Abstract

Introduction

The World Health Organization (WHO) expresses human sexuality as an interaction of different aspects - which can include “sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy and reproduction”¹1 Organização Mundial da Saúde. Saúde sexual, direitos humanos e a lei. UFPR, IFRS, UFRGS, tradutores. Porto Alegre: UFRGS; 2020. (p. 25) - which is present at all stages of a human being’s life. Far beyond biological elements, it also includes “psychological, social, economic, political, cultural, legal, historical, religious and spiritual” constructs¹1 Organização Mundial da Saúde. Saúde sexual, direitos humanos e a lei. UFPR, IFRS, UFRGS, tradutores. Porto Alegre: UFRGS; 2020. (p. 25).

Owing to the principles that nurses are responsible for holistic care²2 Aaberg V. The state of sexuality education in baccalaureate nursing programs. Nurse Educ Today. 2016; 44:14-9. doi: 10.1016/j.nedt.2016.05.009.
https://doi.org/10.1016/j.nedt.2016.05.0...

3 Hickerson K, Hawkins LA, Hoyt-Brennan AM. Sexual orientation/gender identity cultural competence: a simulation pilot study. Clin Simul Nurs. 2018; 16:2-5. doi: 10.1016/j.ecns.2017.10.011.
https://doi.org/10.1016/j.ecns.2017.10.0...

4 Bosse JD, Nesteby JA, Randall CE. Integrating sexual minority health issues into a health assessment class. J Prof Nurs. 2015; 31(6):498-507. doi: 10.1016/j.profnurs.2015.04.007.
https://doi.org/10.1016/j.profnurs.2015.... ^-55 Burton CW, Nolasco K, Holmes D. Queering nursing curricula: understanding and increasing attention to LGBTQIA+ health needs. J Prof Nurs. 2021; 37(1):101-7. doi: 10.1016/j.profnurs.2020.07.003.
https://doi.org/10.1016/j.profnurs.2020.... and that sexuality is present at all stages of human life, it can be inferred that it permeates health care. This perspective can be found in the recommendations of the WHO, which since the 1970s has emphasized the importance of nursing educators including the theme of sexuality in undergraduate curricula, especially with regard to issues of knowledge, skills, attitudes and values⁶6 World Health Organization. Education and treatment in human sexuality: the training of health professionals, report of a WHO meeting [‎held in Geneva from 6 to 12 February 1974]. Genebra: WHO; 1975. (Technical Report Series,‎ n. 572).. This vision is also included in the Sustainable Development Goals of the 2030 Global Health Agenda⁷7 Organização das Nações Unidas. Transformando nosso mundo: a agenda 2030 para o desenvolvimento sustentável. Genebra: ONU; 2016. , which covers issues related to gender and sexual health, which underscores the need for the subject to be addressed in nursing courses.

However, despite all these indications, there are gaps in the training of these professionals in sexuality care, which can lead to the omission of care, delays in treatment, difficulty in the population’s access to health services and discriminatory behavior²2 Aaberg V. The state of sexuality education in baccalaureate nursing programs. Nurse Educ Today. 2016; 44:14-9. doi: 10.1016/j.nedt.2016.05.009.
https://doi.org/10.1016/j.nedt.2016.05.0... ^,88 Cappiello J, Coplon L, Carpenter H. Systematic review of sexual and reproductive health care content in nursing curricula. J Obstet Gynecol Neonatal Nurs. 2017; 46(5):e157-67. doi: 10.1016/j.jogn.2017.04.132.
https://doi.org/10.1016/j.jogn.2017.04.1... . Although the importance of nurses’ role in promoting sexual health has been recognized for a long time, the lack of an adequate approach to this issue in nursing curricula may reflect a historical, conservative and traditionalist omission in relation to understanding sexuality, which contributes to perpetuating the training of nurses who are unprepared to provide comprehensive care to individuals, with consequences for public health²2 Aaberg V. The state of sexuality education in baccalaureate nursing programs. Nurse Educ Today. 2016; 44:14-9. doi: 10.1016/j.nedt.2016.05.009.
https://doi.org/10.1016/j.nedt.2016.05.0... .

Against this backdrop, this study aims to identify the evidence available in the literature regarding the way in which human sexuality appears in undergraduate nursing curricula. By means of a systematic literature review (SLR), the aim is to answer the following question: what evidence is available in the literature regarding the way in which human sexuality features in undergraduate nursing curricula?

Method

In order to visualize the landscape concerning the proposed objective, we opted for the systematic literature review method because we felt that this was the best way to conduct our research. According to Sampaio and Mancini⁹9 Sampaio RF, Mancini MC. Estudos de revisão sistemática: um guia para síntese criteriosa da evidência científica. Brazilian J Phys Ther. 2007; 11(1):83-9. doi: 10.1590/S1413-35552007000100013.
https://doi.org/10.1590/S1413-3555200700... , the SLR, by bringing together works that have theoretical and empirical approaches, culminates in an expanded perspective that allows researchers to perceive gaps, congruences or, in some cases, discrepancies, favoring the refinement of the field of research and generating results that increasingly contribute to guiding praxis. In this way, the research is defined as qualitative, in terms of its approach, and is characterized as descriptive and exploratory.

In order for the review process to take place properly, a research protocol needs to be drawn up, which will make it possible to cadence the data that will return during its execution¹⁰10 Gomes IS, Caminha IO. Guia para estudos de revisão sistemática: uma opção metodológica para as ciências do movimento humano. Movimento. 2013; 20(1):395. doi: 10.22456/1982-8918.41542.
https://doi.org/10.22456/1982-8918.41542... . Therefore, a research protocol adapted from Paranhos, Willerding and Lapolli¹¹11 Paranhos W, Willerding I, Lapolli É. Formação dos profissionais de saúde para o atendimento de LGBTQI+. Interface (Botucatu). 2021; 25:e200684. doi: 10.1590/interface.200684.
https://doi.org/10.1590/interface.200684... was organized, which is shown in Frame 1.

