Systematic review on health care for transvestites and transsexuals in Brazil

ABSTRACT OBJECTIVE To synthesize scientific evidence to characterize health care for transvestites and transsexuals in Brazil. METHODS This is a systematic review, conducted from July 2020 to January 2021 and updated in September 2021, whose protocol is registered in the International Prospective Register of Systematic Reviews (PROSPERO) platform, under code CRD42020188719. The survey of evidence was carried out in four databases and eligible articles were evaluated for methodological quality, and those with a low risk of bias were included. RESULTS Fifteen articles were selected and the findings were grouped into six categories according to their thematic approaches: Possibilities to transform health care; Transvestiphobia and transphobia: violations inside and outside the Brazilian Unified Health System (SUS); Professional unpreparedness to care for transvestites and transsexuals; Search for health care alternatives; Right to health for transvestites and transsexuals: utopia or reality?; The Transsexualization Process: advances and challenges. CONCLUSIONS There is evidence that health care for transvestites and transsexuals in Brazil is still exclusive, fragmented, centered on specialized care and guided by curative actions, resembling the care models that preceded the SUS and which have been heavily criticized since the Brazilian Sanitary Reform.


INTRODUCTION
Transgender identities are diverse and not limited to a specific definition. However, in this study, transgender people are understood as those who have a gender identity opposite to the sex assigned at birth 1 . In addition, the term transvestite precedes the term transsexual and is more frequent in Brazil and in other Latin American countries, designating people who experience female roles, but who do not recognize themselves as men or women 1 .
In the global context, transvestites and transsexuals represent a small portion of the general population. However, the discrimination and social exclusion imposed on these people put them in the worst health and life conditions 3 . Compared to other population groups, transvestites and transsexuals have high rates of mental suffering, including suicidal ideation and attempts, due to the discrimination and rejection they face throughout their lives and in all institutional spaces. In addition, other health problems are caused, mainly, by bodily transformations resulting from attempts to align the phenotype with gender identity. Thus, these factors end up generating a lower life expectancy and greater difficulties for these people to access health services 3,4 .
In Brazil, similar to the reality of other countries, transvestites and transgender women are socially more vulnerable: among lesbians, gays, bisexuals, queers, intersexuals, asexuals and other categories of gender and sexuality (LGBTTQIA+), they are the main victims of violence, especially bodily injuries and homicides by firearms 5,6 . Given this reality, health care should not be configured only in assistance to this population's health problems, but also in broad and concrete actions to welcome transvestites and transgender people, which help them face gender identity-based discrimination. The Brazilian health system, regulated in 1990 and called the Unified Health System (SUS), is mostly composed of public and free health services, complemented by some services from the private network financed by the State 7 . In addition, SUS is constituted by doctrinal principles (universality, equity and integrality), to which the health care model, expressed in policies, programs, services organization and care provision, must turn to, in order to recognize the social determinants of the health-disease process and health inequalities 8 .
Based especially on the principle of equity, health care practices should be carried out in a more fruitful way to serve the most vulnerable people, including transvestites and transgender people. Initiatives aimed at this population have been implemented in the SUS over the years, such as the National LGBT Comprehensive Health Policy, created in 2011, and the Transsexual Process Program in the SUS, created in 2008 and expanded in 2013 9 .
In the scientific literature, there has been an increase in the publication of articles on the health of the Brazilian LGBTTQIA+ population after the creation of the National LGBT Integral Health Policy 10 , as well as theses and dissertations on transvestism, transsexuality and health, especially after the expansion of the Transsexualizing Process in the SUS 11 . Furthermore, it is possible to identify some integrative reviews on the health of the transvestite and transsexual population in Brazil, specifically on the difficulties these people face in accessing health services 12,13 . However, there are no systematic reviews that present summarized evidence on the other aspects related to health care for the Brazilian transvestite and transsexual population.
Considering that Brazil is a country of continental dimensions, with diverse and profound inequalities, especially in the realization of the universal right to health, the question is: how has health care for transvestites and transsexuals been provided within the scope of the SUS? As a result, the objective of this study is to synthesize scientific evidence to characterize health care for transvestites and transsexuals in the country.

