The aim of the present study was to investigate perceptions of transvestites about oral health and access to dental care services. This article is the result of a qualitative study conducted with transvestites who use the outpatient clinic of the Reference Center for Integral Trans-Specific Health Care of the hospital affiliated with the Federal University of Uberlândia and Center for Research and Trans Reception of the School of Dentistry of the same university. The results revealed precarious access to health services associated with prejudice. To relieve toothache, transvestites often seek allopathic self-medication or the insertion of drugs and sharp objects into the teeth and gums. The perceptions of the transvestites revealed gaps in the public health policy practiced by the public healthcare system, which should be based on the principles of integral, equitable care.

Summary

This article seeks to understand transvestites’ perceptions of oral health and access to dental care services. It is the result of qualitative research, carried out with transvestite users of the outpatient clinic of the Reference Center for Comprehensive Care for Transspecific Health, the Hospital de Clínicas and the Trans Research and Reception Center of the Faculty of Dentistry, of the Federal University of Uberlândia. The study revealed a situation of precarious access to health services, associated with prejudice. To alleviate toothache, transvestites seek allopathic or non-allopathic self-medication; alternatively, they call for the introduction of medicines and sharp objects into the teeth and gums. The transvestites’ perceptions revealed gaps in the public health policy in force in the Unified Health System, founded on principles of comprehensiveness and equity in care.

• Perception; Oral health; Vulnerable populations; Transvestite; Transgender people.

Junior SF, Teixeira F (2024) Oral Health of Brazilian Transvestites: Perceptions about “Smile Trick”. JSM Sexual Med 8(1): 1135.

Studies on access to care and the quality of care offered in the Brazilian public healthcare system for the population of transsexuals and transvestites are recent in the country [1,2]. Most studies take the National Health Policy of Integral Care for the Population of Lesbians, Gays, Bisexuals and Transsexuals (LGBT) as reference for the discussion [3,4]. Such initiatives are relevant and have contributed to the formulation of possible healthcare strategies [5], as well as the discussion on barriers and access to services [3,4], uncovering different forms of violence perpetrated at healthcare services [4,5]. However, the literature has concentrated mainly on sexually transmitted diseases, HIV/ AIDS [6], the abuse of alcohol and illegal drug use [7]. Although dentistry is offered at primary care services, we found no studies addressing oral health and access to oral health services in the Brazilian public healthcare system for the LGBT population [8], and specifically for transvestites.

Access to oral health information and services is difficult and limited for the general population. Such services are offered to schoolchildren between six and 12 years of age and pregnant women [9,10]. Adultsand older people only have access to specific procedures, such as extractions [8,11]. Thus, a discussion on this gap in knowledge is warranted and this article offers an unprecedented look at the scenario of oral health for transvestites.

The aim of aim of the present study was to investigate the perceptions of transvestites regarding oral health. The expectation is that such perceptions   can   reveal   strategies for seeking care, treatment at healthcare services as well as therapeutic notions and conduct. Such knowledge can contribute to the identification of barriers to access and can serve to dispel notions that place the responsibility of the precariousness of care on the transvestites themselves.

The investigations that gave rise to this article were conducted in 2019, but the analysis developed here is anchored on more than a decade of experience with activities of research, extension, teaching and care at the Trans Clinic. Thus, the qualitative study presented in this article is supported by experiences extending back to the year 2006 through the development of an integral healthcare project for the transsexual population in the city of Uberlândia (state of Minas Gerais, Brazil) entitled “On high heels: health, education and civil liberties”. Data obtained from reports and field experiences since this period enabled collective knowledge building on practices related to integral care for the population of transvestites in the city. The qualitative study was conducted through participant observations, field logs and interviews. Focus groups were also held in 2019.

As the aim of this article is to identify perceptions on the part of transvestites regarding oral health, it is important to stress that perception and preceptive processes enable understanding the close relationships between subjectivity, inter-subjectivity and objectivity. Perceptions are not merely opinions, but rather the result of a confluence of informative sources and multiple learning experiences [12]. Thus, perception does not constitute exhaustive knowledge on a subject, but rather an interpretation a process of communication between the given and the evoked that requires the examination of our existence in a process that occurs between experience and the imputation of meanings [13].

In this article, the concept of perception shows how the actions of transvestites and the care offered at health services are socially and subjectively mediated, as these aspects are shaped by collective views regarding gender and sexuality. Notions of gender produce processes of prejudice, discrimination and exclusion from social structures, including healthcare services [14].