It was decided to carry out the search in four different databases: Scopus, Web of Science (WoS), Latin American and Caribbean Health Sciences Literature (LILACS) and PubMed, taking into account their specific characteristics. The Scopus^(e(e)Available at: https://www.elsevier.com/pt-br/solutions/scopus (Accessed: 4 Apr. 2023).⁾ database is considered to be the world’s largest scientific repository and is multidisciplinary. Web of Science^(f(f)Available at: https://clarivate.com/products/scientific-and-academic-research/research-discovery-and-workflow-solutions/webofscience-platform/ (Accessed: 4 Apr. 2023).⁾ also has this characteristic linked to interdisciplinarity, providing comprehensive data that is collected from various academic disciplines and fields of knowledge. LILACS^(g(g)Available at: https://lilacs.bvsalud.org/ (Accessed: 4 Apr. 2023).⁾, on the other hand, is a scientific repository in Latin America and the Caribbean in the area of health. Provided by the US National Library of Medicine, PubMed^(h(h)Available at: https://pubmed.ncbi.nlm.nih.gov/ (Accessed: 4 Apr. 2023).⁾ is a free searchable database with access to citations and abstracts of scientific research articles in health.

The time frame was defined due to the amount of research, which only in 2013 reached a number equal to or greater than one publication in each of the repositories chosen, as can be seen in Figure 1. From 1971 to 2012, at least one of the four databases did not identify any type of published article, but in the last five years there has been a significant increase in publications on the subject in all of them, showing the growing interest in the subject.

The main terms chosen for the search process were: “graduation”, “nursing”, “curriculum” and “sexuality”, which underwent idiomatic translation. In addition, with the help of a librarian, we tried to vary the terms and adapt them according to the database being researched, with a view to expanding the data.

Frame 2 below shows the search strategies and the results found in each database.

Following this information, the Scopus database obtained 181 records; the Web of Science database, 166 records; LILACS, ten records; and PubMed, 78 studies. The articles were included in the Rayyan^® software, which helped conduct the systematic review.

Of the 435 publications selected, 135 were duplicates, resulting in 300 records that had their titles, abstracts and keywords read in order to understand their relationship with the scope of the research, totaling 72 articles that were read in their entirety, seeking to identify the evidence available in the literature in relation to how human sexuality appears in undergraduate nursing curricula. It is important to note that this study focused on generalist nursing training, and articles from specialties - such as obstetric nursing, family nursing, advanced nursing and others - were excluded from the sample. Finally, 37 records were chosen, 17 from Scopus, nine from Web of Science, five from LILACS and six from PubMed.

To construct the analysis, we opted for the content analysis method, which according to Willerding¹²12 Willerding IAV. Arquétipo para o compartilhamento do conhecimento à luz da estética organizacional e da gestão empreendedora [tese]. Florianópolis (SC): Universidade Federal de Santa Catarina; 2015. enables a global reading of the data, allowing for an effective comparative analysis. In the end, the similar data was brought together and five categories of content were constructed, based on the research by Paranhos and Costa¹³13 Paranhos WR, Costa CMI. “Curto uma pegação no sigilo”: o Grindr como território de subjetivações dos espaços de desejo. Periódicus. 2023; 1(18):176-9. doi: 10.9771/peri.v1i18.49899.
https://doi.org/10.9771/peri.v1i18.49899... , namely: forms of approach; content related to the topic; collective construction of the curriculum; cis-heteronormative culture and its reflexes; and proposals for intervention.

Presentation and analysis of the studies’ contributions

After applying the research protocol, it became possible to analyze the data based on the 37 articles presented in Frame 3, arranged in alphabetical order by author.

The following are the content categories created during the data analysis process, which bring together the main evidence found based on the studies from the RSL.

Ways to approach

WHO guidelines establish the need for sexuality to be covered in nursing training⁴⁰40 Saus-Ortega C, Ballestar-Tarín ML, Chover-Sierra E, Martínez-Sabater A. Contents of the sexual and reproductive health subject in the undergraduate nursing curricula of Spanish universities: a cross-sectional study. Int J Environ Res Public Health. 2021; 18(21):11472. doi: 10.3390/ijerph182111472.
https://doi.org/10.3390/ijerph182111472... . In this way, we realized that the studies that came back from our review process focus primarily on three approaches: transversal, extracurricular/optional/elective and one-off.

The transversal approach is one that has an interdisciplinary perspective¹⁵15 Aguiar FAR, Silva RM, Bezerra IC, Vieira LJES, Cavalcanti LF, Ferreira Jr AR. Vocational training and sexual assault against women: challenges for graduation in nursing. Esc Anna Nery. 2020; 24(1):e20190135. doi: 10.1590/2177-9465-EAN-2019-0135.
https://doi.org/10.1590/2177-9465-EAN-20... ^,2020 Clever K, Richter C, Meyer G. Current approaches to the integration of sex- and gender-specific medicine in teaching: a qualitative expert survey. GMS J Med Educ. 2020; 37(2):Doc26. doi: 10.3205/zma001319.
https://doi.org/10.3205/zma001319... ^,2222 Souza FTP, Silva CF, Moreira FTLS, Callou RCM, Belém JM, Albuquerque GA. Interface between women’s health and violence in the training of nurses in Brazil. Invest Educ Enferm. 2021; 39(1):e06. doi: 10.17533/udea.iee.v39n1e06.
https://doi.org/10.17533/udea.iee.v39n1e... ^,2626 Magalhães BC, Silva CF, Silva Filho JA, Pinto AGA, Maia ER, Lopes MSV, et al. How is violence themed in nursing education? Curricular components in Northeastern Brazil. J Interpers Violence. 2022; 37(17-18):NP16859-84. doi: 10.1177/08862605211025845.
https://doi.org/10.1177/0886260521102584... , made up of themes that cut across the most different areas of knowledge, which contributes to the formation of a professional who is contextualized in terms of reality, with qualified scientific and technical knowledge¹⁵15 Aguiar FAR, Silva RM, Bezerra IC, Vieira LJES, Cavalcanti LF, Ferreira Jr AR. Vocational training and sexual assault against women: challenges for graduation in nursing. Esc Anna Nery. 2020; 24(1):e20190135. doi: 10.1590/2177-9465-EAN-2019-0135.
https://doi.org/10.1590/2177-9465-EAN-20... ^,2626 Magalhães BC, Silva CF, Silva Filho JA, Pinto AGA, Maia ER, Lopes MSV, et al. How is violence themed in nursing education? Curricular components in Northeastern Brazil. J Interpers Violence. 2022; 37(17-18):NP16859-84. doi: 10.1177/08862605211025845.
https://doi.org/10.1177/0886260521102584... . This approach poses a risk insofar as stating that sexuality is a cross-cutting theme in the curriculum can encourage other people to take responsibility, i.e. teachers and subjects expect the theme to appear at other times in the course and, as a result, end up not addressing it³⁷37 Petry S, Padilha MI. Approaching sexually transmitted infections in a nursing undergraduate curriculum. Rev Esc Enferm USP. 2021; 55:e20210019. doi: 10.1590/1980-220X-REEUSP-2021-0019.
https://doi.org/10.1590/1980-220X-REEUSP... .

