Artigos

Conteúdo (article):

HORMONIZAÇÃO PARA PESSOAS TRANS EM DIVINÓPOLIS - MG: UMA DESCRIÇÃO POPULACIONAL PARA RECONHECIMENTO DE DEMANDAS DE SAÚDE
HORMONIZATION FOR TRANS PEOPLE IN DIVINÓPOLIS-MG: A POPULATION DESCRIPTION FOR THE RECOGNITION OF HEALTH DEMANDS

Sarah de Farias Lelis1, sarahfalelis@gmail.com, ORCID 0000-0003-1094-805X
Natália Bahia de Camargos1, natybcamargos@gmail.com, ORCID 0000-0002-9782-5046
Vitória Rezende Rocha Monteiro1, vitória_rezende00@outlook.com, ORCID 0009-0002-8847-443X
Ives Vieira Machado1, vieiramachado0@hotmail.com, ORCID 0009-0006-5342-7982
Fabíola Ferreira Villela1, fabiolavillela98@gmail.com, ORCID 0009-0001-0370-2038
Bruna Cristina Silva Martins1, brun220898@gmail.com, ORCID
Aisha Aguiar Morais1, draaishacorpoealma@gmail.com, ORCID 0000-0001-7081-1077
1Universidade Federal de São João del-Rei, campus centro-oeste

RESUMO
Pessoas transgênero não se identificam com os papéis do gênero culturalmente associados ao sexo biológico atribuído ao nascimento. Nesse contexto, a hormonização é uma das alternativas para afirmação da identidade. O presente estudo objetivou avaliar a forma como a hormonização é realizada na população transgênero de Divinópolis/MG de acordo com protocolos nacionais e internacionais, assim como fatores associados. É uma investigação transversal quantitativa com amostra não probabilística elencada através da técnica Bola de Neve Virtual. Os participantes responderam a um questionário on-line na plataforma Google Forms. Entre os 48 colaboradores, setenta e sete por cento (n=37) declararam-se transgênero binário. Trinta participantes relataram hormonização, em 17 deles essa foi considerada inadequada (58,8%). As seguintes variáveis apresentaram a maior discordância com o preconizado pelos protocolos: não realização ou insatisfação com acompanhamento médico (p<0,05) e uso exclusivo do SUS para atendimento em saúde (p<0,05). Um quarto dos participantes afirmaram desrespeito ao nome social ou civil retificado nos locais frequentados, o que foi mais frequente entre os não binários (p=0,03). Houve uma alta incidência de relatos de violência sofrida e de relação sexual desprotegida no último ano.
Palavras-chave: Assistência Integral à Saúde; Serviços de Saúde para Pessoas Transgênero; Protocolos Clínicos

SUMMARY
Transgender people do not identify with the gender roles culturally associated with the biological sex assigned at birth. In this context, hormonization is one of the alternatives for affirming identity. The present study aimed to evaluate the adequacy of hormonization in the transgender population of Divinópolis/MG according to national and international protocols, as well as associated factors. It is a quantitative cross-sectional investigation with a non-probabilistic sample listed using the Virtual Snowball technique. Participants answered an online questionnaire on the Google Forms platform. Among the 48 participants, 77% (n=37) declared themselves to be transgender binary. Thirty participants had received hormonization, and in 17 of them this was considered inadequate (58.8%). The following variables showed the greatest discordance with the recommended protocols: non-compliance or dissatisfaction with medical follow-up (p<0.05) and exclusive use of the SUS for health care (p<0.05). A quarter of the participants stated disrespect for the rectified social or civil name in the places frequented, which was more frequent among non-binary people (p=0.03). There has been a high incidence of reports of violence and unprotected sexual intercourse in the last year.
Keywords: Comprehensive Health Care; Health Services for Transgender Persons; Clinical Protocols.

*Data is available upon reasonable request to the authors.

