ABSTRACT

The LGBTQIA+ population still faces many difficulties in accessing health services and obtaining effective care and assistance. This article provides an analysis of the academic literature on the LGBTQIA+ population’s access to Primary Health Care (PHC) services in Brazil. To this end, a scoping review was conducted in order to identify studies on subjects where literature reviews are still scarce and where different study designs may be possible. As for the results, it was observed that scientific production on access to PHC for the LGBTQIA+ population is still incipient. It emerged that, despite the political gains made through the struggle of social movements, the health process for this population is still permeated by a heteronormative logic that disregards identities and gender orientations and, consequently, imposes major barriers to accessing healthcare services.

KEYWORDS
Sexual and gender minorities; Primary Health Care; Access to health services; Barriers to access to health care

Introduction

This article addresses the access to health policies by the Lesbian, Gay, Bisexual, Transvestite, Transsexual and Transgender, Queer, Intersexual or Intersex, Asexual and other (LGBTQIA+) population, given the historical condition of invisibility of this social group, the denial of their rights in various social sectors, especially in the health field.

The access of the LGBTQIA+ population to the care network is affected by different factors, including the professional approaches to care and specific health strategies and actions available. The welcoming practices and the identification of the demands and specificities of these populations are key aspects for the qualified and effective assistance to meet the needs of this population. In this way, it is important to understand access not only as the population’s arrival at health services, but also as the effective guarantee of their rights, which materializes through attentive looks, welcoming actions and the bonds built capable of capturing the intersubjectivities involved between professionals and users.

Evidence of prejudice related to sexual orientation and gender identity within Primary Health Care (PHC) justifies analyses that question the strategic role of this level of care, in terms of its potential to adequately welcome and refer the demands and expectations of this public to the workflows of the assistance services. However, there are few studies on the offer of healthcare services to the LGBTQIA+ population in PHC, the main gateway to preventive actions and treatment for this group in Brazil.

Considering this context, this article will try to map the literature on that subject and synthesize the evidence produced so as to analyze the LGBTQIA+ population’s access to PHC services in Brazil through a scope review. It will describe how the literature addresses the facilitators and the obstacles faced by these populations in terms of access to healthcare, and also the dimension of professional training to meet the specific health needs of the LGBTQIA+ populations.

Methodology

This study carried out a scoping review on the LGBTQIA+ population’s access to PHC services. This kind of review is a method aimed to examine the extent and the types of productions and concepts on which a particular area of knowledge is based, supporting the systematization and dissemination of their findings which contribute to practices, policies, and future studies. It also helps to identify gaps in the existing literature and to the methodological approaches and trajectories adopted in research in a certain field¹1 Cordeiro L, Soares CB. Revisão de escopo: potencialidades para a síntese de metodologias utilizadas em pesquisa primária qualitativa. BIS, Bol. Inst. Saúde. 2020; 20(2):37-43.,²2 Peters MD, Godfrey CM, Khalil H, et al. Guidance for Conducting Systematic Scoping Reviews. Int. J. Evid. Based Healthc. 2015; 13(3):141-146.. Given the diversity of methods used in literature reviews, it was decided to conduct a scoping review because it proved to be suitable to identify the production on the subject with a focus on the obstacles and facilitators faced by the LGBTQIA+ population in accessing health services.

The bibliographic survey was conducted on the following databases: Portal Regional BVS (VHL Regional Portal), SciELO, PubMed, Scopus and Web of Science, between 2017 and 2022. In all of them, keywords in Portuguese and English languages were used within the search strategy, especially in the international databases PubMed, Scopus and Web of Science.

A total of 502 articles were identified. The titles were then organized in the Mendeley reference management software in order to filter the results and discard those that were repeated or out of scope for the study. In this first stage some articles were eliminated: 251 for being duplicates; 128 articles for being published outside the period between 2017 and 2022; and one article that did not allow free access to the full text. After reading the titles and abstracts, those articles that did not address the issue of access do Primary Health Care (PHC) for the LGBTQIA+ population were also eliminated from the sample. After these procedures, the selected sample consisted of 37 articles. These papers were fully read and eight ended up ended up being rejected for not meeting the research objective. Thus, the final study sample comprised 29 articles identified as relevant for analysis as shown in figure 1.

