ABSTRACT

This study analyzes oral health care for the LGBTQIA+ population in view of the lack of information on oral health in this population and the recent changes in the National Oral Health Policy (PNSB), that have weakened progress and enabled setbacks in this area. A descriptive cross-sectional study was carried out, using a semi-structured questionnaire that was self-applied online. A total of 359 people answered, 329 (91.9%) were eligible. Of these, 38% gays, 23.4% lesbians, and 13.4% transgenders. Most were between 18 and 39 years old (73.3%) and Black (51.4%). The percentage of people receiving care was high in the five years prior to the survey (92.9%), as well as in the last six months (44.7%); it was lower in the transgender population (88.7% and 18.2% respectively). Only 18.8% of this population had been treated in the public health system, and this was higher among transgender people (45.5%) and Black people (25.4%). The self-perception of oral health for the majority was good or very good (53.2%); but bad or very bad (45.5%) for transgender. Most reported preferring to be assisted by an LGBT professional (69.0%). The transgender and Black population were the most vulnerable to assistance, indicating that race, gender, and sexuality directly influence access to health care, so an intersectional approach is essential for the organization of the service.

KEYWORDS
Human rights; Sexual and gender minorities; Oral health; Intersectional framework

Introduction

Historically, healthcare and access to medicine practiced during the colonial period in Brazil were exclusive to the bourgeoisie and the clergy. Marginalized and enslaved people, faced with the need to survive and resist the inhuman and precarious conditions to which they were subjected, relied on health care through the hands of healers, midwives, bleeders and barbers¹1 Pimenta TS. Entre sangradores e doutores: práticas e formação médica na primeira metade do século XIX. Cad. Cedes. 2003; 23-59..

While barbers shaved, many also bled, applied suction cups and performed minor surgeries, including tooth extractions. This was an activity of low social prestige, usually practiced by marginalized people, for example, enslaved or freed Black people²2 Pereira W. Uma História da Odontologia no Brasil. Perspec. 2012; (47):147-173..

In the twentieth century, dentistry underwent various advancements, initially adopting a hygienist healthcare model, with iatrogenic and mutilating dental practices centered on disease. This sparked discussions about the need to align a new dental practice model with the proposals of the Health Reform movement³3 Foratori Junior GA. Brasil Sorridente – reconhecendo a história para reforçar a constante luta pela equidade em Odontologia. Res., Soc. Dev. 2021; 10(10):e75101018745..

The process of consolidating the Unified Health System (SUS) and its doctrinal and organizational principles – such as universality, equity, integrality, decentralization, regionalization, hierarchization, and social participation⁴4 Brasil. Ministério da Saúde. Diretrizes da política nacional de saúde bucal. Brasília, DF: Ministério da Saúde; 2004. – demanded a reorganization and restructuring of oral health actions and services⁵5 Brasil. Ministério da Saúde, Secretaria de Atenção à Saúde, Departamento de Atenção Básica. Saúde Bucal. Brasília, DF: Ministério da Saúde; 2008. (Série A. Normas e Manuais Técnicos) (Cadernos de Atenção Básica; 17).. This process made it possible to break away from obsolete practices and unresolvable techniques that did not meet society’s needs.

In 2004, the Ministry of Health published the guidelines for the National Oral Health Policy (PNSB), Brasil Sorridente (Smiling Brazil), aiming to organize oral health care in the SUS⁴4 Brasil. Ministério da Saúde. Diretrizes da política nacional de saúde bucal. Brasília, DF: Ministério da Saúde; 2004.. This process enabled the breakaway from obsolete practices and techniques that were inadequately solving society’s needs.

