Abstract

Introduction

LGBTQI+ (lesbian, gay, bisexual, transgender, queer, intersexual) people identities that consider themselves in disagreement with the binary and biologic concept of gender identity and expression, as well as with the experience of sexuality¹1 Scott J. Experiência. In: Silva AL, Lago MCS, Ramos TRO, organizadores. Falas de gênero: teorias, análises, leituras. Florianópolis: Mulheres; 1999. p. 21-55.

2 Butler J. Problemas de gênero: feminismo e subversão da identidade. Rio de Janeiro: Civilização Brasileira; 2003.

3 Butler J. Regulações de gênero. Cad Pagu [Internet]. 2014 [citado 22 Set 2020]; (42):249-274. Disponível em: https://tinyurl.com/y5cuj6r5
https://tinyurl.com/y5cuj6r5... -⁴4 Foucault M. História da sexualidade: a vontade de saber. São Paulo: Paz e Terra; 2014. v. 1., being one component of minorities. Gender identity is understood as a person’s identification with a certain gender, and may or may not agree with the gender assigned at birth⁵5 Jesus JG. Orientações sobre identidade de gênero: conceitos e termos [Internet]. Brasília; 2012 [citado 21 Jan 2021]. e-book. Disponível em: https://www.sertao.ufg.br/n/42117-orientacoes-sobre-identidade-de-genero-conceitos-e-termos
https://www.sertao.ufg.br/n/42117-orient... ,⁶6 Bento B. A reinvenção do corpo: sexualidade e gênero na experiência transexual. Rio de Janeiro: Garamond; 2006.. Sexuality, in turn, constitutes a person’s internal desires and external attraction to someone, which is different from a personal sense of belonging to a certain gender⁵5 Jesus JG. Orientações sobre identidade de gênero: conceitos e termos [Internet]. Brasília; 2012 [citado 21 Jan 2021]. e-book. Disponível em: https://www.sertao.ufg.br/n/42117-orientacoes-sobre-identidade-de-genero-conceitos-e-termos
https://www.sertao.ufg.br/n/42117-orient... ,⁶6 Bento B. A reinvenção do corpo: sexualidade e gênero na experiência transexual. Rio de Janeiro: Garamond; 2006..

Sexual binarism and biologicism have their genesis, according to Foucault⁴4 Foucault M. História da sexualidade: a vontade de saber. São Paulo: Paz e Terra; 2014. v. 1., in the origins of the capitalist system, when sexuality becomes controlled, focusing on reproduction. All those identities that do not contribute to the efficiency of the system are marginalized and pathologized because of the “anatomical difference between the sexual organs”⁶6 Bento B. A reinvenção do corpo: sexualidade e gênero na experiência transexual. Rio de Janeiro: Garamond; 2006.(p. 20). Discriminatory processes emerging from that point on exclude and violate identities that do not comply with the biologicist norm, based on the anatomy of the bodies³3 Butler J. Regulações de gênero. Cad Pagu [Internet]. 2014 [citado 22 Set 2020]; (42):249-274. Disponível em: https://tinyurl.com/y5cuj6r5
https://tinyurl.com/y5cuj6r5... ,⁷7 Bourdieu P. A dominação masculina. 2a ed. Rio de Janeiro: BestBolso; 2014..

The health field within a global landscape, follows the daily innovations brought by contemporaneity, and presently is no longer focusing on solely treating diseases, but considers necessary the development of mechanisms for social welfare. These premises focus on finding a new way to “care”⁷7 Bourdieu P. A dominação masculina. 2a ed. Rio de Janeiro: BestBolso; 2014. and not to dichotomize the various levels of care needed in health work, which range from disease treatment to health promotion and population education in this area⁸8 Barreto A, Monica D, Zanetti J, Araújo L, Carrara S. Diversidades, diferenças e interculturalidade. In: Secretaria Especial De Política Para Mulheres, organizadores. Curso de especialização em gênero e sexualidade do CLAM. Brasília: Cepesc; 2010., not only in the technological sense, but also in the collective construction⁹9 Abrahão AL, Merhy EL. Formação em saúde e micropolítica: sobre conceitos-ferramentas na prática de ensinar. Interface (Botucatu). 2014; 18(49):313-324. Doi: 10.1590/1807-57622013.0166.
https://doi.org/10.1590/1807-57622013.01... based on comprehensiveness.

