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.

Conhecimentos, percepções e itinerários terapêuticos de travestis e mulheres trans no cuidado a infecções sexualmente transmissíveis em Salvador, Brasil / Knowledge, perceptions and therapeutic itineraries of travestis and transgender woman in the care of sexually transmitted infections in Salvador, Brazil / Conocimientos, percepciones e rutas terapéuticas de travestis y mujeres trans en la atención de enfermedades de transmisión sexual en Salvador, Brasil

Resumo O artigo objetivou analisar conhecimentos, percepções, práticas de cuidado e Itinerrários Terapêuticos (IT) para o diagnóstico e tratamento das Infecções Sexualmente Transmissíveis (IST), com destaque para sífilis, entre Travestis e Mulheres Trans (TrMT) em Salvador, Brasil. Foram realizados 05 grupos focais e 06 entrevistas semiestruturadas com 30 TrMT. Os achados apontam amplo desconhecimento e percepções contraditórias sobre as IST, especialmente a sífilis; identificação de duas importantes trajetórias de cuidado às IST e o destaque para IT marcados por estigmas e discriminação nos serviços de saúde. Sugere-se a ampliação das ações de saúde para essa população reconhecendo suas necessidades e a construção de novas estratégias de prevenção e tratamento para IST, dialogadas com as TrMT, e garantia de autonomia, ética e sigilo na produção do cuidado.

Abstract The article aimed to analyze knowledge, perceptions, care practices and Therapeutic Itineraries (TI) for the diagnosis and treatment of Sexually Transmitted Diseases (STD), with emphasis on syphilis, among travesti and transgender women (TGW) in Salvador, Brazil. 05 focus groups and 06 semi-structured interviews with travesti/TGW were carried out with a total of 30 participants. The findings point to a wide lack of knowledge and contradictory perceptions about STD, especially syphilis; identification of two important trajectories of care for STD and the emphasis on TI marked by stigma and discrimination in health services. The expansion of health actions for this population is suggested, recognizing their needs and the construction of new prevention and treatment strategies for STD, in dialogue with the travesti/TGW, and guaranteeing autonomy, ethics and confidentiality in the production of care.

Resumen El artículo tuvo como objetivo analizar conocimientos, percepciones, prácticas de atención y Rutas Terapêuticas (RT) para el diagnóstico y tratamiento de las Enfermedades de Transmisión Sexual (ETS), con énfasis en la sífilis, entre las travestidas y mujeres trans (TrMT) en Salvador, Brasil. Se realizaron 05 grupos focales y 06 entrevistas semiestructuradas con 30 TrMT. Los hallazgos apuntan a una amplia falta de conocimiento y percepciones contradictorias sobre las ETS, especialmente la sífilis; identificación de dos importantes trayectorias de atención a las ETS y el énfasis en las RT marcadas por el estigma y la discriminación en los servicios de salud. Se sugiere ampliar las acciones de salud para esta población, reconociendo sus necesidades y la construcción de nuevas estrategias de prevención y tratamiento de las ETS, en diálogo con el TrMT, y garantizando la autonomía, ética y confidencialidad en la producción de cuidados.

Masculinizing gender-affirming surgery for trans men and non-binary individuals: what you should know.

Gender dysphoria, the discordance between one's gender identity and anatomy, affects nearly 25 million people worldwide, and the prevalence of transgender and non-binary identities is increasing because of greater acceptance and awareness. Because of the improved accessibility to gender-affirming surgery (GAS), many providers will care for patients during and after gender transition. For trans men (female-to-male), GAS represents a combination of procedures rather than a single surgery. The particular combination of masculinizing procedures is chosen on the basis of informed patient-provider discussions regarding the patient's goals and anatomy and implemented through a multidisciplinary team approach. In this review, we describe the common procedures comprising masculinizing GAS to improve delivery of specialized care for this patient population.

Benefit of Gender-Affirming Medical Treatment for Transgender Elders: Later-Life Alignment of Mind and Body.

PURPOSE: This study examined whether older age moderates the association between gender-affirming medical treatment and quality of life (QOL) among transgender individuals. METHODS: Transgender men and women from the National Transgender Discrimination Survey who had either recently or never undergone medical treatment were included (n = 2420). A moderation analysis was utilized. RESULTS: As predicted, participants who initiated medical treatment had higher QOL than those who did not. Age moderated this association. The QOL difference was greater for older than for younger transgender individuals. CONCLUSION: Among all transgender men and women, gender-affirming medical treatment can be especially beneficial for elders.

