Gender violence perpetrated against trans women

Objectives: to identify scientific evidence on gender violence perpetrated against trans women. Methods: integrative review, carried out in June 2020, without time frame, in the Scopus, MEDLINE, Embase, CINAHL, WoS, PsycInfo and LILACS databases. The controlled descriptors of DeCS, MeSH and their entry terms were used: “Transgender People”, “Transgender”, “Gender Identity”, “Transsexuality”, “Gender Violence”, “Aggression”, “Sexual Offenses”, “Rape”, “Violence”, “Domestic Violence”. The presentation and synthesis of the results were presented in the PRISMA-2009 flowchart. Results: the final sample, consisting of 16 articles, identified different types of violence (sexual, physical, verbal, psychological and financial), perpetrated by family members, strangers, police officers, intimate partners, health professionals, acquaintances, or friends. Conclusions: trans women suffer violence and social exclusion that result from stigma and discrimination due to gender identity and result in unrestricted damage to physical health. Descriptors: Transgender Persons; Gender Identity; Gender-Based Violence; Violence; Nursing. RESUMO Objetivos: identificar evidências científicas sobre as violências de gênero perpetradas contra mulheres trans. Métodos: revisão integrativa, realizada em junho de 2020, sem recorte temporal, nas bases de dados SCOPUS , Medline, Embase, CINAHL, WoS , PsycInfo e LILACS. Foram utilizados os descritores controlados do DeCS, do MeSH e seus entry terms: “Pessoas Transgênero”, “Transgêneros”, “Identidade de Gênero”, “Transexualidade”, “Violência de Gênero”, “Agressão”, “Delitos Sexuais”, “Estupro”, por familiares, desconocidos, policiales, parceros íntimos, profesionales de salud, conocidos o amigos. Conclusiones: la mujer trans sufre violencias y exclusiones sociales que transcurren de estigmas y discriminaciones por la identidad de género y resultan en daños no restrictos a salud física. Descriptores: Personas Transgénero; Identidad de Género; Violencia de Género; Violencia; Enfermería. research problem; literature search; selection of data from primary studies, evaluation of primary studies; data analysis, synthesis and presentation of results (11)


INTRODUCTION
"Gender" is defined as a set of imposed sociocultural behaviors, delimited by the binary logic to define what it means to be a man or a woman (1) . This definition makes self-perception about oneself difficult, which is subjective and dynamic. Gender identity brings together a set of values, motivations and experiences learned throughout life that legitimizes other ways of being. People who identify themselves in the patterns of appearance and behavior culturally imposed on biological sex are called cisgender or cis men or women, whose gender identity and expression correspond to sex (1)(2)(3) . The linearity between body-sex-gender in Western society means that transgender or trans people do not identify with the gender assigned at birth, legitimized through anatomical sexual characteristics. Thus, transgender women do not recognize themselves in the male gender designated at birth, but, throughout life, they recognize themselves in the female gender as transsexual or transvestite women (2)(3) .
Transgender women are often faced with discriminatory actions in society that stem from stigmas arising from a history of pathologizing their identity by medical science (3) . When seeking to carry out hormones or even surgical procedures in order to have a female body image, they are faced with the lack of preparation and lack of awareness of professionals in health services to welcome and meet these needs. Such a situation can result in abusive treatment, negligence and culminate in conditions harmful to mental, physical and sexual health (4)(5) .
Cisgender or transgender women are more likely to suffer violence at any time in their lives because they are women (6) . Gender violence becomes more serious for those who have precarious socioeconomic conditions, who abuse psychoactive substances and who are sex workers, as they are more exposed to the historical processes that make them vulnerable (7) .
Furthermore, it is noteworthy that gender violence involves three social structures -patriarchy, machismo and capitalism -which act insidiously and operate through logics that will hierarchize bodies and lives (8) . The power relations that permeate society and families, and that make use of the inferiorization of the female gender through the supremacy of patriarchy, feed the gender violence reproduced against trans women. This violence can result in murder, rape, physical, verbal, psychological, sexual aggression, coercion, attacks in public or private environments, discrimination in formal workplaces, health services and educational institutions (9) .
Gender violence perpetrated against trans women in health services sometimes occurs through the reproduction of a binary and discriminatory care practice, immersed in a structure of oppression called institutionalized transphobia. Such situations contribute to assistance that is dissonant to the health needs of trans women, as well as to the disregard of their specificities and favoring the non-search for health care (9) .
According to the National Comprehensive Health Policy for Lesbians, Gays, Bisexuals, Transvestites and Transsexuals, comprehensive health care for these people in the Unified Health System (SUS) recognizes that stigma, discrimination, domestic, sexual and social violence they cause illness and need strategies for coping and care in an intra-and inter-sectorial way, as stated in the guidelines and attributions brought by the policy within the scope of the Ministry of Health and State and Municipal Health Secretariats (10) .
Given the above, it is essential that nurses know the scientific evidence on the phenomenon of gender violence that permeates the lives of trans women, in order to exercise a practice that is coherent with their social and health needs. It is noteworthy that the acquisition or expansion of knowledge necessary for comprehensive health care for these women can contribute to the reduction of new situations of violence in health services and enable visibility through the debate on the theme in social and political spaces.