METHODS
This is a systematic review of the scientific literature, conducted from July 2020 to January 2021 and updated in September 2021. The research protocol 14 followed the recommendations of the checklist Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (Prisma-P) 15 , and is registered on the International Prospective Register of Systematic Reviews (Prospero) platform, under code CRD42020188719.
From the formulation of a well-defined problem-question and an explicit and reproducible methodology, systematic review studies are able to identify, select, evaluate and summarize already available scientific evidence 16 . Likewise, they can point out necessary changes to professional practices or recommendations for carrying out other investigations, aiming to fill gaps in knowledge.
The survey of evidence, in Portuguese and English, that integrates this systematic review was carried out from consultations to the following databases: Scientific Electronic Library Online (SciELO), US National Library of Medicine (Pubmed), Literatura Latino-Americana e do Caribe em Ciências da Saúde (Lilacs) and Biblioteca Virtual em Saúde (BVS). The BVS, a digital platform coordinated by the Centro Latino-Americano e do Caribe de Informação em Ciências da Saúde (BIREME), gathers data from different electronic databases in the health area, such as: Base Regional de Informes de Avaliação de Tecnologias em Saúde das Américas (Brisa), Littérature Scientifique in Santé (Lissa), Medical Literature Analysis and Retrieval System Online (MedLine), Sistema de Información de la Biblioteca de la Organización Mundial de la Salud (Wholis), Índice Bibliográfico Español en Ciencias de la Salud (IBECS), Base de Dados em Enfermagem (BDENF), Bibliografia Brasileira de Odontologia (BBO), among others.
To conduct the electronic search of the studies, previously defined strategies were used after different attempts, consisting of a block of health care-related descriptors in the Brazilian context and a block of keywords related to transvestites and transgender people, respecting the specificities of each database (Box 1).
In the SciELO, Lilacs and BVS databases, the search strategies were composed of descriptors extracted from the vocabulary of the Descritores em Ciências da Saúde (DECS) and, for the search in PubMed, equivalent terms from the Medical Subject Headings (MESH) were used. Strategies were applied covering all indexes (title, abstract, keywords and text).
Eligibility criteria were based on the PECOS anagram 16 , with the necessary adaptations (Box 2).
The adaptation in the PECOS anagram concerned the comparison or control element, not being considered for the inclusion criteria of this study. Therefore, articles resulting from original studies were included in the review, with a qualitative or quantitative  approach, on aspects related to health care for the transvestite and transsexual population in Brazil, and in which the subjects were transvestites, transgender people, health professionals or health managers. Furthermore, the studies included were those published in full in scientific journals from 1990 onwards, the year of SUS regulation, regardless of language.
Studies that addressed health care for transvestites and transsexuals only in the private health system or together with aspects related to health care for other people in the LGBTTQIA+ group were excluded, as well as studies classified as abstracts published in annals, editorials, reflective articles, documentary analyses, literature reviews, technical manuals, chapters, books, monographs, dissertations and theses.
The publications were retrieved by a single researcher and subsequently coded and organized in an electronic spreadsheet for later removal of duplicates. Next, considering the inclusion and exclusion criteria adopted, screening was performed based on the reading of the titles and abstracts of the files, to select those that could be included in the systematic review and that would be read in full.
The full reading stage was carried out to elect those studies with strong potential for inclusion in the systematic review. Through manual search and in a complementary way, the reference lists of the selected articles were also consulted to identify possible misses during the electronic search.
The selected articles were read again in full so that their methodological quality could be assessed by two previously calibrated researchers, aiming to guarantee uniformity in the critical evaluation. This happened through the critical evaluation tools of the Joanna Briggs Institute (JBI), using a specific checklist for studies with a qualitative approach 17 , since all eligible articles had this methodological approach.
Based on the checklist presented by Lockwood et al. 17 , as well as the classification proposed by Almeida et al. 18 , the risk of bias in the articles was rated as high (with up to 49% of affirmative responses), moderate (affirmative responses between 50% and 69%) and low (70% or more of affirmative responses). In this review study, the final synthesis was composed only of articles with low risk of bias.
The entire process of screening, eligibility and assessment of the methodological quality of the articles was carried out by two independent researchers. In case of doubt or disagreement, the researchers met virtually to discuss and establish a consensus. The results of the studies included in the systematic review were grouped categorically, according to their thematic approaches, and interpreted with the support of the scientific literature that deals with the issue investigated here. Finally, the final writing of this manuscript followed the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-analyses checklist (Prisma) 19 .

