Obstacles in the access to public health services by transvestites and transgender persons: an integrative review

Objective : to describe obstacles to the access to health services of the transvestite and transgender population. Methods: integrative review, conducted from July to August 2022, in the following databases: LILACS, MEDLINE, Web of Science and SCOPUS. Results: 472 primary studies were found; however, at the end of the analysis process, 14 productions were included in the study. Obstacles to access to health were observed, such as the invisibility of health specificities, the lack of in - formation and preparation of professionals, the susceptibility, which appears in the juvenile stage, and the resistance to care for sexually transmitted infections, highlighting the need to invest in the production of policies that affirm the right to health for this segment of the population. Conclusion: there was a lack of studies on the access of transvestites and trans - genders to health services. These difficulties are associated with conservatism, heteronormativity, lack of implementa - tion and regulation of public policies for them. Contributions to practice: this article presents information about access to health care for the transvestite and transgender population, facilitating the view of the specific needs of this population. Descriptors:


Introduction
Transgender ("trans") is an umbrella term applied to portray a wide diversity of gender identities whose appearances and characteristics are observed to be divergent, including transvestite and trans people (1)(2) .
Due to the tension of society's binary norms, transsexuality exists concomitantly with the structural historical processes that involve the economic, social, and cultural system (2)(3) . Thus, the various forms of exclusion and society's inability to absorb these human beings are expressed in the denial of basic human rights. This is evidenced in the life expectancy, which, while the Brazilian society is 74.9 years, the trans population is 35 years (3) .
In the health context, transvestites and transgender people face numerous difficulties in accessing health care and services of the Brazilian Unified Health System (SUS). There is evidence of institutional transphobia and disrespect for the social name, among other violations, which are configured as obstacles to access health facilities, which can promote, consequently, the worsening of their health status. Moreover, the pathologizing of trans gender identities during the SUS transsexualization process comes into debate, hindering the entry of this public to health centers (4)(5) .
The National Policy of Integral Health of Lesbians, Gays, Bisexuals, Transvestites and Trans (PN-SILGBT) has as its main axis the promotion of integral health of Lesbians, Gays, Bisexuals, Transvestites and Trans (LGBT) people, aiming to extinguish the marginalization of this population and institutional prejudice, having sexual orientation and gender identity as social determinants of health (6) . However, the social stigmas about this population mean that, often, the care provided by health professionals is limited to aspects of Sexually Transmitted Infections (STIs). Thus, expanding the focus of health care in a comprehensive way and encompassing the broad understanding of health together with human rights and respect for differences is of paramount importance (7) .
Considering the above, this study aimed to describe obstacles to the access to health services of the transvestite and transgender population.

Methods
This is an integrative literature review, with a timeless delimitation and operationalized by the following phases: 1) idealization of the guiding question and delimitation of the object of study; 2) determination of the criteria: inclusion and exclusion of scientific productions; 3) search for articles in databases and virtual libraries; 4) investigation and classification of the literature found; 5) results and argumentation of the findings; 6) presentation of the review/synthesis of the study (8) .
In choosing the guiding question, we used the PICo strategy (P: transvestite and trans; I: difficulties in access; Co: health services). Thus, the following question (9) was defined: What are the difficulties of access to health services experienced by transvestites and transgender persons?
When selecting articles, the following inclusion criteria were chosen: to address the trans population in the title and/or abstract, to present factors related to health care for the trans population, to be an original article, available in full, published in Portuguese, English or Spanish, that adhered to the purpose of the study, timeless, in which the period from 1990 to 2022 was observed in order to seek evidence that would allow us to observe the evolution of publications on this theme, considering the scarcity of articles.
Works in the format of thesis, book, dissertation or book chapter, newspaper article, editorial, integrative, or systematic literature review, reflective study, letter to the reader and experience report were not included in this study, as well as articles that did not answer the guiding question of the study.
The double-blind literature survey by indepen-dent researchers was conducted during the months of June to August 2022 through searches of the following databases: Latin American and Caribbean Literature on Health Sciences (LILACS); Medical Literature Analysis and Retrieval System Online (MEDLINE), Web of Science (WoS), and SCOPUS. The articles were identified using the Health Science Descriptors (DeCS): "Health Care"; "Sexual and Gender Minorities"; "Transgender Persons" and "Transgender Persons"; "Sexual Health". The respective synonymous terms from Medical Subject Headings (MeSH) were used: "Health Care (Public Health)"; "Sexual and Gender Minorities"; "Transgender Persons"; "Sexual Health". The conducted strategy was based on the junction with the Boolean operator AND and OR, implementing the search jointly and individually so that probable divergences were corrected ( Figure 1). The studies were searched by two researchers independently, and there was no disagreement. At first, duplicate studies were eliminated using the Zotero data and reference manager. Then, the Rayyan QCRI ® software was used to organize and query the titles and abstracts of the articles by pairs, to verify the inclusion/exclusion criteria. Subsequently, a collaborator determined a consensus among the articles that provided similarities, and in cases where discrepant divergences occurred, aiming to minimize biases. Then, the final 14 articles were read in their entirety ( Figure 2).

