ORIGINAL RESEARCH

 

Care for transgender people from the nursing resident's perspective

 

Julia Sousa Martins de AlmeidaI; Elizabeth Rose Costa MartinsII; Cristiane Maria Amorim CostaIII; Paula Costa de MoraesIV; Gabriela Dandara Fernandes FerreiraV; Thelma SpindolaVI

I Nurse. Resident, University of the State of Rio de Janeiro, Brazil. E-mail: julialmeidaenf@gmail.com
II Nurse. Ph.D. Assistant Professor, University of the State of Rio de Janeiro. Brazil. E-mail: oigresrose@uol.com.br
III Nurse. Ph.D. Assistant Professor, University of the State of Rio de Janeiro. Brazil. E-mail: cmacosta1964@gmail.com
IV Nurse. Student of the Master´s course in Nursing, University of the State of Rio de Janeiro. Brazil. E-mail: Paula_moraes8@hotmail.com
V Nurse, Piquet Carneiro Polyclinic. Rio de Janeiro. Brazil. E-mail: gabrieladandara@yahoo.com.br
VI Nurse. Ph.D. Associate Professor, University of the State of Rio de Janeiro. Brazil. E-mail: tspindola.uerj@gmail.com

DOI: https://doi.org/10.12957/reuerj.2018.32030

 

 

ABSTRACT

Objectives: to identify training of resident nurses for qualified care of transgender people, and analyze the process of nursing care for transgender people from the nursing resident's perspective. Method: an exploratory, qualitative, descriptive study was conducted in 2017, in the urology unit of a university hospital Rio de Janeiro city, by semi-structured interview of 13 first- and second-year nursing residents of the clinical surgery program. Results: the accounts analyzed led to two categories: nursing training and care for transgender people, and nursing care from the resident's perspective. Conclusion: the findings point to a need to include discussions of, and approaches to, the subject in the nurses' training process, and in care for these clients.

Descriptors: Transgender people; transsexuality; nursing care; nursing resident.

 

 

INTRODUCTION

The purpose of this study is the nursing home point of view of transgender care.

Transsexuality is a word that deals with the identification of gender by the divergence of social rules on the topic. They are individuals of both sexes who express a gender identity different from the anatomical sex they have1.

The Lesbian, Gay, Bisexual, Transvestite, and Transgender (LGBT) Policy is an initiative to build greater equity in resolving emerging gender issues in the Unified Health System (SUS). The Ministry of Health (MS) objective of reducing inequalities was one of the bases of the Mais Saúde - Direito de Todos Program, launched in 2008 and aimed at reorienting health policies to increase access to actions and quality services. Reflecting this policy, this program shows specific goals to promote actions to combat inequalities in health for population groups of blacks, quilombolas, LGBT, gypsies, sex workers (prostitutes), street population, among others2.

The motivation for this study was for a fact occurred in a hospital unit, when a female transsexual patient was admitted; there was a mistake in identifying the patient by the civil name instead of their social identity, as regulated in the Charter of Health Users, which ensures the right to use the social name, causing a situation of discomfort for the patient and the team. This situation has led us to think of the ways of the academy - as the new policies that ensure the rights to health of this part of the population - and in professional practice are being discussed - how the nurse is taking care of this patient.

Para dar conta das questões norteadoras, foram delineados os seguintes objetivos para o estudo: identificar a visão dos enfermeiros residentes acerca de sua formação para o cuidar qualificado de pessoas transexuais e analisar o processo de cuidar desses clientes, na perspectiva do residente de enfermagem.

Therefore, the guiding questions for the study emerged: Did nursing residents have access to content on policies aimed at the LGBT population in their professional training? How does the resident think of nursing care for transgender people?

The following objectives were outlined for the study to answer the guiding questions: to identify the point of view of resident nurses about their training for the qualified care of transsexual people and to analyze the process of caring for these patients from the perspective of the nursing resident.

The justification for this research is based on being a topic that is not discussed in the academic context, reflecting on these professionals who will help in modifications and adaptations to the assistance provided to this patient, attending in the best way public health policies and their programs.

In this way, this study aims to contribute to the nursing profession in broadening its recognition and visibility as a social and political practice. Thus, the approach of this topic in the formative process improves the preparation of the academic to understand and act of this reality. In the research context, it is a field in full expansion, with potential to give prominence to nursing in the production of scientific knowledge in health, considering the nature of its know-how.

 

LITERATURE REVIEW

In 1980, the government determined the first actions directed towards the LGBT population, through public policies for this group, with the objective of reducing the impact of the AIDS epidemic3.

