HEALTH VULNERABILITIES OF TRANSGENDER SEX WORKERS: AN INTEGRATIVE REVIEW

VULNERABILIDADES EN TÉRMINOS DE SALUD DE LAS PERSONAS TRANSGÉNERO QUE OFRECEN SERVICIOS PROFESIONALES DE SEXO: UNA REVISIÓN INTEGRADORA

ABSTRACT

Objective:

to identify the health vulnerabilities of transgender sex workers.

Method:

an integrative review conducted in July 2020 in the PubMed, Web of Science, SCOPUS, CINAHL, IBECS and LILACS databases, with no language or time restrictions. The following descriptors indexed in DeCS and MESH and their respective synonyms were used: “Transgender persons”, “Sex workers” and “Health vulnerability”. The data were analyzed based on thematic analysis.

Results:

a total of 547 articles were retrieved and, after the selection and analysis process, 34 were included in this review. Four thematic classes emerged: “Knowledge, prevention and exposure to STIs in sex work”; “Use (and abuse) of illegal substances and alcohol”; “The social and structural dimension of vulnerabilities: from weakened support networks to violence reproduced against dissident bodies”; and “Psychosocial diseases, discrimination and challenges of transgender sex workers”.

Conclusion:

the health vulnerabilities experienced by transgender sex workers are marked by discrimination, social exclusion, stigma, incarceration contexts, physical, psychological and sexual violence and use of illegal substances and alcohol, in addition to difficulties in accessing essential services such as health, education and leisure.

DESCRIPTORS:
Transgender persons; Sex workers; Health vulnerability; Sexual and gender minorities; Nursing

RESUMEN

Objetivo:

identificar las vulnerabilidades en términos de salud de las personas transgénero que ofrecen servicios profesionales de sexo.

Método:

revisión integradora realizada en julio de 2020 en las siguientes bases de datos PubMed, Web of Science, SCOPUS, CINAHL, IBECS y LILACS, sin restricciones de idioma o de tiempo. Se utilizaron los descriptores indexados en DeCS y en MESH y sus respectivos sinónimos: “Personas transgénero”, “Profesionales del sexo” y “Vulnerabilidad en términos de salud”. Los datos se analizaron sobre la base del análisis temático.

Resultados:

se recuperó un total de 547 artículos y, luego del proceso de selección y análisis, 34 de ellos fueron incluidos en esta revisión. Surgieron cuatro clases temáticas: “El conocimiento, la prevención y la exposición a las ITS en el trabajo sexual”; “El uso (y abuso) de sustancias ilícitas y del alcohol”; “La dimensión social y estructural de las vulnerabilidades: de las redes de apoyo debilitadas a las diversas formas de violencia reproducidas contra los cuerpos disidentes”; y “Las enfermedades psicosociales, la discriminación y los desafíos de las personas transgénero que ofrecen servicios profesionales de sexo”.

Conclusión:

las vulnerabilidades en términos de salud experimentadas por las personas transgénero que ofrecen servicios profesionales de sexo están marcadas por la discriminación, la exclusión social, el estigma, los contextos de encarcelamiento, la violencia física, psicológica y sexual y el uso de sustancias ilícitas y de alcohol, además de las dificultades para acceder a los servicios esenciales como salud, educación y recreación.

DESCRIPTORES:
Personas transgénero; Profesionales del sexo; Vulnerabilidad en términos de salud; Minorías sexuales y de género; Enfermería

RESUMO

Objetivo:

identificar as vulnerabilidades em saúde das pessoas transgênero profissionais do sexo.

Método:

revisão integrativa realizada em julho de 2020 nas bases PubMed, Web of Science, SCOPUS, CINAHL, IBECS e LILACS, sem restrição de idioma e tempo. Utilizaram-se os descritores indexados no DECS e MESH e seus respectivos sinônimos: “Pessoas transgênero”, “Profissionais do sexo” e “Vulnerabilidade em Saúde”. Os dados foram analisados a partir da análise temática.

Resultados:

foram resgatados 547 artigos e, após o processo de seleção e análise, 34 compuseram esta revisão. Quatro classes temáticas emergiram: “O conhecimento, prevenção e exposição às ISTs no trabalho sexual”; “O uso (e abuso) de substâncias ilícitas e o álcool”; “A dimensão social e estrutural das vulnerabilidades: das redes de apoio fragilizadas às violências reproduzidas contra os corpos dissidentes.” e “As doenças psicossociais, discriminação e desafios das pessoas trans profissionais do sexo”.

Conclusão:

as vulnerabilidades em saúde vivenciadas pelas pessoas trans profissionais do sexo são marcadas pela discriminação, exclusão social, estigma, contextos de encarceramento, violência física, psicológica e sexual, uso de substâncias ilícitas e álcool, além das dificuldades de acesso aos serviços essenciais como saúde, educação e lazer.

DESCRITORES:
Pessoas transgênero; Profissionais do sexo; Vulnerabilidade em saúde; Minorias sexuais e de gênero; Enfermagem

INTRODUCTION

Health vulnerability analyses emerged in the North American context in the early 1990s, in studies on the political responses to the epidemic caused by the Human Immunodeficiency Virus (HIV) and the Acquired Immunodeficiency Syndrome (AIDS)1. This perspective was opposed to the epidemiological analyses of the HIV/AIDS epidemic that focused on the risk factors and risk groups.2 Consequently, vulnerability analyses were initiated from an understanding of the totality and complexity that considered the individuals, although contextualizing them based on their social relationships and their relations with the State3^-4.

In its origin, the vulnerability category is designated to groups or individuals who are weakened, either legally or politically, in the promotion, protection and/or guarantee of their citizenship rights5. Vulnerability is taken as a condition or situation that intertwines structural relations of domination or injurious forms of formation of these identities6. Thus, it is understood that vulnerability analyses are powerful analytical tools for understanding the case of certain social groups, such as that of transgender people^*.

The term trans people designates a set of subjects whose gender identities exert tension on the sex-gender-desire unity, typical of the cis-heteronormative logic7. It is evidenced that approximately 0.4% to 1.3% of the population over 15 years of age does not identify with the gender identity attributed at birth8.

Trans people have historically been subjected to relations of power and domination which, at the same time that they undergo processes of invisibilization, take them as abject beings. Abjection makes it impossible for these people to be intelligible from their gender performances, since they break with the hegemonic logic. In a society in which the relationships and the condition of humanity of the subjects go through the sifting of the genification processes, trans people can experience a set of vulnerabilities in their daily lives, notably those who are sex workers8. Experiences of physical, verbal, sexual and psychological violence, hate crimes, torture, exposure to Sexually Transmitted Infections (STIs) and greater susceptibility to the use of psychoactive substances with psychological outcomes of depression and suicide are identified. Thus, the mediatization and visibility of how the power structures - socially and historically imbricated - act on the bodies and lives that “do not matter” can contribute to the promotion and enhancement of the debate among managers, health professionals and civil society, in addition to strengthening public policies aimed at this population in Brazil, such as the Comprehensive Health Policy for Lesbians, Gays, Bisexuals and Transgenders (LGBT+)9.

