Abstract

Public Health undergraduation aims to train health professionals with knowledge focused on the promotion, prevention and health systems management. However, an apparent silencing of debate in the courses is noted regarding the approach to issues of gender and sexuality. The objective is to understand the presence or not of contents that consider gender and sexuality aspects in this undergraduation, using the qualitative analysis, through Documentary Research and Content Analysis, from the research and analysis of the Curricular Pedagogical Projects (CPP) of Brazilian Public Health undergraduate courses. A total of 16 projects were analyzed from the 21 existing courses in Brazil. We present, mainly, that 12 courses have disciplines that discuss gender and sexuality issues during graduation, sometimes mandatorily or optionally. We conclude that the debate on gender and sexuality occurs in most of the Institutions with Public Health undergraduate courses. However, this field of discussion must also be improved in the National Curricular Guideline for Public Health courses, which should explicit these topics, enabling an undergraduation that overcomes prejudice, violence and binarism found in a heteronormative and sexist society.

Key words
Gender; Sexuality; Public Health; Curricular Pedagogical Project

Introduction

Public Health: a field in constant (re)construction

Public Health can be defined as the field of knowledge related to health, diseases and problems, but also to the extent of the social aspects involved in the health-sickness-care process. For this reason, it includes practical, technical, theoretical and political actions¹1 Souza LEPF. Saúde pública ou saúde coletiva? Rev Espaço Saúde 2014; 15(4):7-21.. As a field of academic knowledge, its emergence in the 1950s in the United States is related to the medical education crisis. This formation was and still is characterized by fragmentation and excessive stimulation towards specialization. This proposal was intended to broaden the knowledge about the health-illness-care process and provide a comprehensive view of individuals, focusing on the medical curriculum¹1 Souza LEPF. Saúde pública ou saúde coletiva? Rev Espaço Saúde 2014; 15(4):7-21.^,22 Nunes ED. Saúde coletiva: história de uma idéia e de um conceito. Saúde Soc 1994; 3(2):5-21..

This field of knowledge was consolidated and institutionalized in Brazil in the 1970s, mainly through two institutions. The first was the Brazilian Center for Health Studies (CEBES), which was established in 1976. This center fostered a debate on the democratization of society and the protection of social rights, in particular, the universal right to health. Subsequently, the Brazilian Association of Collective Health (ABRASCO) was founded in 1979 and was initially called the Brazilian Association of Post-Graduation in Collective Health. Through the articulation between education, research, and training centers in Collective Health, it strengthened the dialogue between the technical and scientific community, health services, governmental and non-governmental organizations and civil society, such as the National Health Conferences (CNS)²2 Nunes ED. Saúde coletiva: história de uma idéia e de um conceito. Saúde Soc 1994; 3(2):5-21.

3 Ruela HCG. A formação de sanitaristas e os cursos de graduação em saúde coletiva no Brasil [dissertação]. Rio de Janeiro: Escola Politécnica de Saúde Joaquim Venâncio; 2013.^-44 Lima NT, Santana JP. Saúde coletiva como compromisso: a trajetória da Abrasco. Rio de Janeiro: Editora Fiocruz; 2006..

Collective Health has now grown and is present in the academic and political agendas of several countries, with the mission of supporting individuals and Undergraduate and Postgraduate and Research institutions, and the provision of Public Health Services. Also, public health is expected to expand professional qualification, knowledge production and improvement of health, education, science and technology policies to address the health problems of the Brazilian population⁴4 Lima NT, Santana JP. Saúde coletiva como compromisso: a trajetória da Abrasco. Rio de Janeiro: Editora Fiocruz; 2006..

Given this debate, the Ministry of Health, through Ordinance Nº 256, of March 11, 2013, in its Article 5, includes, in the Table of Brazilian Classification of Occupations (CBO), the SANITARIST CBO:

Sole paragraph. A sanitarist is understood as a higher education professional, graduated in the area of health with post-graduation in public or collective health, or graduated in one of these areas⁵5 Brasil. Ministério da Saúde (MS). Portaria nº 256, de 11 de março de 2013. Estabelece novas regras para o cadastramento das equipes que farão parte dos Núcleos de Apoio à Saúde da Família (NASF) Sistema de Cadastro Nacional de Estabelecimentos de Saúde (SCNES). Diário Oficial da União 2013; 11 mar..