At this phase of process improvement, there was still no holistic health-related view of the transsexual population, and debates associated with an ordinance for its anatomical alteration - this ordinance was decreed in 2008 and called the transsexual process3.

The transsexual process is defined as a set of assistance strategies for transvestites and transsexuals who intend to make corporal modifications, due to a feeling of disagreement between their biological sex and their gender - in compliance with medical legislation and opinions4.

The Ministerial Order 1707 of the Ministry of Health, enacted and called the Transexualization Process in 2008, aimed at the integrality and the humanization of care, resulting in an attention free of discrimination of patients and professionals of the health institution, respecting the particularities of each individual and the dignity of the human being5.

Relationships between the LGBT population and health services can be hampered because there may be inadequate behavior by the health workers when people from the LGBT population do not feel welcomed or well-oriented, or when they do not feel willingness to divulge their sexual orientation6.

From this situation, the LGBT group may be fragile because they have experienced or are experiencing some situation of prejudice that discourages them to trust and follow the guidelines offered by professionals in the health services. Moreover, the relationship between health professional and patient is an asymmetrical relationship of power, in which the former is perceived as the possessor of knowledge and the latter as its recipients. Thus, when the person is afraid and prefers to be silent facing a situation, it makes both the interpersonal and the professional-patient relationship difficult, reducing the level of trust and, consequently, the opportunity for specific orientations and clarifications6.

Currently, there are legislation, norms, and health care guidelines of the LGBT population in Brazil, and it is not clear if this information is being socialized among health professionals, specifically, in the nursing team. This observation becomes alarming when even the educational institutions of these professionals do not have such information7.

The professional training of nurses includes the Laws of Education and Bases of Brazilian Education (LDB 9394/96) that allows changes in curricular programming, providing the preparation of critical and reflexive nurses, with the skills to play their role in different circumstances of the Brazilian scenario. For this reason, it is considered the relevance of training professionals with these characteristics, whose basic actions are ethical and humanitarian principles, consequently, a thinking nurse, humanist and capable of cultivating the holistic vision in the approach of another being8.

The recognition of sex is made at the moment of birth by the anatomical characteristics, registering the individual as belonging to one or the other sex only by the external genitalia. However, the determination of the gender does not happen exclusively of the anatomical characters, no longer being possible to have as reference the concept of sex outside of an appreciation of the biological sex, resulting from genetic, somatic, psychological and social factors.

Transsexuality is classified as a complex-aspect phenomenon. It is defined by the accentuated feeling of non-belonging to anatomical sex with no demonstration of delusional dysfunctions and organic bases9.

The public policy focused on the LGBT population is based on the principles enshrined in 1988 Federal Constitution (CF/88), in its third article (3rd) and IV, guaranteeing citizenship and dignity of the person reinforced in the fundamental objective of The Federative Republic of Brazil "to promote the good of all, without prejudices of origin, race, sex, color, age and any other forms of discrimination".

Training professionals capable of dealing with the diversity and plurality of future relationships, to discuss sexuality and gender in a vocational training institution (and in a course such as nursing), to encompass and respect all individuals who are under their care, and to follow the variations of the concept family, couple and gender is very important7.

 

METHODOLOGY

This is a descriptive, exploratory study with a qualitative approach was carried out with 13 nursing residents from the surgical clinic program of the 1st and 2nd grade of 2017. A urology ward of a university hospital located in the city of Rio de Janeiro was the scenario of study. The exclusion criteria were nursing residents who were away for vacations or leave.

Data collection took place from March to June 2017, after approval by the Research Ethics Committee (CEP), through semi-structured interviews of open and closed questions, allowing free expression of the research subject 11. The interview was recorded to understand how the participants of the study understand the transsexual patient care, for later transcription of the data and analysis according to Bardin 12, allowing the qualitative evaluation of the data obtained. For the differentiation of the subjects and preservation of their identity, the following codes were used: the letter R for resident, followed by the order number of the interviews.

The research was submitted for consideration and approved by the institution's Ethics and Research Committee - Opinion 68633517.8.0000.5282. The participants of the study received the Free and Informed Consent Term, guided about the risks and benefits of the research, voluntary participation and they could desist at any moment.

The object of content analysis is the word, the individual aspect of language; their purpose is the meanings of the words, trying to understand the actors and the environment where they are inserted; it is organized in three stages: pre-analysis, material exploration, and treatment of results, inference, and interpretation13. For the systematization of the findings, a floating reading, a cut of the recording units (RU), verification of the context units was performed; classification of RUs and codification to aggregate them, generating categories12. RU were submitted to statistical analysis, using absolute and percentage frequency calculations14.