Fósseis do campo psi: sobre conversão de orientação sexual e gênero / Psy fossils: on sexual orientation conversion and gender / Fósiles del campo psi: sobre conversión de la orientación sexual y del género

Neste escrito analisamos a atualidade das discussões sociais e políticas em torno das práticas de conversão de orientação sexual e de gênero. Propomos pensar os riscos que teorias e técnicas estruturantes do campo psi - Psicanálise, Psicologia e Psiquiatria - têm de serem capturadas por grupos sociais, políticos e religiosos que podem utilizá-las para legitimar e ampliar o poder e o alcance de suas proposições no tocante ao exercício da sexualidade e à identidade de gênero. Construímos a hipótese de que certos fósseis morais, religiosos e conceituais, que pertencem aos registros lógicos e históricos das teorias e discursividades constituintes do campo psi, acabam sendo registros privilegiados para tal captura de práticas e de sentido conceitual. Dentre estes fósseis, citamos as discussões sobre a natureza psicopatológica da homossexualidade e mesmo sobre a formação de psicanalistas homossexuais, o que provocou debates intensos até tempos bastante recentes.(AU)

In this paper we analyze the current social and political discussions around the practices of conversion of sexual orientation and gender. We propose to think about the risks that the theories and structuring techniques of the field of psychoanalysis, psychology and psychiatry involve if captured by social, political and religious groups that can use them to legitimize and broaden the power and scope of their propositions regarding exercise of sexuality and gender identity. We construct the hypothesis that certain moral, religious, and conceptual fossils, which belong to the logical and historical records of the constituent theories and discursivities of the psy field, end up being privileged records for such capture of practices and conceptual sense. Among these fossils, we cite the discussions about the psychopathological nature of homosexuality and even about the formation of homosexual psychoanalysts, which provoked intense debates until quite recent times.(AU)

En este artículo analizamos las discusiones sociales y políticas actuales sobre las prácticas de conversión de orientación sexual y de género. Proponemos pensar en los riesgos que tienen que capturar las teorías y técnicas de estructuración en el campo psi - psicoanálisis, psicología y psiquiatría por parte de grupos sociales, políticos y religiosos que pueden usarlas para legitimar y extender el poder y el alcance de sus proposiciones con respecto al ejercicio de sexualidad e identidad de género. Presumimos que ciertos fósiles morales, religiosos y conceptuales, que pertenecen a los registros lógicos e históricos de las teorías y discursividades que constituyen el campo psi, terminan siendo registros privilegiados para tal captura de prácticas y de significado conceptual. Entre estos fósiles, citamos discusiones sobre la naturaleza psicopatológica de la homosexualidad e incluso sobre la formación de psicoanalistas homosexuales, lo que ha provocado un intenso debate hasta tiempos muy recientes.(AU)

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.

[Body, rights and comprehensive health: Analysis of the parliamentary debates on the Gender Identity and Assisted Fertilization Laws (Argentina, 2011-2013)]. / Cuerpo, derechos y salud integral: Análisis de los debates parlamentarios de las leyes de Identidad de Género y Fertilización Asistida (Argentina, 2011-2013).

In this paper we present an analysis of the parliamentary debates of the Gender Identity Law (No. 26743) and the Assisted Fertilization Law (No. 26862) carried out in the Argentine National Congress between 2011 and 2013. Using a qualitative content analysis technique, the stenographic records of the debates were analyzed to explore the following questions: How was the public problem to which each law responds characterized? How was the mission of each law conceptualized? To what extent did those definitions call into question ideas of health and illness, in including in the public health system coverage for certain medical treatments of body optimization or modification? In the process of sanctioning both laws, the concepts of health and disease were put into dispute as moral categories. In this context, an expanded concept of comprehensive health arose, in which desires regarding reproduction and the body were included.

Care of the elderly transgender patient.

PURPOSE OF REVIEW: This review examines recent developments regarding the care of the elderly transgender patient. There is scant clinical or other relevant information related to this topic, as the phenomenon of gender incongruity has been largely misunderstood and underreported. It is important that guidelines for appropriate and sensitive care be established, as this population is proliferating due to media attention and greater access to care. RECENT FINDINGS: A preponderance of evidence exists establishing that gender nonconforming elders are subject to discriminatory healthcare treatment. Agencies that serve the elderly are rife with policies and practices that resist acknowledging the needs of this population. Most heathcare and service providers have little experience with this group and limited understanding of non-normative gender identification. Barriers to treatment amplify the challenges of ageing for the transgender person and can lead to nondisclosure of clinically relevant personal information. SUMMARY: Increasing numbers of ageing transgender individuals will be interfacing with health and care providers. Many of these individuals will require medical and surgical interventions for gender dysphoria. Therefore, a concise enunciation of guidelines and standards of care applicable to these elderly, and training of primary care and specialists to provide such care are necessary. Education for nurses, social workers, administrators and others who comprise the comprehensive care system must be mandatory. Finally, institutions and agencies must adapt and become inclusive of the spectrum of diverse individuals found across the changing social landscape.