The reflection about a curriculum that considers sexuality in an extracurricular way can have numerous results, both positive and negative. When they appear as elective or optional¹⁸18 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):1306419. doi: 10.1080/10872981.2017.1306419.^,2020 Clever K, Richter C, Meyer G. Current approaches to the integration of sex- and gender-specific medicine in teaching: a qualitative expert survey. GMS J Med Educ. 2020; 37(2):Doc26. doi: 10.3205/zma001319.
https://doi.org/10.3205/zma001319... ^,2121 Cornelius JB, Enweana I, Alston CK, Baldwin DM. Examination of lesbian, gay, bisexual, and transgender health care content in North Carolina schools of nursing. J Nurs Educ. 2017; 56(4):223-6. doi: 10.3928/01484834-20170323-06.
https://doi.org/10.3928/01484834-2017032... ^,2424 Lim FA, Brown Jr DV, Jones H. Lesbian, gay, bisexual, and transgender health: fundamentals for nursing education. J Nurs Educ. 2013; 52(4):198-203. doi: 10.3928/01484834-20130311-02.
https://doi.org/10.3928/01484834-2013031... , research or extension projects⁸8 Cappiello J, Coplon L, Carpenter H. Systematic review of sexual and reproductive health care content in nursing curricula. J Obstet Gynecol Neonatal Nurs. 2017; 46(5):e157-67. doi: 10.1016/j.jogn.2017.04.132.
https://doi.org/10.1016/j.jogn.2017.04.1... ^,1515 Aguiar FAR, Silva RM, Bezerra IC, Vieira LJES, Cavalcanti LF, Ferreira Jr AR. Vocational training and sexual assault against women: challenges for graduation in nursing. Esc Anna Nery. 2020; 24(1):e20190135. doi: 10.1590/2177-9465-EAN-2019-0135.
https://doi.org/10.1590/2177-9465-EAN-20... , subjects and/or extracurricular activities on sexuality end up limiting the participation of some students, as they attract mostly those who identify with the topic²⁰20 Clever K, Richter C, Meyer G. Current approaches to the integration of sex- and gender-specific medicine in teaching: a qualitative expert survey. GMS J Med Educ. 2020; 37(2):Doc26. doi: 10.3205/zma001319.
https://doi.org/10.3205/zma001319... ^,3434 Nietsche EA, Tassinari TT, Ramos TK, Beltrame G, Salbego C, Cassenote LG. Formação do enfermeiro para o cuidado à população homossexual e bissexual: percepção do discente. Rev Baiana Enferm. 2018; 32:e25174.^,3535 Paiva EMC, Ramos SCS, Martins NS, Nascimento MC, Calheiros AP, Calheiros CAP. Sexualidade e infecções sexualmente transmissíveis: análise da formação de alunos da área da saúde. Rev Pesq Cuid Fundam. 2021; 13:809-14. doi: 10.9789/2175-5361.rpcfo.v13.9190.
https://doi.org/10.9789/2175-5361.rpcfo.... . On the other hand, possibilities are opening up for greater dialog with other areas¹⁵15 Aguiar FAR, Silva RM, Bezerra IC, Vieira LJES, Cavalcanti LF, Ferreira Jr AR. Vocational training and sexual assault against women: challenges for graduation in nursing. Esc Anna Nery. 2020; 24(1):e20190135. doi: 10.1590/2177-9465-EAN-2019-0135.
https://doi.org/10.1590/2177-9465-EAN-20... besides health, providing increasingly broad instruments for students to acquire varied knowledge around those that are not part of the curriculum¹⁸18 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):1306419. doi: 10.1080/10872981.2017.1306419.^,3434 Nietsche EA, Tassinari TT, Ramos TK, Beltrame G, Salbego C, Cassenote LG. Formação do enfermeiro para o cuidado à população homossexual e bissexual: percepção do discente. Rev Baiana Enferm. 2018; 32:e25174..