This research is relevant because it believes in the importance of identifying gaps, barriers and potentialities on this topic, posing reflections about the need for cultural and social changes around the problems faced by LGBTQI+ people, possibilities for the promotion of well-being and in the search for equity in health care from the perspective of the acquisition of competencies of health professionals related to the care of this population¹⁰10 Pierce J. Supporting the Health Care Needs of the LGBTQI Community. J Consum Health Internet. 2017; 21(3):297-304..

Given the need to identify the gaps and potentialities existing in the training process of health professionals in the care of LGBTQI+’s, this study aimed to present a systematic literature review in order to answer the question: What are the gaps and potentialities existing in the literature focused on the professional training process for the care of LGBTQI+ identities?

Method

Looking for evidence on this topic, we started a systematic review of the literature, following a protocol, under which the investigative focus is conducted, with the purpose of fulfilling the established objectives. We used Sampaio and Mancini’s¹¹11 Sampaio RF, Mancini MC. Estudos de revisão sistemática: um guia para síntese criteriosa da evidência científica. Rev Bras Fisioter. 2007; 11(1):83-89. Doi: 10.1590/S1413-35552007000100013.
https://doi.org/10.1590/S1413-3555200700... understanding that the process favors the broadening of the researcher’s view, perceiving gaps and other evidences.

For Willerding¹²12 Willerding IAV. Arquétipo para o Compartilhamento do Conhecimento à Luz da Estética Organizacional e da Gestão Empreendedora [tese]. Florianópolis: Universidade Federal de Santa Catarina; 2015., the systematic literature review is key in the search for evidence, information and gaps through databases, on the subject in question, with coherence and authenticity, in reference to the defined objectives. It allows an articulation of “knowledge from several sources in an attempt to trace paths towards what one wishes to know”¹³13 Gomes IS, Caminha IO. Guia para Estudos de Revisão Sistemática: uma opção metodológica para as ciências do movimento humano. Movimento (Porto Alegre). 2014; 20(1):395-411. (p. 396).

Sampaio and Mancini¹¹11 Sampaio RF, Mancini MC. Estudos de revisão sistemática: um guia para síntese criteriosa da evidência científica. Rev Bras Fisioter. 2007; 11(1):83-89. Doi: 10.1590/S1413-35552007000100013.
https://doi.org/10.1590/S1413-3555200700... suggest the use of a protocol to guide the entire research process, with the objective of finding publications that address the proposed theme. Thus, a protocol was created according to Frame 1.

The search for articles was conducted in three different databases: Scopus, Web of Science (WoS) and SciELO, considering their characteristics. The Scopus database was searched because it is considered the largest scientific database in the world, with more than 22,600 multidisciplinary titles. The Web of Science was chosen because it is also considered multidisciplinary, and SciELO, in turn, is a national database with extensions in several countries.

The search began with the translation of the terms “Training”, “Health professionals” and “LGBTQI+” into English, in order to facilitate the search in the databases. The inclusion of synonymous terms was also accepted:

• For “Training”: “Formation”, “Education”, “Development” or “Qualification”.

• For “Health Professionals”: “Health Providers”.

• For “LGBTQI+”: “LGBTQI+”, “LGBTQI”, “LGBTQ” or “LGBT”.

When these terms were cross-referenced, they yielded the following results, as shown in Frame 2.

The search in the Scopus database obtained 4,061 records, of which 3,987 were disregarded according to the exclusion criteria, resulting in 77 publications. In the Web of Science database, after the search, 2,592 records were obtained, of which, according to the exclusion criteria, 2,522 records were disregarded, resulting in 73 publications. In SciELO, after the search was carried out, 320 records were obtained, from which, according to the criteria, 274 records were disregarded, resulting in 46 publications.

Of the 196 publications selected, 65 were duplicates, resulting in 131 records that were read in their entirety, seeking to identify the state of the art regarding research on the training of health professionals to care for LGBTQI+. After reading, 19 records were selected - by analyzing the content and focus, for the elaboration of considerations on the state of the art of this topic using the narrative method. Of those 19 records, ten came from the Web of Science; six from SciELO; and three from Scopus.