There is evidence that trans people have poor social and community networks; they have few opportunities for formal employment, in addition to reports of transphobia that directly and indirectly interfere in the socioeconomic relationships10^-11. Such a situation is even expressed in the low life expectancy of these individuals: 35 years old8^,12. In addition to this, it is observed that there is a higher rate of transvestites and transsexual women who engage in sex work as a means of survival13. Thus, the objective was to identify the health vulnerabilities experienced by transgender sex workers.

METHOD

The integrative review study was developed in six stages: identification of the theme and guiding question; definition of inclusion and exclusion criteria; definition of the information to be extracted from the selected studies; evaluation of the studies included in the integrative review; interpretation of the results; and knowledge synthesis14^-15.

Initially, the theme and guiding question were identified by means of the PICo strategy16, where P (Population) AND I: (Phenomenon of Interest) AND Co: (Context), where: P=Transgender persons OR Transgenders Person OR Transgender Persons, Transgender OR Transgenders OR Transgender OR Transsexual Persons AND I=Health Vulnerability AND Co=Sex Work OR Work Sex OR Sex Industry OR Prostitution. From the strategy, the following guiding question was generated: what are the health vulnerabilities experienced by transgender sex workers?

Subsequently, sampling was established with the definition of the inclusion and exclusion criteria: the materials included were original articles, with no time limit for the searches, published in any language, and related to the guiding question. Duplicate articles, counted once, were excluded, as well as those that addressed transgender and cisgender people in the same study without presenting the results separately; those that addressed trans people who are not sex workers; review articles; and those coming from the gray literature without scientific publishing.

The search for the articles was carried out in July 2020 through the system of the Central Library of Universidade de São Paulo and the CAPES journal, which provided access to the main databases: PubMed Central, Web of Science, SCOPUS, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Índice Bibliográfico Español en Ciencias de la Salud (IBECS) and Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS). A search strategy was used, adapted for each database according to their recognition specificities, as well as their keywords and their entry terms separated by Boolean operators OR to distinguish them and AND to associate them, in order to integrate and direct the maximum number of studies on the theme, according to Chart 1.

Chart 1 -
Strategies generated from the controlled descriptors and entry terms. Recife, PE, Brazil, 2020.

Database	Strategy
PUBMED, SCOPUS	(((("transgender persons") OR transgenders) OR "Person, Transgender") OR Persons, Transgender OR Transgenders) OR Transgender) OR Transsexual Persons AND (((("Health Vulnerability") AND ((Sex Work") OR Work, Sex) OR Sex Industry) OR Prostitution)
CINAHL WEB OF SCIENCE	#1“transgender persons” OR transgender OR “Person, Transgender” OR “Persons, Transgender” OR “Transgenders” OR “Transsexual Persons” #2: “Health Vulnerability” #3: “Sex Work” OR “Work Sex” OR “Sex Industry” OR “Prostitution” Strategy: #1 AND #2 AND #3
LILACS, IBECS	“Pessoas transgênero” OR “Pessoa trans” OR “Pessoas transexuais” OR “Transexual” OR “Transgênero” OR “Transgêneros” OR “personas transgénero” OR “transgender persons” OR “transgenders” OR “Person, transgender” OR “Transsexual Persons” AND “Vulnerabilidade em Saúde” OR “Vulnerabilidad en Salud” OR “Health Vulnerability” AND “Profissionais do sexo” OR “Trabajadores Sexuales” OR “Sex Workers” OR “Sex Industry” OR “Prostitution”

In the next phase, the studies were categorized the data to be extracted were defined: after the studies were located, the results were exported to the Zotero bibliographic manager software, in order to identify and exclude duplicates. Subsequently, these were transferred to the Rayyan QCRI online platform17, where two independent reviewers read the titles and abstracts. When necessary, a third examiner was introduced in the selection process to settle the disagreements18.

Then, the subsequent stages were evaluation of the studies included with full reading of the selected studies, critical analysis and synthesis of the review results. Data extraction was obtained from a validated methodological form19^-20, consisting of the following variables: identification of the original article, year of publication, country, methodological characteristics of the study; study sample, assessment of methodological rigor, main results, limitations and conclusions.

The level of evidence was assessed based on the proposal by Melnyk and Fineout-Overholt: 1- the evidence is the result of a systematic review, meta-analysis or clinical guidelines from systematic reviews of randomized and controlled trials; 2- evidence of at least one randomized controlled clinical trial; 3- evidence derived from well-designed clinical trials without randomization; 4- evidence from a well-designed cohort and case-control studies; 5- evidence presented from systematic reviews, descriptive and qualitative studies; 6- evidence from a single descriptive or qualitative study; 7- evidence derived from the opinion of authorities and/or experts committee opinion21.

In the phase of interpretation of the results, the articles included in the final sample were analyzed in a qualitative manner, based on thematic analysis22, which enabled categorization into 4 classes: “Knowledge, prevention and exposure to STIs in sex work”; “Use (and abuse) of illegal substances and alcohol”; “The social and structural dimension of vulnerabilities: from weakened support networks to violence reproduced against dissident bodies”; and “Psychosocial diseases, discrimination and challenges of transgender sex workers”. The classes were validated by the research group based on the confrontation of theoretical knowledge, expertise and solid experience of the researchers in this type of analysis. It is noteworthy that the pre-formulated categories were previously presented to the group in question. The descriptive data of the quantitative studies were considered in the categorization of the classes.

The results, screening and selection process were presented using a flowchart in accordance with the recommendations of the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA)23 and also by means of charts and in a descriptive way in order to synthesize and foster discussion on health vulnerabilities of transgender sex workers.

RESULTS

A total of 547 primary articles were identified and 34 articles were included after the selection process. The selection stages are described in Figure 1:

Figure 1 -
Flowchart of the process for selecting the primary studies, adapted from PRISMA. Recife, PE, Brazil, 2020.

A total of 547 articles were obtained in the preliminary search and selection process in the databases, with 34 (100%) being included in this review, coming from research studies conducted in the United States of America (USA) - 8 (23.5%); Canada - 3 (8.8%); Argentina, Dominican Republic, Peru, China, Thailand, Pakistan - 2 (5.8%) and Malaysia, Uruguay, Jamaica, South Africa, Brazil, Turkey, India, Holland, Puerto Rico, Guatemala and Mexico - 1 (3%). All the studies (100%) are in English. As for the original databases, articles were indexed in PubMed, 32.3% (n=11); Scopus, 41.2% (n=14); Web of Science, 23.5 (n=8); and Lilacs. 3% (n=1). The description of the articles included is in Chart 2 and the thematic classes and the synthesis of health vulnerabilities in Chart 3.