Discussion

It is understood that approaches to any aspect of the LGBTQIA+ population cannot be done without introducing the concept of gender. Discussions on this subject remain a taboo in many areas of society due to conservatism and the naturalization of a culture based on heterosexual and cisgender orientation. At the heart of feminist theories, gender is currently regarded as a historically, socially, and culturally constructed category, which is individually accepted through roles, tastes, customs, behaviors, and representations³3 Vieira TR, Paiva LAS. Identidade sexual e transexualidade. São Paulo: Roca; 2009.. Judith Butler⁴4 Butler J. Bodies that matter: on the discursive limits of “sex”. New York: Routledge; 1993. emphasizes that gender needs to be assumed by the person, but this does not happen through a process of choice; rather, it is a process of construction and disputes, because, ultimately, the gender system is hierarchical and involves power relations.

The political struggle for social rights for the LGBTQIA+ population in Brazil dates back to the late 1970s - a period in which various social movements organized themselves in the fight to re-establish democracy in the country, including the homosexual movement⁵5 Facchini R. Entre compassos e descompassos: um olhar para o ‘campo’ e para a ‘arena’ do movimento LGBT brasileiro. Bagoas. 2009; 3(4):131-158.. The debate and numerous demonstrations promoted over the decades gave political visibility to the problems of both private life and social relations involving LGBTQIA+ individuals⁶6 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..

In the field of public health, advances on the demands and needs of this social group included: the creation of AIDS control program in Brazil and the establishment of the National Program for Sexually Transmitted Diseases in the 1980s as a response to the HIV/AIDS epidemic; the inclusion of LGBT rights in the 12^th National Health Conference in 2003; the launch of the Program to Combat Violence and Discrimination against GLTB (Gays, Lesbians, Transsexuals and Bisexuals) and to Promote Homosexual Citizenship, ‘Brazil Without Homophobia’; the establishment by the Ministry of Health⁷7 Brasil. Ministério da Saúde. Portaria nº 2.227, de 14 de outubro de 2004. Dispõe sobre a criação do Comitê Técnico para a formulação de proposta da Política Nacional de Saúde da População de Gays, Lésbicas, Transgêneros e Bissexuais - GLTB. Diário Oficial da União. 15 Out 2004. of the technical committee for the health of the LGBT population; the establishment of the National Guidelines for the Transsexualization Process in the Unified Health System (SUS) in 2008; the guarantee of the use of the social name for SUS users in 2009; the creation of PoLGBT in 2011, among others. It is important to note that these rights which have been progressively achieved by the LGBTQIA+ people cannot be considered concessions or privileges for this population segment, but rather as rights acquired through the organization and struggle of social movements that embraced those causes.

It is also worth observing that, despite several attacks on the public health policies in recent years, there was an important achievement by the LGBTQIA+ population in the health sector, in 2020. Following a historic decision by the Federal Supreme Court, the National Health Surveillance Agency revoked, in 2022, the restriction on blood donation by “male individuals who have had sexual relations with other individuals of the same sex and/or their sexual partners”⁸8 Brasil. Ministério da Saúde, Agência Nacional de Vigilância Sanitária. Resolução da Diretoria Colegiada - RDC nº 34, de 11 de junho de 2014. Dispõe sobre as Boas Práticas no Ciclo do Sangue. Diário Oficial da União. 16 Jun 2014. [acesso em 2022 nov 15]. Disponível em: https://saude.rs.gov.br/upload/arquivos/carga20170553/04145350-rdc-anvisa-34-2014.pdf.
https://saude.rs.gov.br/upload/arquivos/... .

Results

Table 1 shows the articles considered eligible for the research, indicating their identification code as well as their title, author(s), year of publication and the journal in which they were published. Subsequently, the analysis will be presented.