LILACS
Then, there was an analysis regarding the degree of evidence, according to the methodological approach of the Agency for Healthcare Research and Quality (AHRQ): Level I -Systematic review, meta-analysis or clinical guidelines arising from systematic reviews of randomized and controlled clinical trials; Level II -Well-controlled randomized clinical trial; Level III -Well-designed clinical trials without randomization; Level IV -Well-designed cohort and case-control study; Level V -Systematic review, of descriptive and qualitative studies; Level VI -Descriptive or qualitative study; and finally, Level VI -Opinion of authorities and/or opinion of expert committee (10) .
And, also, quality of evidence according to the GRADE system: High -There is strong confidence that the authentic purpose is like that estimated; Moderate -There is moderate confidence in the outcome considered; Low -Reliability of the outcome is limited; and Very Low -Reliability in estimating the outcome is very limited. There is no degree of certainty in the results (11) .
To assess the risk of bias, the Cochrane Collaboration tool was used, based on seven domains (1. random sequence generation; 2. allocation concealment; 3. blinding of participants and professionals; 4. blinding of outcome assessors; 5. incomplete outcomes; 6. selective outcome reporting; and 7. Other sources of bias), these analyze the various types of biases that may be evident in randomized clinical trials, such as selection bias, performance bias, detection bias, attrition bias, reporting bias, and other biases. The judgment of each domain is performed in three categories (high risk of bias, low risk of bias and uncertain risk of bias), based on the signaling questions (12) .
Indicator questions used in this study: 1. randomization sequence generation (randomization sequence? Unbalance between group characteristics? 2. Allocation concealment (allocation secrecy?) 3. Blinding of participants and professionals (Do participants know about the allocation? Does the staff know about the allocation? Was there deviation? Was there impact on outcomes? Balanced biases between groups? 4. Incomplete outcomes (Is the data for the outcome being evaluated incomplete? Is there evidence that the result was not biased by missing data? Could losses be intervention-related? (12) .
The studies were organized in a Microsoft Excel ® table containing the following information: title, database, author, year of publication, objective, methodological design, location and language, level of evidence, and summary of results, enabling a better understanding and visualization of the findings.
The investigation was based on a thorough reading of the selected articles, focusing on qualitative analysis. The flowchart was also created according to  the indications of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) (13) .

Results
Initially, 472 articles were found, and 14 studies were selected at the end of the process, according to the phases described in Figure 2.
In Figure 3, the surveyed studies are arranged showing their title, database, author, year of publication, objective, methodological design, location and language, level/quality of evidence, and sample characteristics (n, age range, instrument, location, and period of study). It can be analyzed that there is a greater number of international articles (n=11), published in English, in the last 2 years (n=6), two national articles and published in English. Regarding the level of evidence, the articles were mostly classified as level VI (10) ; and regarding the quality, they were mostly classified as moderate (11) .

Nº Database
Author  In Figure 4, the surveyed studies are arranged, showing the synthesis of the results that answer the research's guiding question.
When performing the risk of bias analysis, it was observed that, regarding the randomization sequence generation and allocation concealment, 9 (64.3%)

Nº
Summary of the results 1 Greater outreach of cancer prevention among gender and sexual minorities is needed.

