TOOL FOR FAMILY ASSESSMENT OF THE CHILD WITH GENDER INCONGRUITY* INSTRUMENTO PARA A AVALIAÇÃO FAMILIAR DA CRIANÇA COM INCONGRUÊNCIA DE GÊNERO INSTRUMENTO PARA LA EVALUACIÓN FAMILIAR DE NIÑOS CON INCONGRUENCIA DE GÉNERO

Objective: to report the experience of building up an evaluation tool to systematize the nursing care of the child's family with gender incongruity. Method: this is a descriptive study, case report type, on the building up of a tool to systematize nursing care to the family of the child attended in an outpatient clinic for gender and sexualities in childhood and adolescence of a general university hospital. Building up was developed based on the stages of the Nursing Process using the Calgary Models of Family Assessment and Intervention. Conclusion: it was concluded that the use of an assessment tool allows nurses to obtain a macro-assessment of the family's strengths and problems, supporting decision making and providing support for the establishment of nursing problems, strengths and interventions that support the assessment of comprehensive care of the family assisted in this clinic. Descriptors: Nursing Process; Nursing Assessment; Family; Child; Gender Identity; Mental Health.

It is known that children can begin to express the desire to be of the other sex and unhappiness regarding their physical sexual characteristics and functions assigned at birth from the age of two or three, which is called gender incongruity. It is pointed out that its prevalence is difficult to determine, estimating that it corresponds to 0.3% to 1.2% of the population. [1][2] It is noteworthy that, in many societies around the world, there is a stigma associated with gender incongruity, which can lead to prejudice and discrimination, resulting in the so-called "minority stress". Minority stress is defined as unique, chronic and socially based, which can increase the vulnerability of these children and develop mental health problems, such as anxiety, depression and suicide. It is perceived that, in addition to prejudice and discrimination, stigma can contribute to abuse and neglect in relationships with the family, as well as leading to psychological distress. 1,3 It is evaluated, considering the vulnerability of these children that the presence of family support appears as a great influence on the willingness to improve health problems arising from the stress that the child may experience. The results of a study with 66 transgender individuals aged 12 to 24 years found more resilience, less symptoms of depression and improved quality of life in young people who had family support. [4][5] It is believed that many families of children with gender incongruence could benefit from the assistance of health professionals with experience in this area, since these families need to be welcomed in a unique way through listening that makes it possible to identify the main complaints. [6][7] It is specified that the care offered by nurses to family members of children with gender incongruence can be considered important to minimize parents' anxiety in relation to the numerous concerns that may arise. In this sense, it is considered that understanding the repercussions for the child and the family, such as changes in their daily lives, school routine and family conflicts, represents a skill to be developed by nurses, so that they can offer adequate assistance to their individual needs. [6][7] It is verified, in order to establish an environment that facilitates the identification of family issues that the nurse can use a tool that aims, primarily, to promote health and improve the quality of life of individuals: the Nursing Consultation (NC). It is possible for the nurse, through the NC, to welcome these families, identify the problems to be worked on and suggest interventions. 8 It was decided, considering the impact caused on the daily life of the child and the family, to use the Calgary Models of Family Assessment and Intervention (CMFAI), which allow an expanded view of the family system, which includes its internal and external relationships, strengths and weaknesses. It is suggested that the use of this model allows nurses to know the family in its context and identify their needs, as well as the care alternatives specific to their condition. 9 It is necessary, in order to implement the CMFAI in NCs, the construction of an instrument to systematize Nursing care to the family attended in an outpatient clinic for gender and sexualities in childhood and adolescence in a general hospital. It is emphasized that the implantation of an instrument can facilitate the practice of Nursing with an expanded view in which the psychopathological assessment does not reduce the care to the identification of patterns of normality and abnormality and prioritize the integral approach of the patient's needs. 10 • To report the experience of building up an evaluation tool to systematize the nursing care of the child's family with gender incongruity. This is a descriptive study, like an experience report, on the construction of an instrument to systematize nursing care for the family of the child attended at an outpatient clinic for gender and sexuality in childhood and adolescence at a general university hospital in a city in the interior of the State of São Paulo (SP), Brazil.
