What does respect look like? Diversity management practices in the experience of a travesti patient in the public health system

MONTEIRO, ADRIANA KIRLEY SANTIAGO; MESQUITA, RAFAEL FERNANDES DE; PANIZA, MAURÍCIO DONAVAN RODRIGUES; SANTOS, JUUARA JUAREZA BARBOSA DOS

doi:10.1590/1679-395120230205

Abstract

This teaching case aims to highlight the need for organizations to have concrete, intersectoral, and formalized practices around diversity and inclusion management, to treat all stakeholders, particularly customers, with dignity. Based on data obtained from observations and interviews, the case reports on the experience of a travesti patient when accessing a public hospital and the consequences of the lack of preparation of professionals to deal with issues of diversity. Thus, some management dilemmas can be addressed with the application of the case, the main ones being how to make practices more inclusive and how to deal with transphobia or violence on the part of health professionals. The case applies above all to the area of people management, but it can also be applied to disciplines around health management and public management, as it portrays a situation that occurred in the Public Health System. As a result, the case shows that efforts to make organisations more inclusive must be interdisciplinary. Business schools are increasingly demanding tools for teaching inclusive management practices. Although the case is centred on a social marker of diversity—gender identity—the reflections can inspire management practices for other audiences socially constructed as diverse.

Keywords:
Diversity management; Health management; Travesti; Transgenders; Teaching case

Resumo

O objetivo deste caso de ensino é evidenciar a necessidade de as organizações terem práticas concretas, intersetoriais e formalizadas na área de gestão da diversidade e inclusão, a fim de haver um tratamento digno a todos os públicos de relacionamento, em particular clientes. Com base em dados obtidos em observações e entrevistas, o caso relata a experiência de uma paciente travesti ao acessar uma unidade hospitalar pública e os desdobramentos ocorridos pela falta de preparo dos profissionais para lidar com questões de diversidade. Desse modo, alguns dilemas de gestão podem ser abordados com a aplicação do caso, estando os principais ligados a como tornar as práticas mais inclusivas e como lidar com a transfobia ou a violência de parte dos profissionais de saúde. O caso se aplica, sobretudo, à área de gestão de pessoas, mas também é possível ser aplicado em disciplinas da área de gestão em saúde e gestão pública, por retratar uma situação ocorrida no Sistema Único de Saúde. Por consequência, o caso evidencia que os esforços para tornar as organizações mais inclusivas devem ser interdisciplinares. As escolas de negócios demandam cada vez mais instrumentos para o ensino de práticas de gestão inclusivas. Embora o caso esteja centrado num marcador social da diversidade - a identidade de gênero -, as reflexões podem inspirar práticas de gestão para outros públicos socialmente construídos como diversos.

Palavras-chave:
Gestão da diversidade; Gestão em saúde; Travestis; Transgeneridades; Caso de ensino

Resumen

El objetivo de este caso didáctico es destacar la necesidad de que las organizaciones cuenten con prácticas concretas, intersectoriales y formalizadas en el ámbito de la gestión de la diversidad y la inclusión, con el fin de tratar con dignidad a todas las partes interesadas, en particular a los clientes. A partir de datos obtenidos en observaciones y entrevistas, el caso relata la experiencia de una paciente travesti al acceder a un hospital público y las consecuencias de la falta de preparación de los profesionales para tratar cuestiones de diversidad. De esta forma, con la aplicación del caso se pueden abordar algunos dilemas de gestión, vinculados los principales a cómo hacer las prácticas más inclusivas y cómo lidiar con la transfobia o la violencia por parte de los profesionales de la salud. El caso se aplica sobre todo al área de gestión de personas, pero también puede aplicarse a disciplinas del área de gestión sanitaria y gestión pública, ya que retrata una situación ocurrida en el Sistema Único de Salud. Como resultado, el caso muestra que los esfuerzos para que las organizaciones sean más inclusivas deben ser interdisciplinarios. Las escuelas de negocios demandan cada vez más herramientas para enseñar prácticas de gestión inclusiva. Aunque el caso se centre en un marcador social de la diversidad -la identidad de género-, las reflexiones pueden inspirar prácticas de gestión para otros públicos socialmente construidos como diversos.

Palabras clave:
Gestión de la diversidad; Gestión de salud; Travestis; Transgéneros; Caso de enseñanza

INTRODUCTION

This case study, based on real events, recounts the experience of a travesti as a patient in a large public hospital organization. A healthcare appointment, seemingly trivial for cisgender individuals or those not belonging to any marginalized social group, became a situation fraught with dilemmas and challenges. Quick decisions had to be made to ensure the transgender person’s care, but situations related to patient registration information systems, the organization of the environment, and the behavior of individuals on the work teams impacted her experience.