Presentation and analysis of the studies’ contributions

The presentation of evidence, after performing the systematic literature review, is based on the analysis of the 19 selected records, obtained after applying the research protocol, and are listed in chronological order in Table 3.

Paulino, Rasera and Teixeira²⁸28 Paulino DB, Rasera EF, Teixeira FB. Discursos sobre o cuidado em saúde de lésbicas, gays, bissexuais, travestis, transexuais (LGBT) entre médicas(os) da estratégia saúde da família. Interface (Botucatu). 2019; 23(1):1-15. Doi: 10.1590/interface.180279.
https://doi.org/10.1590/interface.180279... identified the discourses regarding access and quality of comprehensive health care for the LGBT population among 15 doctors and physicians linked to the Family Health Strategy. For this purpose, the authors established three categories: a) “No difference discourse”, in an attempt to achieve supposed equality, minimizing differences; b) “Not knowing discourse”, when there is no knowledge about the demands of the LGBT population; and c) “Not wanting discourse”, when professionals believe there are no demands or specific health needs regarding this population. The results of these discourses “potentiate the silencing of issues involving the health conditions of the LGBT population, keeping them away from integral, equitable and universal health care”²⁸28 Paulino DB, Rasera EF, Teixeira FB. Discursos sobre o cuidado em saúde de lésbicas, gays, bissexuais, travestis, transexuais (LGBT) entre médicas(os) da estratégia saúde da família. Interface (Botucatu). 2019; 23(1):1-15. Doi: 10.1590/interface.180279.
https://doi.org/10.1590/interface.180279... (p. 12). It is necessary to rethink and change the way health professionals act toward the LGBT population, since cultural issues regulated by the heterosexual norm are still very latent in public networks.

Cardoso and Ferro¹⁷17 Cardoso MR, Ferro LF. Saúde e população LGBT: demandas e especificidades em questão. Psicol Cienc Prof. 2012; 32(3):552-563. Doi: 10.1590/s1414-98932012000300003.
https://doi.org/10.1590/s1414-9893201200... elaborated a study considering the specificities of LGBT people within health care processes. According to the authors, the Ministry of Health understands that gender and sexual identities are direct components of a discrimination process that can lead to the development of diseases, whether psychological or physical, and from which many situations of vulnerability derive. For the authors, “the discussion about the illness process of the LGBT population also requires the specification of the concepts of sexual identity and gender identity”¹⁷17 Cardoso MR, Ferro LF. Saúde e população LGBT: demandas e especificidades em questão. Psicol Cienc Prof. 2012; 32(3):552-563. Doi: 10.1590/s1414-98932012000300003.
https://doi.org/10.1590/s1414-9893201200... (p. 557), requiring that transformations occur in the health networks, regarding their heteronormative culture as well.

Daley and MacDonnell¹⁴14 Daley AE, Macdonnell JA. Gender, sexuality and the discursive representation of access and equity in health services literature: implications for LGBT communities. Int J Equity Health. 2011; 10(1):1-10., in turn, analyze an important component of health promotion: communication. The authors develop an understanding about the inclusion, or not, of LGBT identities in materials developed by public health institutions in Canada. Most of the materials analyzed use a multicultural discourse, which indicates that this understanding is what permeates the health services, as if diversity were a unique thing, which does not need to be analyzed through the optic of difference, in which equity can be expressed¹⁴14 Daley AE, Macdonnell JA. Gender, sexuality and the discursive representation of access and equity in health services literature: implications for LGBT communities. Int J Equity Health. 2011; 10(1):1-10.. For this reason it is urgent to review the materials developed by institutions - not only the institutions in the health area - based on the basic principle that communication is the first contact with users.

Durso and Meyer¹⁶16 Durso LE, Meyer IH. Patterns and predictors of disclosure of sexual orientation to healthcare providers among lesbians, gay men, and bisexuals. Sex Res Social Policy. 2012; 10(1):35-42. tried to identify the patterns and predictors of disclosure of the sexual orientation of LGB patients for health professionals. In this study, the authors identify that there is no disclosure of sexual orientation in situations related to psychological well-being. And they also indicate that interventionists and physicians should be aware of the differences between bisexual identities and gay/lesbian identities. They suggest that healthcare professionals should identify patients’ sexuality in order to guide interventions that address health disparities toward the LGB population, such as campaigns with public health messages and cultural competency trainings.