Thus, Public Health education aims to have future health professionals with knowledge focused on the critical and reflexive analysis of health-illness-care processes within the Health System. Thus, these professionals may have an understanding of the health needs of the population; of promotion and prevention actions; health surveillance; participation in the development and implementation of public policies and the management of public and private health systems, especially the Unified Health System (SUS); the planning of actions in health and health education. They are also expected to be committed to and respect the population to improve the quality of life⁶6 Conselho Nacional de Saúde (CNS). Recomendações do Conselho Nacional de Saúde à proposta de diretrizes nacionais do curso de graduação em saúde coletiva. Brasília: CNS; 2017..

The first graduation course in Public Health is called Management of Health Systems and Services and was established in 2002 at the State University of Rio Grande do Sul (UERGS). In 2009, more institutions from the Northeast (Federal University of Bahia - UFBA), Southeast (Federal University of Rio de Janeiro - UFRJ, Federal University of Minas Gerais - UFMG) and South (Federal University of Paraná - UFPR, Federal University of Rio Grande do Sul - UFRGS) start new Public Health courses.

There are currently 21 bachelor’s degrees in Public Health distributed in all regions of the country. It is worth emphasizing that the profession of sanitarist was already known before the creation of these baccalaureate courses, and this title was assigned by specialization and postgraduate courses in Collective Health or Public Health⁷7 Cezar DM, Ricalde IG, Santos L, Rocha CMF. O bacharel em saúde coletiva e o mundo do trabalho: Uma análise sobre editais para concursos públicos no âmbito do sistema único de saúde. Sared 2015; 1(4):65-73.^,88 Lorena AG, Santos L, Rocha CF, Lima MSS, Pino MR, Akerman M. Graduação em saúde coletiva no Brasil: onde estão atuando os egressos dessa formação? Saúde Soc 2016; 25(2):369-380..

The discussion on gender and sexuality in Public Health education

The Undergraduate Course in Public Health has academic training focused on the improvement of Public Health. One of its bases is the construction of health equity, with a reduction of the adverse effect of social determinants on health, such as those related to education, race and ethnicity, and gender. These should be guiding the propositions public health policies actions⁹9 Barata RB. Como e por que as desigualdades sociais fazem mal à saúde. Rio de Janeiro: Editora Fiocruz; 2009..

Thus, it is observed that the intersections of gender and sexuality have gained scope in the discussions of Public Health in the last decades. This has been observed since the 1970s with the Feminist movement, which sought to expand the conceptions of health care beyond a reproductive knowledge of the female body¹⁰10 Villela W, Monteiro S, Vargas E. A incorporação de novos temas e saberes nos estudos em saúde coletiva: o caso do uso da categoria gênero. Cien Saude Colet 2009; 14(4):997-1006.. Subsequently, the lesbian, gay, bisexual, transvestite and transsexual (LGBT) movement in the 1980s sought to debate issues of sexual orientation and gender identity¹¹11 Raimondi GA. Saúde da população "trans": uma revisão sistemática da produção teórica brasileira [dissertação]. Uberlândia: Universidade Federal de Uberlândia; 2016..

The 12^th CNS, held in 2003, broadens the discussion on gender and sexuality issues, with essential debates on the intersection of gender, sexuality and health rights. The inclusion of sexual orientation and gender identity issues in health policies is observed for the first time in a national workshop document. The non-discrimination based on gender identity and sexual orientation is reiterated in the SUS and strategies for coping with the health problems of the LGBT population are defined. Also, there was a debate about the necessary advances in Women’s Health and the fight against domestic, sexual and racial violence, seeking to abolish all forms of discrimination against women. The incorporation of educational contents that ensure knowledge about SUS and subjects such as sexuality, access to and use of condoms and reproductive rights in school curricula at all levels of education was one of the strategies listed to solve these situations¹²12 Brasil. Ministério da Saúde (MS). Relatório Final 12ª Conferência Nacional de Saúde: Conferência Sergio Arouca. Brasília: MS; 2004..

Specifically, concerning the issues of the LGBT movement, an important initiative was the “Brazil without homophobia” in 2004. One of the central objectives of this Program was the education and behavioral change of public managers. It should be noted that the “non-violence” motto present in this initiative was cross-cutting to all proposals for actions, evidencing the need for changes in various social spheres¹³13 Brasil. Ministério da saúde (MS). Brasil Sem Homofobia: Programa de combate à violência e à discriminação contra GLTB e promoção da cidadania homossexual. Brasília: Conselho Nacional de Combate à Discriminação; 2004..