RESULTS
By searching the databases of interest for this systematic review, it was possible to retrieve 1,164 titles. After removing duplicates, screening after reading titles and abstracts, including other publications by checking the references of the screened articles, and updating the search, 45 articles were submitted to full reading. Of these, 24 were submitted to methodological quality assessment and 15 were included in the results synthesis, with 14 articles published in Portuguese and one article published in English ( Figure 1).
Source: Authors' preparation. Adapted from Flor et al. 20 . The 15 articles included in this systematic review do not meet the sixth criterion of the checklist used to guide the assessment of methodological quality 17 , that is, they do not present explicit information about the researchers' cultural or theoretical location and its possible influence on the study (Box 3).
In studies with qualitative approaches, researchers' beliefs and values, as well as their theoretical orientations, can inf luence the conduct of the research, from data collection to results dissemination. Therefore, it is important that articles that value methodological rigor explain the possible influences of the researchers in the study, or the strategies adopted to reduce these potential influences 17 .
The synthesis of the included studies (Box 4) reveals that 10 articles, i.e., the majority, were published between 2017 and 2019. The research that originated these articles was developed in the South and Southeast of Brazil, five of them in each region. Therefore, articles resulting from studies carried out in the North region were not included.
In their entirety, the articles have a qualitative approach as the only methodological characteristic. In addition, six of the articles had transvestites and transgender women as research subjects and three were developed with health professionals, specifically nurses, focusing on their perception of health care for transvestites and transsexuals.
According to the summary contained in Box 4, eight articles (the majority) have as their focus of analysis the access of transvestites and transsexuals to health services and the care offered to this public. From the thematic approaches identified in the results of the articles, the findings of this review were grouped into six categories, presented below. Oliveira e Romanini 21 perceptions about transvestites and the technical-scientific preparation to assist them. Data were presented in two thematic categories: "transvestite: meanings constructed from the perspective of nurses" and "(lack of) technical-scientific preparation: repercussions on the care provided to transvestites".
Nurses are unaware of the meaning of being a transvestite and public policies aimed at the LGBT population, one of the reasons given for this lack of knowledge being the fragile approach to gender and sexuality issues during academic training. For the care of transvestites, it is necessary to rethink public health policies for this part of the population, guarantee access and reception in health services, in addition to qualifying the technical-scientific preparation of health professionals on gender and sexuality issues.
Almeida et al. 28 2018 RJ 13 nurses. To identify the training of resident nurses for the qualified care of transgender people and to analyze the process of nursing care for this clientele, from the perspective of the nursing resident. The testimonies were presented in two categories: "nurse education and care for transgender people" and "the process of nursing care from the resident's perspective". In the residents' view, the training of nursing professionals is not aware of the particularities of different gender identities, including those of transgender people. Thus, the unpreparedness of these professionals to provide qualified care, given the needs of transgender people, will be perpetuated.
The unpreparedness of nursing professionals to meet the social and health demands of the transsexual population was evidenced, justified, above all, by the absence of curricular content on transsexuality during professional training.
Souza et al. 29 2014 RS 49 transvestites. To present the therapeutic itineraries of transvestites residing in Santa Maria, a municipality in the central region of Rio Grande do Sul. It was found that transvestites seek multiple ways to obtain health care, including outside institutionalized health services. For a better understanding of the transvestites' therapeutic itineraries, the results of the study were presented in four categories: "the trajectory of the transvestite construction", "the itinerary of care in the spaces covered by transvestites", "the itinerary in public health services" and "the itinerary in the Afro religion, the batuque". The study revealed that transvestites avoid public health services, because when they seek them they are always victims of discrimination. Such health services are not prepared to meet their needs and demands. Therefore, the therapeutic itineraries of the transvestites in Santa Maria, Rio Grande do Sul, are constituted by other scenarios and health practices, in addition to the institutional spaces of the SUS, such as living spaces, prostitution points, in public spaces and religious meeting places (casas de santo).
Oliveira et al. 30 2019 DF 2 transgender people. To understand how trans social movements in the Federal District understand the right to health. It is understood that the right to health is related to three thematic units: "right to exist", such as the search for basic human rights (use and respect for the social name); "right to equity", since health services must be prepared to meet the specific needs of the trans population; and "implementation of the trans clinic and social participation", highlighting the importance of social control for the realization of the right to health. The fight for recognition of the specific needs of the trans population and the winning of social equipment to satisfactorily serve this population, such as the trans outpatient clinic, are initiatives that can provide a permanent dialogue between trans people and health professionals for the production of specific and qualified care, reverberating in the realization of the right to health and citizenship. in the team. The data strongly support a gender-affirming approach to transgender health, in which HIV programming for transgender women is not limited to individual and biomedical strategies such as increased PrEP intake or increased testing rates. There is a need to affirm the diverse subjectivities of transgender women and support their autonomy as they cultivate health and empowerment, both for themselves and their communities. Access and health care are limited and fragmented due to the small number of professionals and health services that meet the general demands of the population of the municipality of Chapecó, and the lack of preparation of the municipal health system to meet the specific demands of the trans population.

