Sociodemographic profile and access to health services among people attending the Transgender Outpatient Clinic: a cross-sectional study, Brazilian Federal District, 2018-2022Abstract
Objectives To characterize the sociodemographic profile, gender transition trajectory, and access to health services of trans persons and travestis, as well as to identify factors associated with not having been accessed by the Family Health Strategy (FHS).
Methods This was a cross-sectional study by means of analysis of medical records of trans persons and travestis (≥18 years) attending the Federal District Transgender Outpatient Clinic, 2018-2022. Descriptive analysis stratified by gender was performed. Associated factors were analyzed using bivariate analysis (prevalence ratio [PR] with 95% confidence interval [95%CI]) and multivariate analysis using binary logistic regression (adjusted odds ratio [OR] with 95%CI).
Results Out of 261 records (57.0% trans men, 37.6% trans women, and 5.4% travestis), the majority were young people (66.0%, 18-29 years old), Black (61.3%), with paid employment (46.7%) and complete high school or lower level education (54.3%); 25.0% had legally changed their name, 73.2% reported discrimination, and 49.0% of trans women and travestis began their transition without support. Mental disorders (46.4%) were the most frequently reported; and 17.2% had health insurance. Higher use of public urgent care and emergency services (56.7%) was observed compared to primary care (21.1%). Seeking care at a primary health care center when becoming ill decreased the odds of a negative outcome by 86.0% (OR 0.14; 95%CI 0.05; 0.37).
Conclusion Sociodemographic inequities, inequalities in gender transition trajectories, as well as in access to healthcare were evident, with underutilization of primary care. Being linked to a primary health care center proved to be a protective factor, emphasizing the FHS as essential for comprehensive care.
Keywords
Transgender Persons; Transvestites; Access to Health Services; Primary Health Care; Cross-Sectional Studies
Resumo
Objetivos Caracterizar perfil sociodemográfico, percurso de transição de gênero e condições de acesso a serviços de saúde de pessoas trans e travestis, além de identificar fatores associados a não ter sido acessado(a) pela estratégia saúde da família (ESF).
Métodos Estudo transversal mediante análise de prontuários de pessoas trans e travestis (≥18 anos) atendidas no Ambulatório Trans do Distrito Federal, 2018-2022. Realizou-se análise descritiva estratificada por gênero. Os fatores associados foram analisados por meio de análise bivariada (razão de prevalência [RP] com intervalo de confiança de 95% [IC95%]) e análise multivariada por regressão logística binária (odds ratio [OR] ajustado com IC95%).
Resultados Entre 261 prontuários (57,0% homens trans, 37,6% mulheres trans e 5,4% travestis), predominaram pessoas jovens (66,0%, 18-29 anos), negras (61,3%), com ocupação remunerada (46,7%) e ensino médio completo ou menor nível (54,3%); 25,0% retificaram o nome, 73,2% relataram discriminação, e 49,0% das mulheres trans e travestis iniciaram a transição sem acompanhamento. Doenças psiquiátricas (46,4%) foram as mais relatadas; e 17,2% tinham plano de saúde. Observou-se maior utilização de serviços públicos de urgência e emergência (56,7%) que na atenção primária (21,1%). O fato de buscar atendimento na unidade básica de saúde (UBS) quando do adoecimento diminuiu em 86,0% a chance do desfecho negativo (OR 0,14; IC95% 0,05; 0,37).
Conclusão Evidenciaram-se iniquidades sociodemográficas, desigualdades na trajetória de transição de gênero e no acesso à saúde, com subutilização da atenção primária. O vínculo com a UBS mostrou-se fator protetor, o que reforça a ESF como essencial ao cuidado integral.
Palavras-chave
Pessoas Transgênero; Travestis; Acesso a Serviços de Saúde; Atenção Primária à Saúde; Estudos Transversais
Resumen
Objetivos Caracterizar el perfil sociodemográfico, la trayectoria de transición de género y el acceso a los servicios de salud de personas transgénero y travestis, así como identificar los factores asociados a la falta de acceso a la Estrategia de Salud Familiar (ESF).
Métodos Estudio transversal mediante el análisis de expedientes médicos de personas transgénero y travestis (≥18 años) atendidas en la Clínica de Atención Ambulatoria para Personas Transgénero del Distrito Federal, entre 2018 y 2022. Se realizó un análisis descriptivo estratificado por género. Los factores asociados se analizaron mediante análisis bivariado (razón de prevalencia [RP] con intervalo de confianza del 95 % [IC95%]) y análisis multivariado mediante regresión logística binaria (odds ratio [OR] ajustado con IC95%).