The qualitative study was conducted through participant observations, field logs and interviews. The main technique was a structured focal group with non-directive moderation developed in two meetings. Twenty transvestites who resided in the city of Uberlândia participated in two focal groups held on the same day: 12 in one group and eight in the other. Each meeting lasted approximately 45 minutes.

A focal group is a research method that uses triggering materials to foster and sustain group discussions that enable the exchange of knowledge, beliefs and experiences among the participants [15,16]. We organized the discussions with guiding questions composed of start-off, follow-up and more in-depth questions characterized as follows:

1. questions that enabled the exchange of experiences on how the participants determined the time to seek dental care, what paths were taken, how they recognized the need and what strategies were employed prior to decision making;
2. questions that enabled reporting and sharing experiences at the dental office (public or private), how they evaluated the care received and resolution of the need presented at the time; and
3. questions that allowed the participants to talk about how they perceived the possibility of caring for their oral health and questions on how they understood the offer of the care performed and what suggestions they may have for the service and team at the Trans Clinic.

The conversations began with the transvestites reflectingon how they were represented and how they circulated at the services or sought care. The issues were then directed to how they were treated at the healthcare services, difficulties related to oral health care, the specialists they met, ways of dealing with dental pain, extractions, etc. Lastly, we investigated perceptions regarding oral health in the trajectories of the transvestites.

The groups were conducted by the coordinating board of the outpatient clinic of the Reference Center for Integral Trans- Specific Health Care at the hospital affiliated with the Federal University of Uberlândia, which is recognized as an ally and has the trust of transvestites. The conversations were recorded in audio, followed by transcription and analysis. This study received approval from the institutional human research ethics committee (certificate number: 92164318.7.0000.5152).

Class, schooling and mode of work marked the discourse of the transvestites during the study. The hostel in which they reside on the outskirts of the city is close to a highway. The simple brick home has several rooms and a large backyard, with access to basic sanitation, electricity and the internet. About 30 transvestites live in dormitories with bunkbeds. Each room accommodates up to five people. All reported work in the sex market, primarily at night, and slept throughout the morning period, with days off on Mondays. The domestic routine included housework, personal care (especially hair and nails), light shopping and the administration of their social media profiles in preparation for going out. These observations are compatible with those of other studies conducted with similar populations in other regions of Brazil [5,17].

Inequality marked the scenario of the study, as the participants are from the lower classes, in which housing conditions shape a precarious existence [18-20]. with the (re)production of health inequalities and the unequal distribution of access to information, goods and health services, including oral health [21,22]. Excluded from the family and school when very young, most did not complete a primary school education, which hinders inclusion in the formal job market [20]. One the consequences of this is the entrance in the sex work market as one of the most efficient means of survival, exercising a marginalized and marginalizing occupation [17]. Considering this situation and its relationship with the perceptions of transvestites, we organized the focus groups.

Focus groups

The preparatory conversations prior to the focal groups expressed concerns with halitosis, dental procedures and oral health status. The participants in these conversations stated the need to visit a dentist and reported their perceptions about their own oral health, marked by the expression “postbox”.

“That one there has bad breath and no one can stand sleeping in the same room with her.” (Participant 1) “We have to go [to the dentist] before [there is a problem] and not only when we need to.” (Participant 2) “No, we have to go before ... Take care of the postbox.” (Participant 3).

In the literature, the association between oral health and sociodemographic indicators is well documented. Disparities are found in the frequency of daily oral hygiene, plaque, gingival bleeding and dental caries, which are related to halitosis and are significantly worse in groups pertaining to the lower classes [11]. To transvestites, halitosis seems to accuse a person of being careless, placing the issue on the individual level, translating it into guilt and negligence – a reason for shame and embarrassment.

The expression “postbox” was used in this initial conversation in reference to one’s smile and the greater value placed on anterior teeth over posterior teeth. In contemporary society, the smile is one of the most valued elements in the composition of a standard of beauty and what most attracted the onlooker’s gaze. Novel oral esthetic technologies are valued and the concern with dental esthetics has surpassed the concern with dental function [18]. The smile (or absence of it) was the topic that mobilized the conversations that preceded the formal beginning of the focal groups and, not without reason, came up again in the focal group meetings.