The National Policy for the Integral Health of Lesbians, Gays, Bisexuals, Transvestites and Transsexuals was instituted in 2011 with the aim of promoting comprehensive health for this population⁶6 Brasil. Ministério da Saúde. Portaria nº 2.836, de 1º de dezembro de 2011. Institui, no âmbito do Sistema Único de Saúde (SUS), a Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais, Travestis e Transexuais (Política Nacional de Saúde Integral LGBT). Diário Oficial da União. 2 Dez 2011.,⁷7 Brasil. Ministério da Saúde, Secretaria de Gestão Estratégica e Participativa, Departamento de Apoio à Gestão Participativa. Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais, Travestis e Transexuais. Brasília DF: Ministério da Saúde, 2013.. It also seeks to eliminate discrimination and institutional prejudice, as well as contributing to the reduction of inequalities and consolidating SUS as a universal, comprehensive and equitable system, although access to public health services for the LGBTQIA+ population is guaranteed in the Federal Constitution⁸8 Brasil. Constituição, 1988. Constituição da República Federativa do Brasil. Brasília, DF: Senado Federal; 1988. and reiterated with the principle of universality of SUS⁹9 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. 20 Set 1990.. The acronym LGBTQIA+ is the most widely used today, and is an abbreviation for Lesbian, Gay, Bisexual, Transsexual, Transvestite, Transgender, Queer, Intersexual or Intersex, Asexual and other possible existences. Like people, LGBT terminology is evolving with a view of inclusion, though different acronyms can be used depending on the context or the position of those using them.

We live in a society with a cis-heteronormative and binary standard – feminine and masculine – where men and women are defined according to their sexual organs. However, this construction is not biological; it is social¹⁰10 Jesus JG. Orientações sobre a população transgênero: conceitos e termos. Brasília, DF: Autor, 2012. 24 p.. Therefore, it is essential to use inclusive concepts and terms: “Writing or speaking according to a vocabulary recognized by the people represented is essential for valuing citizenship”¹⁰10 Jesus JG. Orientações sobre a população transgênero: conceitos e termos. Brasília, DF: Autor, 2012. 24 p., ¹¹11 Conselho Nacional de Saúde. I Conferência Nacional de Saúde Bucal: Relatório Final. Brasília, DF: 10 out 1986., ¹²12 Conselho Nacional de Secretários de Saúde. A Atenção Primária e as Redes de Atenção à Saúde. Brasília, DF: Conass, 2015., ¹³13 Brasil. Ministério da Saúde, Secretária de Atenção Primária à Saúde, Departamento de Saúde da Família, Coordenação Geral de Saúde Bucal. SB Brasil 2020 – Pesquisa Nacional de Saúde Bucal – Projeto Técnico. Brasília, DF: Ministério da Saúde; 2021..

The importance of accessing and guaranteeing oral health in Brazil has been thought about and built up for over 30 years, since the first National Oral Health Conference (CNSB) in 1986¹¹11 Conselho Nacional de Saúde. I Conferência Nacional de Saúde Bucal: Relatório Final. Brasília, DF: 10 out 1986., after the Nacional Health Conference.

In this context, the PNSB focuses on universal care, but in a generalized way, with organization into lines of care: life cycles, and age groups⁴4 Brasil. Ministério da Saúde. Diretrizes da política nacional de saúde bucal. Brasília, DF: Ministério da Saúde; 2004.. In addition, the publications that build the Oral Health Care Network (RASB) do not make it explicit that there is a cross-cutting approach – a principle of the National Humanization Policy¹²12 Conselho Nacional de Secretários de Saúde. A Atenção Primária e as Redes de Atenção à Saúde. Brasília, DF: Conass, 2015. – with policies and programs for specific populations.

The National Oral Health Survey (2021/2022) aims to assess the oral health epidemiological profile of the Brazilian population, but makes it impossible to identify LGBTQIA+ people, as it does not include gender identity and sexual orientation¹³13 Brasil. Ministério da Saúde, Secretária de Atenção Primária à Saúde, Departamento de Saúde da Família, Coordenação Geral de Saúde Bucal. SB Brasil 2020 – Pesquisa Nacional de Saúde Bucal – Projeto Técnico. Brasília, DF: Ministério da Saúde; 2021..

In this context, the PNSB focuses on universal care, but in a generalized way, with the organization along lines of care: life cycles and age group⁴4 Brasil. Ministério da Saúde. Diretrizes da política nacional de saúde bucal. Brasília, DF: Ministério da Saúde; 2004.. Furthermore, the transversality – principle of the National Humanization Policy¹²12 Conselho Nacional de Secretários de Saúde. A Atenção Primária e as Redes de Atenção à Saúde. Brasília, DF: Conass, 2015. – with policies and programs for specific populations is not explicit in the publications that build the Oral Health Care Network (RASB).