Resultados Entre 261 registros (57,0% hombres trans, 37,6% mujeres trans y 5,4% travestis), la mayoría eran jóvenes (66,0%, de 18 a 29 años), negros (61,3%), con empleo remunerado (46,7%) y con estudios secundarios o inferiores (54,3%); el 25,0% había cambiado legalmente su nombre, el 73,2% reportó discriminación y el 49,0% de las mujeres trans y travestis iniciaron su transición sin apoyo. Las enfermedades psiquiátricas (46,4%) fueron las más frecuentes; y el 17,2% tenía seguro médico. Se observó mayor utilización de los servicios públicos de urgencia y emergencia (56,7 %) en comparación con la atención primaria (21,1%). Acudir a un centro de atención primaria de salud al enfermar redujo la probabilidad de un desenlace negativo en 86,0% (OR 0,14; IC95%: 0,05; 0,37).
Conclusión Se evidenciaron inequidades sociodemográficas, desigualdades en las trayectorias de transición de género y en el acceso a la atención sanitaria, con una baja utilización de la atención primaria. La vinculación con el centro de atención primaria de salud demostró ser un factor protector, reforzando la ESF como esencial para una atención integral.
Palabras clave
Personas Transgénero; Travestis; Acceso a los Servicios de Salud; Atención Primaria de Salud; Estudios Transversales
This research respected ethical principles, having obtained the following approval data:
Research ethics committeeOpinion number, Certificate of submission for ethical appraisal , Approval date
Universidade de Brasília 6,333,242, 69644223.4.0000.0030, 29/9/2023
Secretaria de Saúde do Distrito Federal 6,650,598, 69644223.4.3002.5553, 15/2/2024
Informed consent record Exempted.
Introduction
The Brazilian Unified Health System (Sistema Único de Saúde, SUS) has achieved significant progress in providing care to the Brazilian population. However, political, programmatic, social and economic challenges persist that prevent its full implementation [1]. Access to health is not limited to one-off appointments, but constitutes a continuous process of care, conditioned by the effectiveness of care actions [2]. Comprehensive health care requires that services, at all levels of care, organize processes and practices to adequately meet demands [3].
The precepts of the National Primary Care Policy [4] define Primary Health Care (PHC) as the preferred entry point to the SUS, which must be free from any form of exclusion. The Family Health Strategy (FHS) is a PHC care model, focusing on illness prevention and health promotion and recovery. It is the responsibility of the Brazilian states and Federal District to strengthen it as a priority action, based on action in defined territories. A person having been accessed by the FHS indicates monitoring of a health situation or a home visit made by the FHS team, for example. This can reduce the demand for emergency services, prevent unnecessary hospitalizations and ensure referrals to specialized care.
In practice, ensuring access for transgender (trans) people to primary health care and specialized care services is a challenge. This population faces a reality marked by multiple barriers and systematic rights violations, especially when their health needs require comprehensive care that transcends the gender affirmation process [5].
In the Federal District, 1% of adults self-identified as trans in 2021 [6]. The reality of this population is marked by a contradiction: despite the existence of the Transgender Outpatient Clinic, which provides specialized care with a clinical and psychosocial approach, structural problems still persist, such as fragmentation of the care network, overloading of the service and limited PHC capacity to attend to trans people [7].
This study has proven itself to be relevant by filling gaps in research on care pathways (especially primary health care), as well as contributing to the development of more equitable health policies for trans people and transvestites (travestis) at all levels of care. Two scientific articles [8,9] produced in the context of the Transgender Outpatient Clinic were identified, but they address themes distinct from this research.
The objectives of this study were to: characterize the sociodemographic profile, gender transition trajectory, and health service access conditions of travestis, trans women, and trans men; and to identify factors associated with not having been accessed by the FHS.
Methods
Design
This is a cross-sectional study conducted using data from the research project entitled “Project Athena: building evidence for action and decision-making on comprehensive health, infectious diseases and co-infections.” The project is a partnership between the University of Brasília and the Federal District Health Department Specialized Center for Infectious Diseases.
Setting
This study was conducted at the Transgender Outpatient Clinic, part of Specialized Center for Infectious Diseases, created in 2017 [7]. However, the Outpatient Clinic was only accredited by the Ministry of Health to provide specialized care in August 2024 [10].
The main ways of accessing the service are: spontaneous demand; referral by the Specialized Social Assistance Reference Center (Centro de Referência Especializado de Assistência Social, CREAS) for Diversity; and referral by other social and health services. Reception carried out by the multidisciplinary team at the outpatient clinic upon patient arrival follows three stages: admission group; individual interview, using the reception form; and scheduling appointments according to needs [7].