Finally, there is the one-off approach to the subject of sexuality, which becomes peripheral even when it is included in subjects considered traditional in the field of Nursing, such as Health Assessment, Ethics, Women’s Health, Diversity in Health, Fundamentals of Nursing, Medical-Surgical Nursing, Pharmacology, Anatomy and Physiology, Adult Health, Child and Adolescent Health, Sexual and Reproductive Health, Mental Health and Public Health³3 Hickerson K, Hawkins LA, Hoyt-Brennan AM. Sexual orientation/gender identity cultural competence: a simulation pilot study. Clin Simul Nurs. 2018; 16:2-5. doi: 10.1016/j.ecns.2017.10.011.
https://doi.org/10.1016/j.ecns.2017.10.0... ^,88 Cappiello J, Coplon L, Carpenter H. Systematic review of sexual and reproductive health care content in nursing curricula. J Obstet Gynecol Neonatal Nurs. 2017; 46(5):e157-67. doi: 10.1016/j.jogn.2017.04.132.
https://doi.org/10.1016/j.jogn.2017.04.1... ^,2121 Cornelius JB, Enweana I, Alston CK, Baldwin DM. Examination of lesbian, gay, bisexual, and transgender health care content in North Carolina schools of nursing. J Nurs Educ. 2017; 56(4):223-6. doi: 10.3928/01484834-20170323-06.
https://doi.org/10.3928/01484834-2017032... ^,2323 Kim M, Shin M. Development and evaluation of simulation-problem-based learning for sex education. Comput Inform Nurs. 2016; 34(1):17-25. doi: 10.1097/CIN.0000000000000200.
https://doi.org/10.1097/CIN.000000000000... ^,2828 Maruca AT, Diaz DA, Stockmann C, Gonzalez L. Using simulation with nursing students to promote affirmative practice toward the lesbian, gay, bisexual, and transgender population: a multisite study. Nurs Educ Perspect. 2018; 39(4):225-9. doi: 10.1097/01.NEP.0000000000000302.
https://doi.org/10.1097/01.NEP.000000000... ^,3030 McDowell A, Bower KM. Transgender health care for nurses: an innovative approach to diversifying nursing curricula to address health inequities. J Nurs Educ. 2016; 55(8):476-9. doi: 10.3928/01484834-20160715-11.
https://doi.org/10.3928/01484834-2016071... ^,3131 McEwing E. Delivering culturally competent care to the lesbian, gay, bisexual, and transgender (LGBT) population: education for nursing students. Nurse Educ Today. 2020; 94:104573. doi: 10.1016/j.nedt.2020.104573.
https://doi.org/10.1016/j.nedt.2020.1045... . In this approach, in some institutions, discussions on the subject are no more than superficial reflections³⁴34 Nietsche EA, Tassinari TT, Ramos TK, Beltrame G, Salbego C, Cassenote LG. Formação do enfermeiro para o cuidado à população homossexual e bissexual: percepção do discente. Rev Baiana Enferm. 2018; 32:e25174. in the face of such a complex and important issue for nurses’ training, pointing to a possible weakness¹⁵15 Aguiar FAR, Silva RM, Bezerra IC, Vieira LJES, Cavalcanti LF, Ferreira Jr AR. Vocational training and sexual assault against women: challenges for graduation in nursing. Esc Anna Nery. 2020; 24(1):e20190135. doi: 10.1590/2177-9465-EAN-2019-0135.
https://doi.org/10.1590/2177-9465-EAN-20... ^,2020 Clever K, Richter C, Meyer G. Current approaches to the integration of sex- and gender-specific medicine in teaching: a qualitative expert survey. GMS J Med Educ. 2020; 37(2):Doc26. doi: 10.3205/zma001319.
https://doi.org/10.3205/zma001319... ^,2222 Souza FTP, Silva CF, Moreira FTLS, Callou RCM, Belém JM, Albuquerque GA. Interface between women’s health and violence in the training of nurses in Brazil. Invest Educ Enferm. 2021; 39(1):e06. doi: 10.17533/udea.iee.v39n1e06.
https://doi.org/10.17533/udea.iee.v39n1e... ^,2626 Magalhães BC, Silva CF, Silva Filho JA, Pinto AGA, Maia ER, Lopes MSV, et al. How is violence themed in nursing education? Curricular components in Northeastern Brazil. J Interpers Violence. 2022; 37(17-18):NP16859-84. doi: 10.1177/08862605211025845.
https://doi.org/10.1177/0886260521102584... . The motivations for this occurrence are varied, with the prominence of “moral behaviors [...] that end up influencing teaching and the approach to the student-teacher relationship”³⁴34 Nietsche EA, Tassinari TT, Ramos TK, Beltrame G, Salbego C, Cassenote LG. Formação do enfermeiro para o cuidado à população homossexual e bissexual: percepção do discente. Rev Baiana Enferm. 2018; 32:e25174. (p. 4), an aspect that leads to the next content category.

Cis-heteronormative culture and its reflexes

The reflection about a curriculum that perceives, on a global level, the cis-heteronormative social context and that discusses unconscious biases is a way of uncovering the hidden curriculum³³33 Morris M, Cooper RL, Ramesh A, Tabatabai M, Arcury TA, Shinn M, et al. Training to reduce LGBTQ-related bias among medical, nursing, and dental students and providers: a systematic review. BMC Med Educ. 2019; 19(1):325. doi: 10.1186/s12909-019-1727-3.
https://doi.org/10.1186/s12909-019-1727-... . The curriculum, as a living instance, directly interferes in everyday academic life, either through what is expressed or what is not expressed, creating gaps for biases to become established³⁹39 Rosser BRS, Mkoka DA, Rohloff CT, Mgopa LR, Ross MW, Lukumay GG, et al. Tailoring a sexual health curriculum to the sexual health challenges seen by midwifery, nursing and medical providers and students in Tanzania. Afr J Prim Health Care Fam Med. 2022; 14(1):e1-e9. doi: 10.4102/phcfm.v14i1.3434.
https://doi.org/10.4102/phcfm.v14i1.3434... . If there are such spaces, moral judgments become part of the academic environment³⁷37 Petry S, Padilha MI. Approaching sexually transmitted infections in a nursing undergraduate curriculum. Rev Esc Enferm USP. 2021; 55:e20210019. doi: 10.1590/1980-220X-REEUSP-2021-0019.
https://doi.org/10.1590/1980-220X-REEUSP... , given the existence of teaching autonomy which, at the same time as being a positive aspect, can also be negative.