Regarding the need for health care professionals to have knowledge, skills, and cultural competency aimed at sexual and gender diversity, Mizock et al.²⁴24 Mizock L, Hopwood R, Casey H, Duhamell E, Herrick A, Puerto G, et al. The transgender awareness webinar: reducing transphobia among undergraduates and mental health providers. J Gay Lesbian Ment Health. 2017; 21(4):292-331. analyze the development, dissemination, and pre- and post-event evaluation of webinar effectiveness for raising awareness about transgender individuals in order to reduce Transphobia-stigma toward these individuals. According to the authors, transphobic attitudes reduced significantly after the completion of the webinar, and they suggest that awareness and training about transgenderism may be effective in reducing Transphobia, depending on demographic variables, contact, and prior education about transgender individuals.

Daley and MacDonnell²⁰20 Daley AE, Macdonnell JA. ‘That Would Have Been Beneficial’: LGBTQ education for home-care service providers. Health Soc Care Community. 2015; 23(3):282-291. bring up contributions to an area of healthcare characterized by a scarcity of studies and research: home care. In the study, the authors intersect the theme with the category of LGBTQ identities, in order to identify what level of training and information professionals working in home care for the elderly and/or dependents have about the specificities of the public that does not meet the sex and gender binary standards. The authors verified that trainings give about six hours of class time and that they approach the LGBTQ topic, pointing out concepts and terminologies through audiovisual material. In addition, most of the contents have biologic aspects related to diseases, without discussing other needs of the patient.

Pierce¹⁰10 Pierce J. Supporting the Health Care Needs of the LGBTQI Community. J Consum Health Internet. 2017; 21(3):297-304. reported that healthcare organizations have a history of institutionalization and discrimination against the various LGBTQIs identities due to lack of understanding, institutional policies, and ignorance. Given this context, the author says that health-focused care ends up marginalizing LGBTQI audiences because genuine communication about issues does not happen and needs are not fulfilled. He considers that agencies and institutions are working on educating health care professionals to improve health care outcomes for LGBTQI+ patients, and additionally, social change around the issues of LGBTQIs is happening rapidly in recent years. According to Pierce, there are available tools in order to minimize barriers related to healthcare and, by extension, to improve self-care for this population, as well as informational materials for LGBTQIs patients, their families, and the community.

Homosexuality and transsexuality once pertained among the diseases of the Diagnostic and Statistical Manual of Mental Disorders (DSM), being treated as “sociopathic personality disorder”, which, according to Fredriksen-Goldsen et al.¹⁹19 Fredriksen-Goldsen KI, Simoni JM, Kim H, Lehavot K, Walters KL, Yang J, et al. The health equity promotion model: reconceptualization of lesbian, gay, bisexual, and transgender (LGBT) health disparities. Am J Orthopsychiatry. 2014; 84(6):653-663., would also be a major generator of stigma and prejudice against the LGBT community. The authors propose a Health Equity Promotion Model, structured specifically for the care of LGBT identities. The model is based on the intersectionality of the social context - which considers the categories of analysis: black, elderly, indigenous, LGBTs, among others³²32 Piscitelli A. Interseccionalidades, categorias de articulação e experiências de migrantes brasileiras. Soc Cult. 2008; 11(2):263-274.. Using this model, three pillars are observed: a) structural and individual context; b) behavioral context; and c) physical and mental health. The authors emphasize that it is necessary to analyze public policies, considering the fact that they are important instruments for the promotion of equity.