The National Oral Health Survey (2021/2022) aims to evaluate the epidemiological profile in oral health of the Brazilian population, but makes it impossible to identify LGBTQIA+ people, as it does not include gender identity and sexual orientation¹³13 Brasil. Ministério da Saúde, Secretária de Atenção Primária à Saúde, Departamento de Saúde da Família, Coordenação Geral de Saúde Bucal. SB Brasil 2020 – Pesquisa Nacional de Saúde Bucal – Projeto Técnico. Brasília, DF: Ministério da Saúde; 2021.

However, changes in the national political scene have jeopardized the achievements of years of struggle. Progressive losses with the dismantling of SUS, neoliberalism and fascism strengthened through fake news, and other tricks have put democracy and the achieved rights at risk. The dismantling of the SUS through de-funding makes it unfeasible to implement public policies, particularly for the most vulnerable populations, such as the LGBTQIA+ population¹⁴14 Stevanim LF. Previne Brasil: mudança sem debate. Radis. 2019; (207):19-22..

The study sought to identify the difficulties highlighted by LGBTQIA+ people regarding access to the public oral health service, as well as to give visibility to the singularities of these users in order to qualify the RASB. Therefore, the objective of the study was to analyze oral health care for the LGBTQIA+ population from the user’s perspective. It was also inspired by the lack of information about the oral health of the LGBTQIA+ population and the dismantling of the PNSB.

Methodology

This was a descriptive cross-sectional observational epidemiological study to find out about the use of oral health care and the difficulties faced by the LGBTQIA+ population. In a cross-sectional study, the unit of analysis was the individual from a well-defined population and period with the aim of cutting across the historical flow of the event of interest in order to describe its characteristics. Data was collected at a single point in time for all the previously established variables of interest¹⁵15 Almeida Filho N, Barreto ML, organizadores. Epidemiologia e Saúde: fundamentos, métodos, aplicações. Rio de Janeiro: Guanabara Koogan; 2014..

The eligible participants for the study were LGBTQIA+ people who answered the semi-structured, self-administered questionnaire online using Google Forms. Participants were reached via a WhatsApp group by means of an invitation letter using the snowball technique, with the initial contacts being students on the first author’s master’s degree course. In addition, the link to access the research was shared within social movements.

The questionnaire covered socioeconomic and demographic characteristics: sexual orientation (lesbian, gay, bisexual, asexual, heterosexual and others), gender identity (cisgender and transgender), race/color (white, black, yellow or indigenous), schooling (up to complete elementary school, incomplete or complete high school, incomplete higher education or higher), occupation (unemployed, public servant or in a high school, technical or higher education occupation), age (18 to 39 years, 40 years and over), municipality, state and region of residence of the study participants; as well as discrimination, self-assessment (good or very good, fair, poor or very poor) and use of oral health care in the last five years, and the difficulties experienced.

The prevalence of use of oral health care in the studied population and the respective 95% confidence interval (IC95%) were calculated, as well as the percentage of each category of the other variables. Pearson’s chi-square test was calculated to assess the existence of a statistically significant difference (p ≤ 0.05) between the strata, with Yates’ correction when necessary. The data were exported to the Excel® program and analyzed using the R statistical program R version 3.4.3.

The research (CAAE: 54050321.8.0000.5240) was approved by the Research Ethics Committee (CEP) of the National School of Public Health Sergio Arouca, number 5.196.679, issued on January 10, 2022.

Results

The questionnaire was accessed by 359 people, but 1 did not agree to take part and 29 were ineligible. Of the 329 (91.9%) eligible for the study, 125 (38%) were gay; 77 (23.4%) lesbian; and 44 (13.4%) transgender (table 1). Among transgender people, the majority were heterosexual (36.4%) or bisexual (34.1%). Transsexual men accounted for 52.3% of trans-gender participants.

The participants were predominantly between the ages of 18 and 39 (73.3%); black (51.4%); with incomplete higher education or more (69.6%); living in the Southeast region (79.6%), mainly in the state of Rio de Janeiro (62.9%); and civil servants or in middle, technical and higher education occupations (43.8%) (table 2). The transgender population was proportionally higher than the cisgender population in terms of black race/color (65.9%; p = 0.028); having completed high school or less (68.2%; p < 0.001); living in the North (25%; p < 0.001), mainly in the state of Amazonas (20.5%); and unemployment (15.9%; p < 0.001). Among lesbians, there were proportionally more residents in the Northeast region (19.5%; p < 0.001), especially in the state of Bahia (18.2%), and the other populations were younger (77.4%; p = 0.004).