Participants
The convenience sample consisted of consecutive medical records of trans people and travestis, aged 18 or older, who began attending the outpatient clinic between 2018 and 2022. The year 2020 was excluded due to the disruptive impact of the COVID-19 pandemic and interruption of services at the clinic. This aimed to ensure that the analysis reflects the regular dynamics of access to services, without the distortion caused by this exceptional event.
Variables
In order to ensure statistical robustness and maintain an adequate sample size for analyses of association, variables were recategorized using two main criteria: grouping categories with insufficient frequency and preserving statistical power in the analyses. This approach resulted in a distribution organized into three distinct blocks, as follows.
-
Sociodemographic characteristics: age group at admission to the clinic (18-29, 30-39, 40-49, 50+ years), sexual orientation (heterosexual, homosexual, bisexual, other), race/skin color (mixed race, Black, White, Asian, Indigenous, unable to answer), marital status (single, married, stable union, divorced, widowed, preferred not to answer, unavailable/unknown), schooling (incomplete elementary education, complete elementary education, incomplete high school education, complete high school education, incomplete higher education, complete higher education, postgraduate education, unavailable/unknown), occupation (paid activity, sex work, unemployed, student, other, unavailable/unknown), welfare benefits (yes, no, unavailable/unknown) and housing situation (shelter/reception institution, street dweller, rented or free accommodation, own property, unavailable/unknown)
-
Gender transition trajectory: prior knowledge of the Transgender Clinic (through friends or acquaintances, referral by a health service, social networks, Social Assistance Reference Center [Centro de Referência de Assistência Social, CRAS] and/or CREAS, other, unavailable/unknown), reason for seeking care (hormone therapy, multidisciplinary care, medical care, endocrinology care, surgery, psychiatric care, other, unavailable/unknown), how gender transition was begun (by themselves, not yet begun, professional support, internet groups, friends, guidance from other trans people, other, unavailable/unknown), prior use of hormones (yes), method of obtaining hormones (pharmacies without a prescription, pharmacies with a prescription, friends/colleagues, “pumpers”, SUS, internet, other), source of guidance (health professional, other travestis/transsexuals, friends, internet groups, other), prior body modification (yes), experience of gender discrimination (yes), discrimination setting (family, employment, school, public spaces, health services, religious practices, other), support at home (yes), support from other networks (yes) and name change (yes, no, unavailable/unknown).
-
Characteristics of access to health services and clinical history: service sought when becoming ill (public hospital emergency service, urgent care service, primary health care center, private hospital emergency service, private clinic or consulting room, public hospital outpatient clinic, pharmacy, public specialty center/polyclinic, Family Health Strategy (FHS) professional at home, other, unavailable/unknown), accessed by the FHS (yes, no, unable to answer, unavailable/unknown), last medical consultation (in the last 12 months, 1-2 years, 2-3 years, >3 years, never been to a doctor/health service, unavailable/unknown), health insurance beneficiary (yes), preexisting condition (mental disorders, HIV, syphilis, hepatitis B, hepatitis C, other sexually transmitted infections – STIs, hypertension, obesity, asthma, diabetes, dyslipidemia, neoplasms, other, unavailable/unknown), previous use of psychotropic substances (yes), testing for STIs in the last 12 months (yes) and STI/HIV/AIDS prevention method (no prevention method most of the time, condoms, post-exposure prophylaxis, pre-exposure prophylaxis, other method, unavailable/unknown).
Age when starting attendance at the outpatient clinic (calculated by the difference between first attendance date and date of birth) underwent the Shapiro-Wilk test to assess normality [11]. Given the non-normal distribution identified, we decided to describe it using median and interquartile range values.
The “reason for seeking care”, “discrimination setting”, “service sought when becoming ill” and “preexisting illness” variable categories permitted multiple responses.
Data source
The data were extracted from physical and electronic medical records, based on the interdisciplinary reception interview form. Data collection was carried out by healthcare professionals at the service who were familiar with the form. The study analysis database was built using anonymized data, coded with sequential numbers to ensure confidentiality.
Bias
The data collection instrument used was the same standardized reception interview form employed routinely by the service. During the process of its incorporation by the healthcare team, this form underwent prior revisions and adjustments. However, for the purposes of this study, it was not possible to make additional modifications to the instrument, since the data collection was based on preexisting service records.
Study size
The analysis included 261 medical records with complete data for the period defined for attendance at the clinic and data collection.