OBJECTIVES
To identify scientific evidence on gender violence perpetrated against trans women.

Ethical aspects
As this is a review study, there was no need for approval by the Ethics Committee for Research with Human Beings.

Study type
This is a descriptive study, integrative literature review type, in which the following steps were followed: identification of the research problem; literature search; selection of data from primary studies, evaluation of primary studies; data analysis, synthesis and presentation of results (11) .

Methodological procedure
The guiding question was elaborated through the PICo (12) strategy, in which: "P" (population) -trans women; "I" (phenomenon of interest) -gender violence (physical, psychological, sexual); "Co" (context) -violence. The use of the strategy generated the following question: What is the scientific evidence on gender violence perpetrated against trans women?
For this study, original articles were included, in Portuguese, English or Spanish, with no time frame. Duplicate articles were excluded, being counted once in the database with the highest number of publications; articles that did not distinguish in their results the type of gender violence against trans women; publications without scientific editing not indexed; and gray literature (thesis, dissertations, course completion papers, handouts, annals, ordinances, and ministerial publications).

Data collection and organization
Searches in the databases took place in June 2020, by two researchers, through the Portal de Periódicos CAPES, with access made available by the Federal University of Pernambuco (UFPE). To access the articles, a single search strategy was defined, adapted according to the specificities of each database, as seen in Chart 1. The strategy consisted of controlled descriptors: Health Sciences Descriptors (DeCS), Medical Subject Headings Section (MeSH) and its entry terms, separated by Boolean logic, with OR between synonyms and AND to direct searches.
The search strategy was formulated according to the PICo strategy (P AND I AND Co) in which: P -Transgender persons OR Transgenders OR Gender identity OR Transsexualism; I -Gender based Violence OR Aggression OR Sex offenses OR Rape; Co -Violence OR Domestic Violence.
The following classification of evidence levels was considered: Level I -systematic review or meta-analysis; Level II -randomized clinical trial; Level III -non-randomized clinical trial; Level IV -cohort study or case-control study; Level V -study resulting from systematic review, descriptive and qualitative study; Level VI -study derived from a single descriptive or qualitative study; Level VII -expert opinion (17) .
The articles that made up the final sample were read to identify the main elements on gender violence perpetrated against trans women. The results were validated by the research group with a view to a confrontation of theoretical knowledge, expertise, and solid experience of researchers regarding the type of analysis carried out in conjunction with the subject under study. The presentation and synthesis of the results were prepared following the flowchart model Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA-2009) in Figure  1 and Chart 2 (18) . LILACS "transgender persons" OR "transgender persons" OR "transgender persons" OR "transgender persons" OR transgender OR "gender identity" OR "gender identity" OR "gender identity" OR transsexuality OR transsexuality OR Transsexualism AND "gender violence" OR "violence of gender" OR "gender-based Violence" OR aggression OR aggression OR aggression OR "sexual offences" OR "sexual offences" OR "sex offenses" OR rape OR rape OR rape AND violence OR violence OR violence OR "domestic violence" OR " domestic violence" OR "domestic violence"