The prevalence of oral health care in the five years prior to the survey was high (92.9%; 95%CI: 89.7% – 95.3%), being proportionally lower for the transgender population (88.7%; 95%CI: 76% – 95.1%) than for the cisgender population (93.7%; 95%CI: 90.2% - 96%). The majority of participants had had oral health treatment in the last six months (44.7%; 95%CI: 39.4% - 50.1%) (table 3). There was no statistically significant difference in the prevalence of use between lesbians and other sexual orientations (p = 0.184) or in relation to race/skin color (p = 0.993). However, with regard to the transgender population, most of them had last been to the dentist 2 years ago or more (40.9%; p < 0.001).

Oral health care was mainly provided in the private sector (50.5%), whereas among transgender people, attendance was proportionally higher in the public sector than among cisgender people (45.5%; p < 0.001) (table 4). The majority did not inform the reason for the consultation (27.1%). However, the main reason was preventive care, such as a checkup, routine, prevention or cleaning (26.6%). A minority reported having experienced difficulties with care (24.9%), but this was proportionally higher among the transgender population (54.5%; p< 0.001), who also experienced more discrimination (13.6%; p < 0.001), especially due to LGBTphobia. Difficulty in accessing care was particularly due to delays or the impossibility of making an appointment (40.2%), and financial difficulties (22%).

Tooth loss was also proportionally greater among transgender people (61.4%; p = 0.040). The main cause reported by participants was caries, periodontal disease or abscess (29.8%), followed by poor oral hygiene, lack of care or interruption of treatment (19.9%). Among those who had tooth loss (151), 72.8% had less than five teeth (72.8%).

Regarding self-assessment of oral health (table 5), the cisgender population reported being good or very good (57.5%), while the transgender population said it was bad or very bad (45.5%; p < 0.001). The majority of participants reported preferring to be seen by an LGBTQIA+ professional (69%).

Discussion

The prevalence of oral health care utilization among the LGBTQIA+ population participating in the study was high in the last five years (92.9%), particularly in the six months prior to the survey (44.7%). The prevalence among whites and blacks was similar, but the transgender population, which represented only 13.4% of participants, had a lower prevalence (88.7%), especially in the last six months (18.2%). Transgender participants also had proportionally less schooling, lived in the North, and were unemployed compared to the others (p < 0.001). In the national survey carried out in 2013, more than 40% of those interviewed reported having seen a dentist in the last year¹⁶16 Souza JL, Henriques A, Silva ZP, et al. Posição socioe-conômica e autoavaliação da saúde bucal no Brasil: resultados da Pesquisa Nacional de Saúde. Cad. Saúde Pública. 2019; 35(6):e00099518.,¹⁷17 Bastos TF, Medina LPB, Sousa NFDS, et al. Income inequalities in oral health and access to dental services in the Brazilian population: National Health Survey. 2013. Rev. Bras. Epidemiol. 2019; 22(supl2):E190015. SUPL.2.,¹⁸18 Bordin D, Fadel CB, Santos CB, et al. Caracterização da condição percebida de saúde bucal na população adulta brasileira. Ciênc. saúde coletiva. 2020; 25(9):3647-3656.. Regular visits to the dentist were reported by 63.7%, with greater variation in relation to schooling, 36.6% among those with no schooling and 85.5% with more than 11 years of schooling; however, being black, living in the North or Northeast and belonging to a lower social class were also more likely to have never been to the dentist or to have irregular follow-ups¹⁹19 Galvão MHR, Souza ACO, Morais HGF, et al. Desigualdades no perfil de utilização de serviços odontológicos no Brasil. Ciênc. saúde coletiva. 2022; 27(6):2437-2448..

Only 18.8% of the participants in the study had been treated in the public health system, but this was proportionally higher among transgender people (45.5%). However, a survey carried out in 2013 found out that 11% of those interviewed had been treated in the SUS¹⁸18 Bordin D, Fadel CB, Santos CB, et al. Caracterização da condição percebida de saúde bucal na população adulta brasileira. Ciênc. saúde coletiva. 2020; 25(9):3647-3656..

