Introduction

In Brazil, health is a constitutional right guaranteed since 1988, from the creation of the Unified Health System (SUS), regulated by Federal Law 8080/90, which consolidates health as “a fundamental human right, and the State must provide the indispensable conditions for its full exercise”.¹ The basic principles of the SUS are universality, integrality and equity. The latter aims to reduce social inequalities, which means recognizing the existence of different social groups that require specific and differentiated care to meet their needs and overcome social injustices.^2,3 In 2011, the National Policy for the Comprehensive Health of Lesbians, Gays, Bisexuals, Transvestites and Transsexuals (Portuguese acronym: PNSI-LGBT),⁴ was established as a response to the demands and specificities of this population, which were made invisible. The institution of the PNSI-LGBT represents a historic milestone of resistance and struggle of this population to guarantee their rights.⁵ Prior to the creation of this policy, the launch of the Brazil Without Homophobia Program in 2004,⁶ also fruit of the coordination between civil society and the State, and a milestone for the strengthening of citizenship, rights and dignity for the LGBTQIA+ population also stands out. The access to health services free of any discrimination is one of the main agendas of this community.^3,7

Discrimination based on sexual orientation and gender identity is characterized as a social determinant of health as it triggers processes of suffering, illness and premature death resulting from different types of violence perpetrated against the LGBTQIA+ population.^8,9 In addition, formal access to health services is permeated by symbolic, technical or organizational barriers that commonly depersonalize care and produce inequities.¹⁰ The transgender population faces greater difficulties in social insertion because their differences are marked in their bodies, often read as abject and, thus, placed on the social margins.¹⁰ Transgender people do not identify with the gender assigned to them at birth, and may identify as a transsexual man, transsexual woman or transvestite, whether or not they are in the man or woman binarity.¹¹ In this scenario, transgender people have specific health needs, such as carrying out body modifications through hormone therapy, gender reassignment surgery, among others, often demanded for their gender affirmation. Thus, Primary Health Care (PHC), as the main and priority door of the Health Care Network (Portuguese acronym: RAS),¹² and nurses as components of the minimum team in basic health units, play a fundamental role in this process, providing general and specific care and acting in user embracement for the production of comprehensive care.^13,14

According to the National Primary Care Policy of 2017,¹⁵ nurses are important professionals for this articulation, as they act directly in the management, planning and care in the different spaces of PHC.¹⁴ Therefore, nursing professionals in PHC must know the community and establish bonds, perform and supervise user embracement with qualified listening and risk classification according to established protocols, promote disease prevention and health protection actions, identify individual and collective health problems, implement and keep routines, protocols and flows related to their area of competence at the basic health unit updated, work with groups by respecting and interacting with cultural differences, demonstrate knowledge of the population’s health problems and of social determinants, among others.^15,16 In view of this, nurses in PHC, as members of the team, have a fundamental role in the construction of spaces for embracement of the transgender population, performing functions based on the principles of the SUS, not admitting discrimination of any kind.¹⁷

In this context, in spite of what is provided for by legislation and health policies, care to the transgender population has been neglected by PHC professionals.¹⁰ This population faces different types of barriers to access health services, such as weaknesses in user embracement, inadequate training of professionals and incipient implementation of the PNSI-LGBT.⁵ These barriers also result from social prejudice and stigma, which act through institutional discrimination and distance transgender patients from health services.¹⁷ Therefore, the aim of this review of the literature is to describe the care provided to the transgender population in PHC by nursing.

Methods

This is an integrative literature review, a method that provides the synthesis of knowledge and incorporation of the applicability in practice of results from significant studies.¹⁸ It was carried out through six steps: 1) choice of theme and elaboration of the guiding question; 2) literature search or sampling; 3) data collection; 4) critical analysis of included studies; 5) discussion of results; and 6) presentation of the integrative review. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was adopted as a guideline for its development.¹⁹

In order to answer the guiding question of the study: “How has nursing care been provided to the transgender population in PHC?”, in December 2021, a search was performed in databases of the Virtual Health Library (VHL), Public Medline (PubMed) and Web of Science (WoS) using the descriptors “Pessoas Transgênero”, “Identidade de gênero”, “Cuidados de Enfermagem” and “Atenção Primária à Saúde”, from the Descriptors in Health Sciences (DeCS) and its correspondents in English “Transgender persons”, “Gender identity”, “Nursing care” and “Primary health care”, from Medical Subject Headings (MeSH). Terms in both languages were combined using the Boolean operator OR for the first two terms, and AND for the other terms.

Regarding selection criteria for publications, complete articles in Portuguese, English and Spanish available electronically, portraying the theme related to the review were included. Duplicated articles and those not directly addressing the theme were excluded. A timeframe was not established for the searches in order to increase the scope of the research.

At first, 22 articles were found in VHL, 148 articles in PubMed and 105 articles in WoS, totaling 275 articles. The analysis performed by reading the records led to the selection of 11 articles (Figure 1).

After selecting the articles, a spreadsheet containing the title, author, country of origin, year of publication, journal title, objectives, main results and conclusions was created in Excel 2010. It constituted the study database. The articles were grouped, producing categories that were presented, analyzed and discussed in light of the available literature on the subject.

Figure 1 Publication selection flowchart 

Results

The 11 studies analyzed were published between 2008 and 2021 in ten different journals. With regard to the countries of origin of publications, five were from Brazil,^20-24 two from Canada^25,26 and four from the United States.^27-30 Five articles were published in Portuguese and six in English. Articles in Spanish were not selected. The general characteristics of included studies are systematized in Table 1.

After reading and structuring the information from selected studies, four thematic categories emerged: I - Embracement and healthcare; II - Implementation of Public Health Policies; III - Weaknesses in academic training; IV - Barriers between theory and practice.