Statistical methods
In the initial stage of the analysis, descriptive statistics were used, presenting absolute (n) and relative (%) frequencies, stratified by gender identity. In the second stage, factors associated with the outcome “not having been accessed by the Family Health Strategy” in the period prior to starting attendance at the outpatient clinic were investigated. We opted for the joint use of prevalence ratios (PR) and odds ratios (OR) in accordance with different stages of the analysis. The PR were calculated in the bivariate analyses, while the OR were estimated in the final multivariate model, the latter being the standard measure generated by the logistic regression analysis.
Initially, bivariate analyses were performed using Pearson’s chi-square test (or Fisher’s exact test, when applicable). For each association, PRs were calculated together with their corresponding 95% confidence intervals (95%CI) and p-values. The explanatory variables were recategorized for better suitability to the statistical analysis.
In order to be included in the multivariate model, variables were selected based on the following criteria: p-value<0.20 in the bivariate analysis (for factors with potential statistical significance), PR magnitude, plausibility of other relevant variables, and consideration of possible confounding variables. Binary logistic regression (a method suitable for analyzing dichotomous outcomes) was used to identify the model that best estimated the probability of the outcome based on the selected predictors. ORs were estimated with their respective 95%CI. We adopted a 5% significance level (p-value<0.05).
The explanatory variables included: i) sociodemographic characteristics (gender identity [travestis versus others], race/skin color [mixed race and others vs. Black], schooling [incomplete high school vs. other]); ii) gender transition trajectory (how gender transition was begun [by themselves vs. other ways], method of obtaining hormones [without a prescription vs. with a prescription]); and iii) health service access conditions (last medical consultation [<12 months vs. >12 months], health insurance beneficiary [yes vs. no], seeking care at a primary health care center when becoming ill [yes vs. no]). The “how hormones are obtained” variable was excluded due to a high proportion of unavailable/ignored data (56.3%), with no impact on the sample size.
The “gender identity” and “health insurance” variables were excluded due to perfect separation [12], a condition in which the variables classify all observations correctly, which makes it impossible to estimate the logistic model, as the coefficients would tend to infinity.
The final logistic model was evaluated for discriminative ability (area under the ROC curve [receiver operating characteristic]), goodness of fit (Hosmer-Lemeshow test), and presence of multicollinearity. All analyses were performed using R software, version 4.4.3 (R Core Team, 2025).
Results
The sociodemographic characteristics of the sample (n=261) were presented, with a predominance of trans men (57.0%) (Table 1). Median age was 24 years (interquartile range 18-30), with 65.9% of the sample in the 18-29 age group. The majority of people were Black (61.3%), single (77.0%), heterosexual (70.1%), and had complete high school education (27.6%) or incomplete higher education (28.0%). Less than half (46.7%) reported having paid employment. Sex work was reported exclusively by trans women and travestis (5.0% of the sample); 9.2% received welfare benefits; and 44.1% lived in rented or free accommodation.
Distribution of people attending the Transgender Outpatient Clinic according to sociodemographic characteristics. Brazilian Federal District, 2018-2022 (n=261)
39.1% of participants found out about the clinic through friends (Table 2). The main reasons for seeking care were hormone therapy (76.6%) and multidisciplinary care (73.6%). Before consulting, 56.7% were already using hormones – 37.8% without a prescription (including 6 of the 10 travestis) and 35.2% with a prescription (especially trans men). Body modifications had already been performed by 48.0% (59.2% trans women). Gender discrimination affected 73.2% of the sample, and 25.3% had legally changed their legal name (no travestis had done so).
Distribution of people attending the Transgender Outpatient Clinic according to characteristics of their gender transition trajectory. Brazilian Federal District, 2018-2022 (n=261)
There was predominance of use of urgent/emergency services (56.7% in total) compared to primary health care centers (21.0%); 69.0% had not been accessed by the FHS; and 17.2% had health insurance (Table 3). High prevalence rates of reported mental disorders (46.4%) and psychotropic sustance use (49.0%) were observed, with alcohol, tobacco and marijuana being the most frequently cited. HIV infection was reported by 9.8% among trans women and travestis, with no cases among trans men. The proportion of people who reported not using HIV and other STI prevention methods most of the time was noteworthy, especially among trans men (37.6%). Use of post-exposure prophylaxis and pre-exposure prophylaxis was low (5.1%) and was restricted to trans women.
Distribution of people attending the Transgender Outpatient Clinic according to characteristics of access to health services and clinical history. Brazilian Federal District, 2018-2022 (n=261)
Not seeking care at a primary health care center was significantly associated with higher probability of not being accessed by the FHS (PR 1.36; 95%CI 1.11; 1.66; p-value<0.001) (Table 4).