It is noteworthy that sexual orientation and gender identity were included in the analysis of the social determinants of health only in 2007, at the 13^th CNS. This reiterates one of several demands of the social movement on the need to include these social markers of difference in health analyses. Some recommendations were made at this Conference in this regard, such as the development of intersectoral actions in human rights education and respect for diversity and the implementation of school campaigns and curricula that address human rights¹⁴14 Brasil. Ministério da Saúde (MS). Relatório Final da 13ª Conferência Nacional de Saúde: Saúde e Qualidade de vida: políticas de estado e desenvolvimento. Brasília: Conselho Nacional de Saúde; 2008..

In 2011, the Report of the 14^th CNS reiterated the agreement, implementation and expansion of the National LGBT Comprehensive Health Policy, of that same year, assuring the qualification of health professionals, managers and the development of actions to cope with any discrimination. It also highlights the need to strengthen the Women’s Health Care Policy, reaffirming the assurance of sexual and reproductive rights, and care to women in situations of violence. The implementation of the Men’s Health Program in all municipalities, aiming at health promotion and prevention, is also recommended. All this highlights the need to broaden the debate on health education and care concerning gender and sexuality issues¹⁵15 Brasil. Ministério da Saúde (MS). Relatório Final da 14ª Conferência Nacional de Saúde: Todos usam o SUS; SUS na Seguridade Social Política Pública; Patrimônio do Povo Brasileiro. Brasília: CNS; 2012..

However, what is observed in this CNS is a non-pronouncement on the specificities of health care, as well as on gender equality, transsexuality and transvestitism issues, as had previously occurred. One can observe this, even in the guiding document and in the final report of the 15^th CNS¹⁶16 Brasil. Ministério da Saúde (MS). Documento Orientador de apoio aos debates da 15ª Conferência Nacional de Saúde. Brasília: CNS; 2015.. In the latter document, these issues are implicit in the terms “LGBT” and “gender”, showing the lack of specificity to this population, as opposed to the intensification of academic and popular movements aimed at the comprehensive health of the LGBT population¹¹11 Raimondi GA. Saúde da população "trans": uma revisão sistemática da produção teórica brasileira [dissertação]. Uberlândia: Universidade Federal de Uberlândia; 2016..

At the same time, the World Health Organization (WHO) in 2006 points out, in a first global document, that the gender debate is an essential part of the health professional’s curriculum, in order to address the health inequalities related to gender issues. The key to achieving this goal is to make gender issues a part of the curricula of health professionals, through teacher training and advocacy for policy change related to health worker curricula¹⁷17 World Health Organization (WHO). Integrating gender into the curricula for health professionals. Geneva: Department of Gender, Women and Health (GWH), WHO; 2006..

The Pedagogical Projects of the Undergraduate Courses

The National Curricular Guideline (DCN) for the Undergraduate Courses in Public Health establishes the profile of the bachelor in Public Health and the curricular components fundamental to its formation and was approved by the National Education Council (CNE) in April 2017. As a recent document, the curricular pedagogical projects (CPP) of the courses are mainly based on the DCNs that regulate undergraduate courses in the area of Health and the Education Guidelines and Bases. It is known that undergraduate courses in Public Health have an intimate relationship with the institutions related to this field and social movements also related to this health practice. However, there is a need to broaden the debate about the social determinants of health, as well as the gender and sexuality issues, in the DCN of undergraduate courses in Public Health.

Thus, despite the guidelines for addressing gender and sexuality issues in undergraduate courses in the health professions, as shown, it is observed that there is a lack of pedagogical/political actions on this debate in undergraduate health courses. Thus, this paper aims to question the presence or not of contents that consider gender and sexuality aspects in the formation of sanitarists in our country.

Methods

This is qualitative research, with the use of Documentary Research, from the survey and analysis of the CPP of undergraduate courses in Public Health in Brazil, analytically supported by a thematic review.

We analyzed the CPPs available from each undergraduate course in Public Health from 2008, when the first projects emerged, up to the documents of 2016. Since they are public domain documents, there was no need to submit this research to the Research Ethics Committee.

The first method of retrieving the CPPs of the courses was through a systematized search in the electronic sites of the 21 institutions that offer the undergraduate courses in Public Health. Due to the non-public availability of some CPPs, sending was requested by e-mail. The CPPs that were not sent after the third attempt to retrieve via e-mail were disregarded.

