Health care for transgender people in Brazil: a systematic review protocol

doi:10.21203/rs.3.rs-58007/v1

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Health care for transgender people in Brazil: a systematic review protocol

https://doi.org/10.21203/rs.3.rs-58007/v1

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Background

At the global level, transgender people (transvestites and transsexuals) live in worse health and living conditions due to the stigma and violence they face, including within health services. In Brazil, the Unified Health System must offer comprehensive care to the population, regardless of social class and gender. The aim of this article is to establish a systematic review protocol to analyze how health care occurs for the transgender population in the Unified Health System.

Methods

This protocol was guided by PRISMA-P and the bases SCIELO, LILACS, BVS and PUBMED will be consulted. Empirical studies, with a qualitative or quantitative approach, that deal with health care for the transgender population in the Unified Health System, where the respondents are transgender people, health professionals or health managers, will be included in the systematic review. For the definition of the final sample, the articles will undergo an assessment of methodological quality and risk of bias, with the help of the critical assessment tools of the Joanna Briggs Institute, using a specific checklist for each type of study. The synthesis of the findings will be carried out through the formal narrative and the presentation of tables with summarized data, with the final writing of the review guided by PRISMA.

Discussion

Based on scientific evidence, it is intended to present an overview of health care for the transgender population in the Unified Health System. In addition, to point out possible strategies to qualify the political, organizational and attitudinal aspects related to health care for that population.

Systematic review registration:

PROSPERO CRD42020188719.

Health Economics & Outcomes Research

Brazil

Health care

Transgender persons

Systematic review

Transsexual women and men have a gender identity different from the biological sex determined at birth, understanding that this identity is built from social and cultural experiences and interactions¹. Transvestites, on the other hand, a term more widespread in Brazil and other countries in Latin America, are recognized as a female figure who seeks to build a unique image, not undoing some male characteristics and experiencing a constant flow between these two genders².

In the global context, transgender people, a term used to refer to transsexual women and men, as well as transvestites, represent a small portion of the general population³. However, the discrimination and social exclusion imposed on these people puts them in worse health and living conditions⁴.

Transgender people are the biggest consumers of alcohol, tobacco and illicit drugs and have high rates of psychological distress, including suicidal ideation and attempt; unique health problems, caused mainly by bodily changes arising from attempts to align the phenotype with gender identity; lower life expectancy and greater difficulties in accessing health services^4,5.

In Brazil, despite the reality of other countries, transgender people are at greater vulnerability, being, among the LGBTI population, the main victims of violence, especially of bodily injuries and homicides by firearms^6,7. In view of this reality, health care should not be configured only in assisting the health needs and demands of this population, but also in broad and concrete actions to welcome transgender people and assist them in facing transphobia.

The Brazilian health system, created in 1990 and called SUS, is mainly composed of free public health services, with the complementation of some private health services financed by the State⁸. In addition, this health system is constituted by doctrinal principles (universality, equity and integrality) in which the health care model, expressed in policies, programs, organization of services and provision of care, must focus, primarily, on the recognition of the social determinants of the health-disease process and health inequities⁹.

Especially based on the principle of equity, health care practices must be carried out in a more fruitful way to serve the most vulnerable people, including transgender people. National health policies directed at the transgender population have been implemented in SUS over the years, such as the National Comprehensive Health Policy LGBTI, created in 2011, and the Transexualizador Process program in SUS, created in 2008 and expanded in 2013¹⁰.

In Brazilian literature, there is an increase in scientific articles publication approaching LGBTI population health after the creation of the National Comprehensive Health Policy LGBTI¹¹, as well as theses and dissertations on transvestite, transsexuality and health after the expansion of the Transexualizador Process in SUS¹². From this perspective, it is possible to identify some integrative reviews on transgender people health in Brazil, specifically on the difficulties that this population faces in order to access health services^13,14.

However, there are no systematic reviews that present summarized evidence on the other aspects related to health care for transgender population in Brazil. Considering that Brazil is a country of continental dimension with several and profound inequalities, especially with regard to the realization of the universal right to health, it is questioned: how has health care for the transgender population occurred within the scope of SUS? As a result, the objective of this study is to establish a systematic review protocol to analyze how health care for the transgender population in SUS occurs.