Based on this initial context, the proposed case study aims to highlight the need for organizations to have concrete, intersectoral, and formalized practices in the area of diversity and inclusion management, in order to ensure dignified treatment for all stakeholders. Thus, through didactic development, the study seeks to understand the collective challenges faced by the transgender population in Brazil, particularly transgender women and travestis, regarding the specific situations experienced by a marginalized group in accessing public health services, recognizing the complexity that guides the construction of diversity and inclusion practices. Although the focus of the case is access to a healthcare organization, the reported events allow for discussion about inclusion/exclusion in other organizational contexts.

The case study’s application can spark relevant discussions for disciplines in the areas of human resource management and healthcare, particularly in topics related to diversity, equity, and inclusion management, as well as humanized healthcare. Adaptations were made, without compromising the reported facts, to ensure the anonymity of the participants and the non-identification of the institution involved, which does not compromise the didactic objective of the case study. Another relevant point to highlight is that the text was technically reviewed by a transgender consultant with experience in the field of diversity and inclusion. It was understood that this action was a relevant and essential step in the development of the case study, since, although the importance of allied individuals for the institutionalization of inclusive organizational practices is recognized, some experiences are exclusive to people who are part of a specific social group.

Regarding the structure of the case study, in the following topics, in addition to describing the organizational context, the character, and the organizational dilemmas present, that is, the narration of the case itself, teaching notes are presented, which include methodological explanations about how the case history was constructed, the possible pedagogical applications of the material, and the reference literature for its application, which included a general overview of the bibliography on transgender people in organizations and the world of work, as well as a brief discussion on the complexity of building organizational diversity and inclusion practices. At the end of the teaching notes, bibliographies produced by transgender authors were indicated, which can enrich the knowledge obtained based on the application of this case study.

CONTEXTUALIZING THE HOSPITAL ORGANIZATION AND INFORMATION GUIDELINES FOR PATIENT REGISTRATION

The General Hospital Casa do Povo is a large-scale organization dedicated to the care of adults and seniors, part of a hospital network and integrated into the Brazilian Public Health System. As part of a hospital network, the institution follows standardized routines, protocols, and management systems. An example of this is the use of software that standardizes administrative practices, such as inventory control, and care practices, such as the electronic medical record of each patient. The proposal to unify patient registrations and other care data in a single application avoids duplicate information, facilitates access to data from previous hospitalizations, integrates records from different members of the multidisciplinary team, enables scheduling of appointments and consultations, provides data reports useful for management and research, allows for control and calculation of hospital expenses in an agile and personalized way, provides scheduling and visualization of exams, among other benefits.

On the other hand, the network is composed of hospitals with different characteristics located in various regions of the country, which led to this software being developed by professionals unfamiliar with the routine and specificities of each hospital. Thus, this standardization does not always meet the needs of the units, and any changes or adaptations become unfeasible due to the high cost or because they are demands of great specificity, becoming uninteresting for a large number of hospitals in the network.

Regardless of whether a new patient enters the hospital through the outpatient clinic or the emergency room, registration is the starting point for inclusion in this software. To this end, a phonetic search of the patient is initially performed, using the full name — with specific fields for the inclusion of legal name and social name — and confirmation of the mother’s name and date of birth, to check for duplicates. If it is confirmed that the patient is not registered, the registration of personal, documentary, and contact data begins, in order to generate a medical record number. This number will remain the same for all future hospitalizations, outpatient consultations, and/or examinations and procedures performed in the hospital network.

Once the medical record is generated, all services provided in these hospitals are recorded in specific modules within the same application. This allows for the sharing and consultation of information at any time, immediately, by various professionals. As it is also software intended for administrative practices, handled by professionals with different functions, access to the modules is made available in a personalized way, allowing each professional to view, modify, and/or include only the information necessary for their practice, which guarantees the protection of sensitive data of each patient.

In addition to the concern with data confidentiality and information security, the software has functionalities that serve to meet the patient safety goals proposed by the World Health Organization (WHO). This is the case of the printing of identification wristbands, generated based on the registration information and containing the patient’s full name, medical record number, ward, bed, and date of birth. The initial version did not include the date of birth on the identification wristband. The inclusion in more recent versions considered a common demand of all hospitals, with a view to enabling compliance with the patient safety goal 1, which refers to identification by name and at least one other qualifier, for which the date of birth or the mother’s name is suggested. The current version does not include the registration of the social name on the wristband, which is generated only with the registration of the legal name.