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Trans women do not have basic rights met, such as the right to health; they do not receive information about health processes and procedures and are discriminated against by health professionals and other users within health services. Two thematic categories emerged: "weaknesses in transvestite care" and "specialization in transvestite care ". The first category reveals situations of prejudice in health services due to body changes, generating insecurity on the part of this population when using services. The second category suggests that the creation of specific services for transvestites could minimize situations of embarrassment. It was evident that there is a need for greater integration between the different social segments and health services, the qualification of professionals to guarantee the reception of transvestites and urgent reflection on the discriminatory nature of the specialized services implemented by SUS, even though it is a door for transvestites to enter the health system.

Possibilities to Transform Health Care
With regard to health care for transvestites and transsexuals in Brazil, the articles reveal, almost unanimously, the existing difficulties for implementing the basic principles of the SUS. In view of the diagnosis of these difficulties, which will be addressed in the following categories, possibilities are pointed out to transform this health care model, such as: development of intersectoral strategies to combat discrimination against transvestites and transsexuals, including in health services 23,33 ; constant dialogue between SUS management and the social segments that represent transvestites and transgender people, with a view to understanding and respecting the health specificities of this part of the population [24][25][26]30,33 ; implementation of the National LGBT Comprehensive Health Policy, guaranteeing access for transvestites and transsexuals to the different establishments of the SUS [25][26][27] ; strategies to disseminate the meaning of being a transvestite or transsexual to the community in general, aiming to assert subjectivities and respect these people's needs 24,31 ; review of work practices in health, involving the rescue of the promotion of care, altruism by health professionals, development of autonomy for transvestites and transsexuals and inclusion of transsexual workers in health teams 24,25,31 ; and changes in professional training in health, encouraging the integration of teaching-service-community, the inclusion of content on gender and sexuality in the curricula of courses in the health area and the development of permanent education actions regarding humanized care for transvestites and transsexuals to SUS workers 21,[24][25][26][27]30 .

Transvestiphobia and Transphobia: Violations Inside and Outside the SUS
In the course of their lives, transvestites as well as transgender women and men are victims of prejudiced attitudes, a reflection of structural violence (transvestiphobia and transphobia) caused by the simple fact that it is a group that breaks with the hegemonic pattern, which tries to define the gender only by the anatomy of genital organs.
This aversion soon emerges within the family, when transvestites and transsexuals in search of recognition of their gender identities are not accepted by the family itself. This non-acceptance also occurs on the part of people from social circles 22,34 . In addition, more than structural, transvestitephobia and transphobia are also institutional violence, that is, they are present in institutions such as the SUS.
Therefore, recognizing the violence suffered by transvestites and transsexuals must be part of the work process in the health area, in order to try to welcome and support the victims. However, discriminatory acts, such as disrespect for the social name and lack of understanding about transvestism and transsexuality on the part of health professionals and managers 31,34 , negatively inf luence health care practices for this specific public.
As a result, transvestites and transsexuals feel insecure when using health services 33,34 , even avoiding them 22,29 . In the case of transsexual men, as reported by Sousa and Iriart 23 based on a study carried out in Salvador, Bahia, institutional transphobia prevents their access to health services that meet their specific needs and demands, including hormonal monitoring for body modifications.
Data from a study with Brazilian transsexual women reveal that health professionals' previous conception that they would live with the Human Immunodeficiency Virus (HIV), among other Sexually Transmitted Infections (STIs), causes these users to stop seeking SUS services, considered discriminatory by these women 31 . In addition, the prejudice and stigma of health professionals related to them ends up keeping them away from access to combined HIV prevention strategies, such as the use of PrEP 31 .

Professional Unpreparedness to Care for Transvestites and Transsexuals
The findings reveal that health professionals, especially nursing professionals, are not properly qualified to welcome and care for transvestites and transgender people in health services 25,27,28,35 . In their view, the unpreparedness for health care for this specific public is due to the fragile approach to questions about gender diversity and sexuality during the professional training process 27 .
As a result, some nurses are unaware of the subjectivities of a transvestite or transsexual person and their health needs and demands 27,28 . In addition, the absence of permanent educational actions, which disseminate the guidelines of the National Policy for Integral LGBT Health and which qualify the care for transvestites and transsexuals in the SUS, makes nursing professionals perpetuate stigmas and continue to limit care for these people, disrespecting them and basing their care practices only on curative actions 35 .