Protocol and registration

This systematic review protocol was prepared in accordance with the recommendations of PRISMA-P¹⁵ (see Additional file 1) and has been registered on the PROSPERO platform since July 5, 2020, under registration CRD42020188719.

Eligibility criteria

The eligibility criteria are based on the PECOS strategy, with the necessary adaptations (Table 1).

Table 1

Elements of the research question according to the PECOS strategy.
Element	Abbreviation	Description
Participants	P	Transvestites, transsexual women and men, health professionals, health managers
Exposure	E	Health policies and programs, organization of health services, provision of health care
Comparison or control	C	-
Outcome	O	Health promotion, access to health services, responses to health demands and needs
Types of study included	S	Empirical studies with a qualitative or quantitative approach

The review will include articles resulting from empirical studies, with a qualitative or quantitative approach, dealing with health care for the transgender population in SUS, in which the respondents are transgender people, health professionals or health managers. Studies published in full form in scientific journals from 1990, the year of SUS regulation, will be included, regardless of language.

Studies that address health care for the trans population only in the private health system or in conjunction with health care for gays, lesbians, bisexuals, intersexuals or other categories of gender and sexuality will be excluded, as well as studies classified as abstracts published in annals, editorials, reflective articles, documentary analysis, literature reviews, technical manuals, book chapters, books, course completion papers, dissertations and theses.

Information sources and search strategy

For the search for evidence that will integrate the systematic review, the SCIELO, LILACS, BVS and PUBMED databases will be consulted. Previously defined strategies will be used after different attempts, composed of a block of descriptors related to health care in the Brazilian context and a block of descriptors related to transgender people, respecting the specificities of each base (Table 2).

Table 2

Search strategies for each database.
Database	Search Strategy
SCIELO	("atenção à saúde" OR "sistema único de saúde" OR SUS OR brasil) AND (travesti OR travestilidade OR travestismo OR transexual OR transexualidade OR transexualismo OR transgênero OR "pessoas trans")
LILACS	("atenção à saúde" OR "sistema único de saúde" OR SUS OR brasil) (travesti OR travestilidade OR travestismo OR transexual OR transexualidade OR transexualismo OR transgênero OR “pessoas trans”)
BVS	("atenção à saúde" OR "sistema único de saúde" OR SUS OR brasil) (travesti* trans*)
PUBMED	(“health care” OR “health systems”) AND brazil AND (“transgender persons” OR transvestism OR transsexualism)

In the SCIELO, LILACS and BVS databases, the search strategies will be composed of descriptors extracted from the DECS portal and for the search in PUBMED, equivalent terms of the MESH will be used. The strategies will be applied to all indexes of the studies (title, abstract, keywords and text).

Data selection

The studies will be retrieved by a researcher and, soon after, coded and organized in a Microsoft Excel spreadsheet for later removal of duplicates. Then, considering the inclusion and exclusion criteria defined, a screening will be carried out based on the reading of the titles and abstracts of the texts, by two independent researchers, to select those who will undergo a full reading. In case of doubt or disagreement, a third researcher will be consulted.

The screened articles will be read in full in order to extract the following data: title, authorship, year of publication, descriptors, objective, sample/target audience, place of study (federative unit of Brazil), type of study, collection method used, main results and conclusions. The reading phase in full will also be carried out by two researchers, independently, in order to select those with strong potential for inclusion in the systematic review. In case of doubt or disagreement, a third researcher will be consulted.

If any relevant data from the analyzed articles is missing or hidden, the authors of the studies will be contacted to provide this information. If these data are not obtained, they will be excluded from the analysis and reported in the discussion section. Through manual search, the references of the sorted articles will also be consulted to identify possible losses during the electronic search.

Bias risk and quality assessment

The selected articles will be read again, in order to carefully evaluate their methodological quality and risk of bias. This assessment will take place through the Joanna Briggs Institute's critical appraisal tools, using a specific checklist for each type of study found. From the assessment of methodological quality based on the tools of the Joanna Briggs Institute, studies with up to 49% of affirmative responses will be classified as studies with a high risk of bias, studies with affirmative responses between 50% and 69% will be classified as studies with moderate risk of bias and studies with 70% or more of affirmative responses will be classified as studies with low risk of bias¹⁶.