Chart 2 -
Authorship, Year of publication, Research design, and Level of evidence of the studies included in the final sample. Recife, Pernambuco, Brazil, 2020. (N=34)

Authorship	Year of publication	Research design	Level of evidence
Russi JC et al.24	2003	Quantitative - Epidemiological, descriptive	V
Sausa LA et al.25	2007	Qualitative	VI
Reisner SL et al.26	2009	Mixed	V, VI
Wilson EC et al.27	2009	Quantitative - Cross-sectional, descriptive	V
Infante C et al.28	2009	Qualitative	VI
Farias MSR et al.29	2011	Quantitative - Epidemiological, descriptive	V
Farias MSR et al.30	2011	Quantitative - Epidemiological, descriptive	V
Cortez FCP et al.31	2011	Quantitative - Cross-sectional, descriptive	V
Nemoto B et al.32	2011	Quantitative - Cohort	VI
Altaf A et al.33	2012	Quantitative - Cross-sectional, analytical	V
Nurena CR et al.34	2013	Qualitative	VI
Nemoto T et al.35	2013	Mixed	VI
Cai Y et al.9	2016	Quantitative - Cross-sectional, descriptive	V
Giguere R et al.36	2016	Quantitative - Randomized clinical trial	II
Logie CH et al.10	2017	Quantitative - Cross-sectional, descriptive	V
Budhwani H et al.13	2017	Quantitative - Cross-sectional, descriptive	V
Nuttbrock LA et al.37	2017	Quantitative - Longitudinal, prospective	V
Lyons T et al.38	2017	Qualitative	VI
Lyons T et al.39	2017	Qualitative	VI
Samudzi Z et al.40	2017	Qualitative	VI
Ganju S et al.41	2017	Qualitative	VI
Budhwani H et al.42	2017	Quantitative - Cross-sectional, descriptive	V
Wickersham JA et al.43	2018	Quantitative - Epidemiological, descriptive	VI
Matthen P et al.44	2018	Mixed	V, VI
Degtyar A, et al.45	2018	Qualitative	VI
Khalid M et al.46	2019	Quantitative - Cross-sectional, descriptive	V
Sherman SG et al.47	2019	Quantitative - Cohort	IV
Jarrett D et al.48	2019	Qualitative	VI
Guler E et al.49	2020	Qualitative	VI
Wang Q et al.50	2020	Quantitative - Cross-sectional, descriptive	V
Drückler S et al.51	2020	Quantitative - Cross-sectional, descriptive	V
Miller WM et al.52	2020	Quantitative - Cross-sectional, descriptive	V
Poteat T et al.53	2020	Quantitative - Cohort	IV
Capous-Desyllas M et al.54	2020	Qualitative	VI

Chart 3 -
Thematic categorization and Synthesis of the health vulnerabilities of transgender sex workers. Recife, PE, Brazil, 2020. (N=34)

Thematic Categorization	Synthesis of the health vulnerabilities of transgender sex workers
Knowledge, prevention and exposure to STIs in sex work	The following was revealed: lack of knowledge about the transmission of the HIV virus and the fragile knowledge about the identification of signs and symptoms of some STIs, such as HPV warts. “Sexual agreements” favor low adherence to condom use. The performance of anal sexual practice (insertive and receptive) and ejaculation in the mouth without a condom and how the feminization of transsexual women can influence the use or not of the condom were identified. It was also possible to evidence high prevalence values of HIV, Hepatitis B and syphilis, in addition to the high-risk genotypes of HPV9,13,26,29-30,33-37,41,43,45-47,53.
Use (and abuse) of illegal substances and/or alcohol	The use of drugs such as cocaine was identified, in addition to injectable and inhalation drugs during sex work. There are reports of excessive alcohol use, professional practice under the influence of alcohol and combined use of alcohol and drugs during and/or before the sexual practice, describing that “physical work is easier”10,24,35,42-43,47,50-52.
The social and structural dimension of vulnerabilities: from weakened support networks to violence reproduced against dissident bodies	Economic and interpersonal adversities stand out, a history of home evictions, weak support networks and difficulties in employment due to gender, in addition to the exclusion that restricts access to social spaces. Insertion in sex work is considered a “norm” for young transgender women due to prejudice and difficulties in the formal job market, making it possible to identify that the population under 36 years of age was more involved in sex work. Involvement in sex work is often due to survival needs. The context of violence and harassment against transgender sex workers emerged, as well as how this prejudice is shaped by the socio-structural context, in addition to the incarceration and criminalization scenarios. In general, vulnerability is influenced by the social context and stigma, as well as access to scarce support networks and lack of support in terms of health and social programs10,24-25,27-28,31,35,37-42,44,47-49,52.
Psychosocial diseases, discrimination and challenges of transgender sex workers	Sex for money was associated with depression, suicidal ideation and higher levels of harms. Negative feelings in relation to dealing with stereotypes and stigmas are described. There are several challenges that involve from transphobia experiences of clients to feelings of disgust reproduced by family, clients and society, which will culminate in contexts of psychological distress10,31,35,54.

DISCUSSION

Knowledge, prevention and exposure to STIs in sex work

The health vulnerabilities of transgender sex workers identified in this study are located in several contexts of professional work which, analyzed from a macrosocial perspective, alludes to concepts such as the quality of information about self-care, the ability to incorporate preventive practices in daily life, and the level of concerns that contribute to exposure to or protection from illness.49

The risks of illness in the exposure of sex work are recognized due to the social conditions imposed by violence, prostitution, and use of drugs and alcohol50. It was possible to identify how the negotiation of the sex work prices aiming at sexual practices without a condom, in addition to the fulfillment of sexual desires related to fetishization of the body and the exploitation of people considered abject39, result in sexual commercialization associated with physical and psychological aggression to the detriment of health and lives that “do not matter”7^,30^,41.

Ignorance of the risks and of certain diseases may be involved, in some scenarios, with the denial of access to education and to the socioeconomic status that conditions trans people to disinformation regarding the transmission and infection by several STIs. It is possible to observe that transgender sex workers are at a higher risk of being infected by HIV, in addition to the estimate that 27.3% of the transgender sex workers worldwide have HIV55^-57. Logie et al (2020) suggest that trans women who are sex workers have nine times higher rates of HIV infections compared to trans women who are not sex workers10^,13^-14^,37^,39^-40.

In a study carried out in Malaysia, it is observed that 28.3% of the transgender sex workers have syphilis, as well as significant rates of gonorrhea. All of these data suggest that misinformation can be linked, to some extent, with the infection and transmission of some of these diseases, such as HIV, syphilis and gonorrhea43. In a study carried out in Portugal with transvestites who are sex workers, it was observed in an ethnography that knowledge about the prevention of HIV and of other STIs was permeated by non-scientific and common sense knowledge, such as ointments, receiving oral sex without a condom, using “hot baths” or unprotected sexual practices when the client was physically fit58.