A categorical content analysis was carried out to verify whether gender and sexuality were included in the curricula. The first step was to read all the projects and identify which ones contained the descriptors “gender” or “sexuality” and which did not. Thus, the categories “includes” and “does not include” were created with the themes of gender and sexuality.

Then, in the projects that included these descriptors, we tried to identify how it was proposed to approach these subjects. Thus, it was possible to present two more categories, namely, “Compulsory Disciplines” and “Elective Disciplines”.

The last step consisted of the analysis of the approach to these subjects through the register of the disciplines. We will show the results, followed by the discussion about what was found. Figure 1 shows the synthesis of the analysis of this research.

Results

We analyzed the documents of undergraduate courses in Public Health in Brazil of the following institutions: State University of Amazonas (UEA), Federal University of Acre (UFAC), Federal University of Roraima (UFRR), Federal University of Bahia (UFBA), Federal University of Mato Grosso (UFMT), Federal University of Rio de Janeiro (UFRJ), University of São Paulo (USP), Federal University of Minas Gerais (UFMG), Federal University of Paraná (UFPR), University of Brasília (UnB) – Campus Ceilândia, Federal University of Rio Grande do Norte (UFRN), Federal University of Uberlândia (UFU), Federal University of Latin-American Integration (UNILA), Federal University of Rio Grande do Sul (UFRGS), Federal University of Pernambuco (UFPE) and Federal University of South and Southeast of Pará (UNIFESSPA).

Due to the unavailability of the documents, it was not possible to analyze the CPPs of the following institutions: Higher Education Association of Caruaru (ASCES), University of Pernambuco (UPE), ABC Faculty of Medicine (FMABC) and Federal University of Health Sciences of Porto Alegre (UFCSPA), University of Brasília (UnB) – Campus Darcy Ribeiro.

Among the Public Health courses that include disciplines with gender and sexuality issues, some disciplines address both, while other discuss one or the other.

The discussion in some institutions is related to Sexually Transmitted Infections (STIs) or other particularities such as race and ethnicity. Disciplines are elective in some Institutions (UFMT, UFMG, UFBA, USP, UFRJ and UFPR) and compulsory in other (UFRGS, UFBA, UFAC, UEA, UFPE, UFRR and UNILA) (Chart 1).

Debates on Gender and Sexuality

Institutions such as UFBA, UFMT, UFRJ, USP and UFPE offer in their disciplines discussions on gender issues in health, concepts about body, sexuality and reproduction, gender theories in the field of health, and sexuality and social inequality relationship. Most of these subjects are elective. Only the discipline of UFPE is compulsory. UFBA offers four disciplines with a gender/sexuality approach. These include “gender, race, sexuality and health”, where the main focus is on gender relationships in health studies, examining the cultural and historical construction of the meanings of gender and sex, and their interfaces with race, ethnicity and social class. The generation of meanings and their influence on body experience and health- disease processes are explored. The focus is on social and historical processes in which meanings about gender, ethnicity, race, and class are constructed, negotiated, imposed or combated. There is also an optional course entitled “AIDS, sexuality and gender” that analyzes the relationship between AIDS and social inequalities, discussing the main theoretical concepts to understand the complex relationship between sexuality, gender, power and vulnerability to HIV/AIDS.

The UFMT offers the discipline “Indigenous Peoples, Gender and Health: Anthropological Aspects”, where it is proposed to discuss the ethnology of the indigenous peoples of South America. There is a focus on gender/health and sexuality/health relationship addressing some topics such as the concept of person and body; nutrition; sexuality; reproduction; social organization and health; politics and health; indigenous health policies and others.

UFRJ, with the discipline “Gender and Health”, discusses the historical, conceptual and methodological aspects of gender in healthcare, care models, educational practices, reproductive rights, the issue of sexuality in the field of health, emergence of men in gender studies. It also addresses gender-based violence and maternal mortality.

USP offers the discipline “Gender, Sexuality, Race/Ethnicity and Public Health” that aims to understand the concepts of gender, race and ethnicity applied to the health field, gender, race/ethnicity differentials in healthcare, sexuality as a realm of health; the field of reproductive health in its epidemiological, welfare and educational expressions. The theoretical-methodological foundations of the analysis of the articulation of the social relationships of gender, race/ethnicity and social class in Brazilian society, both through history and in the present time, are discussed.