Search for Health Care Alternatives
Due to professional unpreparedness, and the discriminatory acts experienced within SUS establishments already pointed out in the results of this article, transvestites and transsexuals avoid seeking care in these institutional spaces 22,29,[32][33][34] . Faced with these violations, a minority of transvestites and transsexuals opt for private assistance, but most cannot afford a health plan, becoming dependent on alternative self-care practices, on the support of people in the social network or religious spaces of African origin, or body transformations without proper professional follow-up 26,29,32 .
In this context, body transformations, such as inappropriate hormone therapy, industrial silicone grafting and breast self-mutilation, can cause other health problems, such as cardiovascular and aesthetic complications. This clearly characterizes another risk factor for the lives of transvestites and transgender people 26 .

Right to Health for Transvestites and Transsexuals: Utopia or Reality?
According to the Federal Constitution of Brazil, access to health is a basic right for all people, guaranteed through public policies aimed at reducing the risk of diseases and injuries, as well as allowing universal and equal access to health actions and services 36 . However, for Brazilian social minorities, such as transvestites and transsexuals, this fundamental right has not been real.
The right to health for transvestites and transsexuals, or the lack of it, can be understood by three aspects: the right to exist, considering that these people still struggle to have their social names respected, including in the SUS; right to equity, as health services are not yet prepared to assist transvestites and transsexuals; and social participation, because transvestites and transsexuals need to exercise social control to access and remain in health services, and to demand the creation of specific services to offer transsexualizing procedures 30,32,34 .

The Transsexualization Process: Advances and Challenges
In Brazil, the transgender procedures, on an experimental basis, have been authorized by the Federal Council of Medicine (CFM) since 1997, being incorporated into the SUS in 2008, when the Ministry of Health founded the Transsexualizing Process program and formally recognized that body transformations are also health needs of the transvestite and transsexual population 9 . Such procedures, as well as the creation of qualified services to offer them, represent a step forward in promoting the health of transvestites and transsexuals.
Therefore, it is expected that the services enabled to offer the procedures provided for in the Transsexualization Process are welcoming, discrimination-free environments, as they are made up of multidisciplinary teams duly qualified to care for transvestites and transsexuals in a humane way 33 . However, there is a fragile bond between health professionals and users, especially with trans women 21 .
According to Oliveira and Romanini 21 , this situation can be explained by the existence of medical superiority and a care protocol, lasting two years, which treats gender identity transition as a disorder, making this diagnosis a condition for access to specific health services for this part of the population. As a result, in these services, transvestites and transsexuals are constantly asked about the veracity of their gender identities and intentions, not allowing them autonomy in the production of care.