Unadjusted prevalence ratios (PR) and 95% confidence intervals (95%CI) for not being accessed by the family health strategy (FHS) among people attending the Transgender Outpatient Clinic, according to sociodemographic, gender transition trajectory and health service access conditions characteristics. Brazilian Federal District, 2018-2022 (n=261)
The adjusted logistic model demonstrated good discriminative capacity (ROC 0.847) and goodness of fit and calibration, confirmed by the Hosmer-Lemeshow test (p-value 0.963); absence of multicollinearity (variance inflation factor test 1); analysis of outliers; and adequate distribution of residuals. Seeking care at a primary health care center reduced the odds of absence of linkage to the FHS by 86.0% (OR 0.14; 95%CI 0.05; 0.37; p-value<0.001) (Table 5). The high intercept (OR 25.27; 95%CI 2.39; 266.77; p-value 0.015) indicated a high baseline probability of not having been accessed by the FHS. Other variables did not show statistical significance in Tables 4 e 5.
Adjusted odds ratios (OR) and 95% confidence intervals (95%CI) for not being accessed by the family health strategy among people attending the Transgender Outpatient Clinic, according to sociodemographic, gender transition trajectory and health service access conditions characteristics. Brazilian Federal District, 2018-2022 (n=261)
Discussion
The results revealed that more than half of the people attending the Federal District Transgender Outpatient Clinic were trans men, followed by trans women and travestis, predominantly young, Black, single, heterosexual individuals with at least high school education. The main challenges identified included a low rate of identity document updating for name and gender change, diverse discrimination settings, starting gender transition without professional support, high prevalence of mental disorders, and concentration of care in emergency services instead of PHC. Prior attendance at primary health care centers increased linkage with the FHS, which reduced the likelihood of lack of care.
Disparities were also evident between the gender categories studied, especially among travestis. Despite constituting the smallest percentage of the total, they presented the most precarious socioeconomic conditions. This reality was confirmed by a study conducted in Rio de Janeiro which, despite methodological differences, also identified travestis as the group with the poorest indicators for income, education and access to health [13].
In Brazil, lack of official data on gender identity makes it difficult to accurately characterize this population. Available estimates suggest that 1% of the adult population in 2021 identified as binary trans people, with a balanced distribution between men and women [14]. However, these estimates do not distinguish between the trans women and travesti categories.
In comparison with national data, overrepresentation of young people was identified in this sample (more than twice that of the general Brazilian population), while the proportion of Black people approached the national composition, representing more than half of the total [15]. The possible intersectionality of these variables intensifies health disparities, as in the case of young Black trans people in Canada, who, in 2023, were twice as likely to not receive necessary physical care compared to their White peers [16].
The proportion of trans people with complete higher education in this study was 23% lower than that of the general population aged 25 or older [15]. School exclusion and structural barriers in the academic trajectory of trans people lead to educational dropout, limit professional opportunities and perpetuate socioeconomic marginalization in adulthood [17].
The sample investigated presented a lower percentage of heterosexuals when compared to the general population [18]. Gender identity and sexual orientation are distinct, non-fixed dimensions and can vary throughout life [19]. Both trans and cisgender (cis) people can have any sexual orientation, which shows the plurality of human identity experiences.
The high frequency of gender identity-based discrimination was confirmed by research conducted in five Brazilian capitals with trans women and travestis [20]. The increase in this form of discrimination was associated with a history of violence and sociodemographic characteristics comprising greater vulnerability.
The greater demand for hormone therapy and multidisciplinary care when compared to surgery can be understood by taking the principle of gender self-determination, which stems from identity processes built from life experiences. This includes hormone therapy as an essential resource for gender affirmation, regardless of the need for surgical procedures [21].
The practice of hormone self-medication in this population has already been recorded in Brazilian research [8]. The predominance of starting gender transition without professional supervision (especially among trans women and travestis) contrasts with findings from a Chilean study [22], in which 58% of trans people using hormones stated that they obtained them through health professionals. The regional inequality in the provision of specialized services in Brazil [10] hinders this population’s access to adequate care. In Brazil, the fact that testosterone is a controlled medication may restrict hormone therapy without professional supervision among trans men, since this procedure constitutes one of the main demands for body modification in this group [23].
Lack of legal name change negatively impacts socioeconomic indicators and leads people to postpone seeking health services [24]. This structural and institutional violence, when intersecting with other forms of oppression, constitutes a barrier to diverse social rights. In Argentina [25], trans women discriminated against by health professionals were three times more likely to avoid health services than those not discriminated against.