Perceptions with regards to seeking care

Addressing perceptions with regards to seeking oral health care on the part of the transvestites and the ways to resolve problems in the case of dental pain required seeing beyond an attempt of an individual solution to an identified problem. This study enabled understanding that the participants seek (or not) solutions for oral health problems that they do not recognize as a disease and are not considered conditions that aggravate general health, but rather are understood as discomfort of minor importance considering the set of vulnerabilities and precarities that are (re)produced in their daily lives.

“We always take medication, right? Medication gets rid of the pain and you end up not going [to the dentist]. Dipyrone... generally any one for pain. There is no specific one for toothache, you know?” (Participant 4)

In the meetings, the participants stated turning to therapeutic efforts, such as self -medication and the insertion of medication directly into the dental cavity. They also reported the use of toxic substances, such as isopropyl alcohol. In dentistry, self- medication occurs mainly in the form of analgesic and anti- inflammatory drugs taken to control pain [19].

Among the actions taken for immediate pain relief, they insert needles and other sharp objects into dental cavities or the gingival tissue, triggering additional trauma and increasing the risk of infection.

“Because I hurt it. I poked it with a needle. So, it opened up and became inflamed. Poking at the entire tooth, uncontrollably. And then it broke and was only a cavity. The root stayed in there, hurting. I asked them to pull it out, because, otherwise, I couldn’t stand it. I wanted to extract the tooth and get rid of the pain once and for all.” (Participant 5). “Potato leaf tea is good!” (Participant 3).

A study conducted at an urgent dental care service showed that 60.3% of patients placed something on the tooth to relieve the pain and 79.3% ingested some medication for the same purpose [19]. Thus, other population groups with little access to oral health services seek the unofficial “folk system” for care, adopting care strategies that are not specific to transvestites [20,21]. Considering the issue raised by Tamietti et al [19]. regarding self-medication, this practice, to some extent, may be related to inaccessibility to healthcare services.

Pain relief strategies are aimed at eliminating suffering. Similar practices have been observed among individuals from the lower classes [21], such as seeking analgesia through rinsing the mouth with copaiba (Copaifera langsdorffii) oil, teas and other substances or the direct application of cotton soaked in toxic substances, such as alcohol and creosol [22]. Along this line of conduct, the transvestites reported placing alcohol on the affected tooth and rinsing the mouth with potato leaf tea, which indicates that their pain relief practices seem to be anchored in shared experiences.

Expanded, integral care seems not to be part of the possible repertoire for these transvestites. When they seek public and/or private services, they demand a rapid solution – extraction. Some reported being counseled on therapeutic procedures directed at the preservation of the tooth, but such counseling did not prevail in the decision for the demand for removal.

“I had to spend the night at the hospital in order to have a tooth pulled. ‘Is it hurting?’ I would say ‘no, it isn’t hurting, but I want to pull it out.’ They didn’t want to! ‘Is it hurting?’ I would say ‘no, it isn’t hurting.’ But it was throbbing! It’s because they didn’t pull hurting teeth there. When it’s hurting, they don’t pull it out! You can’t pull it. You have to make use of the tooth. I don’t want to make use of it. I want to pull it. Then she went and pulled it. The tooth was infected.” (Participant 14)

This passage reveals that the speaker has previous experience at healthcare services and put forth her argument to obtain the type of care she desired. What seems to be a success for the patient may be perceived as a limitation of the service on the part of the professional. It is also possible that there was a lack of an explanation from the professional regarding the meaning of pain and the pertinence of preserving or not preserving the tooth with regards to its possibilities in terms of rehabilitation. In any case, what draws our attention is the lack of effective conditions for the promotion of oral health and the execution of public policy. The transvestites presented similar reasons as those identified by Poletto et al. [21], regarding the decision for extractions, such as a lack of another conservative therapeutic option and the high cost of restorative procedures. Extraction is the prevalent therapeutic approach motivated by intense pain in cases of emergency and mainly occurs in more advanced stages of dental caries [22]. Care at urgent and emergency dental services should be preceded by screening to establish a classification of risk, thereby orienting the pertinence of care and the creation of a hierarchy of care priority. In this space, patient care is linked to procedures that seek to maintain and rehabilitate the affected tooth, but also its removal. This decision involves the patient’s desire and the technical availability offered by the services, which are situations that do not always coincide. The impossibility of follow-up (limitations related to the patient and/or the offer at the service) should also be considered. In this multifactorial context that guides therapeutic decision making, extraction ends up being the most frequent resolutive option.