It is registered that the ambulatory belongs to the department of Medical Psychology and Psychiatry of the hospital and offers multidisciplinary care to children and adolescents up to the age of 20 who experience the incongruity related to the sex of birth. It is pointed out that the service aims at the assessment and promotion of mental health and the quality of life of these children and adolescents, as well as their families, through outpatient monitoring by health professionals, such as psychiatrists, endocrinologists, gynecologists, nurses, psychologists, speech therapists and art therapists.
It is observed that the access to the clinic happens through contact by email with the team, which is usually done by the family members themselves or by health professionals in the region. Afterwards, a reception is scheduled, when the demands will be heard and the outpatient's vision explained. Then, the monitoring begins, if the service has the possibility to meet the demands of the child or adolescent, following a specific flowchart.
It appears that the instrument development process took place between the months of January and July 2018. Its construction was based on the stages of the Nursing Process (NP) -investigation, Nursing diagnoses / problems, planning, implementation and evaluation nursing careguiding it by the CMFAI. 9,11 NP is defined as the work method that Nursing uses for care. It is known that its creation dates back to the years 1950-1960, in the United States and Canada. At that time, it was reinforced that nursing activities are not isolated, but are part of a process. The NP method was disseminated to other countries and today it is used in health institutions worldwide. Its use is associated with better information quality, interprofessional communication and measurement of nursing actions. 11 As the NP was created and implemented, models and theories were established as guides for the practice of Nursing professionals. It was decided, after an extensive bibliographic survey, to use the CMFAI to guide nurses to help the families of children and adolescents attended at the clinic, considering that the intention of the service is to provide the best quality of life. 9,11 It is understood that the Calgary Family Assessment Model (CFAM) is a multidimensional, integrated structure, supported by the theoretical foundations of systems, cybernetics, communication and theory of change and influenced by postmodernism and the biology of cognition. The Model allows the nurse to obtain a macro-assessment of the family's strengths and problems. It is pointed out that the CFAM covers three main categories: structural; development and functional. 9 It is noted that, after a thorough evaluation is completed, the nurse and the family can then determine whether the intervention is necessary or not. In this way, the Calgary Family Intervention Model (CFIM) is associated with the CFAM, being the first intervention model in the family that emerges in the field of Nursing. 9 It appears that the CFIM is a model based on strengths and oriented towards resilience that focuses on promoting, improving and sustaining effective family functioning in the three domains: cognitive, affective and behavioral. It is verified, through the NC, that the family and the nurse develop together and collaborate to discover the most appropriate adjustment. 9 Interventions are made based on circular questions with the aim of triggering change in the cognitive domain (offering new ideas, opinions, beliefs, information or education about a particular health problem or risk), in the affective domain (where interventions are aimed at reducing or increasing intense emotions that can block the family in solving problems) and in the behavioral domain (helping family members to interact and behave differently from each other). 9 Thus, an instrument was constructed based on these concepts to systematize nursing care to the family of the child or adolescent with gender incongruence, subdivided into the categories: reasons for referral / family discourse; expectations; structural evaluation; development assessment; functional assessment; nursing problems; interventions and evaluation.
It is pointed out that, in order to start the NC, the instrument presents the initial approach to the family member, collecting sociodemographic data, such as name, sex, age, kinship, profession / occupation, origin and telephone number. The data of the patient in question are also collected, such as registration name and social name, age, origin and medical record number.
It is necessary, at this point, to know the health care network of this family, therefore, the use of the Unified Health System (UHS) or care in private institutions is considered.
It is known that UHS is one of the largest and most complex public health systems in the world, ranging from simple care for blood pressure assessment, through primary care, to organ transplantation, ensuring comprehensive, universal access and free for the entire population of the country. With its creation, universal access to the public health system was provided, without discrimination.
It is understood that comprehensive health care, and not only assistance care, has become a right for all Brazilians, since pregnancy and throughout life, focusing on health with quality of life, aiming at prevention and health promotion.