Low health insurance coverage – lower than the average for the Federal District (33%) and lower than the national average (25%) [26] – indicated that most of the people investigated are SUS users. Despite the increase in FHS coverage in the Federal District from 34% in 2017 to 77% in 2023 [27], this expansion proved insufficient to overcome the care gaps verified in this study, within the scope of PHC.
Regarding preexisting health conditions, some similarities were observed with North American research, in which trans women reported poorer health outcomes compared to trans men, with the exception of depression [28]. Although the present research did not specify types of mental disorders, prevalence of self-reported cases of these conditions was four times higher than prevalence of positive screening for depression in the Brazilian adult population [29]. Beyond gender-affirming care, an approach that fully incorporates mental health is needed, addressing discrimination in both individual and social contexts [30].
Use of psychotropic substances by trans women and travestis showed a similar percentage to that found in previous Brazilian research [31], which pointed to alcohol, tobacco and marijuana as the most consumed substances. Multiple use of substances, when associated with greater violence, unemployment and informal work, is possibly a strategy for coping with suffering and marginalization.
Low adherence to pre-exposure prophylaxis among trans women is corroborated by findings from a national study [32], which shows that only 6% of trans people in Brazil use this prophylaxis (vs. 94% of cis people). HIV and other STI prevention requires integrated approaches that combine diverse strategies and specific adaptations for each gender group studied.
This research presented limitations, mainly due to its cross-sectional design, which prevents inference of causal or temporal relationships. Furthermore, self-reporting can compromise the reliability of sensitive variables and introduce information biases.
The non-probabilistic sample only included trans people and travestis treated at the clinic, which constitutes a selection bias by not incorporating those who had not yet accessed the service. Non-binary individuals and those of other gender identities, although treated by the service, were also not included in the study. However, an attempt was made to characterize in detail the other groups that had access to the service.
The context of the Federal District, with its particular service structure, may also differ from other realities and limit generalization of the results. Although the outpatient clinic recorded data not captured by other services, the fact of this research being limited to routinely recorded variables may not encompass important social and cultural aspects. High proportions of unavailable or unknown data for some variables, such as individual and family income, had to be excluded because they restricted the analysis. The modest sample size may have been insufficient to detect significant differences between the groups, although it allowed for descriptive and associational analyses.
Furthermore, significant underrepresentation of travestis and overrepresentation of trans men were observed, limiting specific analyses for these groups. The stratified presentation of data on travestis was maintained as a methodological and political strategy to highlight their specific identity and confront their historical social invisibility, even though the term “trans” is frequently used in the literature in its broad sense to encompass diverse gender identities. Furthermore, our investigation did not analyze whether broader demands of the people cared for were met, nor did it investigate in detail their connection with services provided by the care network and other health needs.
Despite its limitations, this study represents a relevant contribution, serving as an exploratory basis for future research, including qualitative research.
In conclusion, the results showed sociodemographic inequities, inequalities in gender transition trajectories and access to health services, with underutilization of PHC. Linkage with primary health care centers proved to be protective, emphasizing the FHS as a model for comprehensive care. In addition to linking PHC with specialized services, it is necessary to expand, equitably, FHS coverage in the Federal District to reduce the demand for urgent care services and implement preventive measures for mental disorders and other morbidities.
The findings also revealed the need for intersectoral policies at the Federal District and national levels to ensure full social rights. These actions, combined with anti-discrimination campaigns, are essential for mitigating barriers and guaranteeing equity in access, in keeping with the principles of the SUS.
-
Peer Review Administrator
Izabela Fulone (https://orcid.org/0000-0002-3211-6951)
-
Peer Reviewers
Renata Castro Martins (https://orcid.org/0000-0002-8911-0040),
-
Policardo Gonçalves da Silva (https://orcid.org/0000-0001-9095-6409)
-
Data availability
In order to protect study participant privacy and ensure confidentiality, only consolidated data is available. The complete database remains restricted due to the sensitive and individualized nature of the information, which, even after anonymization, may present risks of identification.
-
Use of generative artificial intelligence
Artificial intelligence was used to assist with the conciseness of some paragraphs.
References
- 1 Paim JS. Os sistemas universais de saúde e o futuro do Sistema Único de Saúde (SUS). Saúde Debate. 2019;43(spe5):15-28.
- 2 Travassos C, Martins M. Uma revisão sobre os conceitos de acesso e utilização de serviços de saúde. Cad Saúde Pública. 2004;20(Suppl 2):S190-8.
