert to treat me with kindness and compassion: something as simple as the name you call me makes a huge difference³⁰ .

Consequences

Discrimination leads trans individuals to avoid medical care and thus become more vulnerable, having a higher risk of suffering stress related to minority status, depression, and suicide, and even contracting HIV and other STIs¹⁷ , ²² , ²³ . Furthermore, these individuals suffer the social consequences of their condition – including stigmatization, violence, and marginalization –, in addition to the anguish related to their own gender identity, which concerns their sexual health, which few understand and accept as it is²⁰ .

The mental health consequences to transgender people are also severe, and this population is more likely to live in poverty, be discriminated against in job interviews, and suffer violence from non-transgender people. They are also more predisposed to family abandonment and homelessness. These problems are aggravated in the case of trans Black women, whose rates of social disparity are higher and access to health ones lower²⁴ .

Possible interventions

An international manual lists six practices that can contribute to the creation of a healthy and inclusive environment in health care:

1. Cultural humility and care without prejudice should be offered, respecting individual preferences in the use of gender identity terminologies;

2. Employees need training on health issues of transgender people;

3. Waiting areas of health services should contain pamphlets, magazines, and images that include this population, indicating the commitment to their care;

4. Bathrooms should preferably allow the individual to choose which one to use based on their predilection;

5. Health service professionals must be fluent in the basic terminologies used by the trans community;

6. Local or individual specificities of a population must be known²⁵ .

The guidelines of the World Professional Association for Transgender Health recommend a health care professional capable and trained in behavioral health, who can conduct a competent assessment of gender dysphoria even before the start of hormone therapy. Also, applying an informed consent form for the beginning of hormone therapy is recommended, since some trans patients may not feel prepared – both physically and psychologically – for the body changes²⁶ .

Another intervention proposal would be to replace the pathologizing model of access to the transition process with a free and informed consent standard. Likewise, promoting continuing education on trans experiences to train health professionals and invest more in research on/with trans individuals in Brazil and worldwide, especially in the medical environment, to support the most humanized and appropriate care for this population is important²⁷ .

Final considerations

The greatest difficulty faced by transgender people in the search for care in the Brazilian public health system is the lack of acceptance in health centers, which results in discrimination, prejudice, and hostility in care. Moreover, the lack of technical-scientific training of health professionals in the reception, treatment, and offer of gender-affirming procedures to this population is a limiting factor in their access to SUS. Although to a lesser extent, they also face other difficulties.

To minimize the segregation of transgender individuals from public health, the main proposal for intervention is to provide an inclusive and welcoming environment, respecting social names and the terminologies used by these individuals. Furthermore, training health professionals based on bioethical principles to perform reception and follow-up of transgender patients and shifting towards a model informed consent would be important.

It is noteworthy that we observed some difficulty in finding national and international literature on the subject, which increases the importance of the present study. We also emphasize the need to instigate scientific productions on this subject, including in Brazil, given the lack of materials in Brazilian databases.

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• ²¹
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• ²²
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• ²³
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Publication Dates

• Publication in this collection
  09 May 2022
• Date of issue
  Jan-Apr 2022

History

• Received
  25 Oct 2020
• Reviewed
  28 Sept 2021
• Accepted
  26 Oct 2021