Ruiz López, García Gómez and García García²¹21 Ruiz López APR, García Gómez LC, García García EG. Entre la regulación y la emancipación: el caso de las políticas de atención en salud para mujeres trans (Bogotá D.C., 2008-2013). Aletheia. 2015; 7(1):52-69. Doi: 10.11600/21450366.7.1aletheia.52.69.
https://doi.org/10.11600/21450366.7.1ale... conducted a case study about public health policies for trans women in the city of Bogotá/Colombia. Since 2008, the city has been receiving changes in the public health structure, largely motivated by the implementation of a municipal legislation. The process of transgenerization attracts special attention because it is, among the context of sexual and gender diversity, the one that is still pathologized. Because of this fact, people who consider themselves to be of a gender different from their biological sex are already categorized as sick as soon as they arrive at the health services²¹21 Ruiz López APR, García Gómez LC, García García EG. Entre la regulación y la emancipación: el caso de las políticas de atención en salud para mujeres trans (Bogotá D.C., 2008-2013). Aletheia. 2015; 7(1):52-69. Doi: 10.11600/21450366.7.1aletheia.52.69.
https://doi.org/10.11600/21450366.7.1ale... . The authors defend the need for “a broad debate in society oriented toward cultural transformation, which accentuates the visibility of these demands in the public arena and that may reopen space for an urgent dialogue between the natural and social sciences, the public and the private”²¹21 Ruiz López APR, García Gómez LC, García García EG. Entre la regulación y la emancipación: el caso de las políticas de atención en salud para mujeres trans (Bogotá D.C., 2008-2013). Aletheia. 2015; 7(1):52-69. Doi: 10.11600/21450366.7.1aletheia.52.69.
https://doi.org/10.11600/21450366.7.1ale... (p. 67).

In a study about the implementation of the National Policy for Lesbian, Gay, Bisexual, Transvestite and Transgender Integral Health in Paraná, Silva et al.³¹31 Silva ACA, Alcântara AM, Oliveira DC, Signorelli MC. Implementação da política nacional de saúde integral de lésbicas, gays, bissexuais travestis e transexuais (PNSI LGBT) no Paraná, Brasil. Interface (Botucatu). 2020; 24:1-15. Doi: 10.1590/interface.190568.
https://doi.org/10.1590/interface.190568... analyze the process of implementation and execution of this public policy through four main axes: access of the LGBT population to comprehensive health care; health promotion and surveillance actions; permanent education and popular health education; and monitoring and evaluation of health actions. According to the authors, the policy recognizes that the effects of discriminatory processes and the reproduction of violence impact directly on the health of the LGBT population, and through this policy they prioritize overcoming them. The Ministry of Health recognizes booth the free exercise of sexual orientation and gender identity as direct agents towards health promotion³¹31 Silva ACA, Alcântara AM, Oliveira DC, Signorelli MC. Implementação da política nacional de saúde integral de lésbicas, gays, bissexuais travestis e transexuais (PNSI LGBT) no Paraná, Brasil. Interface (Botucatu). 2020; 24:1-15. Doi: 10.1590/interface.190568.
https://doi.org/10.1590/interface.190568... .

The first major barrier, as pointed out by the study, is the inexistence of health curricula that address this topic and its consequences in an effective and direct manner. According to the authors, the report of the I National Seminar on LGBT Health informed that deficits in training and education of health professionals regarding awareness practices and specific clarifications about this population are primary causes of the development of stigmas and prejudices. They go against the cornerstones of the Brazilian National Health System (SUS), which recommend the development and promotion by its management agencies, of actions focused on health education, based on humanization and equity³¹31 Silva ACA, Alcântara AM, Oliveira DC, Signorelli MC. Implementação da política nacional de saúde integral de lésbicas, gays, bissexuais travestis e transexuais (PNSI LGBT) no Paraná, Brasil. Interface (Botucatu). 2020; 24:1-15. Doi: 10.1590/interface.190568.
https://doi.org/10.1590/interface.190568... .

Focusing on the access of LGBTQ people to primary health care, Gahagan and Subirana-Malaret²⁶26 Gahagan J, Subirana-Malaret M. Improving pathways to primary health care among LGBTQ populations and health care providers: key findings from Nova Scotia, Canada. Int J Equity Health. 2018; 17(76):1-9. set out to explore the barriers encountered by this population in accessing primary network services. Health service users and professionals were selected, both those who considered themselves LGBTQ identities and those who did not, allowing for the analysis through different perspectives. The authors identify that, in continuing education programs for physicians, there is no approach aimed at the care of LGBTQs and alert to the biologicist standard of care for these identities, disregarding their emotional aspects. There is a stigma posing that this population seeks health services to treat aspects related to sexually transmitted diseases or to gender transition processes and sexual resignification²⁶26 Gahagan J, Subirana-Malaret M. Improving pathways to primary health care among LGBTQ populations and health care providers: key findings from Nova Scotia, Canada. Int J Equity Health. 2018; 17(76):1-9..