Data analysis
The selection of primary articles occurred, initially, with the export of studies from the databases to the reference management software, Zotero, for the extraction of duplicates (13)(14) . Then, in order to compose the table of articles included in this research, based on the eligibility criteria, it was decided to use the internet application Rayyan Qatar Computing Research Institute -Rayyan QCRI (15) . The selection of extracted studies was done by pairs; and, in the event of an impasse on the inclusion of articles, there was the participation of a third reviewer to establish a consensus.
The data extracted for the qualitative analysis of the articles were based on an elaborated and validated instrument (16) and were compiled in a Microsoft Excel spreadsheet with the purpose of presenting the following items: title, author, year and country of publication, journal, level of evidence, objective and main results. The final selection of the sample resulted in 16 original articles.
As for the institutions where the studies were carried out, those corresponding to the main author were registered, being ten (62.5%) universities, three (18.75%) institutions promoting health research, one (6.25%) institution of research in several areas, one (6.25%) institution linked to the prevention and combating of crimes and one (6.25%) unidentified. The year with the most publications was 2019, with five articles (31.25%), followed by 2016, 2017 and 2020 with two (12.5%) articles each year; the other years, with one (6.25%) article each; and one was published in 1995. The 16 articles found were published in 13 journals, of which 5 (38.46%) were in the health area, 1 (7.69%) was specifically in Nursing, and the others in the areas multidisciplinary: Social Work, Geography, Immigration and Violence. The levels of evidence identified were VI (81.25%) and V (18.75%), divided into mixed methods, descriptive or qualitative studies.
As for the aggressors, police authorities were mentioned in six studies (37.5%), professionals from health institutions, in three (18.75%), in addition to: intimate partners (31.25%); family members (43.75%); friends or acquaintances (18.75%); neighbors (12.5%); and unknown (43.75%). Offenders were not reported in two studies (12.5%). Transsexual women are at risk of physical aggression, humiliation, stoning, rape, gang rape and murder. The hostile social context with several aggressors does not allow them to react against aggression, which leads to the potential risk of injuries and infection such as HIV; the latter is still a potentiator of more stigma and various types of violence, including institutional.
Namaste K. (26) 1995 Canada Genderbashing: sexuality, gender, and the regulation of public space Descriptive study VI Trans women, even when adopting procedures or behaviors that make them more feminine, such as surgeries, makeup, and clothes, are still susceptible to verbal, physical and sexual aggressions in public spaces due to their identity. Furthermore, environments such as prisons are potential places for rapes.
To be continued 8 of Gender violence perpetrated against trans women Silva ICB, Araújo EC, Santana ADS, Moura JWS, Ramalho MNA, Abreu PD.

DISCUSSION
Scientific evidence on gender-based violence perpetrated against trans women is presented in different forms and severities in different contexts (19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33) . It is essential to highlight that 78.8% of the murders of transgender and gender non-compliant people in the world occur in Latin America and the Caribbean, being derived from gender violence and transphobia that oppresses and makes abject the lives that affront the gender normativity (34) . Above all, the life expectancy of these people around the world stands out: 35 years old (34) .
Gender violence gives the person, in general the woman, the distorted image of less control and power over themselves in relation to a dominant figure, most of the time, male. The latter believes that they can even control the lives they judge to be inferior, which, in the condition of trans women, causes more exposure to social and health problems, such as HIV and other morbidities (20)(21)25,27,29,32,35) . Gender violence perpetrated against trans women is supported by female behavior and the expression of this woman's identity, permeating the psychological, verbal, physical, economic, sexual, family and labor fields, with a worsening of the context of exclusion and stigma (36) .
When trans women suffer rejections because of their gender identity, which can happen from childhood or adolescence, in the public or private sphere, there is the potential of marginalized contexts, the experience of educational evasion and precarious socioeconomic conditions (37) . Trans women with physical disabilities or some mental disorder, and who bring social markers such as race (black) and class (unfavorable socioeconomic condition), may be exposed to more violence, including perpetrated by reference services for people who have experienced sexual violence, psychological, domestic, chemical dependency, or mental illness. This highlights racism and social exclusion within care institutions (22,32) .
Trans women living with HIV may face a double stigma when seeking care in reference health institutions, regardless of their nationality. This situation occurs because they present a female gender identity and live with the virus, a condition that Quantitative study VI Transsexual women in the migration process, in addition to being exposed to sexual violence, still have increased risks of contracting HIV because they cannot negotiate the use of condoms.
Ritterbusch AE. (28) 2015 Colombia Mobilities at Gunpoint: The Geographies of (Im)mobility of Transgender Sex Workers in Colombia Qualitative study VI In addition to being expelled from their families by paramilitary groups, the exodus and establishment of trans women in other cities are marked by police violence and situations of beatings, rapes, verbal abuse, psychological violence, sex work and stigmatization of their identities intertwined with HIV.