1. INTRODUCTION
The concept of gender is constantly being discussed and reconstructed as a period of history unfolds. In this context, transgender people are those who present varying degrees of gender non-conformity, i.e. the gender with which they identify differs from the sex-gender binomial assigned at birth. However, the way in which each individual asserts their identity varies, giving rise to the most diverse possible identity situations. Thus, according to Brazilian trans activists, the term transgender encompasses not only trans men and trans women, but also transvestite women, non-binary people and the queer gender1, 2.
Affirmation of identity and gender expression can be achieved through (inter alia) changes in name, pronouns and physical appearance3. Hormonization, as well as plastic surgery and aesthetic procedures, is one of the strategies available for gender affirmation4,5. Hormonization seeks to induce physical changes that reflect gender identity, while maintaining hormone levels in the physiological range for this purpose. This is done in order to reduce endogenous hormones by administering hormones of the opposite sex, either orally, transdermally or by intramuscular injection.1
In transgender women and transvestites, the aim is to achieve breast development, the gynecoid distribution of body fat and a reduction in the pattern of hair growth common in bodies considered to be male. Oestrogens are responsible for the secondary sexual characteristics common in bodies considered female, and anti-androgens block androgen receptors and/or reduce testosterone production. The main risk is the occurrence of thromboembolic events, mainly associated with high-dose oral administration and the use of ethinylestradiol. Other possible side effects include weight gain, resistance to insulin, an increase in blood pressure and inflammatory and pro-thrombotic markers1,5.
In trans men, androgen hormonization has as its objective virilization, including an androgenic pattern of pilification, muscular hypertrophy, clitoromegaly and amenorrhea. In these cases, testosterone is used in different formulations, via the intramuscular or transdermal route, to gain the secondary sexual characteristics considered masculine. Hormonization is safe for most patients. The most frequent adverse effect is erythrocytosis, which should be screened for and treated with dose adjustment and/or an androgen interval. Possible side effects include high blood pressure, weight gain, hypertriglyceridemia, changes in liver enzymes, acne and psychological changes, such as aggressive behavior1,4.
The importance of specific health care for this group of people in Brazil began to be recognized with the establishment of the Transsexualization Process within the Unified Health System (SUS) in 20086,7. The proposal aims to guarantee comprehensive, multidisciplinary care for transgender individuals by attracting professionals trained to care for this group. There are currently 42 Specialized Care establishments accredited by the SUS in this country, which is certainly not enough to cater for an estimated population of 3 million individuals.8
The particular characteristics of caring for a trans person go far beyond hormonization. This is because, since they suffer various forms of marginalization and violence, this group presents high rates of mental disorders, including depression, anxiety and substance abuse. In addition, they have disparities in relation to physical and sexual health, such as a high prevalence of various sexually transmitted infections (STIs) when compared to the cisgender population.9,1
Despite their unique characteristics related to health risks and outcomes, there is an insufficient number of scientific studies on the trans population that seek to understand their health determinants. The lacunae exist in all areas of knowledge, more specifically in the percentage of adequacy of hormonization in trans bodies, since there are no studies that directly evaluate such adequacy11.
Thus, the general objective of this study was to assess, in an unprecedented manner, the concordance of hormonization in the transgender population of Divinópolis with national and international protocols, as well as possible associated factors. Concordant hormonization is defined as that carried out using medications, methods and doses recommended by the protocols selected in the study, with a medical prescription, laboratory monitoring tests carried out in the last year and evaluated by a doctor. Among the specific objectives, we evaluated the frequency of use of hormone therapy; sociodemographic, socioeconomic and health factors; forms of health care and those professional requirements this group considers most important in the event a specific health service is set up in the municipality in the future. It is also hoped that the data obtained will contribute to the body of literature on the subject.
Limited data in the existing literature estimate that people with gender diversity represent 0.1 to 2% of the general population. Therefore, considering the 242,505 inhabitants of Divinópolis, it is estimated that there are between 242 and 4,067 transgender people in the city8,12,13.
2. METHODS
This is a quantitative cross-sectional study with a non-probabilistic sample selected using the Virtual Snowball technique. The research was publicized on various social networks, especially Instagram, in addition to interviews with the authors of the study on local broadcast media channels, on the website and e-mail of the Federal University of São João del-Rei (UFSJ) and the distribution of flyers in various locations around the city. Data was collected using an online questionnaire on the Google Forms platform. The electronic survey format was chosen because it allowed greater access to this segment of the population, since it is a group that is difficult to reach due to the stigmatization it suffers.14 Furthermore, participation in the survey was completely anonymous, since no identifying information was requested. Data was collected from February 2023 to May 2023.