It was observed that anal and oral sex with ejaculation in the mouth proved to be a routine practice in the daily life of the target population, thus constituting relevant risk factors, motivating these practices by the clients' “eccentric” desires36^,38. Infection by HPV, for example, can be the result of sexual practices with multiple partners, of the failure to identify anal warts and of the practice of anal sex without a condom, factors that are linked to denial and to the difficulty of access to education and health. In addition to this, various studies were found in which there is an association and evidence of the prevalence of HIV with transgender sex workers; however, this population is also exposed to syphilis and chlamydia, showing the need for articulation not only in the prevention of HIV/AIDS but also of other STIs31^,36^-38.

Vulnerabilizing relationships permeate the lives of transgender individuals and impact on the health-disease process. In several contexts, the successful experiences result from activism in the face of these people's social and health difficulties; however, they are still insufficient and demand the participation of the social actors in the fight against transphobia, in the defense of life and in solidarity. Nursing plays a plural role in care; consequently, nurses can provide services in a singular manner, listen to and actively participate in the health promotion actions and in the prevention of diseases and health problems, offer basic and specialized assistance in an interdisciplinary fashion and with inclusion of the social movements in decision-making and permanent education spaces.

Use (and abuse) of illegal substances and/or alcohol

The night experience of transgender people in places of prostitution was sometimes associated with the use and abuse of legal and illegal drugs offered by clients and socialized, occasionally, by the professionals. It is estimated that 77% of these individuals use drugs, either due to client imposition or to addiction31^,40. It is stated that drug use is often initiated since leaving the parents' home and remains in the daily lives of trans people, especially in the prostitution spaces, which can culminate in contexts of incarceration, criminalization and violence40.

It can be inferred that experiencing certain contexts of the sexual profession enhances the use and association of psychoactive substances in sex work or outside of it, even allowing for the commercialization of these substances such as cocaine and injectable drugs. The association of the use of illicit drugs in sex work is also reported, showing itself as one of the reasons for non-adherence to condoms and as a way to “escape” from the reality that produces contexts of distress40^,43. The use of psychoactive substances in sex work spaces is also characterized by the ease of access in the sexual practice with the client or due to addiction46.

Both the consumption of alcoholic beverages and illicit drugs was shown to be intense in the studies identified since, in some way, it is part of the daily routine of trans sex workers. Another factor to be considered is the associated use of alcohol and illicit drugs, requiring guidelines on the risks of this combination, for example: the harmful effects caused by the simultaneous use of crack and alcohol. However, the importance of not associating the experiences and experiences of trans people with the use of drugs is emphasized, given that such process reasserts the prejudice that is based on the structural relations of power, the stigma, and the negative representations of these people present in society59.

The importance of the role of managers and health professionals in assisting trans sex workers who use and abuse illicit drugs is also emphasized. Free of value judgments, the support provided by these trained professionals can enable the creation of a network of actions aimed, above all, at screening, discussion of harm reduction, rehabilitation and prevention of complications.

The social and structural dimension of vulnerabilities: from weakened support networks to violence reproduced against dissident bodies

The recognition, by the health sector, of the importance of identifying the influence of macrosocial processes on the lives of people dissenting from the norm takes place based on the consideration and interaction of the contexts of the social actors in vulnerabilizing situations. However, this recognition is not, by itself, sufficient to resolve unequal contexts and social injustices, as is the case with trans sex workers. In the family network itself, for example, the population in question is the target of physical, verbal and psychological violence10^,38 where they cannot express their gender identity, resorting to friends or colleagues who can assist in this phase38^,52.

The family network is the main pillar of affection and support and the denial of this base weakens the protection alliances, culminating in the expulsion of transgender youths from their homes. When that link weakens, trans people hardly have access to school and other social services, being forced to live on the street and to initiate strategies that can assist in their survival26^,29.

The survival context can be linked to transphobia, which impacts on the exercise of the right to citizenship of transgender sex workers, guaranteed by laws and advocated worldwide12^,15^,25^,27. Social exclusion is configured as a complex process and grounded on material and political dimensions, a way that involves people and their relationships with each other, being asserted from different perspectives: cultural and ethnic, economic, sexual, gender and pathological44. in addition to this, it is observed that the gender relationship of transvestites and/or trans women with society - and here the power structures and hierarchies taken from the logic of heterosexual and cisgender hegemony are mentioned - will, to this extent, enhance not only social exclusion, but an entire chain of inferiorization, even evidencing problems such as violence and the experience of vulnerable contexts60.

The association between stigma and social exclusion results in violence that impacts on the life expectancy of trans people, which does not exceed 35 years old12. In the TGEU report, released in 2017, the following is observed: 11% of the transgender people murdered between January 1^st, 2008 and December 31^st, 2017 were under the age of 20; 46% were between 20 and 29 years old; 29%, between 30 and 39 years old; 11%, between 40 and 49 years old; 3%, between 50 and 59 years; and 1% was over 60 years old8^,16.

What is shaped in the social thinking of the figure of transsexual women, for example, is situated in the common sense of social breakdown, in which trans people and the prostitution scene are linked, in addition to poverty, incarceration and trafficking. This representation emerges from a system that has cis-heterosexuality as a device for the production of distress and that locates people dissenting from the norm in a social and existence periphery. It is necessary to understand that the vulnerabilities in this population are not only in the access to the public policies, but to education, leisure, work and their right to exercise their citizenship. Therefore, the health vulnerabilities of transgender sex workers are due not only to the form of the risks that sex work imposes, but also to the strengthening of structural processes that legitimize “which lives matter”. In addition to this, not only the individual aspects within the context of vulnerability should be considered, as this would be simplistic and inductive to blaming the subjects.

Psychosocial diseases, discrimination and challenges of transgender sex workers

When discussing the existence of trans people in society, this is permeated by a set of mechanisms that have social control as a way to regulate actions instituted against people who exert tension on the norm, being characterized by operations that will favor the experience of social stigmas and discrimination61.

Discrimination against transgender sex workers is present in different spheres: it occurs in the family, resulting in expulsion of the family; in formal institutions, such as school and work, corroborating school evasion and entry into precarious activities and linked to subordination, with prostitution being the most recurrent practice; in access to the health services, which does not meet the demands of this population, as well as it does not respect the use of the social name and has services intertwined in coercive and transphobic practices62^-63. Such situations produce contexts that will potentiate the emergence of psychosocial diseases and reassert a location in society that involves the system of social stratification and hierarchy64.