UFPE’s Public Health course offers students the discipline “Gender and Sexuality Theory” during graduation, which aims to address fundamental theoretical-methodological issues for the studies of gender and sexuality relationships in their social, psychological realms and cultural realms. It also seeks to address the various interpretations of gender concepts, feminism in the West and its transformations, and women’s political struggles. It aims to bring about the discussion about the relevance and emergence of studies of gender and sexuality relationships and male identities. The syllabus also proposes to address homoaffectivity, the LGBT movement and gender and sexuality in the Northeast.

Debates on Gender only

UFMG, UFRJ, UFPR, UNFIL, UFRGS, UFAC, UFBA and UAS present more gender issues in their subjects, which are compulsory, except for UFMG and race, ethnicity and gender in Public Health offered by UFBA.

UFMG proposes to address in the discipline “Health and Gender Seminars” the history of the formation of gender identity in Brazilian society, the repercussions of gender issues in the world of work and the health and gender relationship. UFBA also seeks to address studies of race, racism, and gender, articulating with the field of Public Health through the discipline “Race, ethnicity and gender in Public Health”.

UFRJ aims to study the AIDS-gender relationship in the Gender and Health discipline, which is offered on an elective basis. In UFPR, UNILA and UFRGS, discussions propose a focus on human diversity and their respect for health, race/ethnicity, class and gender relationships and their contributions to the illness-care process.

UEA, UFBA and UFAC teach the discipline “Society, Culture and Health II”, in which it is proposed to discuss health inequalities by social class, gender and race/ethnicity and social policies. This discipline’s prerequisite is the “Society, Culture and Health I” discipline, which studies the Health, Society and Culture relationship, the social and health determinants and the historicity of the health and disease concepts.

UFRR also offers the discipline “Society, Culture and Health II”, with a different syllabus. It proposes the study of the theoretical and methodological models applied to the study of the social determinants of the health-disease process.

Debates on Sexuality only

UFRR offers the discipline “Introduction to indigenous health”, in which it is proposed to approach subjects related to the concepts of body, sexuality and indigenous reproduction. All the disciplines in this particular course are geared toward the indigenous population.

Gender and Sexuality beyond the disciplines

It should be noted that at UNILA, UFMG and UFPE, the word gender is mentioned not only in the syllabus or curricular matrix.

In its guidelines, UNILA encourages that issues such as gender, race and ethnicity in professional and personal work are highlighted in its curricular components. The Institution thus points out behaviors and postures that can help in the improvement of health services and those that work in their surroundings, reaching the subject, finally, whether another professional or user.

UFMG advises that legal bases and ethnic-social and gender relationships should be addressed in their disciplines. In the text, the Institution encourages students to take these elective disciplines.

UFPE offers disciplines for cross-cutting training not only to the undergraduate students in Public Health but all undergraduate students, such as the Gender and Sexuality Theories, Brazilian Sign Language and Environmental Education.

Discussion

The debate around the theme of gender and sexuality, presented in the CPPs of undergraduate courses in Public Health, elucidates the clashes around the bodies in health education, bodies that are traversed by a series of elements such as gender and sexuality, as well as by ethnicity, race, social class, among others.

It is important to emphasize that the disciplines that approach these bodies from the gender aspects bring about the socio-historical component of this debate as one of the main focuses to understand the performances around this concept that materializes in the relationships of care in health. In this respect, Joan Scott¹⁸18 Scott JW. Gender: A Useful Category of Historical Analysis. Am Historical Rev 1986; 91(5):1053-1075. already pointed out that gender was, and still is, a useful category of historical analysis by highlighting the strategies of classifying certain social phenomena, permeated by the power relationships in the materialization of these classificatory differentiations. Thus, with the use of the term “gender” in dialogue with the feminist movement and queer theory, the CPPs point to a distinction between “sexual practices” and “sex roles”, extending traditional concepts of the body beyond the biological component¹⁸18 Scott JW. Gender: A Useful Category of Historical Analysis. Am Historical Rev 1986; 91(5):1053-1075..