Difficulty in finding care has also been higher among transgender people (54.5%) than others (20.4%); as well as having suffered discrimination – 13.6% and 1.8% respectively. Transgender people find it more difficult to access services, so they avoid seeking health care for fear of discrimination²⁰20 Calazans C, Kalichman A, Santos MR, et al. Necessidades de saúde: demografia, panorama epidemiológico e barreiras de acesso. In: Ciasca SV, Hercowitz A, Lopes Junior A, organizadores. Saúde LGBTQIA+: Práticas de cuidado interdisciplinar. Santana de Parnaíba [SP]: Manole; 2021. p. 82-91.. The majority of participants reported preferring to be seen by an LGBTQIA+ professional (69%), especially among transgender people (79.5%) and Black people (74%); but the differences between the proportions were not statistically significant (p ≥ 0.115), probably due to the small sample size in the category that has no preference.

It is important to emphasize that transgender people experience various difficulties in the society they live in, since their transvestility and transsexuality are exposed in their bodies. Louro²¹21 Louro GL. Um corpo estranho: ensaios sobre sexualidade e teoria queer. Belo Horizonte: Autêntica; 2018. points to the social construction of a binary and heterosexual matrix that shapes sexual and gender patterns. In this context, the insecurity inherent in gender norms shows that these people are despised and are on the margins of society, where there is no guarantee of rights and their very humanity is denied. This is echoed in various spheres, including health²²22 Butler J. O parentesco é sempre tido como heterossexual? Cad. Pagu. 2003; (21):219-260..

On the other hand, cisgender people find it easier not to reveal their sexual orientation to health professionals and are, therefore, less vulnerable to discrimination because of the assumption that they are heterosexual, like lesbians²⁰20 Calazans C, Kalichman A, Santos MR, et al. Necessidades de saúde: demografia, panorama epidemiológico e barreiras de acesso. In: Ciasca SV, Hercowitz A, Lopes Junior A, organizadores. Saúde LGBTQIA+: Práticas de cuidado interdisciplinar. Santana de Parnaíba [SP]: Manole; 2021. p. 82-91.,²³23 Gomes R, Murta D, Facchini R, et al. Gênero, direitos sexuais e suas implicações na saúde. Ciênc. saúde coletiva. 2018; 23(6):1997-2006..

In this sense, the LGBTQIA+ population avoids attending health services, postpones or abandons clinical and preventive treatments as a result of negative experiences²⁴24 Russell S, More F. Addressing health disparities via coordination of care and interprofessional education: lesbian, gay, bisexual, and transgender health and oral health care. Dent. Clin. North Am. 2016; 60(4):891-906.. In an integrative review study²⁵25 Varotto BLR, Massuda M, Nápole RCD, et al. População LGBTQIA+: o acesso ao tratamento odontológico e o preparo do cirurgião dentista-uma revisão integrativa. Rev. Abeno. 2022; 22(2):1542-1542., it was concluded that the LGBTQIA+ population has less access to oral health services and that there is a lack of formal preparation of undergraduate students for care. Furthermore, recurrent discrimination at the institutional level predisposes this population to the risk of diseases and disorders, such as depression, anxiety, poor diet, weight loss and, in particular, lack of hygiene – factors that, together, affect multiple facets and have an impact on oral health.

A study conducted in Ontario, Canada, identified that 43.9% of the transgender population did not succeed in accessing healthcare, presenting a percentage three times lower than cisgender and heterosexual individuals, as well as having a worse evaluation of health services²⁶26 Giblon R, Bauer GR. Health care availability, quality, and unmet need: A comparison of transgender and cisgender residents of Ontario, Canada. BMC Health Serv Res. 2017; 17(1):283.. A study in the United States also identified that the transgender population tends to experience more fear and anxiety regarding dental treatment, which correlates with the high prevalence of discrimination and poor treatment experienced²⁷27 Heima M, Heaton LJ, Ng HH, et al. Dental fear among transgender individuals - a cross sectional survey. Spec. Care Dent. 2017; 37(5):212-22..

This situation is evident with the high percentage of participants who have experienced tooth loss (45.9%), especially among transgender individuals (61.4%) and Black individuals (55.6%). However, international studies indicate that periodontal diseases and increase in caries do not differ when compared with the heterosexual population, i.e. what differs is the inherent self-perception of oral health²⁵25 Varotto BLR, Massuda M, Nápole RCD, et al. População LGBTQIA+: o acesso ao tratamento odontológico e o preparo do cirurgião dentista-uma revisão integrativa. Rev. Abeno. 2022; 22(2):1542-1542..