The social, economic and psychological context in which transgender sex workers are inserted is, within the macrosocial context to which these individuals are configured, situated in a social map perspective64. Thus, it is pointed out that social discrimination can result in illness and distress, with the possibility of presenting itself in different types of violence. The stigmatization experiences suffered by this population contribute to the emergence of mental and psychological distress in trans people. Depression, anxiety, mood disorders and self-inflicted violence were identified in people who suffer discrimination, being accentuated when the reason for prejudice is associated with gender issues61^-62

Therefore, discrimination is materialized by social exclusion, violence and stigma, as well as by the stereotypes reproduced by society, by the family and even by the very clients of the professionals. The psychological state is weakened due to the rejection and insecurity experienced and influenced by such a context of sex work, leading to suicidal32 and depressive ideas, as shown by a study from Argentina65, in which it is made explicit that at least one third of the participating sex workers reported attempted suicide resulting from the social context experienced by the population in question62.

The implications of the results evidenced can enhance the discussion about the vulnerable processes and how these structures act in the context of trans sex workers. Such results can also aid the understanding by health professionals, managers and the Nursing team to comprehend and develop strategies that may be able to dialog with the needs of transgender sex workers and that understand the socio-cultural dynamics established from of the way of life, promoting problematizations and dialogs that favor the reception, access and resolution of the demands of the target population.

Thematic categorization performed in the analysis is pointed out as a study limitation, since the same study could fall into different categories, but not at the same predominance levels. Thus, it was decided to allocate the study to the thematic classes that were related and which not necessarily addressed only a specific theme. In addition to this, the chosen databases are highlighted, which may have limited, to some extent, the identification of other studies and the predominant levels of evidence VI and V of the studies included in the final sample.

CONCLUSION

The analyzed publications showed that the health vulnerabilities experienced by transgender sex workers are marked by discrimination, social exclusion and stigma, linked to gender dissent and enhanced by sex work. In addition to this, the following were identified as social inequalities: difficulty in accessing essential services such as health, education and leisure; incarceration; and neglect to provide health services, resulting from processes based on structures of social power and regulation. In this aspect, it is possible to reflect on the need for articulation of processes that can give visibility to the demands and existence of these people, for the recognition of their specificities in different spheres; as well as on the need for an equitable, holistic service that understands the social and historical context without inferring value judgments or reproducing prejudices and violence.

In addition to this, knowledge gaps were identified, even in the context of trans sex workers, such as the absence of studies that addressed aspects outside the logic centered solely on HIV infection, but also by other contexts that can produce vulnerability scenarios and that will, to some extent, enhance their entry into the sex work market. Therefore, it is suggested to formulate and conduct empirical studies - either in Health Sciences or in Human Sciences - that may foster debates on this gap identified.