Based on the data obtained and subsequent evaluation, it was possible to organize them into two categories: Nursing training and transgender care and Nursing care process from the perspective of the resident.

 

RESULTS AND DISCUSSION

The training of nurses and the care of transgender people

Order 1707/2008 that addresses the transsexual process has the education and training of the health team as one of its bases5. However, the participants´ discourses show that the academy, in principle, is not attentive to the training of the nursing professional, to the particularities of the male gender, and also, for the different gender identities, such as transsexual people. This situation was evidenced by the following statements:

I did not have any incentive in my college for the subjects involved in this topic [...]. (R2)

I did not have any subject at undergraduate level, which actually addressed transsexualism [...]. (R10)

This lack of knowledge can be associated with the reduced number of reference centers in the country, with only five units, and one of them is the University of the State of Rio de Janeiro - Hospital Universitário Pedro Ernesto (HUPE) - Rio de Janeiro, which reduces learning and practice of this reality5.

Another possibility to fill this knowledge gap would be a curriculum that would address the emerging issues under discussion in today's society. These implementations could lead the scholar to reflect, to seek readings and discussions about this population and its particularities, and consequently, such study would aid in the caring process.

The initiation/omission of the subject transsexualism in the curricula of the universities of the medical and nursing areas can cause the incapacity of these professionals before the confrontation of emergent social demands 14.

The following testimonies confirm the inexistence in the academic training of the approach of topics about transsexualism:

I did not really have any training for patient care. I had no specific subject [...]. (R1)

I was not even 'a little trained' in this topic [...]. (R7)

I think that as a nurse, I did not have any training. At graduation, this topic was not so well addressed. I did not have any subject that actually addressed transsexualism [...]. (R10)

Professional construction in the health area is based on the repetition of conservative teaching standards, centered on pathophysiology, equipment for diagnostic and therapeutic support, and reduced to learning in university hospitals15.

In this context, the progress made in the management of the health system in recent years has determined the need for re-qualification of health professionals and highlighted the review of the training models applied, containing SUS principles and assumptions as a pillar for the methodologies and programmatic content used in teaching16. Nurses recognize that the training they have received is insufficient to ensure the provision of quality care for these patients, as the speeches show:

In fact, I did not have training, I had to find it outside [...]. (R1)

I need a lot of improvement. Nothing I can say 'Oh, I'm prepared' is something I did not experience at undergraduate level. So I am enabled not by my graduation, but by my trajectory [...]. (R5)

My life is my training, As a student, I think this subject should have been addressed more accurately and in greater quantity... many times during graduation. [...] The subject could have been spoken several times and it was not. So as a nurse, my preparation is bad. And it is improving with the residence [...]. (R10)

Among the responsibilities and duties of nurses, the Nurses´ Code of Ethics emphasizes: to provide nursing care without discrimination of any kind, respecting, recognizing and carrying out actions that guarantee the right to make decisions about their health, treatment, comfort and well-being and respect for the modesty, privacy and intimacy of the human being throughout his life cycle17.

Residents demonstrated some ethical guiding principles in nursing care to such patient, such as equality and respect, as the testimonies indicate:

My childhood was very peaceful, as a person. So I brought this to my professional side. Today I consider myself full to care for the 'trans' person be it in transformation or not, but not for the training I had in the university [...]. (R11).

It is an issue that concerns me, respect, privacy, the elimination of any kind of prejudice, a more specific care for this people [...] (R4)

The Code of Ethics emphasizes that its technical, scientific, ethical and legal competence should be carefully assessed and only accept charges or assignments when capable of exercising the activity and safe performance for itself and for other individuals17.

Although nursing residents are guided by the Code of Ethics17 to care for the transgender patient, they are unable to provide quality care to them, considering their specificities, as the reports indicate:

I do not know how I'm going to deal with this situation of wanting to stay in an infirmary that is not her sex. I do not even know how to talk," For example, the person is a man, but he wanted to be a woman, but she wants to be in a woman's ward. I do not know how to deal with it [...]. (R2)

At first, I would be scared, I would ask: 'Guys, where do you start? ' 'What do I do? 'What I speak? (R9).

During the training of human resources in the health area, curricular grades are reprimanded with dominance of compulsory subjects on the electives, creating obstacles for students to practice their autonomy and move in different possibilities of choice, building and following their pedagogical course15,16,18.

Also, the emphasis given to the programmatic content and teaching methods that keep students away from the processes that provide the search and the training of their own knowledge is questioned.