Self-perception of oral health was good or very good (53.2%) for the majority of participants in the study, as well as for cisgender (57.5%), lesbian (61.0%) and black (43.7%) people; however, for transgender people, it was bad or very bad (45.5%). A study based on the 2013 survey found that the prevalence of positive self-perception of oral health was 67.4% and that negative self-perception was higher in the population with an income of less than one minimum wage, illiterate people and precarious or elementary jobs¹⁶16 Souza JL, Henriques A, Silva ZP, et al. Posição socioe-conômica e autoavaliação da saúde bucal no Brasil: resultados da Pesquisa Nacional de Saúde. Cad. Saúde Pública. 2019; 35(6):e00099518.. Bordin e colaborators¹⁸18 Bordin D, Fadel CB, Santos CB, et al. Caracterização da condição percebida de saúde bucal na população adulta brasileira. Ciênc. saúde coletiva. 2020; 25(9):3647-3656. found that negative self-perception of oral health is mainly related to difficulty in eating, negative evaluation of the last dental visit, negative self-perception of general health, and failure to adopt preventive dental measures such as flossing and routine check-ups.

A study on healthy lifestyle habits, such as self-care, not smoking, moderate drinking and physical activity, among others, found that lesbian and bisexual women were less likely to accept such habits when compared to heterosexual cisgender women. Transgender men, on the other hand, were more likely than transgender women and heterosexual cisgender people. There was no difference in the proportion of such habits among heterosexual cisgender men, gay men, and bisexual men²⁸28 Padilha WAR, Crenitte MRF, Lopes Junior A. Prevenção e cuidados das doenças crônicas. In: Ciasca SV, Hercowitz A, Lopes Junior A, organizadores. Saúde LGBTQIA+: Práticas de cuidado interdisciplinar. Santana de Parnaíba: Manole; 2021. p. 346-356..

A limitation of the study is that the research participants had high levels of education and were concentrated in large urban centers, especially in the city of Rio de Janeiro, a population that tends to have more access to information, services, and income, not representing the reality of the majority of the

LGBTQIA+ population. It is important to note, however, that even within this group, the transgender and/or Black population had the worst outcomes.

On the other hand, the study contributes to the topic by including, in an unprecedented way, oral health of the LGBTQIA+ population, encompassing gender identity and sexual orientation, while national research did not even include the binary perspective – female and male. Additionally, the study also included the lesbian population, providing greater visibility to this often neglected and invisible population in health studies and research, seeking to address the demand for lesbian identity in the reorganization of public health policies²⁹29 Jesus JG, organizador. Transfeminismo: teorias & práticas. Rio de Janeiro: Editora Metanoia; 2015. 206 p..

There is an insufficient amount of scientific literature on the topic of LGBTQIA+ oral health, with the majority coming from international sources. This lack of studies in other countries and the absence of national research further highlight and reinforce the invisibility in professional training and health research²⁵25 Varotto BLR, Massuda M, Nápole RCD, et al. População LGBTQIA+: o acesso ao tratamento odontológico e o preparo do cirurgião dentista-uma revisão integrativa. Rev. Abeno. 2022; 22(2):1542-1542.,³⁰30 Bezerra MVR, Moreno CA, Prado NMBL, et al. Política de saúde LGBT e sua invisibilidade nas publicações em saúde coletiva. Saúde debate. 2019: 43(esp8):305-323.,³¹31 Eliason MJ, Dibble SL, Robertson PA. Lesbian, gay, bisexual, and transgender (LGBT) physicians’ experiences in the workplace. J. Homosex. 2011; 58(10):1355-1371..

Discrimination and obstacles to accessing healthcare services are common occurrences. A patriarchal and heteronormative society stigmatizes, discriminates against, and excludes the LGBTQIA+ population due to a culture that predominantly focuses on heterosexuality; thus, health inequalities are growing significantly³²32 Guimarães RCP, Cavadinha ET, Mendonça AVM, et al. Assistência a população LGBT em uma capital brasileira: o que dizem os Agentes Comunitários de Saúde? Tempus. 2017; 11(1):121-139..

The LGBTQIA+ population faces barriers in their daily lives when it comes to healthcare. There is a difficulty in finding health professionals who understand the real needs of this population, who treat them with discrimination delay or even refuse to provide care, failing to safeguard their right to health³³33 Ferreira AP, Nichele CST, Jesus JG, et al. Evidências científicas sobre o acesso aos serviços de saúde pela população LGBTQI+: Revisão de escopo. Res., Soc. Dev. 2022; 11(10):e229111032519..