REFERENCES

• 1. Rocha MDHA. História Social da AIDS no Mundo: a vulnerabilidade dos sujeitos. Rev Científica ITPAC [Internet]. 2016 [cited 2020 June 15];9(1):1-5. Available from: https://assets.itpac.br/arquivos/Revista/77/Artigo_8.pdf
  » https://assets.itpac.br/arquivos/Revista/77/Artigo_8.pdf
• 2. Czeresnia D, Freitas CM. Promoção da saúde: conceitos, reflexões, tendência. Rio de Janeiro, RJ(BR): Editora Fiocruz; 2003.
• 3. Ayres JRCM, Paiva V, França Jr I, Gravato N, Lacerda R, Della Negra M, et al. Vulnerability, human rights, and comprehensive health care needs of young people living with HIV/AIDS. Am J Public Health [Internet]. 2006 [cited 2020 June 15];96(6):1001-6. Available from: https://doi.org/10.2105/ajph.2004.060905
  » https://doi.org/10.2105/ajph.2004.060905
• 4. Grangeiro A, Escuder MML, Castilho EA. Magnitude and trend of the AIDS epidemic in Brazilian cities, from 2002 to 2006. Rev Saúde Pública [Internet]. 2010 [cited 2020 June 15];44(3):430-441. Available from: https://doi.org/10.1590/S0034-89102010005000013
  » https://doi.org/10.1590/S0034-89102010005000013
• 5. Alves JAL. Os direitos humanos como tema global. São Paulo, SP(BR): Perspectiva; 1994.
• 6. Butler J. The Psychic Life of Power. Theories in Subjection. Palo Alto, CA (US): Stanford University Press; 1998.
• 7. Butler J. Problemas de Gênero: feminismo e subversão da identidade. 2nd ed. Rio de Janeiro, RJ(BR): Editora Record; 2003.
• 8. Transgender Europe (TGEU). TMM annual report 2016. TvT Publication Series [Internet]. 2016 [cited 2020 June 15]. Available from: https://transrespect.org/wp-content/uploads/2016/11/TvT-PS-Vol14-2016.pdf
  » https://transrespect.org/wp-content/uploads/2016/11/TvT-PS-Vol14-2016.pdf
• 9. Cai Y, Wang Z, Lau JT, Li J, Ma T, Liu J. Prevalence and associated factors of condom less receptive anal intercourse with male clients among transgender women sex workers in Shenyang, China. J Int AIDS Soc [Internet]. 2016 [cited 2020 June 18];19(3 Suppl 2):20800. Available from: https://doi.org/10.7448/IAS.19.3.20800
  » https://doi.org/10.7448/IAS.19.3.20800
• 10. Logie CH, Wang Y, Lacombe-Duncan A, Jones N, Ahmed U, Levermore K, et al. Factors associated with sex work involvement among transgender women in Jamaica: a cross-section study. J Int AIDS Soc [Internet]. 2017 [cited 2020 June 15];20(1):21422. Available from: https://doi.org/10.7448/IAS.20.01/21422
  » https://doi.org/10.7448/IAS.20.01/21422
• 11. Ministério da Saúde (BR). Secretaria de Gestão Estratégica e Participativa. Departamento de apoio à gestão participativa. Transexualidade e Travestilidade na Saúde. Brasília, DF(BR): Ministério da Saúde; 2015. [cited 2020 June 15]; Available from: http://bvsms.saude.gov.br/bvs/publicacoes/transexualidade_travestilidade_saude.pdf
  » http://bvsms.saude.gov.br/bvs/publicacoes/transexualidade_travestilidade_saude.pdf
• 12. Ministério da Saúde (BR). Secretaria de Gestão Estratégica e Participativa. Departamento de apoio à gestão participativa. Política Nacional de Saúde Integral das Lésbicas, Gays, Bissexuais, Travestis e Transexuais. Brasília, DF(BR): Ministério da Saúde; 2013. [cited 2020 June 17]. Available from: http://bvsms.saude.gov.br/bvs/publicacoes/politica_nacional_saude_lesbicas_gays.pdf
  » http://bvsms.saude.gov.br/bvs/publicacoes/politica_nacional_saude_lesbicas_gays.pdf
• 13. Budhwani H, Hearld KR, Hasbun J, Charow R, Rosario S, Tillotson L, et al. Transgender female sex workers’ HIV knowledge, experienced stigma, and condom use in the Dominican Republic. PloS One [Internet]. 2017 [cited 2020 June 17];12(11):e0186457. Available from: https://doi.org/10.1371/journal.pone.0186457
  » https://doi.org/10.1371/journal.pone.0186457
• 14. Whittemore R, Knafl K. The integrative review: updated methodology. J Adv Nurs [Internet]. 2005 [cited 2020 June 17];52(5):546-53. Available from: https://doi.org/10.1111/j.1365-2648.2005.03621.x
  » https://doi.org/10.1111/j.1365-2648.2005.03621.x
• 15. Melnyk BM, Fineout-Overholt E. Evidence-based practice in nursing & healthcare. A guide to best practice. 4th ed. Philadelphia (US): Wolters Kluwer Health; 2018.
• 16. Apóstolo, J. Síntese da evidência no contexto da translação da ciência. Coimbra (PT): Escola Superior de Enfermagem de Coimbra (ESEnfC); 2017.
• 17. Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan-a web and mobile app for systematic reviews. Syst Rev [Internet]. 2016 [cited 2020 June 17];5:210. Available from: https://doi.org/10.1186/s13643-016-0384-4
  » https://doi.org/10.1186/s13643-016-0384-4
• 18. Soares CB, Hoga LA, Peduzzi M, Sangaleti C, Yonekura T, Silva DRADS. Integrative review: concepts and methods used in nursing. Rev Esc Enferm USP [Internet]. 2014 [cited 2020 June 17];48(2):329-39. Available from: https://doi.org/10.1590/S0080-6234201400002000020
  » https://doi.org/10.1590/S0080-6234201400002000020
• 19. Stetler CB, Morsi D, Ruck S, Broughton S, Corrigan B, Fitzgerald J, et al. Utilization-focused integrative reviews in a nursing service. Appl Nurs Res [Internet]. 1998 [cited 2020 June 17];11(4):195-206. Available from: https://doi.org/10.1016/s0897-1897(98)80329-7
  » https://doi.org/10.1016/s0897-1897(98)80329-7
• 20. Ursi ES, Galvão CM. Prevenção de lesões de pele no perioperatório: revisão integrativa da literatura. Rev Latino-Am Enfermagem [Internet]. 2006 [cited 2020 June 17];14(1):124-31. Available from: https://doi.org/10.1590/S0104-11692006000100017
  » https://doi.org/10.1590/S0104-11692006000100017
• 21. Melnyk BM, Fineout-Overholt E. Making the case for evidence based practice in nursing & health care. A guide to best practice. Philadelphia (US): Lippincot Williams & Wilkins; 2005.
• 22. Braun V, Clarke V. Using thematic analysis in psicology. Qual Res Psychol [Internet]. 2006 [cited 2020 June 17];3(2):77-101. Available from: https://doi.org/10.1191/1478088706qp063oa
  » https://doi.org/10.1191/1478088706qp063oa
• 23. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche P, Ioannidis JPA, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med [Internet]. 2009 [cited 2020 June 22];6(7):e1000100. Available from: https://doi.org/10.1371/journal.pmed.1000100
  » https://doi.org/10.1371/journal.pmed.1000100
• 24. Russi JC, Serra M, Vinõles J, Pérez MT, Ruchansky D, Alonso G, et al. Sexual transmission of hepatitis B virus, hepatitis C virus, and human immunodeficiency virus type 1 infections among male transvestite commercial sex workers in Montevideo, Uruguay. Am J Trop Med Hyg [Internet]. 2003 [cited 2020 June 18];68(6):716-20. Available from: https://www.ncbi.nlm.nih.gov/pubmed/12887033
  » https://www.ncbi.nlm.nih.gov/pubmed/12887033
• 25. Sausa LA, Keatley JA, Operario D. Perceived risks and benefits of sex work among transgender women of color in San Francisco. Arch Sex Behav [Internet]. 2007 [cited 2020 June 20];36(6):768-77. Available from: https://doi.org/10.1007/s10508-007-9210-3
  » https://doi.org/10.1007/s10508-007-9210-3
• 26. Reisner SL, Mimiaga MJ, Bland S, Mayer KH, Perkovich B, Safren SA. HIV risk and social networks among male-to-female transgender sex workers in Boston, Massachusetts. J Assoc Nurses AIDS Care [Internet]. 2009 [cited 2020 June 18];20(5):373-86. Available from: https://doi.org/10.1016/j.jana.2009.06.003