Although there is a consensus that the absence of sexuality in the nursing curriculum can lead to problems for public health, it is the attitudinal and unconscious barriers that culminate in its exclusion from the curriculum guidelines, sometimes expressed in the form of justifications such as lack of time, lack of priority, lack of qualified teachers, lack of comfort in tackling the subject and the discourse that sexuality is too specific to be part of the nursing curriculum³3 Hickerson K, Hawkins LA, Hoyt-Brennan AM. Sexual orientation/gender identity cultural competence: a simulation pilot study. Clin Simul Nurs. 2018; 16:2-5. doi: 10.1016/j.ecns.2017.10.011.
https://doi.org/10.1016/j.ecns.2017.10.0... ^,88 Cappiello J, Coplon L, Carpenter H. Systematic review of sexual and reproductive health care content in nursing curricula. J Obstet Gynecol Neonatal Nurs. 2017; 46(5):e157-67. doi: 10.1016/j.jogn.2017.04.132.
https://doi.org/10.1016/j.jogn.2017.04.1... ^,1515 Aguiar FAR, Silva RM, Bezerra IC, Vieira LJES, Cavalcanti LF, Ferreira Jr AR. Vocational training and sexual assault against women: challenges for graduation in nursing. Esc Anna Nery. 2020; 24(1):e20190135. doi: 10.1590/2177-9465-EAN-2019-0135.
https://doi.org/10.1590/2177-9465-EAN-20... ^,2727 Maley B, Gross R. A writing assignment to address gaps in the nursing curriculum regarding health issues of LGBT+ populations. Nurs Forum. 2019; 54(2):198-204. doi: 10.1111/nuf.12315.
https://doi.org/10.1111/nuf.12315... .

This culture is also related to the pedagogy of the closet, in which all the people who make up the educational context end up, for fear of reprisals, hiding their conceptions of sexuality, affecting the potential that exists in intergroup contact³³33 Morris M, Cooper RL, Ramesh A, Tabatabai M, Arcury TA, Shinn M, et al. Training to reduce LGBTQ-related bias among medical, nursing, and dental students and providers: a systematic review. BMC Med Educ. 2019; 19(1):325. doi: 10.1186/s12909-019-1727-3.
https://doi.org/10.1186/s12909-019-1727-... . Furthermore, it should be noted that there are teachers who speak in favor of including sexuality in the curriculum, but who adopt completely adverse attitudes in practice¹⁶16 Aslan F, Şahin NE, Emiroğlu ON. Turkish nurse educators knowledge regarding LGBT health and their level of homophobia: a descriptive-cross sectional study. Nurse Educ Today. 2019; 76:216-21. doi: 10.1016/j.nedt.2019.02.014.
https://doi.org/10.1016/j.nedt.2019.02.0... . In addition, because they are aware that the subject is taboo, many teachers justify not dealing with sexuality in their classes because they are afraid of reactive movements on the part of students and management⁸8 Cappiello J, Coplon L, Carpenter H. Systematic review of sexual and reproductive health care content in nursing curricula. J Obstet Gynecol Neonatal Nurs. 2017; 46(5):e157-67. doi: 10.1016/j.jogn.2017.04.132.
https://doi.org/10.1016/j.jogn.2017.04.1... ^,3636 Petry S, Padilha MI, Bellaguarda MLR, Vieira AN, Neves VR. The said and the unsaid in the teaching of sexually transmitted infections. Acta Paul Enferm. 2021; 34: eAPE001855. doi: 10.37689/acta-ape/2021AO001855.
https://doi.org/10.37689/acta-ape/2021AO... .