It is pointed out that, in order to start the NC, the instrument presents the initial approach to the family member, collecting sociodemographic data, such as name, sex, age, kinship, profession / occupation, origin and telephone number. The data of the patient in question are also collected, such as registration name and social name, age, origin and medical record number.
At this point, it is necessary to know the health care network of this family, therefore, the use of UHS or care in private institutions is considered.
It is known that UHS is one of the largest and most complex public health systems in the world, ranging from simple care for blood pressure assessment, through primary care, to organ transplantation, ensuring comprehensive, universal access and free for the entire population of the country. With its creation, universal access to the public health system was provided, without discrimination.
It is understood that comprehensive health care, and not only RESULTS assistance care, has become a right for all Brazilians, since pregnancy and throughout life, focusing on health with quality of life, aiming at prevention and health promotion. It is proposed, considering the qualitative nature of this study, that the nurse transcribes the reasons why the family sought the clinic with their own words, as well as their expectations regarding the service. One proceeded with the structural assessment, which concerns those who are part of the family, what is the affective bond between its members and what is their context. Therefore, it was also sought to know the meaning of the term "family" for the interviewees. The assessment can be supported by two instruments: the genogram and the ecomap. It appears that the genogram is a diagram of the family group and the ecomap, on the other hand, is a diagram of family contact with other individuals outside the immediate family. Thus, it is possible to observe who are the people with whom the child has more affinity, as well as the existing family conflicts, making it possible to identify potential problems. Standardized symbols and concepts are made available to assist the professional. 9    In the functional assessment, the routine activities of the child / adolescent and family members are described, as an example of everyday problematic situations and strategies for coping and solving problems. There is also a space for the family member to describe how they are dealing with these situations and what they think is their responsibility in relation to the child / adolescent. 9 After the assessment, the strengths and problems existing in the family relationship are detected. It is observed that each of these strengths and problems will lead to an intervention, which should suggest adjustments for each of the domains of family functioning: cognitive, affective and behavioral. 9 Finally, a space is reserved for the evaluation of interventions to be filled in each return of the family member with the nurse.

 Theoretical perspective of support for the application of the instrument
It is assessed that nurses involved in the care of children and adolescents who have issues related to gender identity have an important role, considering their interaction with the patient and their family, throughout a continuous care process. High quality nursing care is based on systematic scientific methods and theoretical knowledge. It is understood that the NP, which is the most important tool for putting Nursing knowledge into practice, is a systematic problem solving method to determine an individual's health needs and to provide personalized care, promoting critical thinking, creativity, problem solving and decision making in clinical practice. 1 It is noticed that the care provided through the use of NP increases the quality of care and the level of satisfaction of individuals who receive care. Thus, it is understood that the nurse, as a member of a multidisciplinary team, is able to provide care to these families, using the NP, through Nursing consultations, psychotherapy and support groups. 1,12 Through the NP, the needs of the patient and family and the planned and prescribed care can be assessed, thus guaranteeing quality care. In this way, it becomes possible for nurses to discuss with the multidisciplinary team the care that was planned and why -and what results are intended to be achieved. It is necessary, considering that the care offered by Nursing works in conjunction with other team members, the documentation of this process in an easily understood instrument.  It appears that the nursing documentation in health services, when structured according to the NP, allows estimating how the process is operated by nurses and, at least in part, the quality of nursing care offered. It is required to document all the component phases of the NP: evaluation; Nursing diagnosis; planning; intervention and evolution. 13 It is pointed out that the first stage of the NP involves collecting information from the patient and his family about his condition and perceived problems. It can be defined as a planned, systematic, continuous and deliberate process of collecting, classifying and categorizing individualized information, in order to recognize individuals' responses to their health, real or potential problems and needs. 14 At this stage, the individualized assessment necessary to define a care plan involving specific interventions is allowed, and the focus of care is the patient and how they experience their problems. 14 In the case in question, the focus of the nurse's care is established, the family of the child or adolescent with gender incongruity. It is also intended, by this instrument, to present the reason for the family's search for the clinic, as well as their expectations, in order to guide the care.