  » https://doi.org/10.1016/j.jana.2009.06.003
• 27. Wilson EC, Garafalo R, Harris RD, Herrick A, Martinez M, Martinez J, et al. Transgender female youth and sex work: HIV risk and a comparison of life factors related to engagement in sex work. AIDS Behav [Internet]. 2009 [cited 2020 June 18];13(5):902-13. Available from: https://doi.org/10.1007/s10461-008-9508-8
  » https://doi.org/10.1007/s10461-008-9508-8
• 28. Infante C, Sosa-Rubi SG, Cuadra SM. Sex work in Mexico: Vulnerability of male, transvestite, transgender and transsexual sex workers. Cult Health Sex [internet]. 2009 [cited 2020 June 23];11(2):125-37. Available from: https://doi.org/10.1080/13691050802431314
  » https://doi.org/10.1080/13691050802431314
• 29. Farías MS dos R, García MN, Reynaga E, Romero M, Vaulet MLG, Fermepín MR, et al. First report on sexually transmitted infections among trans (male to female transvestites, transsexuals, or transgender) and male sex workers in Argentina: high HIV, HPV, HBV, and syphilis prevalence. Int J Infect Dis [Internet]. 2011 [cited 2020 June 18];15(9)e635-640. Available from: https://doi.org/10.1016/j.ijid.2011.05.007
  » https://doi.org/10.1016/j.ijid.2011.05.007
• 30. Farías MS dos R, Picconi MA, García MN, González JV, Basiletti J, Pando ML, et al. Human Papilloma virus genotype diversity of anal infection among trans (male to female transvestites, transsexuals or transgender) sex workers in Argentina. J Clin Virol [Internet]. 2011 [cited 2020 June 18];51(2):96-9. Available from: https://doi.org/10.1016/j.jcv.2011.03.008
  » https://doi.org/10.1016/j.jcv.2011.03.008
• 31. Cortez FCP, Boer DP, Baltieri DA. A psychosocial study of male-to-female transgendered and male hustler sex workers in São Paulo, Brazil. Arch Sex Behav [Internet]. 2011 [cited 2020 June 20];40(6):1223-31. Available from: https://doi.org/10.1007/s10508-011-9776-7
  » https://doi.org/10.1007/s10508-011-9776-7
• 32. Nemoto T, Bödeker B, Iwamoto M. Social support, exposure to violence and transphobia, and correlates of depression among male-to-female transgender women with a history of sex work. Am J Public Health [Internet]. 2011 [cited 2020 June 22];101(10):1980-8. Available from: https://doi.org/10.2105/AJPH.2010.197285
  » https://doi.org/10.2105/AJPH.2010.197285
• 33. Altaf A, Zahidie A, Agha A. Comparing risk factors of HIV among hijra sex workers in Larkana and other cities of Pakistan: an analytical cross sectional study. BMC Public Health [Internet]. 2012 [cited 2020 June 23];12:279. Available from: https://doi.org/10.1186/1471-2458-12-279
  » https://doi.org/10.1186/1471-2458-12-279
• 34. Nurena CR, Brown B, Galea JT, Sánchez H, Blas MM. HPV and genital warts among Peruvian men who have sex with men and transgender people: knowledge, attitudes and treatment experiences. PLoS One [Internet]. 2013 [cited 2020 June 1];8(3):e58684. Available from: https://doi.org/10.1371/journal.pone.0058684
  » https://doi.org/10.1371/journal.pone.0058684
• 35. Nemoto T, Iwamoto M, Perngparn U, Areesantichai C, Kamitani E, Sakata M. HIV-related risk behaviors among kathoey (male-to-female transgender) sex workers in Bangkok, Thailand. AIDS Care [Internet]. 2012 [cited 2020 June 18];24(2):210-9. Available from: https://doi.org/10.1080/09540121.2011.597709
  » https://doi.org/10.1080/09540121.2011.597709
• 36. Giguere R, Lopez-Rios J, Frasca T, Lentz C, Balán IC, Dolezal C, et al. Use of HIV self-testing kits to screen clients among transgender female sex workers in New York and Puerto Rico. AIDS Behav [Internet]. 2020 [cited 2020 June 22];24(2):506-15. Available from: https://doi.org/10.1007/s10461-019-02730-2
  » https://doi.org/10.1007/s10461-019-02730-2
• 37. Nuttbrock LA, Hwahng SJ. Ethnicity, sex work, and incident HIV/STI among transgender women in New York City: a three year prospective study. AIDS Behav [Internet]. 2017 [cited em 19 Jun 2020];21(12):3328-35. Available from: https://doi.org/10.1007/s10461-016-1509-4
  » https://doi.org/10.1007/s10461-016-1509-4
• 38. Lyons T, Krüsi A, Pierre L, Kerr T, Pequeno W, Shannon K. Negotiating violence in the context of transphobia and criminalization: the experiences of trans sex workers in Vancouver, Canada. Qual Health Res [internet]. 2017 [cited 2020 June 20];27(2):182-90. Available from: https://doi.org/10.1177/1049732315613311
  » https://doi.org/10.1177/1049732315613311
• 39. Lyons T, Krüsi A, Pierre L, Small W, Shannon KE. The impact of construction and gentrification on an outdoor trans sex work environment: Violence, displacement and policing. Sexualities [Internet]. 2017 [cited 2020 June 20];20(8):881-903. Available from: https://doi.org/10.1177/1363460716676990
  » https://doi.org/10.1177/1363460716676990
• 40. Samudzi Z, Mannell J. Cisgender male and transgender female sex workers in South Africa: gender variant identities and narratives of exclusion. Cult Health Sex [Internet]. 2016 [cited 2020 June 20];18(1):1-14. Available from: https://doi.org/10.1080/13691058.2015.1062558
  » https://doi.org/10.1080/13691058.2015.1062558
• 41. Ganju D, Saggurti N. Stigma, violence and HIV vulnerability among transgender persons in sex work in Maharashtra, India. Cult Health Sex [Internet]. 2017 [cited 2020 June 22];19(8):903-17. Available from: https://doi.org/10.1080/13691058.2016.1271141
  » https://doi.org/10.1080/13691058.2016.1271141
• 42. Budhwani H, Hearld KR, Hasbun J, Charow R, Rosario S, et al. Transgender women’s drug use in the Dominican Republic. Transgender Health [Internet]. 2017 [cited 2020 June 23];2(1):188-94. Available from: https://doi.org/10.1089/trgh.2017.0032
  » https://doi.org/10.1089/trgh.2017.0032
• 43. Wickersham JA, Gibson BA, Bazazi AR, Pillai V, Pedersen CJ, Meyer JP, et al. Prevalence of human immunodeficiency virus and sexually transmitted infections among cisgender and transgender women sex workers in greater Kuala Lumpur, Malaysia: Results from a respondent-driven sampling study. Sex Transm Dis [Internet]. 2017 [cited 2020 June 18];44(11):663-70. Available from: https://doi.org/10.1097/OLQ.0000000000000662
  » https://doi.org/10.1097/OLQ.0000000000000662
• 44. Matthen P, Lyons T, Taylor M, Jennex J, Anderson S, Jollimore J, et al. “I walked into the industry for survival and came out of a closet”: how gender and sexual identities shape sex work experiences among men, two spirit, and trans people in Vancouver. Men Masc [Internet]. 2018 [cited 2020 June 23];21(4):479-500. Available from: https://doi.org/10.1177/1097184X16664951
  » https://doi.org/10.1177/1097184X16664951
• 45. Degtyar A, George P, Mallma P, Díaz D, Cárcamo C, García P, et al. Sexual risk, behavior, and HIV testing and status among male and transgender women sex workers and their clients in Lima, Peru. Int J Sex Health [Internet]. 2018 [cited 2020 June 23];30(1):81-91. Available from: https://doi.org/10.1080/19317611.2018.1429514
  » https://doi.org/10.1080/19317611.2018.1429514
• 46. Khalid H, Martin EG. Relationship between network operators and risky sex behaviors among female versus transgender commercial sex workers in Pakistan. AIDS Care [Internet]. 2019 [cited 2020 June 22];31(6):767-76. Available from: https://doi.org/10.1080/09540121.2018.1557317