DISCUSSION
The health care model consists of a set of knowledge and combinations of resources (financial, technological, human, etc.) to meet individual and collective health needs 37 . Therefore, analyzing the health care model, whether for the general population or for specific groups, such as the group of transvestites and transgender people, implies understanding what public health policies exist to mitigate or nullify inequities and how these policies reflected in programs, actions, services and research for this purpose 38 .
In view of the results of this systematic review, it is clear that health care for transvestites and transsexuals in Brazil is still exclusionary, fragmented, centered on specialized care and guided by curative actions, resembling the care models that preceded the SUS and which have been strongly criticized since the 1970s, from the Brazilian Sanitary Reform movement. At the time, the critics highlighted the importance of profound changes not only in the health system, so that care was humanized, equitable and comprehensive, guaranteeing universal access to all men and women 38 .
According to Arán et al. 39 , despite transsexuality being a phenomenon recognized since the late 19th century, issues related to transgender identities in the Brazilian public health began to be visible only after 1979, with the possibility of medical interventions, when the CFM was consulted for the first time on mammoplasty in transgender people.
Going forward in time, and acknowledging the existence of numerous debates that took place on the subject, including in the legal field, in 1997 -as already discussed in this article -the reassignment procedures were authorized by the CFM and incorporated into the SUS 11 years later 9 . It should be noted that the existence of these procedures in the SUS is a fundamental initiative not only to meet a need for transvestites and transsexuals, but also to assist in the construction of subjectivities and identities neglected by society and the State.
However, criticisms are made of the care protocols established by the Ministry of Health, through regulations 40,41 , so that transvestites and transsexuals can benefit from these specialized health services, especially psychiatric follow-up for at least two years in order to confirm the diagnosis of transsexuality. While this diagnosis represents the winning of the right to health for transvestites and transsexuals, it also contributes to the permanence of the stigma on these people, as it does not consider the personal and historical issues of each subject, assigning the recognition of gender identity to a psychiatric and normalizing procedure 39 .
Furthermore, access to reassignment procedures is not the only health need for transvestites and transsexuals in Brazil. In addition to access to these procedures, it is necessary to promote the fight against discrimination based on gender identity so that transvestites and transsexuals can access any space with dignity, such as health promotion spaces, without being victims of violence 26 .
If access to gender reassignment procedures were the only health need of Brazilian transvestites and transsexuals, it would be very unequal and far from being met, since in the country there are only ten services authorized by the Ministry of Health to offer the procedures provided for in the Transsexualizing Process program, most of them located in the Southeast and none in the North 9 .
The findings of this systematic review also reveal possible ways to transform the current health care model for transvestites and transsexuals in the SUS: it would be interesting to develop intersectoral strategies to combat discrimination against transvestites and transsexuals 23,33 , constant dialogue between SUS management and the social segments that represent transvestites and transsexual people [24][25][26]30,33 , the implementation of the National LGBT Comprehensive Health Policy [25][26][27] , strategies to disseminate the meaning of being a transvestite or transsexual to the community in general 24,31 , review of work practices in health 24,25,31 and changes in professional training in health 21,[24][25][26][27]30 .
Considering these possibilities, the relevance of the participation of social movements representing this segment in the formulation and conduction of public health policies, through the exercise of citizenship and social control, is highlighted here. In the process of building the SUS and its health policies, joining the social struggle for the country's re-democratization, the LGBTTQIA+ movement played an important role, placing sexual and gender diversity on the agenda as social markers and structural determinants of the health-disease process 42,43 . LGBT Health, etc. 44 In conclusion, health care for transvestites and transsexuals in Brazil does not correspond to the health care model advocated in the legal-legal framework of SUS. Therefore, it is necessary to develop strategies to deal with specific issues of transvestites and transsexuals, with emphasis on the vulnerabilities that permeate these people's lives.
In addition to guaranteeing health care, it is necessary to provide opportunities for access to education, employment, housing, food, etc. These actions should not only come from transvestites and transsexuals, but from those who believe in the potential of the SUS and in an egalitarian and democratic society.
With regard to the actions of health professionals in relation to transvestites and transsexuals, this analysis focused on nursing professionals, as the studies retrieved and included in this review addressed only this professional category. In order not to induce that the professional lack of preparation for the health care of transvestites and transgender people in the Brazilian health system is a specificity of nursing professionals, and considering that the work in the SUS must be interprofessional and collaborative, further studies are recommended that investigate the way in which other health professionals deal with transvestites and transgender people.
At the same time that criticisms are made, it is important to highlight that this analysis about the work of nurses, in favor of care for transvestites and transsexuals, may result from advances in research on gender diversity in the field of nursing. However, as shown in the results presented here, it is still necessary to change work practices, allowing a significant transformation in the daily life of health care spaces for transvestites and transsexuals.
As limitations of the study, we point out the possibility that some articles do not use the descriptors adopted in the search strategies of this review and the existence of other articles indexed in databases not consulted. However, to bypass this possible situation, manual searches were performed.
In addition, other limitations refer to the non-inclusion of studies developed in the North region of Brazil, considering that the SUS is present throughout the national territory, and to the authors' choice to exclude from the systematic review articles that analyzed health care for transvestites and transsexuals together with aspects related to health care for other people in the LGBTTQIA+ group.
The non-inclusion of articles that deal with health care for transvestites and transsexuals in states in the North region is justified by the fact that existing studies did not meet the inclusion criteria adopted in the systematic review, or did not have a low risk of bias, according to the checklist used to assess the methodological quality of the articles 17 .
The choice to exclude articles that addressed health care for transvestites and transsexuals together with health care for other people in the LGBTTQIA+ group is justified by virtue of the National Policy for LGBT Integral Health, which partially recognizes the specific needs and identities of transvestites and transsexuals, because, despite the existence of intersections between gender and sexuality issues, they demand different analyses and investments.
In this sense, it would be important to put in place new policies and specific programs for the health of transvestites and transsexuals, prioritizing coping with the vulnerabilities faced by these people 11,45 . However, these decisions may have limited the results of the systematic review, as it is expected that aspects about transvestites and transsexuals will be addressed together with those related to lesbian, gay, bisexual, non-binary people, etc., due to the existence of a single health policy for the entire LGBTTQIA+ population in Brazil.