Within this scope, possible solutions include teacher training on the subject of sexuality³⁴34 Nietsche EA, Tassinari TT, Ramos TK, Beltrame G, Salbego C, Cassenote LG. Formação do enfermeiro para o cuidado à população homossexual e bissexual: percepção do discente. Rev Baiana Enferm. 2018; 32:e25174., enabling the inclusion of this subject as a curricular component⁴⁵45 Yang HC. What should be taught and what is taught: integrating gender into medical and health professions education for medical and nursing students. Int J Environ Res Public Health. 2020; 17(18):6555. doi: 10.3390/ijerph17186555.
https://doi.org/10.3390/ijerph17186555... , and the development of work focused on the autonomy and uniqueness of the student³⁴34 Nietsche EA, Tassinari TT, Ramos TK, Beltrame G, Salbego C, Cassenote LG. Formação do enfermeiro para o cuidado à população homossexual e bissexual: percepção do discente. Rev Baiana Enferm. 2018; 32:e25174., which can be achieved through didactic practices and resources such as: simulation³3 Hickerson K, Hawkins LA, Hoyt-Brennan AM. Sexual orientation/gender identity cultural competence: a simulation pilot study. Clin Simul Nurs. 2018; 16:2-5. doi: 10.1016/j.ecns.2017.10.011.
https://doi.org/10.1016/j.ecns.2017.10.0... ^,1919 Burkey DF, Fetty A, Watson-Huffer K. Infusing LGBTQ cultural competency into nursing curriculum. Nurse Educ Today. 2021; 96:104642. doi: 10.1016/j.nedt.2020.104642.
https://doi.org/10.1016/j.nedt.2020.1046... ^,3333 Morris M, Cooper RL, Ramesh A, Tabatabai M, Arcury TA, Shinn M, et al. Training to reduce LGBTQ-related bias among medical, nursing, and dental students and providers: a systematic review. BMC Med Educ. 2019; 19(1):325. doi: 10.1186/s12909-019-1727-3.
https://doi.org/10.1186/s12909-019-1727-... , problem-based learning²⁰20 Clever K, Richter C, Meyer G. Current approaches to the integration of sex- and gender-specific medicine in teaching: a qualitative expert survey. GMS J Med Educ. 2020; 37(2):Doc26. doi: 10.3205/zma001319.
https://doi.org/10.3205/zma001319... ^,2323 Kim M, Shin M. Development and evaluation of simulation-problem-based learning for sex education. Comput Inform Nurs. 2016; 34(1):17-25. doi: 10.1097/CIN.0000000000000200.
https://doi.org/10.1097/CIN.000000000000... , discussion forums¹⁸18 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):1306419. doi: 10.1080/10872981.2017.1306419., case studies¹⁹19 Burkey DF, Fetty A, Watson-Huffer K. Infusing LGBTQ cultural competency into nursing curriculum. Nurse Educ Today. 2021; 96:104642. doi: 10.1016/j.nedt.2020.104642.
https://doi.org/10.1016/j.nedt.2020.1046... ^,2424 Lim FA, Brown Jr DV, Jones H. Lesbian, gay, bisexual, and transgender health: fundamentals for nursing education. J Nurs Educ. 2013; 52(4):198-203. doi: 10.3928/01484834-20130311-02.
https://doi.org/10.3928/01484834-2013031... ^,2727 Maley B, Gross R. A writing assignment to address gaps in the nursing curriculum regarding health issues of LGBT+ populations. Nurs Forum. 2019; 54(2):198-204. doi: 10.1111/nuf.12315.
https://doi.org/10.1111/nuf.12315... , discussions on cultural competence and/or humility that include skills training and language suitable for the LGBTIAP+ and queer⁽ⁱ(i)For the construction of this text, we decided to use the acronym LGBTIAP+ and queer, in reference to lesbian, gay, bisexual, transsexual, transvestite, transgender, intersex, asexual, pansexual and queer people - as a social and political position/recognition -, as indicated by Manzoni de Almeida and Paranhos46.⁾population³3 Hickerson K, Hawkins LA, Hoyt-Brennan AM. Sexual orientation/gender identity cultural competence: a simulation pilot study. Clin Simul Nurs. 2018; 16:2-5. doi: 10.1016/j.ecns.2017.10.011.
https://doi.org/10.1016/j.ecns.2017.10.0... ^,55 Burton CW, Nolasco K, Holmes D. Queering nursing curricula: understanding and increasing attention to LGBTQIA+ health needs. J Prof Nurs. 2021; 37(1):101-7. doi: 10.1016/j.profnurs.2020.07.003.
https://doi.org/10.1016/j.profnurs.2020.... ^,1717 Bell LM, Brennan-Cook J, Sisson J, Steigerwald M, Cook C, Cicero EC, et al. Learning about culturally humble care of sexual and gender minority patients. Teach Learn Nurs. 2019; 14(3):216-8. doi: 10.1016/j.teln.2019.04.006.
https://doi.org/10.1016/j.teln.2019.04.0... ^,1919 Burkey DF, Fetty A, Watson-Huffer K. Infusing LGBTQ cultural competency into nursing curriculum. Nurse Educ Today. 2021; 96:104642. doi: 10.1016/j.nedt.2020.104642.
https://doi.org/10.1016/j.nedt.2020.1046... ^,2828 Maruca AT, Diaz DA, Stockmann C, Gonzalez L. Using simulation with nursing students to promote affirmative practice toward the lesbian, gay, bisexual, and transgender population: a multisite study. Nurs Educ Perspect. 2018; 39(4):225-9. doi: 10.1097/01.NEP.0000000000000302.
https://doi.org/10.1097/01.NEP.000000000... ^,3131 McEwing E. Delivering culturally competent care to the lesbian, gay, bisexual, and transgender (LGBT) population: education for nursing students. Nurse Educ Today. 2020; 94:104573. doi: 10.1016/j.nedt.2020.104573.
https://doi.org/10.1016/j.nedt.2020.1045... , extracurricular strategies aimed at raising awareness and reducing biases³²32 McNiel PL, Elertson KM. Advocacy and awareness: integrating LGBTQ health education into the prelicensure curriculum. J Nurs Educ. 2018; 57(5):312-4. doi: 10.3928/01484834-20180420-12.
https://doi.org/10.3928/01484834-2018042... and reflection “on the interdisciplinarity and multidisciplinarity of a curriculum that meets all the health needs of the population”³⁶36 Petry S, Padilha MI, Bellaguarda MLR, Vieira AN, Neves VR. The said and the unsaid in the teaching of sexually transmitted infections. Acta Paul Enferm. 2021; 34: eAPE001855. doi: 10.37689/acta-ape/2021AO001855.
https://doi.org/10.37689/acta-ape/2021AO... (p. 8).

Even if some teachers are uncomfortable with the approach, it is possible to embrace emotion and use it as a means of learning. As with any other subject, teachers are not expected to have complete knowledge, but they should be able to teach the main concepts, be creative in their teaching strategies, be available and flexible to learn from their students and know at least what resources are viable for questions they are unable to answer⁴4 Bosse JD, Nesteby JA, Randall CE. Integrating sexual minority health issues into a health assessment class. J Prof Nurs. 2015; 31(6):498-507. doi: 10.1016/j.profnurs.2015.04.007.
https://doi.org/10.1016/j.profnurs.2015.... .

Content related to the topic

Content is an extremely important curricular component in the technical training of future nurses, as it provides guidance for discussions on a wide variety of topics. The studies from this RSL offer numerous indications of what could be defined as content in undergraduate nursing courses, as well as in other health courses. These contents are shown in Frame 4.

Bearing this in mind, curricula should be built in a way that is closer to the academic community’s experience, enabling singularities to be perceived and establishing respect for differences. In addition, a dialogue must be created with specialists so that they can contribute their different levels of knowledge on the subject⁴³43 Tsai LY, Huang CY, Liao WC, Tseng TH, Lai TJ. Assessing student nurses’ learning needs for addressing patients’ sexual health concerns in Taiwan. Nurse Educ Today. 2013; 33(2):152-9. doi: 10.1016/j.nedt.2012.05.014.^,4444 Tsai LY, Huang CY, Shih FF, Li CR, Lai TJ. Undergraduate nursing education to address patients’ concerns about sexual health: the perceived learning needs of senior traditional four-year and two-year recurrent education (RN-BSN) undergraduate nursing students in Taiwan. Nagoya J Med Sci. 2014; 76(3-4):273-84. .