In this systematic review, only articles with a low risk of bias will be included. The evaluation of the methodological quality of the articles, as well as the classification of the risk of bias in each one, will also be carried out independently by two researchers. In case of doubt or disagreement, the final decision will also be arbitrated after consulting a third researcher. In order to ensure uniformity in the critical evaluation, the evaluating researchers will be previously trained and calibrated.

Data analysis and synthesis

The synthesis of the findings will be carried out through the formal narrative and the presentation of tables with summary data. The main characteristics of the studies will be extracted from the spreadsheet built in the Microsoft Excel program and interpreted with the support of the scientific literature, aiming to dialogue with the objective and results of the systematic review.

The conduct of the systematic review guided by this protocol is summarized in Fig. 1 and its final wording will be prepared based on the PRISMA guideline¹⁷.

From preliminary searches, it was possible to identify that disrespect to the social name and the classification of transgender identities as pathologies, are considered the greatest barriers to humanized, welcoming and comprehensive care for transgender people in the various services and levels of health care^18–21. Considering the difficulties of access to public health establishments, added to the socioeconomic limitations to bear the costs in the private network, transgender people seek assistance as a last resort and, on many occasions, by clandestine treatments for body treatments (use of hormones, silicone applications and genital self-harm), leading to illnesses and increasing their vulnerabilities^22,23.

It is necessary to widely discuss the consequences of the cisgender pattern for these people, as discrimination by gender identity affects the social determination of health, by triggering illness and premature death resulting from prejudice and social stigma towards trans women and men, as well as transvestites. To change the way transgender people are seen in SUS, it is necessary to turn to the theoretical and conceptual basis of health care that founded the section on health in the Federal Constitution of Brazil and the legal framework of SUS itself.

Therefore, in order for them to have a good quality of life, it is necessary to guarantee medical assistance, but also to provide opportunities for access to education, employment, housing, food, etc. This action should not only come from transgender people, but from all those who believe in the potential of SUS and in a more egalitarian and democratic society.

This study presented a systematic review protocol to analyze how health care for transgender population has been provided in SUS. The future systematic review will integrate a work plan that has been developed in the Doctoral course of the Postgraduate Program in Public Health at the Federal University of Rio Grande do Norte, located in the Northeast of Brazil.

Therefore, it intends, based on scientific evidence, to present an overview of health care for the transgender population in the Brazilian health system. In addition, to point out possible strategies to qualify the political, organizational and attitudinal aspects related to health care for this population.

LGBTI

Lesbian, gay, bisexual, transgender and intersex.

SUS

Sistema Único de Saúde, Unified Health System.

PRISMA-P

Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols.

PROSPERO

International Prospective Register of Systematic Reviews.

SCIELO

Scientific Electronic Library Online.

LILACS

Latin American and Caribbean Literature in Health Sciences.

BVS

Biblioteca Virtual em Saúde, Virtual Health Library.

PUBMED

National Library of Medicine.

DECS

Health Sciences Descriptors.

MESH

Medical Subject Headings.

PRISMA

Preferred Reporting Items for Systematic Reviews and Meta-Analyzes.

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Availability of data and materials

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Funding

Not applicable.

Authors' contributions

RRTL contributed to the design of the study, writing of the manuscript and approval of the final version. TBMF contributed to the review of the manuscript and approval of the final version. ABS contributed to the review of the manuscript and approval of the final version. LRAN contributed to the design of the study, review of the manuscript and approval of the final version.

Acknowledgements

Not applicable.

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Health care for transgender people in Brazil: a systematic review protocol

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Version 1

Abstract

Background

Methods

Discussion

Systematic review registration:

Figures

Background

Methods

Protocol and registration

Eligibility criteria

Information sources and search strategy

Data selection

Bias risk and quality assessment

Data analysis and synthesis

Discussion

Conclusion

Abbreviations

Declarations

References

Supplementary Files

Status:

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