Gender Transition Assisted by the Unified Health System (SUS) in Brazil and Care in Primary Health Care Units: An Integrative Review

Abstract

This integrative review aimed to rigorously examine studies published in the last 10 years related to the gender transition process assisted within the scope of the Brazilian Unified Health System (SUS), with a focus on practices carried out in Primary Health Care Units (UBS). It also investigated the achievements and challenges in the reference medical units of SUS responsible for surgeries in the gender reassignment process. METHODS: This integrative review was conducted in the PubMed, ScienceDirect, Cochrane Library, and Scielo databases, considering studies published between 2014 and 2024. Case reports, clinical studies, randomized trials, systematic reviews, and meta-analyses were included. The descriptors used were "Gender Change", "Unified Health System", "Sex Reassignment Procedures", "Sex Reassignment Surgery", "Gender Health", and their English equivalents: "Transsexualism", "Unified Health System", "Sex Reassignment Procedures", "Sex Reassignment Surgery", and "Gender and Health". The Boolean operator "AND" was applied to refine the searches. Additional keywords included "Gender Transition", "Unified Health System (SUS)", "Brazil", "Primary Health Care Units", "Transgender Population", and "Public Health". Inclusion criteria encompassed studies in English or Portuguese, published during the specified period, focusing on services provided exclusively by SUS and conducted in Brazil. Articles addressing services in private networks or abroad, as well as studies unrelated to the topic, were excluded. The initial search resulted in 60 articles, 8 of which were removed due to duplication, and 22 were excluded after abstract analysis for not meeting the study's objectives. In total, 30 full-text articles were included in the review. RESULTS: The study identified significant legislative advancements related to the gender reassignment process in SUS, such as the creation of the Health Users' Rights Charter in 2006, which ensured the use of social names, and Ordinance No. 1,707/2008, which established the gender reassignment process, initially for trans women. Ordinance No. 2,803/2013 expanded access to trans men and transgender people, marking a significant advance. The process involves multidisciplinary follow-up, including endocrinologists, psychologists, and social workers, hormone therapy, and surgeries such as mastectomy, hysterectomy, phalloplasty, and vaginoplasty, performed at accredited hospitals. Despite progress, there are still significant challenges, such as long waiting lists for consultations, hormone therapy, and surgeries, which negatively impact the mental health and quality of life of the transgender population. The limited number of accredited hospitals for performing surgeries, concentrating care in certain regions, makes access difficult for individuals from other locations. Additionally, discrimination and stigma in healthcare settings represent barriers to access and continuity of treatment. The lack of trained professionals to provide humanized care is also an important obstacle. Recent advances include changes in gender classification in 271 procedures in SUS, expanding access for trans men and women, as outlined in the 2021 Ordinance. There has also been an increase in awareness and debate about the health of the transgender population, with greater participation from activists, healthcare professionals, and government bodies. CONCLUSION: In conclusion, this study verifies that gender transition assistance provided by SUS is an evolving and growing field, with significant legislative achievements aimed at supporting the health of the population needing gender transition services. The study also highlights that SUS provides care which, despite facing significant challenges, demonstrates accomplishments that pave the way for a future where the health rights of all transgender individuals are respected and guaranteed. The fight for equity in the healthcare of transgender individuals is a matter of social justice, requiring collective commitment from all sectors of society.