Collective construction of the curriculum

Building a curriculum is a process that involves overcoming a lack of interest²⁰20 Clever K, Richter C, Meyer G. Current approaches to the integration of sex- and gender-specific medicine in teaching: a qualitative expert survey. GMS J Med Educ. 2020; 37(2):Doc26. doi: 10.3205/zma001319.
https://doi.org/10.3205/zma001319... , in which collective work indicates the possibility of unique powers that are achieved through an exercise that includes the different players in the school context, as well as contact with other fields of knowledge. Thus, thinking about a nursing curriculum that addresses the issue of sexuality in its complexity and understands it as a health need is a difficult task that can be better carried out collectively.

This is a need that even comes from the students themselves²⁹29 McCann E, Brown M. The needs of LGBTI+ people within student nurse education programmes: a new conceptualisation. Nurse Educ Pract. 2020; 47:102828. doi: 10.1016/j.nepr.2020.102828.
https://doi.org/10.1016/j.nepr.2020.1028... ^,3535 Paiva EMC, Ramos SCS, Martins NS, Nascimento MC, Calheiros AP, Calheiros CAP. Sexualidade e infecções sexualmente transmissíveis: análise da formação de alunos da área da saúde. Rev Pesq Cuid Fundam. 2021; 13:809-14. doi: 10.9789/2175-5361.rpcfo.v13.9190.
https://doi.org/10.9789/2175-5361.rpcfo.... , opening up space for the emergence of a leader to motivate the whole team, which could be the students, as well as an LGBTIAP+ and queer member of the teaching staff with experience outside teaching. Attention should be paid to the fact that centralizing responsibility in a single teacher can discourage others from being co-responsible for building a curriculum that understands and works with differences⁴4 Bosse JD, Nesteby JA, Randall CE. Integrating sexual minority health issues into a health assessment class. J Prof Nurs. 2015; 31(6):498-507. doi: 10.1016/j.profnurs.2015.04.007.
https://doi.org/10.1016/j.profnurs.2015.... ^,3636 Petry S, Padilha MI, Bellaguarda MLR, Vieira AN, Neves VR. The said and the unsaid in the teaching of sexually transmitted infections. Acta Paul Enferm. 2021; 34: eAPE001855. doi: 10.37689/acta-ape/2021AO001855.
https://doi.org/10.37689/acta-ape/2021AO... ^,3737 Petry S, Padilha MI. Approaching sexually transmitted infections in a nursing undergraduate curriculum. Rev Esc Enferm USP. 2021; 55:e20210019. doi: 10.1590/1980-220X-REEUSP-2021-0019.
https://doi.org/10.1590/1980-220X-REEUSP... .

As well as being a space that protects plurality, collective construction enables the creation of bonds that protect students, teachers and the institution, reinforces its sustainability and reduces the biases between the formal and hidden curriculum³⁸38 Pratt-Chapman ML. Implementation of sexual and gender minority health curricula in health care professional schools: a qualitative study. BMC Med Educ. 2020; 20(1):138. doi: 10.1186/s12909-020-02045-0.
https://doi.org/10.1186/s12909-020-02045... . It is worth highlighting the fact that joint construction, which involves interaction between different academic-scientific contexts, makes it possible for topics such as sexuality to form part of a common curriculum, which will have a positive impact on the training and professional performance of future nurses³⁹39 Rosser BRS, Mkoka DA, Rohloff CT, Mgopa LR, Ross MW, Lukumay GG, et al. Tailoring a sexual health curriculum to the sexual health challenges seen by midwifery, nursing and medical providers and students in Tanzania. Afr J Prim Health Care Fam Med. 2022; 14(1):e1-e9. doi: 10.4102/phcfm.v14i1.3434.
https://doi.org/10.4102/phcfm.v14i1.3434... .

Intervention proposals

Thinking about interventions, in their most varied formats, means creating bridges between the curriculum and the changes taking place in society, which is a “challenge for traditional higher education in educational institutions with fixed curricula”³⁴34 Nietsche EA, Tassinari TT, Ramos TK, Beltrame G, Salbego C, Cassenote LG. Formação do enfermeiro para o cuidado à população homossexual e bissexual: percepção do discente. Rev Baiana Enferm. 2018; 32:e25174. (p. 7). In these linking processes, the macro and micro come together, as well as the external and internal contexts of the institutions, and political-organizational effects cannot be disregarded, whether through the federation, states or municipalities, which also make up the socio-political conjuncture³⁸38 Pratt-Chapman ML. Implementation of sexual and gender minority health curricula in health care professional schools: a qualitative study. BMC Med Educ. 2020; 20(1):138. doi: 10.1186/s12909-020-02045-0.
https://doi.org/10.1186/s12909-020-02045... .

Building a dialogue between faculty, students and external experiences, with the participation of specialists, patients and organizations such as LGBTIAP+ and queer organizations - through panels, lectures, seminars and conversation circles - can act as a great catalyst, transforming the educational environment based on knowledge and practical experiences³3 Hickerson K, Hawkins LA, Hoyt-Brennan AM. Sexual orientation/gender identity cultural competence: a simulation pilot study. Clin Simul Nurs. 2018; 16:2-5. doi: 10.1016/j.ecns.2017.10.011.
https://doi.org/10.1016/j.ecns.2017.10.0... ^,1919 Burkey DF, Fetty A, Watson-Huffer K. Infusing LGBTQ cultural competency into nursing curriculum. Nurse Educ Today. 2021; 96:104642. doi: 10.1016/j.nedt.2020.104642.
https://doi.org/10.1016/j.nedt.2020.1046... ^,3838 Pratt-Chapman ML. Implementation of sexual and gender minority health curricula in health care professional schools: a qualitative study. BMC Med Educ. 2020; 20(1):138. doi: 10.1186/s12909-020-02045-0.
https://doi.org/10.1186/s12909-020-02045... ^,4545 Yang HC. What should be taught and what is taught: integrating gender into medical and health professions education for medical and nursing students. Int J Environ Res Public Health. 2020; 17(18):6555. doi: 10.3390/ijerph17186555.
https://doi.org/10.3390/ijerph17186555... .