Silva et al. [23], found that even individuals who have access to dental services make the choice for extraction due to the belief that this is the least burdensome and most agile resolutive procedure. The authors also identified other reasons for extraction, such as a lack of knowledge regarding measures of preserving the teeth and barriers to access to oral health services [23]. In another study, 18% of extractions were performed based on patient demands [24]. The reasons cited were the cost, sensation of pain relief and the perception that the preservation of the tooth could mean having to face further symptomatic conditions [24]. One should also consider the fact that dentistry maintained less conservative practices for a long time and extractions were indicated to be the most viable solution for dental pain in individuals belonging to the lower classes [22].

The discourses of the transvestites suggest that they seem determined not to negotiate any clinical procedure other than the elimination of the pain through extraction. They seek extraction as a way to achieve immediate pain relief, despite the consequences, such as negative impacts on esthetics and chewing capacity. This decision seems to be guided by a sense of urgency (pain) that reveals an institutional shortcoming (the absence of the offer of services). This scenario underscores the need to expand oral health policies, which have been centered on students and pregnant women and are insufficient in terms of ensuring equity in access to oral health information and services [25]. Thus, one can understand the transvestites’ decision for extraction, which represents immediate pain relief, generally discarding any other oral health care possibilities. These paths to care and the perceptions that guide choices seem to be aligned with procedures and notions on the part of a large portion of the Brazilian population positioned at the bottom of the social class pyramid [11].

For this study, it is important to consider that inserting the condition of transvestites in the set of (non-)access to dental treatment due to the lack of offer at public services is an important sign for taking them from a place of exception and exotism while at the same time showing that the implementation of an oral health policy in the country is frail and has little reach. However, other factors are added to the scenario and make the trajectory of transvestites in their search for care more complex and difficult.

A barrier that makes itself known: prejudice and discrimination

Prejudice and discrimination are encountered in the transvestites’ experiences when seeking dental care. Some abandoned treatments that they had initiated and others did not return to the dentist after initiating the transition process for fear of suffering discrimination or due to a lack of courage or interest. Consequently, they spend long periods of time without seeking a dentist.

“I have to say I went to a… It was last year. I began treatment with a ‘people’s’ dentist [dentist who offers care for low-income populations]. I felt a certain prejudice when he saw that I was trans. I felt the looks. Each one avoided looking the other in the eye... I saw some prejudice. I think that was why I stopped treatment. I came back here and took out the retainer and stopped going.” (Participant 6)

And the receptionists! It’s where we become more embarrassed, because it’s filled with people there. So, we sit in a corner, withdrawn. So, we leave. ‘Ah! I’m not going to wait my turn. They don’t call my name, don’t call me… That one is staring at me’... It’s like that. Many times, I end up leaving. I get up quietly and leave. Then I call and set up another [appointment].” (Participant 2)

The discourses of the transvestites reveal a barrier to access to healthcare services and a lack of preparation on the part of oral health teams that contribute to a web of exclusion found in both public and private services. The reports indicate that these services/health professionals do not respect gender identity or social names, despite the fact that Health Ministry Ordinance no 1820, from August 13th 2009, also refers to oral health services [25,26], which are ensured in Resolution nº CNJ nº 270/2018 [27].

The prejudice and discrimination reported above exert an impact on the transvestites’ decisions about seeking healthcare services and the ways that such services establish interactions [2,4]. Discomfort in the presence of transvestites at dental offices reveals the lack of preparedness on the part of dentists and receptionists.

Although healthcare providers, especially those in the field of dentistry, do not develop skills during their undergraduate studies that enable reflections on gender, sexuality, sexual diversity and the relationships with social determinants of health, continued education and updating are technical and ethical requirements. In this context, which is directly related to the establishment of barriers to the access of transvestites to healthcare services, we believe a parallel can be established with the “do not know/ want” relationship (notion that transvestites are unaware of or do not want to know about healthcare services or do not wish to use such services) as the main strategy for denying rights used by family and community physicians to justify not providing care for the LGBT population [2].

What is lacking is not always money: what is missing in care

“More of a question of a lack of interest… laziness. Since we work at night, we generally have to rest during the day, right? So, only when there’s pain. Because that’s when you really have to go [to a dentist].” (Participant 13).