Discussion

Publications converge on the need for user embracement services that respect the use of the social name, the pronoun by which the individual wishes to be identified, display of safe space signs (use of non-binary forms), gender-neutral bathrooms and training with cultural competence for all professionals. Fragilities in user embracement, academic training, insufficient in-service education for professionals and negligence in the implementation of public policies on transgenderism indicate important obstacles in accessing PHC health services.

In Brazil, nursing care aimed at transgender individuals in PHC is still incipient and restricted to dispensing condoms and testing for HIV/AIDS. On the other hand, studies conducted in Canada indicate ways to structure a PHC prepared to meet the needs of this group, highlighting how nursing care has been practiced in these spaces.^25,26 Furthermore, there is a need to create care protocols that support and provide subsidies to nursing for an adequate practice in the care of the transgender population. To this end, it is suggested that nursing^24,28,29 acting in PHC demands from class and manager councils in order to modify the reality of the health of the transgender population in their different territories.

User embracement is an operational guideline of the SUS, which has the following principles: to assist all people who seek health services, guaranteeing universal accessibility and assuming its main role of listening to the demands of the population, therefore being resolutive; to reorganize the work process aimed at its displacement from the central axis, which is the doctor, to a multidisciplinary team in charge of the care process, committing itself to solve users’ health problem; to qualify the worker-user relationship, which should be based on humanitarian, solidarity and citizenship parameters.^4,31,32 In this sense, user embracement is a fundamental tool for an inclusive work process with the potential to break barriers of access in PHC, as it mobilizes the sensitivity of health workers, requiring reflective action, ethical and solidary development to listen and dialogue, generating reciprocal satisfaction.¹³

User embracement is still a major challenge for the SUS, especially when directed at the transgender population,¹⁰ who requires health professionals with knowledge about gender and sexuality, who break social taboos in a way to overcome many of the discriminations experienced by this public.^5,33 Thus, it is necessary to break with social stigmas, address concepts permeating the transgender population and know their main demands and needs.^24,30

It is important that professionals reflect on their practice, reflect on the population of their territory and their demands, and be transforming agents.^33,34 In Brazil, for example, campaign models, such as “Pink October” and “Blue November” determine the gender to which these campaigns are aimed (women and cisgender men), making the transgender population completely invisible in this process, as well as their health needs, such as gynecological ones (for transgender men and people with vagina/uterus), urology (for transgender women and people with prostate) etc., reinforcing exclusionary practices.^10,27 Thus, nursing has much to contribute to improve health access for the transgender population in PHC, making it possible, together with a multidisciplinary team, that Basic Health Units become places to which the transgender population feel they belong and where their health demands are met.^28,29) In this context, the managers’ inertia in the face of the urgent need to implement the PNSI-LGBT and in the development of care strategies (care flows, protocols, among others), especially in the context of PHC, shows the marginalization of the demands of this population in the SUS, evidencing multiple barriers.⁵ All that also converges with the Report of the First National LGBT Health Seminar, which points to the lack of training of managers and health professionals as an important critical point in the implementation of the PNSI-LGBT.³⁵

Nursing plays an extremely important role, among others, as a PHC component that can contribute to the care of the transgender population.²⁴ The nursing professional must encourage and support the implementation of the PNSI-LGBT, keeping routines and protocols up to date, as well as care flows related to their area of competence at the Basic Health Unit.¹⁵ In addition, they can make proposals at PHC team meetings, stimulating changes in the ambience, user embracement and care flows. Furthermore, Nursing can discuss and develop strategies with the team to bring the Basic Health Unit closer to the transgender population in an active search movement in the territory. In this sense, the construction of health actions should also be performed together with this population, admitting their protagonist role in the production of their health.^7,36

An Australian study found that the incipient knowledge and unpreparedness of professionals are the most important obstacles to the LGBT population’s access to health services.³³ These limitations in academic training reinforce the cis-heteronormative character reproduced in educational institutions, in which the theme under study is addressed only on occasion in their curriculum matrices.³⁷ In Brazil, the scarcity of discussions on the subject during undergraduate nursing courses is due to outdated curriculum matrices centered on traditional models that do not broadly include professional nursing education in curricular components addressing care with an approach to gender and sexuality.³⁸ Many studies, not only in the national context, discuss the existing lack of integration in nursing courses of contents addressing care to the transgender population in a transversal manner.^28,39 The limited approach to this theme in the academic training of nursing professionals has contributed to the inflexible care based on individual and collective discriminatory values, reduction of the demands of the transgender population to HIV/AIDS, thereby reinforcing stigmas and disregarding the health of this group in a broader sense.³²

Conclusion

The articles analyzed in this literature review showed a limited overview of nursing care for the transgender population, given the few studies found at the national and international level. Nonetheless, the scarcity of academic works focused on this theme is an important indication that care has been incipient or even non-existent in the context of PHC.

It was also evident that structural and interpersonal stigmas materialized in discriminatory and prejudiced practices perpetrated by managers, professionals and health institutions constitute the greatest challenges to be overcome for comprehensive, equitable and humanized care for the transgender population. Stigma, in turn, produces discrimination, which is materialized by social exclusion and the most varied forms of violence, including institutional violence, present in various social structures that directly affect transgender people’s access to health services. Given the above, there is an urgent need to reorganize the curricular matrices of nursing courses, so that they also address the health of the transgender population in a transversal way to the training process.

Study limitations. This is a review text, and the chosen databases may not reflect the set of studies, even though they adequately signal the productions related to nursing care for the transgender population. In addition, many successful practices may be hidden and are not properly disclosed, as publishable academic work often discloses empirical results that privilege practices with other social groups - structural stigma is also part of scientific production.