In the face of this situation, these curricular components invite students to question the physical reality based only on the biological realm¹⁹19 Separavich MA, Canesqui AM. Girando a lente socioantropológica sobre o corpo: uma breve reflexão. Saúde Soc 2010; 19(1):249-259., thus questioning the idea of the “natural”, “nature”, inherent in the bodily processes²⁰20 Moore H. Understanding sex and gender. In: Ingold T, editor. Companion encyclopedia of anthropology. London: Routledge ed.; 1997. p. 813-830.. This idea often fixes the subject on a heteronormative identity matrix, reiterating that particular genitalia indicates a particular genus that, in turn, induces a certain affective-sexual orientation²¹21 Louro GL. Um corpo estranho: ensaios sobre sexualidade e teoria queer. 2ª ed. Belo Horizonte: Autêntica; 2013.^,2222 Butler J. Problemas de gênero: feminismo e subversão da identidade. 11ª ed. Rio de Janeiro: Civilização Brasileira; 2016.. That is, the presence of a vagina would indicate that the person is of the female gender and that she has an affective sexual attraction for a person of the opposite gender, constituting then a heterosexual relationship in which, obligatorily, that other person would have a penis. Moreover, a debate is ongoing about the power relationships between men/women and their (re-)(de-)construction in our society, questioning the device of sexuality²³23 Foucault M. História da sexualidade 1: a vontade de saber. 3ª ed. São Paulo: Paz e Terra; 2015. in our healthcare practices.

Thus, the questionings produced by these disciplines on this often naturalized “social order”, which seeks to organize the (im)possible patterns of bodies and subjects, as well as the (upper/lower) power relationships enable students to reflect on the systematic subjugations, violence and exclusions of certain bodies and subjects of health care²⁴24 Teixeira FB. Dispositivos de dor: saberes poderes que (con)formam as transexualidades. São Paulo: Annablume/Fapesp; 2013.^,2525 Ferraz D, Kraiczyk J. Gênero e Políticas Públicas de Saúde - construindo respostas para o enfrentamento das desigualdades no âmbito do SUS. Rev Psicol Unesp 2017; 9(1):70-82., thus understanding the effects of health inequities⁹9 Barata RB. Como e por que as desigualdades sociais fazem mal à saúde. Rio de Janeiro: Editora Fiocruz; 2009.. Thus, for some disciplines, understanding the explanatory models of the society-culture-health relationship is a fundamental prerequisite for understanding inequalities in society as a phenomenon with multiple realms.

Thus, there is theoretical feasibility for the training in Public Health to question what it is to be a woman and to be a man in our society, as already pointed out by some curricular units of the analyzed CPPs, for example, that question the issue of masculinity. In this case, specifically, there is a proposed debate on an alleged hegemonic masculine cultural identity that is often identified as one of the barriers to comprehensive health care²³23 Foucault M. História da sexualidade 1: a vontade de saber. 3ª ed. São Paulo: Paz e Terra; 2015.^,2626 Couto MT, Dantas SMV. Gênero, masculinidades e saúde em revista: a produção da área na revista Saúde e Sociedade. Saúde Soc 2016; 25(4):857-868.. Thus, this problem is shown in several public policies (Women’s Comprehensive Healthcare, Men’s Comprehensive Healthcare, LGBT population’s Comprehensive Healthcare) as one of the strategies of articulation between health and education to reduce the barriers in health care and promote comprehensive health care as part of the Brazilian citizens.

In the wake of these discussions, many CPPs analyzed explicitly intersectionality of gender and sexuality with other gap social markers, such as race and ethnicity and the debate around indigenous peoples. Some documents propose a cross articulation, by explaining this intersectionality throughout the Project. Thus, we seek to show that gender and sexuality traverse and are traversed by other social determinants (skin color/race/ethnicity, and social class). This is fundamental for the formation in Public Health since they are crucial determinants in understanding social inequalities¹⁰10 Villela W, Monteiro S, Vargas E. A incorporação de novos temas e saberes nos estudos em saúde coletiva: o caso do uso da categoria gênero. Cien Saude Colet 2009; 14(4):997-1006.. Perhaps this cross-sectional element in the document is a strategy to reaffirm the relevance of an analysis that articulates different markers to enhance the critical reflection of the ways that power devices produce difference, subjugation, exclusion and violence²⁷27 Moutinho L. Diferenças e desigualdades negociadas: raça, sexualidade e gênero em produções acadêmicas recentes. Cad Pagu 2014; 42(1):201-248..

Regarding the presence of issues that articulate gender and sexuality with indigenous peoples, specifically in two CPPs, it should be pointed out that this may also be related to the fact that the geographical regions of these Institutions evidence a sizeable indigenous concentration of the country, according to the Brazilian Institute of Geography and Statistics (IBGE)²⁸28 Instituto Brasileiro de Geografia e Estatística (IBGE). Os indígenas no Censo Demográfico 2010: primeiras considerações com base no quesito cor ou raça. Rio de Janeiro: IBGE; 2012.. This fact may highlight a possible pursuit of the CPP to approach the regional specificities, showing a social commitment of the Institutions with their sociocultural environment.