For transvestites who work in the sex market, moving to other regions of the country or abroad in search of new work spaces interferes with the planning of oral health care and more resolutive treatment. The work routine, which is nearly exclusively at night, requires the division of daytime hours among caring for the body, beauty care and the need to rest during the day, with little time left for other activities.

“No, it’s not like that. ‘I’ll set aside a little money and I’ll go tomorrow.’ We have a lot of things to do. ‘I’ll go tomorrow. Today I’ll go out and make a little money and tomorrow I’ll go.’ I keep doing that. But I sometimes forget to go.” (Participant 11)

They do not have access to formal financing for treatment, which requires financial planning that includes either the whole amount or paying in installments, which is negotiated directly with the dentist. This financing requires mediation and someone plays the role of an informal guarantor, which is generally the owner of the hostel. Otherwise, treatment is put off until returning back the city of origin or to where some bond has previously been established.

“I used to do it [orthodontic treatment]. I haven’t done it for three months. It’s because I broke a tooth and then taking it out and putting one in… I used to go back there to put my tooth in, to Goiânia.” (Participant 9) “I began my treatment in São Paulo and recently arrived in Uberlândia. (...) I went back there [São Paulo] to change a denture that I had.” (Participant 8)

The offer of basic oral health (endodontic, esthetic, orthodontic and prosthetic) procedures for adults is not always sufficient at public services [10]. Such procedures are generally performed in the private sector and treatment requires financial planning. For transvestites, it is also necessary to consider expenses related to transportation and daily expenses during the period in which they cannot work when undergoing more invasive dental procedures.

“For transportation and to begin paying for treatment, we always have to make a down payment. So, treatment is not that cheap. That’s how it was in my case. It was partly because of the financial aspect and also a lack of care in going.” (Participant 10)

Such logistics are not favorable to adherence to dental care and exert an impact on their perceptions. Thus, when transvestites seek dental services in cases of dental pain, a set of previous experiences related to the impossibility of acquiring care seems to give further strength and meaning to the desire for extractions. Here again, the perceptions indicate relationships between the body, perception and knowledge [28,29]. In the case of transvestites, the discontinuity of dental treatments is not only associated with financial limitations, but also internal migration and the limitations of the informality of the work that they exercise.

“In my case, it’s easier now because of this project also, isn’t it? [the interviewer refers to the project developed by Center for Research and Trans Reception of the dental hospital of the Federal University of Uberlândia]. But it used to be because of financial issues also. To get around, in order to begin paying for treatment, we always have to make a down payment. It was partially the financial aspect and also a lack of care in going.” (Participant 12)

Described by different participants, the lack of care seems to be part of the difficulty of establishing a life project [29]. The transvestites reported the need for prevention, hygiene and regular visits to the dentist, but such aspects are not materialized in their daily lives. These preventive measures do not encounter paths for materialization at public oral health services, considering the scarcity of services and the limited actions directed at adults and older people, as mentioned above. Prevention is presented in a way that is decontextualized from the needs of the population, which receives unsatisfactory information regarding the importance of regular dental checkups [31]. In this equation, the lack of interest is not only an aspect of the individual; it is complexified by the relationship between modes of living and the network of services (not) offered.

“Meat generally gets caught between the teeth. It’s tiresome. So, I don’t generally have the habit of using dental floss. You pick up the floss, hurt the gums and blood comes out... [She mimes a person pulling sewing thread from the skirt) ... (Participant 16)

“It’s been a long time since I changed my toothbrush.” (Participant 17).

When discussing discomfort related   to   cavities   caused by dental caries that result in the trapping of food scraps in inter-dental spaces and gingival bleeding, the transvestites demonstrated knowledge regarding the need for adequate oral hygiene. However, they are unaware of the need to change toothbrushes and improvise the use of dental floss, replacing it with sewing thread, when they feel discomfort. These practices demonstrate intentionality with regards to care, although executed in the wrong way. They insist in having access to a type of oral hygiene that seems to be within grasp.

In Brazil, a toothbrush, toothpaste and dental floss are used by only 53% of the population and differences are found in the use of these hygiene materials according to schooling. While 83.2% of individuals with a higher education use all three products, this figure drops to 29.2% among the population without schooling and with an incomplete primary school education [32]. The reduction in the incidence of dental caries and, consequently, the number of missing teeth in the young population in recent decades is associated with oral hygiene practices and products, which play an important role in the prevention of oral diseases [30-32]. However, oral hygiene standardscontinue to be unsatisfactory in the Brazilian population and are not exclusively related to socioeconomic status [31].