The training of the health team members includes considerations that must go beyond the accessible structural resources in each educational institution, valuing the multidisciplinary study.

The teaching and learning process and the variables that result in their constitution is important, such as the behavior of teachers in teaching practices - accompanying cultural, technological and scientific evolution - their ways of acting in the production of services, their adherence to the needs of the students, among others19.

In this perspective, educational institutions should fulfill their function of working with the purpose of a professional training whose profile respects the needs and particularities of the population at all levels of care and during their social and vital processes, that health education seriously influences the quality of services and the degree of contentment of its patients20.

Thus, educational institutions must ensure learning, in which the student experiences his productive path, preventing the formation of unreflective professionals, focused exclusively on their specific attributions, without placing them at the service of an integral project, due to the team work20.

The nursing care process from the perspective of the resident

The caring process must involve respect for the individuality of the human being and build a concrete space in the health institutions, which legitimates the human of the people involved. The nurse to take care in a humanized way must be able to understand himself and the other, expanding this knowledge by an action and becoming aware of the values ​​and principles that guide this action.

Care participates in the life of the human being since the beginning of the existence of the human race, as a reflex to support their needs. To perform care as an integral member of the multidisciplinary team, the nurse has a set of skills that provides the pretension of resolution to the responses of the health phenomena defined by the International Council of Nurses21 as health issues regarding to nursing practice.

For the nurse, caring is perceived as the application of scientific knowledge in day-to-day, correlated with the ability to use emotion and sensitivity as the foundation of communication to perform nursing care, respecting the patient as a human being22. These actions are mentioned in the statements:

I think the professional nurse has to have a greater psychological capacity to deal with these people not to hurt them because they have already been hurt several times throughout their life by that transformation they had been suffering or is suffering [.. .]. (R11)

I think the care is the same by being a person. I think that my concern as a nurse if I take a patient in a ward would it be his psychological issue, especially if he prefers, as he prefers to be called if he feels more comfortable in staying in the wing than a wing depending on the gender, sex [...]. (R7).

It is a care with a person. It would not be difficult for me to treat a transsexual if he is a person, he is a patient, the care would be the same [...]. (R7).

These reports bring a contradiction because if caring is proposed in a holistic and individualized view, an authentic care, one cannot develop the same care for all people, without attention to their particularities.

In the perception of the participants of the study, the accomplishment of the care is directed towards a generalized care, without attention to the transsexual person with responsibility and from a body of knowledge of nursing and other sciences. This situation leads the study participants to have difficulties in thinking about the nursing care to be developed with this population. Here, there are the reports:

The care I think is generalized, because people think a lot about sexual issues regarding transexual. [...]. (R6)

Specific care? I have no concept, I can only think of psychology alone. In nursing, I cannot think [...]. (R9)

The caring process brings a level of complexity when dealing with situations that involve personal, cultural, social, religious, among others. This situation is very clear when the participant of the study says he does not know what to do, especially when it is not discussed certain situations experienced individually in the team, to give quality to the care of the patient, in his singularity, as well as satisfying the worker.

Also, it is a differentiated and unknown patient to be cared by the nursing professionals, either after graduation or in the residence and in the condition of nurses. Information on transsexual politics, called the transsexual process is scarce or non-existent, according to the speeches:

I've never even heard of it. So, I do not know, I do not know. I did not even know you had this policy [...]. (R8)

I know they have the rights to them, the civil name too, the right to change identity and everything, but I do not know that policy in depth. I even have to read more [...]. (R1)

I have no knowledge of it [...]. (R9)

Honestly, I've never read this policy. So I believe that I have no specific information whatsoever [...]. (R10)

 

CONCLUSION

The health area has a great deal to develop about the topic. Thus, when choosing the object of this study, we had in mind to develop research that could bring contributions to nursing, when discussing the care of transgender people in the point of view of the resident.

There is a lack of nurse-patient care about the social and health demand of the transsexual population, characterized by the omission of the transsexualism subject in the curricula of this professional's academic training.

Also, regarding the academic training, it is not adequate to the care of transsexual people, since the participants of the study point out the inexistence of discussions and even of knowledge of the peculiarities of this population as well as of public policies of health directed to such topic.

It is necessary to think of a holistic care, in which the individual is considered in his social context, cultural and not only biological, in an authentic and individualized care rather than generalized.

Therefore, the study showed the analyzed discourses, the need to improve curricula and educational strategies, modifying the conservative teaching, training more qualified nurses to better serve the population, including new problems and technologies.

 

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