The survey instrument was developed by the authors together with transgender people and health professionals who are references in the study and/or care of the transgender population. The aim was to improve the survey instrument in terms of clarity, relevance and scope of the questions. After approval by the Ethics and Research Committee (CEP), this questionnaire was then applied in the pilot project to trans people from other municipalities, in order to make the final adjustments.
In the final version of the questionnaire, in addition to hormonization, we also gathered information regarding age, ethnicity, schooling, monthly income, employment, housing, STI diagnoses and events of violence suffered. It also assessed the use of the corrected social or civil name, the performance of sexual reassignment surgery and the suggestion of professionals for a team of assistants for trans people to be created in the municipality.
Hormonization was considered adequate when using the medications, methods and doses included in any of the national and international protocols selected for the trans population. These are: Protocol for the care of transsexual people and transvestites in the municipality of São Paulo, 2020; International Medical Advisory Panel (IMAP) Statement on Hormone Therapy for Transgender People, 2015 and Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline, 2017.15,16,17
It should be noted that there were slight variations between the medications and their dosage. In these cases, the extremes of dosage, as well as the greater variability of medications, were considered acceptable for adequate hormonization. In addition, the following were considered criteria for adequate hormonization: medical prescription, laboratory monitoring tests carried out in the previous year and evaluation thereof by a doctor. Note that hormone microdosing, carried out due to intolerance of higher doses or just to maintain the expected effect, was not considered in the analysis, being regarded as a special case.
The criteria for inclusion were self-declared transgender, age of 18 or over and a connection with the municipality of Divinópolis in the last 3 months in the form of residence, work, study and/or health care. Hormonization was not a condition for taking part in the study.
Frequency and central tendency statistics were calculated for the variables analyzed in the study. The relationships between outcomes and the variables in question were calculated using the chi-square test. Differences were considered significant when the p-value was less than 0.05. It is worth noting that the statistical power of the analyses may be limited due to the small size of the sample.
3. RESULTS
3.1 Sample profile
There were 60 responses to the questionnaire, but the final sample consisted of 48 participants. Seven participants were excluded from the study because they declared themselves to be cisgender, two because they dropped out, two because they had no ties with Divinópolis and one because he was under 18.
The average age of the participants was 27 (standard deviation 8.83) and their ethnicity was in line with that of the general Brazilian population. 77 % per cent (n=37) declared themselves to be binary transgender.
3.2 Hormonization
Thirty participants (63.9%) reported being hormonized at the time of the study, with a similar distribution between the genders (n=17, 56.67%, using estrogens and antiandrogens and n=13, 43.33%, using testosterone). Only one participant on hormonization declared himself to be non-binary. Another two participants (4.25%) would like to start hormonization, but have not yet done so because they are afraid or because of the cost of the medication. Four participants (8.5%) said they did not see the need for hormonization.
Most of the participants reported hormonization that was classified as discordant in relation to what is recommended (n=17, 58.8%), with no statistical difference between hormonization with estrogens and antiandrogens and hormonization with testosterone (68.7% and 46.2%, respectively, p=0.274). The discrepancies found can be seen in Figure 1. There were two variables related to these discordances. The first was the absence of or dissatisfaction with medical care during the transsexualizing process compared to the statement of satisfaction with care (88.2% versus 11.8%, p<0.05). And the second was the exclusive follow-up in the SUS compared to that done exclusively through supplementary and/or private healthcare (84.6% versus 12.5%, p<0.05). Of the participants, 46.6% (n=22) were monitored exclusively by the SUS and 28% (n=13) did not use the public health system for this purpose.
The most frequent discrepancies were the absence of laboratory tests in the last year (n=15, 88.2%) and their evaluation by doctors (n=12, 70.58%). Thirteen respondents (44.82%) also had no medical prescription for the hormone(s) in use.
Among the 17 participants with hormone levels outside the parameters adopted in the reference protocols, four were identified as being overdosed or using inappropriate substances. Three of them reported self-medication based on information obtained on the internet and the other received a prescription from a general practitioner. Among the participants who reported using doses higher than those recommended reference was made to overdoses of Estradiol Valerate + Spironolactone and Estradiol TD, both used for hormonization in trans women or transvestites. Among the substances not recommended by clinical protocols were Ultragestan micronized progesterone and Landerlan testosterone. The latter is not registered with the National Health Surveillance Agency (ANVISA) and is purchased by importation from Paraguay.
Most of the self-medication was based on content from the internet, including social networks (n=7, 23.3%). Hormonization was prescribed by doctors in 53.3% of cases (n=16), 13 of them by specialists.
Estrogen therapy was administered exclusively with estradiol, most frequently by mouth (n=9, 61.6%). Among the anti-androgens, spironolactone (n=8, 60%) was preferred to cyproterone acetate (n=4, 40%). As for masculinizing hormones, testosterone was used exclusively by intramuscular injection, with a predominance of Testosterone Cypionate (n=5, 41.7%).
Regarding the user\'s perspective on the dosage of the hormone (Figure 2), the majority considered it to be normal (n=19, 65.5%), with no difference between adequate and inadequate (p = 0.309). The remaining participants (n=10) considered the dosage used to be very low or were unable to assess it, and the majority of these used dosages that were not in accordance with the protocols (n=7, 70.0%). In the cases where it was not possible to assess the dosage, this difficulty was due to the lack of complete data on the drug(s) being used. The justifications for using a low dosage or for those who were unable to assess the dosage were the inability to buy the medication in the correct dosage, fear of possible side effects and difficulty in following the doctor\'s prescription. No participant considered the dosage used to be excessive.
Figure 1