Wilson et al.¹⁸18 Wilson CK, West L, Stepleman L, Villarosa M, Ange B, Decker M, et al. Attitudes toward LGBT patients among students in the health professions: influence of demographics and discipline. LGBT Health. 2014; 1(3):204-211. explore the relationship between professionals, demographics, training characteristics, and attitudes of health care students toward LGBT patients. This study highlights the need for programmatic interventions focused on providing care to LGBT patients. It also highlights the urgent inclusion of institutional initiatives in curriculum assessments specific to LGBT audiences, and to focus efforts on the needs of LGBT patients related to the level of knowledge, skills, and cultural competency required of professionals-all elements addressing sexual and gender diversity.

Obedin-Maliver et al.¹⁵15 Obedin-Maliver J, Goldsmith ES, Stewart L, White W, Tran E, Brenman S, et al. Lesbian, gay, bisexual, and transgender-related content in undergraduate medical education. JAMA. 2011; 306(9):971-977. analyze healthcare curricula, looking for disparities and specific care for LGBT audiences. According to the authors, educating students to provide comprehensive care for the LGBT patient is still somewhat unknown. The authors suggest, as strategies for success of this topic in teaching-learning, the need for increased content and the inclusion of curriculum material focused on the LGBT audience, related to health care disparities of these various sexual and gender identities.

Braun et al.²³23 Braun HM, Ramirez D, Zahner GJ, Gillis-Buck EM, Sheriff H, Ferrone M. The LGBTQI Health Forum: an innovative interprofessional initiative to support curriculum reform. Med Educ Online. 2017; 22(1):1-8. reported the experience of the implementation of a special forum, linked to the University of California, directed to the dissemination of studies, research and other knowledge tools about LGBTQIs identities in the training process of health academics, considering that the official curricula do not address this topic. The authors emphasize that, during the ten years of the forum, observing the teaching processes and their modification during this period, it became evident that, despite efficiently instrumentalizing the education of the students, this forum may not have the same value as curricular subjects, considering that the scientific knowledge about the themes is still limited.

Regarding the need to include the LGBTQI theme in the training curriculum of health professionals, Sanchez et al.²²22 Sanchez AA, Southgate E, Rogers G, Duvivier RJ. Inclusion of lesbian, gay, bisexual, transgender, queer, and intersex health in Australian and New Zealand medical education. LGBT Health. 2017; 4(4):295-303. conducted an online study to establish the inclusion of these subjects in the medical curricula of Australia and New Zealand. As a result, the researchers highlighted that most schools reported dedicating around five hours to LGBTQI content during the pre-clinical phase, interspersing them throughout the curriculum, but still related to limited content on LGBTQI health, focusing on sexuality.

The need for changes in the performance of healthcare professionals was also a concern for DeVita, Bishop, and Plankey²⁷27 Devita T, Bishop C, Plankey M. Queering medical education: systematically assessing LGBTQI health competency and implementing reform. Med Educ Online. 2018; 23(1):1-8., understanding that LGBTQIs people face health issues and that US medical schools have been inconsistent in training for the care of these people. Following a curriculum audit between 2015 and 2016 at 170 medical schools with 4,262 students, several problems related to physical, behavioral, and sexuality health were highlighted. The authors describe the need for curriculum reforms and insertion of contents regarding LGBTQIs, as some medical students are not prepared to meet the needs of these patients, in order to minimize the health disparities faced by these communities.

Due to the fact that some health professionals are not prepared to care for patients whose identities are LGBT, Negreiros et al.²⁹29 Negreiros FRN, Ferreira BO, Freitas DN, Pedrosa JIS, Nascimento EF. Saúde de lésbicas, gays, bissexuais, travestis e transexuais: da formação médica à atuação profissional. Rev Bras Educ Med. 2019; 43(1):22-31. Doi: 10.1590/1981-52712015v43n1rb20180075.
https://doi.org/10.1590/1981-52712015v43... analyzed medical training for health care of the LGBT population, having as research subjects 14 doctors linked to Basic Health Units (BHU). They show that the doctors had no training or course on LGBT health, and did not attend lectures, symposiums and seminars on the subject. The authors state that they perceive the challenge and “the urgency in the dissemination and implementation of the National LGBT Health Policy as an effective tool to promote human rights among medical professionals from graduation to professional practice”²⁹29 Negreiros FRN, Ferreira BO, Freitas DN, Pedrosa JIS, Nascimento EF. Saúde de lésbicas, gays, bissexuais, travestis e transexuais: da formação médica à atuação profissional. Rev Bras Educ Med. 2019; 43(1):22-31. Doi: 10.1590/1981-52712015v43n1rb20180075.
https://doi.org/10.1590/1981-52712015v43... (p. 23), as well as the need to insert content that considers LGBT health in medical school curricular guidelines in an interdisciplinary manner, facilitating the understanding, resolution and use of interventions in the care provided to this specific public.