Institutional support in dissolving the so-called hidden curriculum is also extremely important, as it is based on an action to reconfigure the academic culture. This exercise involves the continuous development of strategic planning, in which the related variables can be observed and controlled together. Financial resources are also needed to develop specific projects related to sexuality, such as research in the area²⁰20 Clever K, Richter C, Meyer G. Current approaches to the integration of sex- and gender-specific medicine in teaching: a qualitative expert survey. GMS J Med Educ. 2020; 37(2):Doc26. doi: 10.3205/zma001319.
https://doi.org/10.3205/zma001319... ^,3838 Pratt-Chapman ML. Implementation of sexual and gender minority health curricula in health care professional schools: a qualitative study. BMC Med Educ. 2020; 20(1):138. doi: 10.1186/s12909-020-02045-0.
https://doi.org/10.1186/s12909-020-02045... .

Curriculum revision appears to be the most prominent indication in the findings of this study, in order to evaluate the mandatory and necessary content for the training of undergraduate students⁸8 Cappiello J, Coplon L, Carpenter H. Systematic review of sexual and reproductive health care content in nursing curricula. J Obstet Gynecol Neonatal Nurs. 2017; 46(5):e157-67. doi: 10.1016/j.jogn.2017.04.132.
https://doi.org/10.1016/j.jogn.2017.04.1... ^,2424 Lim FA, Brown Jr DV, Jones H. Lesbian, gay, bisexual, and transgender health: fundamentals for nursing education. J Nurs Educ. 2013; 52(4):198-203. doi: 10.3928/01484834-20130311-02.
https://doi.org/10.3928/01484834-2013031... ^,3535 Paiva EMC, Ramos SCS, Martins NS, Nascimento MC, Calheiros AP, Calheiros CAP. Sexualidade e infecções sexualmente transmissíveis: análise da formação de alunos da área da saúde. Rev Pesq Cuid Fundam. 2021; 13:809-14. doi: 10.9789/2175-5361.rpcfo.v13.9190.
https://doi.org/10.9789/2175-5361.rpcfo.... ^,3737 Petry S, Padilha MI. Approaching sexually transmitted infections in a nursing undergraduate curriculum. Rev Esc Enferm USP. 2021; 55:e20210019. doi: 10.1590/1980-220X-REEUSP-2021-0019.
https://doi.org/10.1590/1980-220X-REEUSP... ^,3838 Pratt-Chapman ML. Implementation of sexual and gender minority health curricula in health care professional schools: a qualitative study. BMC Med Educ. 2020; 20(1):138. doi: 10.1186/s12909-020-02045-0.
https://doi.org/10.1186/s12909-020-02045... ^,4040 Saus-Ortega C, Ballestar-Tarín ML, Chover-Sierra E, Martínez-Sabater A. Contents of the sexual and reproductive health subject in the undergraduate nursing curricula of Spanish universities: a cross-sectional study. Int J Environ Res Public Health. 2021; 18(21):11472. doi: 10.3390/ijerph182111472.
https://doi.org/10.3390/ijerph182111472... ^,4545 Yang HC. What should be taught and what is taught: integrating gender into medical and health professions education for medical and nursing students. Int J Environ Res Public Health. 2020; 17(18):6555. doi: 10.3390/ijerph17186555.
https://doi.org/10.3390/ijerph17186555... , creating an inclusive and welcoming curriculum, a movement that must be continuous and renewed periodically, as the dynamics of classes and academic semesters change, making it necessary for educational teams to be constantly trained in sexuality and its consequences¹⁸18 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):1306419. doi: 10.1080/10872981.2017.1306419.^,2020 Clever K, Richter C, Meyer G. Current approaches to the integration of sex- and gender-specific medicine in teaching: a qualitative expert survey. GMS J Med Educ. 2020; 37(2):Doc26. doi: 10.3205/zma001319.
https://doi.org/10.3205/zma001319... ^,4040 Saus-Ortega C, Ballestar-Tarín ML, Chover-Sierra E, Martínez-Sabater A. Contents of the sexual and reproductive health subject in the undergraduate nursing curricula of Spanish universities: a cross-sectional study. Int J Environ Res Public Health. 2021; 18(21):11472. doi: 10.3390/ijerph182111472.
https://doi.org/10.3390/ijerph182111472... .

Final considerations

Despite being a structural aspect of human life and, for this reason, being recommended for inclusion in undergraduate nursing curricula, sexuality is still a topic surrounded by taboos, which have a direct impact on the way it is approached in the academic context. The aim of this study was to show ways in which the subject can be effectively included in the training of nurses.

The one-off approach to the subject of sexuality was most evident, pointing to a difficulty in thinking about it in an interdisciplinary way due to unconscious biases, even though its presence is guaranteed by the curricula. The contents, in turn, indicate the multiple possibilities for including the subject in the curriculum. The collective construction of the curriculum would be an alternative to this issue, since it allows teachers, students and managers to participate in the process of preparation and constant revision, committing themselves to the theme.

It is essential that the nursing course environment is a space to address topics related to social stigma, sexual health, prejudice, structural violence, health disparities and minority stress, since neglecting to include the theme of sexuality in the curriculum has repercussions on the professional performance of nurses in global health care; even if professionals show positive attitudes, unprepared nurses end up omitting issues related to sexuality and, due to their lack of knowledge, instead of acting as facilitators, they adopt discriminatory attitudes, leading to iatrogenic behavior in healthcare environments.

References

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History