-
3 Mattos RA. Os sentidos da integralidade: algumas reflexões acerca de valores que merecem ser defendidos. In: Pinheiro R, Mattos RA, organizators. Os sentidos da integralidade na atenção e no cuidado à saúde [Internet]. Rio de Janeiro: UERJ/IMS; Abrasco; 2006 [cited 2025 Apr 10]. p. 39-64. Available from: https://lappis.org.br/site/os-sentidos-da-integralidade-na-atencao-e-no-cuidado-saude/4604
» https://lappis.org.br/site/os-sentidos-da-integralidade-na-atencao-e-no-cuidado-saude/4604 -
4 Brasil. Ministério da Saúde. Portaria nº 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS) [Internet]. Diário Oficial da União, Brasília. 2017 Set 22;183(Seção 1):68. Available from: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2017/prt2436_22_09_2017.html
» https://bvsms.saude.gov.br/bvs/saudelegis/gm/2017/prt2436_22_09_2017.html - 5 Rocon PC, Wandekoken KD, Barros MEB, Duarte MJO, Sodré F. Acesso à saúde pela população trans no Brasil: nas entrelinhas da revisão integrativa. Trabalho, Educação e Saúde. 2020;18(1):1-18.
-
6 Instituto de Pesquisa e Estatística do Distrito Federal. Retratos sociais 2021 LGBTQIA+ [Internet]. Brasília: IPEDF; 2021 [cited 2025 Apr 11]. Available from: https://www.ipe.df.gov.br/documents/d/ipedf/2023-06-30-retratos-sociais-lgbtqia-sumario-pdf
» https://www.ipe.df.gov.br/documents/d/ipedf/2023-06-30-retratos-sociais-lgbtqia-sumario-pdf - 7 Vieira VF. Ambulatório Trans de Brasília: trajetória, políticas e experiências [dissertação]. Brasília: UnB; 2023.
- 8 Krüger A, Sperandei S, Bermudez XPCD, Merchán-Hamann E. Characteristics of hormone use by travestis and transgender women of the Brazilian Federal District. Rev Bras Epidemiol. 2019;22(Suppl 1):e190004.
- 9 Corrêa FHM, Rodrigues BB, Mendonça JC, Cruz LR. Suicide thoughts among transgender population: an epidemiological study. J Bras Psiquiatr. 2020;69(1):13-22.
-
10 Brasil. Ministério da Saúde. Indicadores habilitações: habilitações - 3002 - Atenção Especializada no Processo Transexualizador - Modalidade Ambulatorial [Internet]. Brasília: MS; 2024 [cited 2024 Nov 15]. Available from: https://cnes2.datasus.gov.br/
» https://cnes2.datasus.gov.br/ - 11 Razali N, Wah Y. Power Comparisons of Shapiro-Wilk, Kolmogorov-Smirnov, Lilliefors and Anderson-Darling tests. Journal of Statistical Modeling and Analytics. 2011;2:21-33.
- 12 Albert A, Anderson JA. On the existence of maximum likelihood estimates in logistic regression models. Biometrika. 1984;71(1):1-10.
- 13 Carrara S, Hernandez JG, Uziel AP, Conceição GMS, Panjo H, Baldanzi ACO, et al. Body construction and health itineraries: a survey among travestis and trans people in Rio de Janeiro, Brazil. Cad Saúde Pública. 2019;35(4):e00110618.
- 14 Spizzirri G, Eufrásio R, Lima MCP, Carvalho Nunes HR, Kreukels BPC, Steensma TD, et al. Proportion of people identified as transgender and non-binary gender in Brazil. Sci Rep. 2021;11(1):2240.
-
15 Instituto Brasileiro de Geografia e Estatística. Censo Demográfico 2022: panorama [Internet]. Rio de Janeiro: IBGE; 2023 [cited 2025 Apr 15]. Available from: https://censo2022.ibge.gov.br/panorama/
» https://censo2022.ibge.gov.br/panorama/ - 16 Chan A, Pullen Sansfaçon A, Saewyc E. Experiences of discrimination or violence and health outcomes among Black, Indigenous and People of Colour trans and/or nonbinary youth. J Adv Nurs. 2023;79(5):2004-13.
- 17 Viana CP, Delgado IM, Rosa A, Neves VR, D’Emery Siqueira L. Transgender students’ experience at college. Acta Paul Enferm. 2022;35:eAPE01966.