2
Data highlight barriers to accessing Assisted Reproduction (AR) services for transgender people. The main barriers involve the education and training of AR service providers; the quality of services, clinical practices, and the clinical environment. 3 The results of this study demonstrate that the overall health of trans respondents is related to vulnerabilities that are unique to trans people, in addition to other well-known determinants of health.

4
This study highlights the disparity in unmet health care needs that existed between trans Ontarians and their cisgender counterparts, despite similarities in perceptions of health care between these two populations.

5
Transgender and gender non-conforming (GNC) adults face barriers to health care that may be due to a variety of reasons, including discrimination in health care, employment, public policy, or lack of awareness among health care providers about transgender health issues.

6
The prevalence of seropositivity among trans women was 16.5%, of which 92.0% reported having a doctor with whom they consulted regularly about Human Immunodeficiency Virus (HIV). In addition, 8.2% of trans men and 12.5% of gender diverse people did not know their HIV status. Finally, 71.0% of participants were unaware of post-exposure prophylaxis.

7
The Cuban state approaches sexuality and sexual identity as health-based challenges. Cuba provided an example of how the right to health for all improves health outcomes for those with trans health needs. 8 Psychiatric disorders were highly prevalent among trans and non-binary adult patients. New findings include associations of lack of integration of psychiatrist in primary care with acuity and use of case management with outpatient behavioral health involvement.

9
The present study observed the lack of services for the transsexual population, as well as the incompatibility in the need for follow-up services for hormone and surgical treatments, among other services. The invisibility of this population makes it more susceptible to diseases caused by the improper and unmonitored use of hormones and body modifiers.

10
In this study, it was possible to analyze the shortage related to management and health professionals in relation to transsexuality, as a condition of invisibility of this population in health units.

11
It was found that there is a shortage of resources and knowledge for the provision of health services to the trans population, resulting in adverse experiences. Transgender care policies and training of health professionals will contribute to the improvement of access to health care units for this population.

12
Vital innovations to avoid delays in care and ensure quality of services for transgender and gender non-conforming (TGGNC) patients in emergency departments are increased attention to provider education and basic adaptations in service delivery settings.

13
Transgender women in China face high social rejection and discrimination, along with unmet need for various types of health care. The expansion of transgender-specific services, including gender-affirming medical care, mental health care, and HIV/Sexually Transmitted Infections (STI) prevention, are warranted to address the social, medical, and mental health of transgender women in China.
14 Issues hindering Transgender and Non-Binary (TGNB) youth relate to transphobia, lack of social support, pathologizing of transsexuality, low self-esteem, and anxiety symptomatology.  of the studies presented low risk of bias; regarding the blinding of participants and professionals, only 1 (7.1%) study with uncertain risk of bias, and finally, regarding incomplete outcomes, all studies presented low risk of bias ( Figure 5).