3.3 Sociodemographic, economic and health monitoring aspects
Eighty five per cent of the participants had completed high school or more. Less than two thirds were employed. The average per capita income was R$1.302,00. Per capita income was less than one minimum wage for more than 80% of the respondents.
Fourteen participants (29.8%) already have their civil name rectified and 11 more have tried to change it, but without success. 20% of the participants said they were not called by their social or civil name in any of the places they frequented. This situation was more frequent among non-binary than among binary people (86.8% versus 13.2%, p=0.03). The other results can be seen in table 1.
Table 1

Of the 45 respondents who had received medical care for their general health, 19 (42.22%) reported using SUS exclusively and 8 said they did not receive any health care. All of the respondents, including those who did not undergo hormonization, expressed an interest in receiving multi-professional monitoring by the SUS in Divinópolis, if this service were offered. The professional categories chosen can be seen in Figure 3.
Figure 3

Three participants have already undergone surgery related to gender expression, all of them mastectomies and none of them through the SUS. Another 35 participants (74.5%) have never had surgery to reaffirm their gender, but wish to do so.
The only STI reported was syphilis, by 2 participants. 12 respondents reported never having been tested for STIs and 32 reported negative tests in the past. 28 respondents (59.6%) said they had had sex in the last year without a condom (female or male), therefore involving risk. Of the 12 who said they had never been tested, only 3 participants had not had unprotected sex. Five (10.6%) participants said they worked or had worked as sex workers.

Thirty of the 47 respondents (63.8%) reported having been victims of violence. The most frequently reported complaints were humiliation, verbal abuse and moral harassment. However, 10 participants said they had suffered physical violence and 8 sexual violence (Figure 4).
Figure 4

