Itinerário terapêutico de pessoas transgênero: assistência despersonalizada e produtora de iniquidades / Therapeutic itinerary for transgender people: depersonalized care produces iniquities

Resumo Este artigo analisa o itinerário terapêutico de pessoas transgênero em uma cidade do interior da Bahia. Os participantes foram selecionados pelo critério do método da "bola de neve" e utilizou-se entrevista semiestruturada para produção dos dados. Na análise dos itinerários terapêuticos, emergiram três categorias temáticas: 1) Lugares de busca para o cuidado em saúde: traçadores de iniquidades no SUS; 2) Abordagem profissional: reforça os estigmas e cinde a relação terapêutica; e 3) Demandas específicas por cuidado: percalços ao longo do itinerário terapêutico. Os resultados mostraram que o acesso ao serviço formal esteve permeado por barreiras simbólicas, técnicas e/ou organizacionais que, muitas vezes, transferiam para cada um/uma dos/as entrevistados/as a responsabilidade pela busca de outros percursos formais ou recomposição do cuidado por trajetórias nem sempre seguras. A busca pelo setor privado foi preponderante e, paralelamente, houve a desvalorização do SUS. O estigma institucional resultou em abandono de tratamento, retardo na busca por cuidado ou desistência de procura aos serviços. Por fim, a dificuldade de acesso no SUS produzia iniquidades e conduzia as pessoas transgênero, sobretudo as mais vulneráveis, a exposição e experimentação de procedimentos, muitas vezes, inadequados.

Abstract This article examines the therapeutic itineraries of transgender people in a city in the Bahia countryside. Participants were selected using the "snowball" method using semi-structured interviews to produce the data. In the analysis of therapeutic itineraries three thematic categories emerged: 1) Locus of seeking health care: tracers of inequities in SUS; 2) Professional approach: reinforcing stigmas and interrupting the therapeutic relationship; and 3) Specific demands for care: mishaps along the therapeutic itinerary. Results showed that access to formal services was permeated by symbolic, technical and/or organizational barriers. Those barriers frequently transferred the responsibility for the search of alternative formal paths or the restoration of care upon the interviewees, by using trajectories oftentimes unsafe. The search for the private sector was predominant and, in parallel, there was a depreciation of SUS. The institutional stigma resulted in treatment abandonment, delay in looking for care or giving up seeking services. Finally, the difficulties in accessing the SUS produced inequities leading transgender people, especially the most vulnerable, to be exposed and to experiment with often-inadequate procedures.

Gender identity, healthcare access, and risk reduction among Malaysia's mak nyah community.

Transgender women (TGW) face compounded levels of stigma and discrimination, resulting in multiple health risks and poor health outcomes. TGW identities are erased by forcing them into binary sex categories in society or treating them as men who have sex with men (MSM). In Malaysia, where both civil and religious law criminalise them for their identities, many TGW turn to sex work with inconsistent prevention methods, which increases their health risks. This qualitative study aims to understand how the identities of TGW sex workers shapes their healthcare utilisation patterns and harm reduction behaviours. In-depth, semi-structured interviews were conducted with 21 male-to-female transgender (mak nyah) sex workers in Malaysia. Interviews were transcribed, translated into English, and analysed using thematic coding. Results suggest that TGW identity is shaped at an early age followed by incorporation into the mak nyah community where TGW were assisted in gender transition and introduced to sex work. While healthcare was accessible, it failed to address the multiple healthcare needs of TGW. Pressure for gender-affirming health procedures and fear of HIV and sexually transmitted infection screening led to potentially hazardous health behaviours. These findings have implications for developing holistic, culturally sensitive prevention and healthcare services for TGW.