Another point that stands out in the analysis of CPPs is the dialogue on gender and sexuality issues with the debate on HIV/AIDS. This issue becomes relevant because the HIV/AIDS epidemic in the 1980s in Brazil facilitated the voicing of groups hitherto silenced by heteronormativity, expanding the discussion about the possibilities of the existence of subjects¹¹11 Raimondi GA. Saúde da população "trans": uma revisão sistemática da produção teórica brasileira [dissertação]. Uberlândia: Universidade Federal de Uberlândia; 2016.^,2525 Ferraz D, Kraiczyk J. Gênero e Políticas Públicas de Saúde - construindo respostas para o enfrentamento das desigualdades no âmbito do SUS. Rev Psicol Unesp 2017; 9(1):70-82.. However, according to Seffner & Parker²⁹29 Seffner F, Parker R. Desperdício da experiência e precarização da vida: momento político contemporâneo da resposta brasileira à AIDS. Interface (Botucatu) 2016; 20(57):293-304., stigma and discrimination remain present in homosexual subjects who are still tied to the idea of impurity from alleged HIV contamination, as evidenced by the ambiguous stance of the Ministry of Health on the donation of blood by people who self-declared as homosexuals. Besides, we experienced a re-emergence of the HIV/AIDS epidemic in Brazilian society, especially concerning the higher number of deaths and mortality rate³⁰30 Grangeiro A, Castanheira ER, Nemes MIB. A re-emergência da epidemia de aids no Brasil: desafios e perspectivas para o seu enfrentamento. Interface (Botucatu) 2015; 19(52):5-8..

This scenario around HIV/AIDS and gender and sexuality spell out the truth regimes that still systematically increase vulnerability to HIV/AIDS due to prejudice and discrimination. Questioning this in Public Health education brings the potential concretization of (re)thinking public policies that realize health promotion and human rights.

Even because of the incorporation of this debate on the social determinants of health, specifically gender and sexuality, the CPPs seem to focus on presenting these determinants to the students as “must know facts” and not as “conditions to be challenged”. This is because the debate about sex, but not sexism, race and ethnicity, but not of racism, of LGBT-hood and not of LGBT-phobia, is explicitly explained in the CPPs and the various curricular units analyzed. Therefore, this limits the scope of health equity³¹31 Sharma M, Pinto AD, Kumagai AK. Teaching the Social Determinants of Health: A Path to Equity or a Road to Nowhere? Academic Med 2018; 93(1):25-30.. These discourses and the issue of gender inequality must be broadened, including in the agenda, for example, violence against women, since there is an apparent silence and it is hardly debated in the documents analyzed.

It is emphasized that only one discipline analyzed explicitly the study of prejudice and discrimination to the subjects when addressing the issues of racism. Regarding issues involving the LGBT population, it is observed that only one Project addresses this theme, focusing only on homoaffectivity and LGBT movement.

One might think that such debates, such as sexism, racism and LGBT-phobia, occur at opportune moments in Public Health training, in dialogue with the social determinants of health. However, this possibility runs against the teacher’s decision to address what he thinks is most appropriate. The curricular explicitness could guarantee that these approaches will occur, thus avoiding the simplification and silencing of this debate. An example of this issue is the debate about whether or not to include gender in the National Common Curricular Base, which is resisted by conservative sectors of society³²32 Macedo E. As demandas conservadoras do movimento escola sem partido e a base nacional curricular comum. Educ Soc 2017; 38(139):507-524..

Although the subject-matter approach in elective subjects can be considered an achievement in overcoming gender and sexuality inequities, it is not possible to measure, by this analysis, the range of students who choose these subjects through the CPP. Thus, some students can graduate as sanitarists without improving their competencies related to the subject of gender and sexuality.

The offering of the course on a mandatory basis provides the total participation of the students of the course, ensuring that this knowledge is addressed during graduation. It should be noted that a sanitarist – as a health professional, with a formation that is intrinsically related to SUS principles and guidelines, with social determinants as one of the constituent elements for understanding the health-illness-care process and being someone who will interact with other people, seeking to promote health care – must understand these gaps to develop competencies (knowledge, skills and attitudes) that provide comprehensive and equitable health care, as proposed by Law Nº 8.080³³33 Brasil. Lei nº 8.080, de 19 de setembro de 1990. Dispõe sobre as condições para a promoção, proteção e recuperação da saúde, a organização e o funcionamento dos serviços correspondentes e dá outras providências. Diário Oficial da União 1990; 19 set..