4. DISCUSSION
This study evaluated a population of transgender individuals in a medium-sized city in the mid-west of the state of Minas Gerais, around 100 km from the capital. This city has 47 health establishments registered with the SUS, but no health services specifically focused on the transgender population.12 Furthermore, the municipality, considered to have the tenth largest population in the state, has a federal university and a state university with courses in the health area that seek to carry out interdisciplinary actions using the principles, guidelines and concepts related to the SUS. Its trans population was estimated at a minimum of 242 individuals, 48 of whom were assessed through this survey. In this respect, there are no municipal surveys that seek to assess the health and socio-economic context of the trans population in the city.
Trans hormone therapy is one of the main strategies used, or at least targeted, to improve mental health and well-being. The present study corroborates this statement by identifying the endocrinologist as the professional most often chosen to be part of the care team for trans individuals1. This finding is in line with the Mapping of the Transgender Population of the City of São Paulo carried out by the Center for the Study of Contemporary Culture (CEDEC), in which 46% wanted endocrinological monitoring and 55% of those who underwent regular monitoring had hormone therapy as their main motivation.18
Most of the population in our study had already undergone hormonization (n=30, 63.9%), with equal distribution between genders. Other Brazilian studies have found similar results. In the city of São Paulo, the rate was 64% (n=1,144) and in Rio de Janeiro, 80.3% (n=313).18,19 In the Federal District, the rate was 64.5%, when only transvestites and transgender women were analyzed.20
Although frequent, the demand for hormonization is not universal. In our sample, 8.5% (n= 4) reported that they did not feel the need to use hormones. The same percentage (8.5%) was found in a study carried out in São Paulo (n= 153); in a joint study in Rio Grande do Sul and São Paulo, 14.8% (n= 83); and in a study in Rio de Janeiro, 23.3% (n= 91).18, 20,21
In our survey, two participants did not undergo hormonization for financial reasons. It is known that the free supply of hormones by the SUS varies between municipalities. While in the city studied only Spironolactone and Norethisterone Enanthate + Estradiol Valerate are offered free of charge, in the city of São Paulo it is also possible to obtain high-cost medications from the SUS, such as Cyproterone and Testosterone Undecylate.15,22,23 According to Krüger et al. (2019), this shortage in the supply of medications by the public health system is related to the absence of a Clinical and Therapeutic Guidelines Protocol (PCDT) supporting an update of the National List of Medicines (RENAME) in line with the guidelines for access to the Transsexualizing Process.20
Two other participants stated that they did not undergo hormonization out of fear, a situation that could be alleviated if there were regular medical follow-up with explanations, individualized prescriptions and monitoring of the hormonization. Our study showed that all the participants would like to be assisted by a team focused on the trans population.
Most of the participants undergoing hormonization did so in a way not in accordance with the protocols adopted (n=17, 58.8%), regardless of their trans gender. Despite the extensive literature reviewed, no other studies were found that sought to identify and categorize the trans hormonization adopted by each of the participants.
Among the participants whose hormonization was considered discordant, two were due to overdose. It is inferred that this was unintentional, since they stated that they did not know how to assess their dose. In the entire sample, there were only self-assessments of doses as normal or underdosed. In contrast, in the study by Hernandez et al. (2022) with data collected in the city of Rio de Janeiro in 2016 and 2017, approximately 90% (n=192) of trans women and around 30% (n=35) of trans men were intentionally overdosing in order to speed up the transsexualizing process.
One participant was also found to be using medication not registered with ANVISA. In this respect, another high-risk practice described in the literature is the use of medication intended for veterinary purposes.18 The study by Hernandez et al. (2022) mentions that 3.5% of the participants used this type of medication.
Furthermore, 15 of the 17 participants whose hormone levels were not in line with the protocols reported irregular medical follow-up, either because of the lack of laboratory tests in the last year or because the results were not evaluated by doctors. The fact that the public health system in the city studied does not currently provide serum dosages of sex hormones certainly contributed to this reality.
Medical supervision is essential for safe hormonization. It guarantees gender dysphoria sufferers the selection of candidates without contraindications and the provision of sufficient information to make informed decisions, including realistic expectations.14 Once prescribed, follow-up should be carried out for individualized dosage adjustment, the identification of desirable effects and the control of possible adverse reactions.
However, even when there is access to the health service, it is not always effective. In our study, the absence of or dissatisfaction with medical care during the transsexualizing process was related to hormonization that was discordant with the protocols when compared to the statement of satisfaction with such care (88.2% versus 11.8%, p<0.05).
Furthermore, 19 per cent of those interviewed reported that their corrected social or civil name is not respected in any of the places they frequent. Use of the corrected social or civil name, including by health professionals, is a right guaranteed by law since 2010 and is a minimum condition of respect for transgender people.24 Disrespect for the name is a factor often cited as one of the causes of trans people distancing themselves from health services, as reported by Rocon et al. (2016) and Mota et al. (2022).25,26 In addition, Costa et al. (2018) showed that 57% of participants felt some degree of discomfort in discussing their health needs with the health professionals to whom they had access. Also, 43.2% of the respondents avoided health care when it was necessary, due to the fact that they were trans, even when the need was not related to their gender identity.21
This is largely due to the lack of professional training to care for this section of the public. According to CEDEC (2021), 33% of the respondents who do not seek medical assistance reported disrespect for their gender identity as the reason.18 It is believed that the beginning of this cascade of ignorance is the explicit lack of information focused on trans health in medical schools, which affects the provision of care by not training professionals who are prepared to deal with the particularities of this community.2 The education system and, consequently, the healthcare model, is still very much linked to the existence of a prior pathology as a condition for access, which, in this case, configures the pathologizing of the trans condition.11
This disrespect can be seen more clearly when analyzing the levels of violence reported. Thirty of the 47 respondents (67.8%) reported having been victims of violence. The most frequently reported forms were humiliation, verbal abuse and moral harassment. However, 10 participants said they had suffered physical violence and eight sexual violence. According to the National Association of Transvestites and Transsexuals (ANTRA), Brazil is the country that kills the highest number of trans people in the world, with 184 deaths recorded in 2020.27
The second significant association with hormonization that was discordant with the protocols relates to monitoring only by the SUS compared to monitoring exclusively by the supplementary and/or private health system (84.6% versus 12.5%, p<0.05). Of the participants, 22 (46.6%) were monitored exclusively by the SUS and only 13 (28%) did not use the public health system for this purpose. Furthermore, of the participants, 72.9% (n=35) used the SUS for the transsexualizing process, 46.6% (n=22) exclusively. Similarly, 88% of the respondents in the CEDEC study, from all income brackets, said they used the SUS.18
The importance of offering free care to this section of the population becomes clearer if we understand the social context in which most of them live. Our findings indicate that 40.42% (n=19) of the participants had completed high school and 12.63% (n=5) had completed higher education. These results are similar to the study by Scote (2017), in which 59.4% (n=82) of the respondents had completed high school and 2.2% (n=3) had a college education.28
A relevant fact is that the level of education achieved did not guarantee adequate employment and/or income.8,29 In our study, 34.4% (n=16) of the participants said they were not working, which is in line with the 25% of unemployed people in the Mais Diversidade survey published in 2021.30 The disparity with the 8% of unemployed reported by the IBGE for the general population is evident.31 Furthermore, 80% of the sample in our study reported a per capita income of less than one minimum wage, while the national average for the general population was R$1,625.00 and the average for the municipality studied was 2.1 minimum wages.12,32