Stigma and HIV risk among Metis in Nepal
Qualitative study VI To escape from forced cultural marriages (as men), the Metis, Nepali transsexual women, run away from home and end up doing sex work to survive. In addition to all social exposure to violence, police authorities do not protect Metis' human rights and are also perpetrators of both sexual violence and physical aggression and harassment.

La otra migración: Historias de discriminación de personas que vivieron con VIH en México
Qualitative study VI Trans women in Mexico are under prejudice, violence, and rejection from within the family. In addition to being susceptible to verbal, physical, sexual violence, extortion, rejection, and death, they do not find support even in the health services, as well as, instead of being protected by the police, they end up being more victimized by them. They also face stigmatization when living with HIV.
Thompson LH. (33) 2019 Canada Violence and Mental Health Among Gender-Diverse Individuals Enrolled in a Human Immunodeficiency Virus Program in Karnataka, South India Quantitative study VI Transsexual women in India are very susceptible to all types of violence (physical, sexual, stigma, sex work), including by family members and authorities, which ends up being an impediment to seeking help and rights. This leads to serious mental problems, such as low self-esteem, lack of self-confidence, sleeping difficulties, depression, and suicide. often results from sexual violence. Trans women seek services because they believe they can have treatment conducted under principles of confidentiality, privacy and dignity, but their serology is revealed, being the target of persecution and physical and symbolic violence (19)(20)25,(28)(29)32) . Gender violence practiced in health services is a condition that drives trans women to neglected care, delaying basic treatments and enhancing health inequalities (34) .
Trans women can be inserted in a context of exposure to HIV closely linked to violence, which can accompany them from early adolescence and go through all stages of life. This exposure to the virus and other health problems can occur through forced sexual initiation and through family and social rejection of her identity, which drives her to sex work as a means of survival. The latter can also be the cause of more aggression and extortion from clients and/or ruffians (19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)35) .
Exposure to HIV can also stem from assaults by strangers, sex with multiple partners, prison settings and even abuse by the police or other service providers. One can also add the context of illegal migration, in which the susceptibility to sexual violence is extreme, as well as the fear of being murdered during acts of violence, which prevents them from requesting the use of condoms and from seeking support legal and health (19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)35) .
Non-consensual and unprotected sexual practices (oral and anal) permeate the lives of trans women in various scenarios, in an insertive or receptive way, regardless of sex work, as a way of affirming female inferiority and male control. They are usually accompanied by verbal aggression, intimidation, threats, beatings and extortion (25,35) .
The fear of retaliation when reporting situations of violence, or stigmatization and more violence when seeking support, silences trans women, producing suffering and mental and psychological illnesses such as depression, post-traumatic stress disorder, suicidal ideation, in addition to favoring greater exposure to sexually transmitted infections (23,33) .
Trans people are twice as likely to be assaulted throughout their lives compared to cisgender people, with special attention to sexual violence and violence by intimate partners; and have a 90% to 100% chance of experiencing traumatic events (38) . However, they can also experience the bidirectionality of violence in the relationship, in which they assume the role of perpetrators (24) . It is noteworthy that gender violence committed by intimate partners against trans women is aggravated by the abuse of alcohol and psychoactive substances. Among the most prevalent aggressions, psychological aggression is the most frequent, followed by physical aggression and sexual coercion (24) .
The fear of stigmatization, discrimination and discredit on the part of authorities when reporting intimate partner violence (37) results in low demand for services in which nursing plays an important role in health promotion and in the prevention of injuries as a result of violence, such as HIV and other morbidities.
Many trans women are forced to leave their premises in their early adolescence due to factors such as discrimination, prejudice, rejection, physical and mental violence, abusive relationships committed by family members. In addition, they may flee home or cities because they face threats to their life and that of their family from groups of lawbreakers or gangs, or even to flee forced marriages, in which they would have to assume male roles to contribute the family economy (21,(25)(26)(27)(28)31,33) .
Sex work may appear as a means of survival, and it is possible for them to receive support from other trans women, however, this activity may be restricted by the police, due to gender identity; and they can also be victims of aggression from clients (21,(25)(26)(27)(28)31,33) . The more conditions for social exclusion that exist in the lives of trans women, such as poverty, racism and low education, the more frequent the violence (39) .
When trans women are in a situation of deprivation of liberty, they are placed in male penitentiaries and are susceptible to both aggressions from other people deprived of liberty and from employees of the institution (30) . In the context of deprivation of liberty, verbal attacks occur more frequently against trans women. Rape and sexual favors are also reported, as are blackmail and exploitation of sex work; in addition, their bodies are seen as transport for prohibited items, such as psychoactive substances and telephone devices, which makes them the target of more aggressive approaches by law enforcement authorities (30) .
Trans women deprived of freedom, in general, have fragile support networks, which results in the difficulty to continue harmonization and to receive health care, favoring the maintenance of situations of violence (9) . However, many aggressions and ill-treatment are not reported due to the fear of retaliation and the weakened historical interaction with police authorities (39) , as already mentioned. Health care in this environment is focused on curative and urgent practice, which requires from the health professional a perceptive and discrimination-free look in order to identify the health needs of these women.
State representative institutions designed to protect and take care of the lives of the entire population present and maintain matrixes in gender binarism, with insufficient, unbalanced, and misguided actions to meet the needs of people outside this binary structure. This reveals that there is an urgent need to acquire knowledge and carry out training, especially in the health area, aimed at the specificities of trans women (40) .
Thus, the role of Nursing cannot be dispensed with in the search for knowledge with a focus on comprehensive care and health promotion for trans people, which should begin with the academic training of these professionals, even in educational institutions. In addition, it is necessary to strengthen the discussion through research, disease prevention actions, qualified listening, individual consultation, or emergency procedures. Trans women must be given emancipatory care, based on respect for life and free from negligence in all spheres of care (35) .