It is observed, considering that the evaluation provides a basis for all other stages of the Nursing process, that the data collection must be done in a precise, objective and complete manner. It is DISCUSSION 7. Nursng evolution: important to have an appropriate model for data collection. It is understood, then, thinking about the CFAM as a theoretical reference that supports the development of NP, that the information can be obtained through Nursing consultations in which the essence will be in the interaction that occurs between family members. 9,12,15 It is noticed, in nursing consultations, that the nurse and the family explore the structural, developmental and functional aspects, in search of a broader view of the universe of the child and the family. For this, two important tools that represent the family structure stand out: the genogram and the ecomap. 9 The genogram is defined as an instrument of symbolic-visual representation, with qualitative information on the dimension of family dynamics and functioning, which demonstrates and organizes the genetic, medical, social, behavioral, relational and cultural aspects that belong to the family structure. 16 It is pointed out that the ecomap, in turn, is a diagram of the relationships between the family and the community that helps to assess the available social networks and support and their use by the family, containing the families' contacts with people, institutions or groups. Important events are evidenced, such as deaths, separations, accidents, mental disorders, violence, chemical and alcohol dependence and sexual abuse, in this graphic representation, for planning comprehensive family health care.. 17 It is known that, in any clinical practice environment, nurses benefit from the adoption of a clear conceptual framework or a family map. It is estimated that, in the case of children and adolescents who may be going through a social transition, knowledge of these data is essential. It is emphasized that prejudice, discrimination, conflicts and the rejection of people from the patient's social life, including the family environment, can result in psychopathologies such as anxiety, depression and suicide attempts. Studies have shown that social support is linked to better results in relation to mental health, which justifies knowing the family structure. 18 In a recent study, children who were supported by their parents, extended family and schools in their preferred identities -that is, those who have undergone a social transition -were found to have only a small increase in anxiety symptoms and no elevation depression compared to a control group. 19 After completing this thorough evaluation, this organization encourages the organization of this massive amount of information, apparently disparate, providing a synthesis of the data collected to guide the process of nursing care. This composition is called Nursing diagnosis, representing the second stage of the NP. It is noteworthy that the nursing diagnosis is a clinical decision that involves reactions of the individual, family or society to current or potential health problems. It is pointed out, in order to increase the quality of nursing care and to ensure that the needs of an individual are identified in the same way by all nurses, that a standard terminology can be used in nursing diagnoses. 12 It is understood, however, that the model used proposes, instead of using diagnoses, the generation of a list of strengths and problems, which seeks to present the nurse's perspective and not the "truth" about the family. It should be noted that, due to its rigidity, the Nursing diagnosis may not include sufficient ethnic and cultural considerations. Thus, the nurse is offered, specifying strengths and problems, the flexibility to describe the situations observed at the time of the consultation, without looking for ready diagnoses that, many times, do not address the breadth of the situation in which the relative is finds. 9 It is said that the strengths may be self-care skills or independence in certain areas, or prior knowledge or experience in a given situation. It is understood that the real problems are those that come directly from the evaluation, for example, anxiety. Potential problems are those that could arise from the problem, for example, the risk of developing depressive symptoms. It is instructed that, when developing a list of family strengths and problems, the nurse must validate the structural, developmental and functional items that currently affect family interaction. 9,15 It is suggested, after reviewing the CFAM, identifying and listing the family's strengths and problems and preparing the assessment, that the nurse should develop an intervention plan, which consists of the third stage of the NP. It is observed that the interventions offered must depend on the scope of the nurse's practice, degree of independence, autonomy and responsibility associated with their role in family care. 9,15 It appears that interventions can be planned to promote, improve or sustain family functioning in one or more domains (cognitive, affective and behavioral), but the change in one domain can affect the others. Then, ways can be provided to conceptualize an adjustment between the domains of family functioning and the interventions proposed by the nurse. 9,15 It is indicated that the adjustment applied to both strengths and family problems is of paramount importance. It is known that young transsexuals affirm family rejection as a significant stressor, which can contribute to the suicidal tendency and other negative outcomes for mental health. It appears that family rejection can also lead to homelessness, which, in turn, places youth at greater risk of health. It should be noted that LGBT youth represent 40% of the population of youth shelters in which family rejection due to sexuality or gender identity was the most cited reason for homelessness. 