  » https://doi.org/10.1080/09540121.2018.1557317
• 47. Sherman SG, Park JN, Galai N, Allen ST, Huettner SS, Silberzahn BE. Drivers of HIV infection among cisgender and transgender female sex worker populations in Baltimore City: Results from the SAPPHIRE Study. J Acquir Immune Defic Syndr [internet]. 2019 [cited 2020 June 22];80(5):513-21. Available from: https://doi.org/10.1097/QAI.0000000000001959
  » https://doi.org/10.1097/QAI.0000000000001959
• 48. Jarrett D, Miles G, Quinley JH. “Same same, but different”: A baseline study on the vulnerabilities of transgender sex workers in the sex industry in Bangkok, Thailand. Int J Sociol Soc Policy [Internet]. 2019 [cited 2020 June 23];39(7/8):550-73. Available from: https://doi.org/10.1108/IJSSP-01-2019-0022
  » https://doi.org/10.1108/IJSSP-01-2019-0022
• 49. Guler E. A divided sisterhood: support networks of trans sex workers in urban Turkey. AAPSS [internet]. 2020 [cited 2020 June 22];689(1):149-67. Available from: https://doi.org/10.1177/0002716220919745
  » https://doi.org/10.1177/0002716220919745
• 50. Wang Q, Chang R, Wang Y, Jiang X, Chang S, Shen Q, et al. Correlates of alcohol and illicit drug use before commercial sex among transgender women with a history of sex work in China. Sexual Health [Internet]. 2019 [cited 2020 June 22];17(1):45-52. Available from: https://doi.org/10.1071/sh18194
  » https://doi.org/10.1071/sh18194
• 51. Drückler S, Van Rooijen MS, Vries HJC. Substance use and sexual risk behavior among male and transgender women sex workers at the prostitution outreach center in Amsterdam, the Netherlands. Sex Transm Dis [Internet]. 2020 [cited 2020 June 22];47(2):114-21. Available from: https://doi.org/10.1097/OLQ.0000000000001096
  » https://doi.org/10.1097/OLQ.0000000000001096
• 52. Miller WM, Miller WC, Barrington C, Weir SS, Chen SY, Emch ME, et al. Sex work, discrimination, drug use and violence: a pattern for HIV risk among transgender sex workers compared to MSM sex workers and other MSM in Guatemala. Glob Public Health [Internet]. 2020 [cited 2020 June 22];15(2):262-74. Available from: https://doi.org/10.1080/17441692.2019.1671984
  » https://doi.org/10.1080/17441692.2019.1671984
• 53. Poteat T, White RH, Footer KHA, Park NJ, Galai N, Huettner S. Characterising HIV and STIs among transgender female sex workers: A longitudinal analysis. Sex Transm Infect [Internet]. 2021 [cited 2020 June 23];97:226-31. Available from: https://doi.org/10.1136/sextrans-2019-054414
  » https://doi.org/10.1136/sextrans-2019-054414
• 54. Capous-Desyllas M, Loy V. Navigating intersecting identities, self-representation, and relationships: a qualitative study with trans sex workers living and working in Los Angeles. Sociological Inquiry [Internet]. 2020 [cited 2020 June 23];90(2):339-70. Available from: https://doi.org/10.1111/soin.12350
  » https://doi.org/10.1111/soin.12350
• 55. Poteat T, Wirtz AL, Radix A, Borquez A, Silva-Santisteban A, Deutsch MB, et al. HIV risk and preventive interventions in transgender women sex workers. Lancet [Internet]. 2015 [cited 2020 June 24];385(9964):274-86. Available from: https://doi.org/10.1016/S0140-6736(14)60833-3
  » https://doi.org/10.1016/S0140-6736(14)60833-3
• 56. Beyrer C, Crago A-L, Bekker L-G, Butler J, Shannon K, Kerrigan D, et al. An action agenda for HIV and sex workers. Lancet [Internet]. 2015 [cited 2020 June 24];385(9964):287-301. Available from: https://doi.org/10.1016/S0140-6736(14)60933-8
  » https://doi.org/10.1016/S0140-6736(14)60933-8
• 57. 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 [Internet]. 2013 [cited 2020 June 22];13(3):214-22. Available from: https://doi.org/10.1016/s1473-3099(12)70315-8
  » https://doi.org/10.1016/s1473-3099(12)70315-8
• 58. Ramalho N. Género e Vulnerabilidade: Intervenção com Travestis em Contexto de Prostituição de Rua. In: Costa P. Coming-out for LGBT Psychology in the Current International Scenario. Lisboa (PT): International Academy of LGBT Psychology and Related Fileds; 2013.
• 59. Rocha RMG, Pereira DL, Dias TM. The context of drug use among transvestite sex workers. Saúde Soc [Internet]. 2013 [cited 2020 June 27];22(2):554-65. Available from: https://doi.org/10.1590/S0104-12902013000200024
  » https://doi.org/10.1590/S0104-12902013000200024
• 60. Abreu PD, Araújo EC, Vasconcelos EMR, Moura JWS, Sousa JC, Santos CB. “Mulheridade” transexual e a emergência pelo transfeminismo: retórica do HIV/aids à luz da Teoria queer. Texto Contexto Enferm [Internet]. 2019 [cited 2020 Oct 05];28:e20180294. Available from: https://doi.org/10.1590/1980-265X-TCE-2018-0294
  » https://doi.org/10.1590/1980-265X-TCE-2018-0294
• 61. Magno L, Silva LAV, Veras MA, Santos MP, Dourado I. Stigma and discrimination related to gender identity and vulnerability to HIV/AIDS among transgender women: a systematic review. Cad Saúde Pública [Internet]. 2019 [cited 2020 June 27];35(4):e00112718. Available from: https://doi.org/10.1590/0102-311X00112718
  » https://doi.org/10.1590/0102-311X00112718
• 62. Sousa JA, Rocha TMAC, Barros CRS. Prevalência de discriminação na vida, entre travestis, transexuais e transgêneros. Cad Gênero e Diversidade [Internet]. 2018 [cited 2020 June 27];4(1):43-65. Disponível: Disponível: https://doi.org/10.9771/cgd.v4i1.24974
  » https://doi.org/10.9771/cgd.v4i1.24974
• 63. Santana ADS, Lima MS de, Moura JWS, Vanderley ICS, Araújo EC de. Difficulties in access to health services by lesbians, gays, bisexuals and transgender people. Rev Enferm UFPE On Line [internet]. 2020 [cited 2020 June 27];13:e243211. Available from: https://doi.org/10.5205/1981-8963.2020.243211
  » https://doi.org/10.5205/1981-8963.2020.243211
• 64. Berger PL. Perspectivas Sociológicas: uma visão humanística. 23th ed. Petrópolis, RJ(BR): Editora Vozes; 2014.
• 65. Marshall BDL, Socías ME, Kerr T, Zalazar V, Processado O, Arístegui I. Prevalence and Correlates of Lifetime Suicide Attempts Among Transgender Persons in Argentina. J Homosex [Internet]. 2016 [cited 2020 June 27];63(7):955-67. Available from: https://doi.org/10.1080/00918369.2015.1117898
  » https://doi.org/10.1080/00918369.2015.1117898

NOTES

• *
  Recognizing sexual and gender diversity and trying to encompass greater representativeness when discussing the self-identification categories, during the study, we will use the term “trans people” to refer to all transgender individuals, signaling the specific identities (trans men, transvestites, trans women or non-binary people) where relevant.

NOTES

• ORIGIN OF THE ARTICLE

  Extracted from the dissertation - Social Representations of Penile Cancer by Transvestite Sex Workers, to the Graduate Program in Nursing of Universidade Federal de Pernambuco, in 2019.

• FUNDING INFORMATION

  Coordenação de Aperfeiçoamento de Pessoal de Nível Superior/CAPES. Process Number: 88882379291/201901.

Edited by

EDITORS

Associated Editors: Mara Ambrosina de Oliveira Vargas, Gisele Cristina Manfrini, Monica Motta Lino. Editor-in-chief: Roberta Costa.

Publication Dates

• Publication in this collection
  27 Aug 2021
• Date of issue
  2021

History

• Received
  13 Oct 2020
• Accepted
  13 Jan 2021