In view of the lack of preparedness and/or insufficiency of public health services and limited income, a frequent alternative is hormonal self-medication.21 In our study, 43.3% said they did not receive a prescription from a doctor. A study in the state of Rio de Janeiro found that 34.7% (n=40) of trans men and 74.5% (n=180) of trans women did not obtain a medical prescription.19 Another study, carried out in the Federal District in 2019, with transvestites and trans women, found that 40.8% (n=82) based their hormone therapy on the advice of other trans persons.19 This difference in the percentage of medical prescriptions between the genders can be explained by the fact that it is not compulsory to obtain a medical prescription for estrogenic and antiandrogenic medications.
Support groups, including those on social media, can serve as important social support networks and sources of information for the trans population with little access to the health system. Two data items from our research may corroborate this hypothesis. Firstly, the low percentage of medical follow-up would suggest that the frequency of discordant dosages is higher than that observed. This is verified by the fact that all the participants opted for oestradiol over ethinyl oestradiol in hormonization for trans women, as well as only two hormone therapy discordances due to dosage. Secondly, there was great interest in an Instagram account created for the research. Despite only being in operation for four months, over 400 visits were made to the platform and over 12,000 accounts were reached. In addition, there were frequent contacts with the organizers with demands for clinical care and questions about how to make the transition safely.
With regard to other types of physical interventions, only three participants in our study had undergone surgery, all of them mastectomies. However, 78.3% of binary and 60% of non-binary individuals reported a desire to undergo some kind of surgical procedure. The financial issue was the main obstacle to these procedures, accounting for around 65% of cases for both genders. This form of bodily change, when requested and carried out, is associated with a higher quality of life and satisfaction in relation to self-image.33 COSTA et al. (2018) found that 29.9% (n= 103) of trans women and 11.2% (n= 18) of trans men had already undergone some form of physical modification procedure. In the same study, only 12.4% (n=33) and 18% (n= 6) of trans women and men respectively had not undergone invasive bodily modifications due to unwillingness to do so.21
It should be emphasized that, despite the importance of the surgical procedure, this is not yet part of the reality of most health services. In Divinópolis, there is no public service that performs this type of surgery. In the region, only the Eduardo de Menezes Hospital performs one of these procedures via SUS, namely mastectomy, which is still in the early stages. At this location, which also serves other cities affiliated to the municipality of Belo Horizonte, there is a waiting list of around 12 months.
Data on the participants\' sex lives raises the need for an intervention related to safe sex practices, improved access to barrier methods and periodic testing for STIs. In our study, low STI screening rates were identified (26.7%, n=12), despite frequent abstention from condom use in the preceding year (59.6%, n=28). This high-risk behavior was also observed by Fernandes et al. (2014) (53.6%, n=45) and Santos et al. (2021) (68.7%, n=278). However, this reality is not exclusive to the trans population.29,35 The National Health Survey (PNS), when assessing the general population in 2019, found a frequency of 76% of participants (n=92.28 million) reporting exposure to STI infection in the previous year.34 In our sample, two reports of previous syphilis diagnoses were identified. However, the reality may be more adverse. There is already consensus in scientific literature that there are higher rates of various forms of STI in the trans as compared to the cisgender population. Thus, there is already data on the diagnosis of syphilis (50% versus 2.8% of the general population) and HIV (33% versus 0.5% of the general population).35,36
This study shows advances in relation to the accumulated knowledge on the subject, but calls for further investigation. One weakness of the research is that it uses a sample that is not representative of the population studied. The number of participants, although lower than the total trans population estimated for the municipality, represents a percentage compatible with that of other publications on the subject. The smaller-than-ideal sample is, unfortunately, to be expected as this is a marginalized group, and therefore difficult to reach.
Nevertheless, this study has various strong points. The main one is its originality in assessing each participant\'s trans hormone dosage and classifying this according to national and international protocols. In addition, the questionnaire used was carefully constructed, drawing not only on a detailed bibliographic review, but also on suggestions from representatives of the trans population and professionals who are prominent in the care and/or study of this community. In this way, a tool was obtained that allowed us to understand both the resources used for gender affirmation and the context in which the participants are situated.
5. BIBLIOGRAPHIC REFERENCES
1. Sociedade Brasileira de Patologia Clínica, Sociedade Brasileira de Endocrinologia e Metabologia, Colégio Brasileiro de Radiologia e Diagnóstico por Imagem. Posicionamento conjunto, Medicina Diagnóstica inclusiva: cuidando de pacientes transgênero; 2019.
2. Barbosa MG, Silva MRD da, Seródio AM de B. A População Transgênero sob o Olhar da Bioética: Um Panorama dos Currículos de Graduação e dos Cursos de Bioética das Escolas Médicas do Estado de São Paulo. Rev Bras Educ Med 2020; 44 (3):100.
3. Ministério dos Direitos Humanos. Manual orientador sobre a diversidade; 2018.
4. Tangpricha V, Safer JD. Transgender men: Evaluation and management. UpToDate [online] 2020 [citado 5 Mar 2020]. Disponível em: URL: https://www.uptodate.com/contents/transgender-men-evaluation-and-management
5. Tangpricha V, Safer JD. Transgender women: Evaluation and management. UpToDate [online] 2020 [citado 2020 Mar 5]. Disponível em: URL: https://www.uptodate.com/contents/transgender-women-evaluation-and-management
6. Ministério da Saúde. Portaria nº. 457/2008. Dispõe sobre regulamentação do processo transexualizador no âmbito do sistema único de saúde [Internet]. Brasil: Diário Oficial da União 2008; [citado 2020 Mar 20]. Disponível em: https://bvsms.saude.gov.br/bvs/saudelegis/sas/2008/prt0457_19_08_2008.html
7. Ministério da Saúde. Portaria nº. 2803, de 19 de novembro de 2013. Dispõe sobre redefinição e ampliação do processo transexualizador no sistema único de saúde [Internet]. Brasil: Diário Oficial da União 2013; [citado 2020 Mar 20]. Disponível em: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2013/prt2803_19_11_2013.html
8. Spizzirri G, Eufrásio R, Lima MCP, de Carvalho Nunes HR, Kreukels BPC, Steensma TD, Abdo CHN. Proportion of people identified as transgender and non-binary gender in Brazil. Sci Rep 2021;11(1):2240.
9. Zwickl S, Wong A, Bretherton I, Rainier M, Chetcuti D, Zajac JD, Cheung AS. Health Needs of Trans and Gender Diverse Adults in Australia: A Qualitative Analysis of a National Community Survey. Int J Environ Res Public Health 2019;16(24):5088.
10. Cicero EC, Reisner SL, Merwin EI, Humphreys JC, Silva SG. The health status of transgender and gender nonbinary adults in the United States. PLoS One. 2020 Feb 2020;15(2):e0228765.
11. Rocon PC, Wandekoken KD, Barros MEB de, Duarte MJO, Sodré F. Acesso à Saúde Pela População Trans no Brasil: Nas Entrelinhas Da Revisão Integrativa. Trab. educ. saúde 2020;18(1).
12. Instituto Brasileiro de Geografia e Estatística. Minas Gerais: Divinópolis [Internet]. IBGE, 2023. Disponível em: https://cidades.ibge.gov.br/brasil/mg/divinopolis/panorama
13. Goodman M, Adams N, Corneil T, Kreukels B, Motmans J, Coleman E. Size and Distribution of Transgender and Gender Nonconforming Populations: A Narrative Review. Endocrinol Metab Clin North Am 2019;48(2):303-321.
14. Costa, BRL. Bola de Neve Virtual: O Uso das Redes Sociais Virtuais no Processo de Coleta de Dados de uma Pesquisa Científica. Rev Interdisciplinar de Gestão Social 2018, 7(1):15-37.
15. Amorim, APA, organizadora. Protocolo para o atendimento de pessoas transexuais e travestis no município de São Paulo. São Paulo: Comitê Técnico de Saúde Integral LGBTI. Secretaria Municipal de Saúde; 2020.
16. International Medical Advisory Panel (IMAP). Statement on hormone therapy for transgender people, 2015 [acesso 2023 Jun 22]. Disponível em: https://www.ippf.org/sites/default/files/ippf_imap_transgender.pdf.
17. Leinung MC, Urizar MF, Patel N, Sood SC. Endocrine treatment of transsexual persons: extensive personal experience. Endocr Pract 2013;19(4):644-50.