-
18 Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde [Internet]. Rio de Janeiro: IBGE; 2019 [cited 2025 May 15]. Available from: https://www.ibge.gov.br/estatisticas/sociais/saude/9160-pesquisa-nacional-de-saude.html
» https://www.ibge.gov.br/estatisticas/sociais/saude/9160-pesquisa-nacional-de-saude.html - 19 Louro G. Gênero, sexualidade e educação: uma perspectiva pós-estruturalista. 16. ed. Petrópolis: Vozes; 2014. 184 p.
- 20 Magno L, Leite BO, Sperandei S, Pereira M, Knauth DR, Leal AF, et al. Discriminação por identidade de gênero entre mulheres trans e travestis no Brasil: uma análise de classes latentes e fatores associados. Rev Bras Epidemiol. 2024;27(Suppl 1):e240012.
- 21 Bento B. A Reinvenção do corpo: sexualidade e gênero na experiência transexual. 3. ed. Salvador: Devires; 2017. 245 p.
- 22 Delgado JB, Saiz JL, Guzmán-González M, Bahamondes J, Gómez F, Castro MC, et al. Sociodemographic characteristics, gender identification, and gender affirmation pathways in transgender people: a survey study in Chile. Arch Sex Behav. 2021;50(8):3505-16.
- 23 Sousa D, Iriart J. “Viver dignamente”: necessidades e demandas de saúde de homens trans em Salvador, Bahia, Brasil. Cad. Saúde Pública. 2018;34(10):e00036318.
- 24 Hill BJ, Crosby R, Bouris A, Brown R, Bak T, Rosentel K, et al. Exploring transgender legal name change as a potential structural intervention for mitigating social determinants of health among transgender women of color. Sex Research Soc Policy. 2018;15(1):25-33.
- 25 Socías ME, Marshall BDL, Arístegui I, Romero M, Cahn P, Kerr T, et al. Factors associated with healthcare avoidance among transgender women in Argentina. Int J Equity Health. 2014;13(1):81.
-
26 Instituto de Estudos de Saúde Suplementar. Análise Especial. Nota de Acompanhamento de Beneficiários (NAB) – Edição no 90 [Internet]. São Paulo: IESS; 2024 [cited 2025 Jun 15]. Available from: https://www.iess.org.br/sites/default/files/2024-02/NAB%2090.pdf
» https://www.iess.org.br/sites/default/files/2024-02/NAB%2090.pdf -
27 Distrito Federal. Secretaria de Saúde do Distrito Federal. Estratégia de Saúde da Família chega a mais de 2,1 milhões de brasilienses [Internet]. Brasília; 2024 [cited 2025 Abr 17]. Available from: https://www.saude.df.gov.br/
» https://www.saude.df.gov.br/ - 28 Newcomb ME, Hill R, Buehler K, Ryan DT, Whitton SW, Mustanski B. High burden of mental health problems, substance use, violence, and related psychosocial factors in transgender, non-binary, and gender diverse youth and young adults. Arch Sex Behav. 2020;49(2):645-59.
- 29 Chinazzo IR, Lobato MIR, Nardi HC, Kollerr SH, Saadeh A, Costa AB, et al. Impacto do estresse de minoria em sintomas depressivos, ideação suicida e tentativa de suicídio em pessoas trans. Ciên Saude Colet. 2021;26(Suppl 3):5045-56.
- 30 Melo APS, Bonadiman CSC, Andrade FM, Pinheiro PC, Malta DC. Depression screening in a population-based study: Brazilian National Health Survey 2019. Ciên Saúde Colet. 2023;28(4):1163-74.
- 31 Mota JC, Sperandei S, Boni RB, Dourado I, Veras MASM, Bastos FI. Uso de múltiplas substâncias e fatores associados em mulheres trans e travestis: resultados do estudo TransOdara, Brasil. Rev Bras Epidemiol. 2024;27(Suppl 1):e240011.
- 32 Silva APM, Pereira IO, Alencar TMD, Kamiensky BB, Moura MCM, França FAP, et al. Acesso de pessoas trans e travestis à profilaxia pré-exposição ao HIV no Brasil: estudo descritivo, 2018-2023. Epidemiol Serv Saúde. 2024;33(spe1):e2024322.
Edited by
-
Editor-in-Chief
Jorge Otávio Maia Barreto (https://orcid.org/0000-0002-7648-0472)
-
Scientific Editor
Maria Auxiliadora Parreiras Martins (https://orcid.org/0000-0002-5211-411X)
-
Associate Editor
Fabiana Martins Dias de Andrade (https://orcid.org/0000-0001-8277-6061)
In order to protect study participant privacy and ensure confidentiality, only consolidated data is available. The complete database remains restricted due to the sensitive and individualized nature of the information, which, even after anonymization, may present risks of identification.
