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


 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.


Background
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 interactions 1 .
Transvestites, on the other hand, a term more widespread in Brazil and other countries in Latin America, are recognized as a female gure who seeks to build a unique image, not undoing some male characteristics and experiencing a constant ow between these two genders 2 .
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 population 3 .However, the discrimination and social exclusion imposed on these people puts them in worse health and living conditions 4 .
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 di culties 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 rearms 6,7 .In view of this reality, health care should not be con gured 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 nanced by the State 8 .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 inequities 9 .
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 2013 10 .
In Brazilian literature, there is an increase in scienti c articles publication approaching LGBTI population health after the creation of the National Comprehensive Health Policy LGBTI 11 , as well as theses and dissertations on transvestite, transsexuality and health after the expansion of the Transexualizador Process in SUS 12 .From this perspective, it is possible to identify some integrative reviews on transgender people health in Brazil, speci cally on the di culties 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-P 15 (see Additional le 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).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 scienti c 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 classi ed as abstracts published in annals, editorials, re ective 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 de ned 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 speci cities of each base (Table 2).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 de ned, 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 speci c 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 a rmative responses will be classi ed as studies with a high risk of bias, studies with a rmative responses between 50% and 69% will be classi ed as studies with moderate risk of bias and studies with 70% or more of a rmative responses will be classi ed as studies with low risk of bias 16 .
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 classi cation of the risk of bias in each one, will also be carried out independently by two researchers.In case of doubt or disagreement, the nal 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 ndings will be out through 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 scienti c 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 nal wording will be prepared based on the PRISMA guideline 17 .

Discussion
From preliminary searches, it was possible to identify that disrespect to the social name and the classi cation 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][19][20][21] .Considering the di culties 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.

Conclusion
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 scienti c 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.

Table 1
Elements of the research question according to the PECOS strategy.

Table 2
Search strategies for each database.
Lesbian, gay, bisexual, transgender and intersex.SUS Sistema Único de Saúde, Uni ed Health System.PRISMA-P Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols.PROSPERO International Prospective Register of Systematic Reviews.SCIELO Scienti c Electronic Library Online.
DeclarationsEthics approval and consent to participate Not Consent for publication