The search of this population for healthcare services is immersed in a perspective of denial, violence, neglect, and invisibility, being a structural issue associated with the lack of public policies. Non-recognition and lack of attention are prospectively rooted in patriarchy, sexism, and male-oriented society, along with prejudice that affects all social relationships, occupying all spaces, including educational and healthcare institutions³²32 Guimarães RCP, Cavadinha ET, Mendonça AVM, et al. Assistência a população LGBT em uma capital brasileira: o que dizem os Agentes Comunitários de Saúde? Tempus. 2017; 11(1):121-139.,³⁴34 Ferreira BO, Pedrosa JIS, Nascimento EF. Diversidade de Gênero e Acesso ao Sistema Único de Saúde. Rev. Bras. Promoç. Saúde. 2017; 31(1):1-10..

It is essential that professionals are trained on the subject, which enables a less stigmatized view that is closer to real needs. Permanent health education thus becomes the main resource to be used for recognizing, planning and implementing actions aimed at the LGBTQIA+ population³⁵35 Souza OSL. Desafios no acolhimento à população LGBT nos serviços do Sistema Único de Saúde do município de Caicó, RN: um estudo sobre a atuação dos profissionais da atenção primária. [monografia]. Caicó: Universidade Federal do Rio Grande do Norte; 2021. 36 p..

Therefore, it is urgent to develop and evaluate a proposal for ongoing education for the oral health team, aiming to identify and support vulnerable populations, and to reflect on fight against various forms of discrimination. This is in order to promote the protection of the right to free sexual orientation and gender for the comprehensive health of these individuals, as well as to safeguard human rights and citizenship as provided for, but not fully enforced⁶6 Brasil. Ministério da Saúde. Portaria nº 2.836, de 1º de dezembro de 2011. Institui, no âmbito do Sistema Único de Saúde (SUS), a Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais, Travestis e Transexuais (Política Nacional de Saúde Integral LGBT). Diário Oficial da União. 2 Dez 2011..

Thus, it is a question of promoting the practice of health that is not limited to the treatment of sexually transmitted infections, in other words, integral health based on equity, which will help to tackle the social inequalities inherent in the health of the LGBTQIA+ population⁶6 Brasil. Ministério da Saúde. Portaria nº 2.836, de 1º de dezembro de 2011. Institui, no âmbito do Sistema Único de Saúde (SUS), a Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais, Travestis e Transexuais (Política Nacional de Saúde Integral LGBT). Diário Oficial da União. 2 Dez 2011.,³⁶36 Mello L, Perilo M, Braz CA, et al. Políticas de saúde para lésbicas, gays, bissexuais, travestis e transexuais no Brasil: em busca da universalidade, integralidade e equidade. Sex., Salud Soc. 2011; (9):7-28.,³⁷37 Oliveira CP. Aproximando a equipe de saúde bucal do cuidado às populações vulnerabilizadas. [monografia]. Porto Alegre: Universidade Federal do Rio Grande do Sul; 2021. 30 p..

Final considerations

The research into oral health care for the LGBTQIA+ population aimed to analyze the oral health of these people, contributing in an unprecedented way to the inclusion of gender identity and sexual orientation in a national oral health study. Even among participants with higher education and in large urban centers, the transgender and Black population had the worst results. This demonstrates that race, gender and sexuality directly influence access to health care; therefore, the intersectional approach is essential for organizing the service.

The difficulties faced by this population stem from multiple systems of structural oppressions, which fail to recognize them as individuals due to a patriarchal, heterosexual, cisgender, and white culture. The lack of studies in other countries and the absence of national research further reinforce and highlight the invisibility in professional training and health research.

The lack of studies in other countries and the absence of national research reinforce and highlight the invisibility of professional training and health research. In this sense, it is essential that professionals are trained on the subject, which enables a less stigmatized view that is closer to real needs. Continuous health education, in this context, becomes the main resource to be used for recognizing, planning and implementing actions aimed at this population. Moreover, there is an urgent need to promote and protect the right to free sexual orientation and gender identity, which will help to tackle the social inequalities inherent in the health of LGBTQIA + people.

References

Publication Dates

History