18. Centro de Estudo de Cultura Contemporânea (CEDEC). Mapeamento das pessoas trans no município de São Paulo. Relatório de pesquisa. São Paulo, 2021.
19. Hernández J de G, Silva Junior AL da, Carrara S, Baldanzi AC de O, Uziel AP. Saúde de travestis e pessoas trans no Rio de Janeiro e Região Metropolitana: estratégias e condições de acesso. Sex. salud soc. (Rio J.) 2022, (38): e22301.
20. Krüger A, Sperandei S, Bermudez XPCD, Merchán-Hamann E. Características do uso de hormônios por travestis e mulheres transexuais do Distrito Federal Brasileiro. Rev Bras Epidemiol 2019; 22 (1).
21. Costa AB, da Rosa Filho HT, Pase PF, Fontanari AMV, Catelan RF, Mueller A, Cardoso D, Soll B, Schwarz K, Schneider MA, Gagliotti DAM, Saadeh A, Lobato MIR, Nardi HC, Koller SH. Healthcare Needs of and Access Barriers for Brazilian Transgender and Gender Diverse People. J Immigr Minor Health. 2018;20(1):115-123.
22. Amorim, APA, organizadora. Protocolo para o cuidado integral à saúde de pessoas trans, travestis ou com vivências de variabilidade de gênero no município de São Paulo. São Paulo: Secretaria Municipal da Saúde. Coordenação da Área Técnica de Saúde Integral da População LGBTIA+; 2023.
23. Divinópolis. Relação Municipal de Medicamentos Essenciais. Classificação segundo a Rename: Divinópolis, 2021.
24. Ministério do Planejamento, Orçamento e Gestão. Portaria nº. 233, de 18 de maio de 2010. Dispõe sobre uso do nome social adotado por travestis e transexuais nos serviços públicos, no âmbito da Administração Pública Federal direta, autárquica e fundacional. [Internet]. Brasil: Diário Oficial da União 2008; [citado 2020 Set 23]. Disponível em: Diário Oficial da União 2008, 19 ago.
25. Rocon PC, Rodrigues A, Zamboni J, Pedrini MD. Dificuldades vividas por pessoas trans no acesso ao Sistema Único de Saúde. Cien Saude Colet 2016; 21(8):2517–26.
26. Mota M, Santana ADS, Silva LR, Melo LP . “Clara, esta sou eu!”, acesso à saúde e sofrimento social entre pessoas transgênero. Interface - Comunicação, Saúde, Educação 2022; 26:e210017.
27. Associação Nacional de Travestis e Transexuais (ANTRA). Protocolo Policial para Enfrentamento da Violência LGBTfóbica no Brasil. São Paulo: FGV Direito, 2020.
28. Scote FP. Será que temos mesmo direitos a universidade? O desafio do acesso e a permanência de pessoas transexuais no ensino superior. Sorocaba. Dissertação [Programa de pós-graduação em educação] UFSCar; 2017.
29. Santos PMR, Santos KC , Magalhães LS, Oliveira BR, Carneiro MAS, Souza MM, Caetano KAA, Pacheco LR, Teles SA. Travestis and transsexual women: who are at higher risk for sexually transmitted infections?. Rev Bras Epidemiol 2021; 24: e210017.
30. Pesquisa Mais Diversidade. O Cenário Brasileiro LGBTI+, 2021 [acessado 2023 out 22]. Disponível em: https://drive.google.com/file/d/1uIwHu1nyqUrnOfJWol9gCAfJe3XQiDOb/view.
31. Instituto Brasileiro de Geografia e Estatística (IBGE). Desemprego [Internet]. IBGE, 2023 [acesso 2023 out 13]. Disponível em: https://www.ibge.gov.br/explica/desemprego.php.