FOR HER AND HERS: BÁRBARA. FOR THE OFFICIAL DOCUMENT AND HOSPITAL SOFTWARE REGISTRATION: ANTÔNIO

It was almost noon on a quiet Thursday at the General Hospital Casa do Povo when Bárbara entered the emergency room in a wheelchair. The muffled plea for help, the hunched torso over her abdomen, the pained face, and the inability to walk indicated that this was something that would not tolerate delay. Accustomed to recognizing urgent situations, the receptionist hurried to ensure that Bárbara was immediately directed to medical attention, while collecting her personal documents to fill out the form.

In the emergency room, the on-call physician quickly identified signs suggestive of appendicitis and referred Bárbara to the observation room, where she would receive pain medication and await an imaging exam to confirm the diagnosis and referral for emergency surgery. The standard protocol for such cases is clear and sequentially followed to avoid prolonging problems for patients who meet the established criteria during the risk assessment and first contact with any hospital staff member.

Upon opening the electronic medical record to prescribe the course of action, the doctor noticed that the form did not indicate Bárbara’s name, but that of another patient, named Antônio. Assuming that the form had not been completed, the nurse was asked to expedite the medical record with the receptionist. Until that moment, cases like Bárbara’s were common in the emergency room routine, where care often began concurrently with patient registration. However, the nurse could not hide her surprise when she checked the document in the receptionist’s hands, who, stunned, said: “The document is Bárbara’s, but her name is Antônio!”

BETWEEN EMPATHY AND HOSTILITY: THE DIFFICULTIES OF PATIENT BÁRBARA’S STAY IN THE HOSPITAL ENVIRONMENT

This was the first time the hospital had received a transgender patient. The topic was not entirely new to the receptionist, after all, she had watched a TV series that featured a transgender character. The nurse also recalled reading something about the social names of transgender patients, but nothing seemed to have prepared her for that moment.

Faced with the urgency of expediting the medical record for prescription, the nurse explained the situation to the doctor and asked the receptionist if there was any field dedicated to the social name in the electronic program. At that moment, the receptionist remembered that she had already used a field dedicated to the social name. But, not knowing what it was, she used to fill it in with some nickname that referred to the patient. It was common for a patient named José to have the social name registered as Zé or Zezinho. Despite realizing the previous mistakes, the solution for that immediate case seemed simple: just enter the social name correctly in the electronic medical record.

When they registered Bárbara’s name, the printed materials related to the medical prescription and the request for exams were generated with the legal name accompanied by the social name, which guaranteed the patient’s rights, but required greater attention from the team. However, due to an error in the development of the electronic program, the patient’s identification wristband contained only the legal name and date of birth data, ignoring the social name. This circumstance posed a great risk to the patient’s safety, as she would be identified as Bárbara in the medical record and exam requisition, but would have the name Antônio on the wristband.

The nurse knew that the use of the identification wristband with two identifiers, generally name and date of birth, served to avoid care errors such as medication exchanges between patients with the same name. To comply with the protocol, Bárbara would have to wear the wristband throughout her stay in the hospital, and the healthcare team would be responsible for confirming her identification at each appointment, confirming with the information on the wristband. However, in this situation, the identification of the wristband with the legal name not only posed a risk to the patient, but would also be a form of embarrassment that would accompany her from admission to discharge.

Despite the persistent identification problem, the diagnosis of appendicitis was confirmed, requiring immediate surgery. Noticing the complexity of the situation, the nurse decided to report the case to the manager of the Patient Safety Nucleus, who acknowledged that this scenario had not been foreseen. Aware that the wristband identification would be difficult to solve immediately, as the hospital did not have technological autonomy to modify the electronic program, Bárbara was sent to surgery wearing the wristband with her legal name. In an attempt to prevent errors and reduce embarrassment, the situation was reported to the surgical team, with instructions to use the social name during care.

After surgery, Bárbara needed to be transferred to a ward to receive post-operative care. The hospital maintained the division of wards by two genders: female and male. Bárbara’s self-identification, coupled with her physical attributes and her clothing socially read as feminine, indicated that she should be admitted to a female ward. However, there was a concern that parts of her body might be exposed during dressing changes, bathing, nursing procedures, and clothing changes. This situation could expose her genitalia and provoke negative reactions from other patients, as well as causing her embarrassment. Despite the risks, the nurse and the manager agreed that admitting Bárbara to a male ward was not an option.