20 It is pointed out that, after the intervention is indicated, the nurse must consider how to intervene to facilitate the change, constituting the fourth stage of the NP. It is noted that the implementation of the proposed interventions involves the action or the doing and the actual execution of the nursing interventions described in the care plan. 9 Various interventions for parents and families of young people with gender incongruence have been described in the literature, but none have been tested empirically to date. Multidimensional treatment approaches are presented to work with these young people and their families that involve parent education, individual child therapy, therapy and a multifamily support group for parents, including the provision of psychoeducation in relation to the development of transgender identity, enabling parents to be advocates and source of support for their child, promoting positive and adaptive interactions between parents and children. 21 It is observed that the nurse has the role, then, to identify ways to stimulate family acceptance, reduce rejection behaviors and improve the parent-child relationship to promote resilience in the context of chronic minority stress. Research on resilience has indicated that creating interventions to improve parental strategies and parents' responses to children's experiences with adversity can promote resilience and reduce the impact of that adversity on later psychological problems. 21 However, despite the fact that many parents evolve to positive reactions in relation to gender identity, one study found that approximately 50% continue to react negatively. It is important, then, that the nurse offers the adjustments in agreement with the family, never assuming that he has already obtained the absolute truth about family functioning. In this way, the last stage of the NP is presented as the most important, as it will monitor the evolution of care, observing whether the results have been achieved or not and ascertaining the need for new consultations for the reapplication of the previous phases. 9, It is noteworthy that it is not uncommon for parents to initially disagree about the management of their children's gender nonconformity. It is noticed that the declaration of gender non-conformity of a child, in most cases, also generates a cascade effect in all members of the family system. It is noted, initially, that parents often face uncertainties related to how, where and when they should allow their children to express their gender identity. It is understood that parents may have different opinions about which toys (for example, action figures and dolls) their child can play with and in which places, where and when the child can dress as they wish (for example, in their own room, at home, on the street or at school) and even by what name he or she prefers to be identified. 19 It is recommended that nurses support families, recognizing that the gender non-conformity of young people represents a deviation from the life they expected and the child they imagined. It is believed that families can feel the recognition of their incongruity as a loss, not only of the child they dreamed of, but also of the child they initially had, which can complicate their pain. It is considered beneficial to help parents recognize that they have not lost their child -that is, they remain the same child, just of the opposite gender to what they thought they were. Little research is found on how siblings can be helped to accept a child's preferences or gender identification. It is suggested, in general, that the brothers accept this reality quite easily, and the best approach is for the family to discuss it openly and with love and acceptance. 19 Studies have shown that additional research is needed to determine whether there is a single harmful effect associated with parental rejection based on gender identity compared to rejection that is not directly linked to transgender identities. It is observed if the same mechanisms support the connections between rejection based on transgender identity and other forms of parental rejection with negative psychosocial results and that the psychosocial interventions established to improve interactions between parents and children may be sufficient for young people with incongruity of genre. It should be noted, however, that the development mechanisms that confer risk are exclusive to parental rejection based on gender identity, that interventions need to be modified to achieve the relevant mechanisms. 21 Family support stands out as important in several subgroups of young people, relating to stress, depression and self-esteem in different ways for different subgroups. Studies have shown that a positive relationship with the family is a unique protective factor for LGBTQ teenagers when compared to cisgender heterosexual teenagers. 23 It is noticed that the number of children and adolescents with gender diversity referred to clinics specializing in transgenders grows every year. It is shown that these increasing numbers make knowledge of the psychological functioning of these children and adolescents and their families highly relevant to health professionals in CONCLUSION clinics specializing in gender identity, as well as in general mental health settings.
Finally, it is concluded that families should be supported in the care of their young people with sexual diversity, as family acceptance is associated with physical and mental health, in addition to self-esteem and the prevention of depression.