We also identified that all Institutions approach gender more than sexuality issues, and when discussion on gender and sexuality occurs, it complements gender discussions. The lack of a sexuality approach shows that the sanitarists are likely to graduate without specific knowledge of these subjects, with a possible limitation to good professional practice that considers human diversity and potentiality. This would be in contradiction with the guidelines of the World Association for Sexual Health which, in the Declaration of Sexual Health for the Millennium, states that everyone has the right to an “enlightening sex education” that addresses this issue in articulation with sex, gender identity, sexual affective orientation, eroticism, pleasure, intimacy and reproduction³⁴34 World Association for Sexual Health. Sexual health for the millennium: a declaration and technical document. Minneapolis: World Association for Sexual Health; 2008.^,3535 World Association for Sexual Health. Declaration of sexual rights. Prague: World Associaciation for Sexual Health; 2014.. This is also reiterated by the World Health Organization in the Yogyakarta Principles³⁶36 The International Service for Human Rights. The International Commission of Jurists. The yogyakarta principles plus 10 - Additional principles and state obligations on the application of international human rights law in relation to sexual orientation, gender identity, gender expression and sex characteristics to complement the yogyakarta. Geneva: UN; 2017.^,3737 The International Commission of Jurists; The International Service for Human Rights. The yogyakarta principles - Principles on the application of international human rights law in relation to sexual orientation and gender identity. Yogyakarta: UN; 2007..

Also, we have to consider that some syllabuses tend to be succinct, without much information, sometimes containing only keywords about the contents that will be approached in a particular discipline. Also, certain CPPs do not provide the subjects’ menus, thus limiting our understanding, which are limitations of the study.

Since this research is documentary, we lack information about the live curriculum and other forms of pedagogical approaches used throughout the training, such as lectures, extension projects, mini-courses, etc. These strategies may enable such discussions but are not achieved in this analysis, due to the type of research.

In order to enhance this discussion, new works involving the analysis of the complete CPP files of all undergraduate courses in Public Health in Brazil, as well as the analysis of the living curriculum, present in the real daily life of the sanitarists’ training, are essential.

Conclusion

We note that there are still CPPs that can insert and expand the debate on gender and sexuality. Others make this discussion and syllabuses reveal that the debate can be improved. The absence of the gender and sexuality terms in the official documents about the formation in Public Health shows an essential fragility, leaving the formation at the mercy of the hidden or informal curriculum. The silencing of the subject in the CPP or its association with contexts that limit the comprehensive view of the subject is a significant result on the institutional discourse and its impacts on the formation and healthcare of the Brazilian population, especially regarding the social determinants of gender and sexuality, despite the achievements of the CNS and social movements, especially the feminist and LGBT movements.

What is perceived is that the graduation in Public Health is a very recent academic formation in Brazil, and for that reason, many courses are being structured. The curricular matrices are being revised and updated, as well as the pedagogical projects. Thus, it is essential that the DCN for undergraduate courses in Public Health in the country consider and explain this theme, since silencing reiterates the obstacles that the debate faces in different sectors of academic education.

The sensitization of teachers and students during graduation through these discussions will allow a greater understanding of the health demands related to gender and sexuality, improving access and health care. Bringing these debates to health training enables a new look at people, allowing them to reassess their needs¹⁰10 Villela W, Monteiro S, Vargas E. A incorporação de novos temas e saberes nos estudos em saúde coletiva: o caso do uso da categoria gênero. Cien Saude Colet 2009; 14(4):997-1006..

This work can contribute with the Institutions, showing how these discussions have been proposed in the graduation, especially for the courses that do not consider disciplines with these subjects. Thus, we hope to stimulate its improvement and longitudinal insertion throughout the formation, in the interface with other determinants that traverse health care of the comprehensive being.

Acknowledgments

We are grateful to Prof. Flávia do Bonsucesso Teixeira and Prof. Nilton Pereira Junior for the valuable contributions to this research, during his presentation before the Final Term Paper Examining Board.

We are also grateful to the course on Environmental Health/Public Health Management of the Geography Institute of the Federal University of Uberlândia for the realization of this work.

References

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