Discussion
It has been seen that the Lesbian, Gay, Bisexual, Transvestite and Trans, Queer, Intersex, Asexual/ Agender/Aromantic, Pansexual, Non-Binary and other sexual and gender diversity (LGBTQIAPN+) community has suffered much discrimination over the years, followed by rejection by society, along with neglect in health care.
Denials, violence, neglect, and invisibility of the transvestite and transgender population in health services is sustained in a structural, economic, symbolic, and political conception of society as a whole (28)(29)(30)(31)(32) . The lack of recognition of this population is fed back by an understanding based on patriarchy, sexism, and machismo, which predominate in various spectrums of human relations, even within health institutions (33)(34)(35) . This is explained by a sex-gender system that recognizes only normative subjects, cisgender and fated to experience heterosexuality, influencing the care and quality of health care for transgender people (36) .
The culture of humanization and respect for the social name is essential, since it results mainly in the recognition and respect for the human being, through the way the health team will act, the subjectivities of users and, finally, the collectives (37)(38) . Transphobia, materialized in resistance to the use of the social name, can cause difficulties in the health-disease-care process of transvestites, transsexual women, and men (28) .
The life expectancy of transgender people is 35 years, while the general population has an average life expectancy of 75.8 years (3) . These data come from the death of this population by transphobia, in addition to non-violent deaths of trans people that are associated with complications from HIV infection and those due to body modifications and use of hormones without medical advice (39)(40)(41) .
In the global panorama, education and professional training is necessary to overcome barriers to access to health care by the trans population (42)(43)(44) . In addition, it is imperative the need for public policies that enable greater citizenship, self-awareness of health status, and greater attention to the sexual and reproductive needs of trans people (36,(45)(46)(47) .
The trans population has physical health limitations and a neglected state of general health when compared to cisgender people (46)(47)(48)(49)(50) . Thus, the historical struggle of the trans movement remains present and, in the dispute for meanings, this population seeks to be seen, cared for, and understood as belonging to society, as well as for a more holistic understanding of the individual in their relationship with services and the Health System (47)(48)(49)(50) .
In the late 1970s, the development of public health policies aimed at the trans population in Brazil was implemented. Therefore, it can be noticed that, with the maturation of democracy, these historically neglected civil society movements, such as the LGB-TQIAPN+ population, conquer the implementation of this policy (29)(30)(31) .
Respecting and ensuring, through public policies, the use of the social name is an indispensable tool to contribute to the reduction of discrimination of the trans population by health teams and the barriers faced by the exercise of citizenship (1,31) .
Regarding social representations, the trans population presented difficulties to medical appointments, associated with the presence of heteronormative standard, social prejudice, and institutional stigma. These results expose the susceptibility of this social group to the incessant confrontation of various barriers to achieve their social rights (30) . Furthermore, they induce reflection about the health of this population, especially related to the importance of encouraging the employment of new public policies specific to the population, providing more training for professionals who intend to serve this public (50) .
The progress achieved by the trans population in various spheres is remarkable, especially around health in Brazil, through the organized movements of the trans population that have been taking place, through their specificities manifested in the spaces of social control, such as in the Conferences of Public Policies for LGBTQIAPN+ and in the Health Councils. However, the insecurity presented by the trans population in Brazil is at the point that the institutional guarantees for the right to health of these people tend to have difficulties to be implemented because they are not prioritized in the municipal, state, and federal managements (30)(31)(32) . This is based on a predominant homophobic religious patriarchal culture in political spaces of democratic representation, which, several times, do not recognize the importance of discussing and highlighting the situation to which this population is exposed, fostering the risk for the state principle (29)(30)(31)(32) .
Municipal health care managers manifest difficulties in actively listening and identifying potential actions of the LGBTQIAPN+ community throughout history. This difficulty in visualizing this population causes a negative chain and influences the managers' viability, as well as the way they understand themselves as agents responsible for this population in the health-disease process. The unfeasibility of the demands has a negative influence on the search for knowledge about these experiences by managers, as well as on the perception of their responsibilities to the trans population in the SUS. This hinders the promotion of actions to minimize inequalities and to bring these people closer to the public health system (30)(31)(32) .

Study limitations
There is incipiency of articles on the access of the transvestite and transsexual population to health care from a global perspective. Moreover, when the methodological quality of these articles is analyzed, it is possible to identify weaknesses attributed to the method applied, requiring robust scientific productions as to methodological rigor and levels of evidence.

Contributions to practice
This article presents information about access to health care for the trans population, which con-tributes to facilitate the view of the specific needs of this population; however, prejudice and obstacles still exist. Given this, there is a need for further research that raises this question, so that it is possible to break paradigms and change the practice of care, as well as highlight the importance of health professionals facing the weaknesses faced by the LGBTQIAPN+ population.

Conclusion
In view of the findings, it was observed that society still cultivates normative thoughts about sex and gender, thus presenting themselves as obstacles to social life, as well as to the entry into health services. Thus, they face conservatism, heteronormativity, lack of implementation and regulation of public policies for this population, because although the policies exist, it is not seen in practice its effectiveness, in addition to the susceptibility faced, facing neglect and marginalization in relation to society, in the face of prejudice.