32. Instituto Brasileiro de Geografia e Estatística. IBGE divulga o rendimento domiciliar per capita e o Coeficiente de Desequilíbrio Regional de 2022. IBGE Notícias, Estatísticas Sociais, 31 mai. 2023 [acessado 2023 out 13]. Disponível em: https://agenciadenoticias.ibge.gov.br/agencia-sala-de-imprensa/2013-agencia-de-noticias/releases/37023-ibge-divulga-o-rendimento-domiciliar-per-capita-e-o-coeficiente-de-desequilibrio-regional-de-2022
33. Barros LO, Lemos CRB, Ambiel RAM. Qualidade de vida e satisfação com a imagem corporal de transexuais. Arq. bras. psicol. 2019, 71(1): 184-195.
34. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde (PNS). Ciclos de Vida. Ministério da Economia; Diretoria de Pesquisas; Coordenação do Trabalho e Rendimento, 2019.
35. Fernandes FR, Zanini PB, Rezende GR, Castro LS, Bandeira LM, Puga MA, Tanaka TS, Castro LS, Bertolacci-Rocha LG, Teles SA, Motta-Castro AR. Syphilis infection, sexual practices and bisexual behaviour among men who have sex with men and transgender women: a cross-sectional study. Sex Transm Infect 2015;91(2):142-9.
36. Baral SD, Poteat T, Strömdahl S, Wirtz AL, Guadamuz TE, Beyrer C. Worldwide burden of HIV in transgender women: a systematic review and meta-analysis. Lancet Infect Dis 2013;13(3):214-22.