Study limitation
Studies that addressed conditions related to gender violence against trans women, in a non-specific way, associated with other gender identities and sexual orientations were not considered viable for this review, which may have limited the final sample. Contributions to the field of nursing, health, or public policy Nursing (and other health sciences) must view gender violence as a public health problem and seek to understand the contexts involved in order to adopt actions based on urgent and mediated health needs arising from situations of violence against trans women. It is important that nurses acquire knowledge in the forensic area that is sufficient to collaborate in the search for justice and in the exclusionary social situations experienced by trans women, victims of physical and sexual violence (41) .

CONCLUSIONS
Scientific evidence suggests that gender violence that affects trans women is present globally and in different forms in various cultures. The faces of verbal, psychological, physical, and sexual gender violence perpetrated against trans women, practiced by family members, intimate partners, neighbors, police officers, health care providers, clients and strangers were identified. Trans women experience social exclusion and successive violence that result from stigma and discrimination due to their gender identity and that result in damage to health, which can even cause death.
Gender violence against trans women denotes a serious public health problem that needs to be visible in all spheres of society. Therefore, it is necessary that nurses and other health professionals, from the beginning of their training to their professional practice, know and discuss the gender violence perpetrated against them. The knowledge acquired, or expanded through continuing education, can provide health professionals with tools to collaborate in the fight against violence. This confrontation can take place through the construction of prevention and health promotion actions, which must occur in an interdisciplinary way in all care scenarios.
Finally, it is noteworthy that there is a need for research on the subject, especially empirical, in the context of Nursing, which aim to understand the mechanisms of social representation of trans women on gender violence, in order to promote an equitable and humanized practice.