Bidell²⁵25 Bidell MP. The lesbian, gay, bisexual, and transgender development of clinical skills scale (LGBT-DOCSS): establishing a new interdisciplinary self-assessment for health providers. J Homosex. 2017; 64(10):1432-1460. emphasizes the need for both mental health care and medical care tailored to the LGBT public. However, the author states that there are no qualified health professionals trained to care for them, due to lack of knowledge about the problems faced by this public and because these patients are considered a minority. The author, in his research, applies the Clinical Skills Development Scale Tool for Gay, Bisexual, and Transgender (LGBT-DOCSS) in order to use a reliable and valid self-assessment regarding clinical skills, attitudinal awareness, and basic knowledge within a disciplinary and multinational context about LGBTs.

Dullius, Martins, and Cesnik³⁰30 Dullius WR, Martins LB, Cesnik VM. Systematic review on health care professionals’ competencies in the care of LGBT+ individuals. Estud Psicol (Campinas). 2019; 36:1-14. Doi: 10.1590/1982-0275201936e180171.
https://doi.org/10.1590/1982-0275201936e... conducted a review of the international literature in order to identify the needs in training healthcare professionals for the care of LGBT+ identities. Among the 17 selected articles, there is a predominance of North American publications, demonstrating the need for the development of similar studies in other countries. The basic social structure is based on the normalization of sex and gender as biological, not understanding subjectivity and preventing the expression of identities that do not follow this matrix. Therefore, it is evident that this matrix also operates in health services, a field in which education about gender and sexuality follows concepts linked to psychiatry and, consequently, to illness.

Final considerations

LGBTQI+ identities experience discrimination and violence daily, mainly symbolic⁵5 Jesus JG. Orientações sobre identidade de gênero: conceitos e termos [Internet]. Brasília; 2012 [citado 21 Jan 2021]. e-book. Disponível em: https://www.sertao.ufg.br/n/42117-orientacoes-sobre-identidade-de-genero-conceitos-e-termos
https://www.sertao.ufg.br/n/42117-orient... , through the propagation of social stigmas. Firstly, it is necessary to emphasize that the development of studies such as the present gives voice to these minorities through representativeness, discussing the topic in a scientific environment and therefore reorienting the praxis.

The authors under study point out the normalization of sex as a social structure, obeying a biologicist standard - when it comes to the relationship between sexuality and sexual organ - binary. Because of this phenomenon, the authors are unanimous about the need to promote a space for reflection and deconstruction about the heteronormative precepts. We also conclude that the scientific literature lacks more precise information about LGBTQI+, as well as all the intersectionalities existing in the constitution of these identities, such as generation, race, ethnicity, among others, besides the specificities within the group itself.

The analyses point to the need of developing permanent training and capacitation, involving even those professionals who consider themselves LGBTQI+, and that these trainings may go forward based on humanization, distancing themselves from the biologicist logic that reproduces even more stigmas - when identities converge with diseases such as HIV, which also causes damages to mental health. Another point that can be highlighted is the absence of content related to LGBTQI+ health in training curricula for professionals.

It is recommended for future studies to evaluate and report regarding training practices in the context of health education, in order to enable the sharing of knowledge around the methodologies of trainings aimed at serving the LGBTQI+ public. This study also suggests that the biases, intersectionalities and specificities existing in the context of this population should be analyzed, in order that comprehensiveness of care may become a reality allowing the full experience of health by all humans.

Acknowledgements

To all LGBTQIA+ people for their strength, for their struggle, for their incessant quest to make the world a more diverse, plural, and healthy place.

References

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History