According to Santos et al. [31], the average monthly cost of oral hygiene products for a family of four was 22.42 to 49.01% of the cost of a staple-foodspackage (R$154.48) in 2016. The same study reports that the acquisition of oral hygiene products is not a priority for the general population and concluded that people do not know how to care for their teeth. The cost of oral hygiene products was not brought up as a limiting factor for use by the participants of the focus groups. Oral health seems not to be a priority in the daily self-care practices of the transvestites and they also do not know how to care for their oral health. We saw that they had less access to dental information, products and services [24,31,33], fueling a cycle of (non-)care with oral health. Regarding the non-prioritization of oral health care, it is important to consider that understanding the order of priorities of transvestites in the precariousness of their daily living could be fundamental to the establishment of strategies not anchored in prejudice and preconceived judgments.

“I also went [to the dental office] before becoming trans. I went once. I was 17 years old. Today I am 28.” (Participant 5)

Information on the use of orthodontic appliances – although treatment is often abandoned – indicates a desire for esthetic care that goes beyond the basic care routine. The gap between the desire for some type of care and its effectiveness is represented in a recurring image of missing teeth that exerts an impact on social interactions. When asked about satisfaction with their own smiles in the mirror, nearly all were dissatisfied and stated having strategies for not revealing their oral health status, concealing their smile.

“Ah no. I don’t like my smile – I think it’s ridiculous [laughs].” (Participant 18) “Not only my appearance sometimes...” (Participant 17)

“Gabriela and I, we pout our lips.” (Participant 19)

“She pouts her lips when she’s going to take a photo, which is a way to ‘give the trick’ in order not to show your teeth.” (Participant 18)

They contract their lips, projecting them forward, simulating a kiss in an attempt to disguise missing anterior teeth or inadequate oral health, sensually disguising the smile when approaching clients or when taking selfies to post on social media. They avoid smiling!

In bajubá, which is a dialect originating from Yoruba and widely used by transvestites in their communication, the expression “giving the trick” means to deceive, manipulate situations with the aim of gaining some advantage [34]. A smile with missing teeth has become a constant and naturalizes social inequality; many individuals share this image as a social identity [33]. It is a reason for teasing and blame that often is not directed at the government but at the individual, who is considered careless and negligent. It is also not seen as a natural process of human aging, but the naturalization of inequity and the enormous social abyss that separates those who can and those who cannot have a smile considered beautiful in this divided society.

Positioned in the least privileged strata of society and marked by different processes of exclusion, the transvestites who participated in the present study revealed barriers to access to the sparse oral health services and esthetic dental procedures, even in the private sector. However, by naming the smile and placing it in the network of relations as part of a trick, transvestites not only found a way to deal with daily precariousness, but also to gloss over the failures of the government.

In a world with such precariousness and social inequality, it is up to us researchers, activists and professionals in the field of public health not only become enchanted with the “smile trick”, but, above all, to make collective efforts so that the Brazilian public healthcare system can advance in the assurance of the integrality of care for the most vulnerable groups.

This article sought to make a contribution by addressing a specific topic,   although   insufficiently   considering   the social problems that it involves. The text demonstrated that transvestites are included in public health policies in a precarious manner, especially with regards to oral health. Their perceptions portray a situation of inequality, precariousness and actions that do not produce health.

Upset with the context of precariousness in which they find themselves and discontented with their smiles, transvestites employ the strategy of pouting their lips in a gesture known as “smile trick” as a way of hiding what is missing. Throughout this article, the “smile trick” proved to be an action that reveals gaps in public health policies of the Brazilian public healthcare system, which is founded on the principles of integrality and equity in care.

This is a crucial issue that warrants further analysis and attention. Achieving the principles of integrality and equity for a group that has historically been kept excluded from the right of access to basic health care and the most elementary spheres of sociability is a long-term goal of the public healthcare system.

Lastly, it should be noted that the most recent survey of the Instituto Brasileiro de Geografia e Estatística (IBGE [Brazilian Institute of Geography and Statistics]) [32], did not include information on the population considering gender identity, which hinders the execution of more refined analyses on the oral health of this population. The inclusion of gender identity in future surveys would assist in the promotion of public health policies that could change and qualify the offer of services and the access of transvestites to oral health information, products and services.

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