With Bárbara settled in a female bed, it was up to the nurse to receive her and select one of the nursing technicians on the team to be directly responsible for her care. Thinking of avoiding situations of intolerance, the nurse assigned Bárbara’s care to nursing technician Ângela, a young woman who was often seen on social media alongside gay friends and who seemed to be the least prejudiced person on the staff at the time.

In the following hours, Ângela needed to move Bárbara in the bed, requiring assistance from the team. It was common in this hospital that, in the various work shifts, each team had at least one male nursing technician, whose physical strength was required in moving patients during post-operative care. In that shift, the only nursing technician present was José, strong and young, who refused to assist Ângela in any procedure involving Bárbara. “I don’t touch travestis,” he said. Quite irritated, Ângela reported the case to the nurse and told José that she would report him to the hospital ombudsman. José simply reaffirmed his position, saying: “You can call even the superintendent. It’s not going to happen that someone will make me touch this kind of people.” Noticing the discussion escalating and fearing a greater repercussion, the nurse offered to provide assistance during the movement and in other procedures that required collaboration.

Other work shifts followed, and with each change of shift, the rumors grew. Although Bárbara was the first transgender patient to be treated at the General Hospital Casa do Povo, that is, the first patient with a transgender gender identity, reports of employees demonstrating excessive and invasive curiosity in the treatment of patients with bodies socially read as non-heterosexual are not uncommon. Therefore, the care of any patients interpreted by the teams as belonging to LGBT social groups is impaired. In other words, hostility is explicit towards patients with non-hegemonic sexualities and gender identities. So much so that there are 2 employees informally designated among the team to assist gay and lesbian patients, precisely to avoid conflict situations due to homophobia and lesbophobia on the part of other workers in the organization. This informal division of labor between who could attend and who would not attend under any circumstances also occurred when deciding who would provide healthcare to Bárbara’s body.

Other nursing technicians, including some women, joined José in refusing to provide any kind of assistance to Bárbara. Some nurses thought about reporting the situation to the ombudsman, but gave up because the verbal refusal was difficult to prove and the ombudsman did not always provide effective treatment of cases. Moreover, the disclosure of an internal dialogue could easily reveal the author of the complaint, which would provoke deep disagreements in a team that would continue to have to work together for many years, while Bárbara might never need to return to that place again. One of the nurses, remembering so many situations experienced in that place, justified her decision not to file a complaint, saying: “Friends, I’m tired of just thinking about taking on this fight.”

Concerned, the nurse began to reflect on the situation and how it would affect future care. The hospital and its staff would need to prepare. Some management dilemmas arise as a result of this reflection: how can the practices of care, treatment, and reception of people from a marginalized group (travestis and transgender people), in a healthcare organization, be more inclusive, without compromising patient safety? And how to deal with the refusal of care by professionals in the organization, motivated by transphobia or other types of violence?

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TEACHING NOTES
The teaching notes have restricted access and are only available to professors and instructors associated with an academic institution upon request at: https://periodicos.fgv.br/cadernosebape/article/view/93587/87505
DATA AVAILABILITY
The data set that supports the findings of this study is not publicly available.
ASSOCIATE EDITOR
Fabricio Stocker (Fundação Getulio Vargas, Rio de Janeiro / RJ - Brazil). ORCID: https://orcid.org/0000-0001-6340-9127
REVIEWERS
Eduardo Estellita de Oliveira Santos (Universidade Presbiteriana Mackenzie, Rio de Janeiro / RJ - Brasil). ORCID: https://orcid.org/0000-0002-8936-8033
REVIEWERS
Eloisio Moulin de Souza (Universidade Federal do Espírito Santo, Vitória / ES - Brasil). ORCID: https://orcid.org/0000-0002-0775-7757
PEER REVIEW REPORT
The peer review report is available at this link: https://periodicos.fgv.br/rap/article/view/93585/87501
16
[Translated version] Note: All quotes in English translated by this article’s translator

Edited by

EDITOR-IN-CHIEF
Hélio Arthur Reis Irigaray (Fundação Getulio Vargas, Rio de Janeiro / RJ - Brazil). ORCID: https://orcid.org/0000-0001-9580-7859

Data availability

The data set that supports the findings of this study is not publicly available.

Publication Dates

Publication in this collection
08 Sept 2025
Date of issue
2025

History

Received
20 Dec 2023
Accepted
14 Jan 2024

Este é um artigo publicado em acesso aberto sob uma licença Creative Commons

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