From the scoping review, it was observed that the studies dealt with the Lesbian Gay, Bisexual, Transvestite, and Transsexual (LGBTT) population in general or the trans population in specific - five articles addressed the LGBTT population, and another five approached trans people. The other groups that make up the acronym were not analyzed. The bisexual population in particular is only covered in one of the articles, focusing on bisexual women. In other words, bisexual men were not mentioned in any of the analyzed articles. The topic of bisexuality seems to have been suppressed in the analyzed publications. This may be related to the fact that

Regarding the type of research, most of the articles were qualitative. Only four were quantitative. As for the study design, 19 different types were identified. However, content analysis featured prominently in five articles. Regarding the techniques used for data collection, 11 techniques were identified, with interviews being prominent in 16 articles. In relation to the scope of the research and its location, it was identified that two articles were the result of international/national research and four of them were the result of national research. However, most of the studies were carried out at a local level, in municipalities in Brazil as shown in table 2.

Characterization of access for the LGBTQIA+ population in PHC

One of the complexities of characterizing the access of the LGBTQIA+ population to PHC may be associated with the difference between access and accessibility. Starfield¹²12 Gomes DF, Teixeira ER, Sauthier M, et al. Restrição de políticas públicas de saúde: um desafio dos transexuais na atenção básica. Esc. Anna Nery. 2022; 26:e20210425. discusses the concept of access, stressing the difference between access and accessibility. For him, access must occur in a timely and appropriate manner in order to achieve better health results. Accessibility, on the other hand, refers to the factors that “enable people to reach services”¹⁰10 Starfield B. Atenção primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília, DF: Unesco; Ministério da Saúde; 2002.(225). In other words, accessibility is a possibility of contact made effective by access to health services - but for the LGBTQIA+ population access is often not achieved due to various institutional barriers¹⁰10 Starfield B. Atenção primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília, DF: Unesco; Ministério da Saúde; 2002.. The study found that 23 out of the 29 analyzed articles showed some qualification or characteristics of the population’s entry into health services. Next, it will be described how such characterization was carried out in the studies.

The concept of access is based on the ability to seek and obtain healthcare. In their article, Ferreira and Bonan⁹9 Ferreira BO, Bonan C. Abrindo os armários do acesso e da qualidade: uma revisão integrativa sobre assistência à saúde das populações LGBTT. Ciênc. saúde coletiva. 2020; 25(5):1765-1778. argue that accessibility conditions are related to political, technical, symbolic, and economic determinants. In this sense, inequalities in access and issues such as the unsatisfactory quality of healthcare affect social minorities in particular, such as the LGBTQIA+ population. These authors highlight that the Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais, Travestis e Transexuais (PSNI-LGBT) - National Comprehensive Health Policy for Lesbians, Gays, Bisexuals, Transvestites and Transsexuals), launched by Ordinance No. 2,836 of December 1, 2011, is an important reference for discussions on access and quality of healthcare for the LGBTQIA+ population⁹9 Ferreira BO, Bonan C. Abrindo os armários do acesso e da qualidade: uma revisão integrativa sobre assistência à saúde das populações LGBTT. Ciênc. saúde coletiva. 2020; 25(5):1765-1778.. According to Oliveira et al.¹¹11 Oliveira G, Nogueira J, Costa G, et al. Acesso de Lésbicas, Gays, Bissexuais e Travestis/Transexuais às Unidades Básicas de Saúde da Família. Rev. Rene. 2018; 19:e3295., the PNSI-LGBT is committed to promoting inclusion and reducing inequalities in access to healthcare for the LGBTQIA+ population, reinforcing their historical needs.

The analyzed articles also showed that some of the authors discuss the process of making public policies based on the notion of gender binarity. For Gomes, Teixeira and Sauthier¹²12 Gomes DF, Teixeira ER, Sauthier M, et al. Restrição de políticas públicas de saúde: um desafio dos transexuais na atenção básica. Esc. Anna Nery. 2022; 26:e20210425.(²2 Peters MD, Godfrey CM, Khalil H, et al. Guidance for Conducting Systematic Scoping Reviews. Int. J. Evid. Based Healthc. 2015; 13(3):141-146.), “the health manuals used by professionals address a method of care based on biological concepts”. As a result, the needs of individuals which go beyond the binary of male and female end up being neglected and ultimately having a negative effect on access to and use of the health system.

In this sense, Mota et al.¹³13 Mota M, Santana ADS, Silva LR, et al. “Clara, esta sou eu!” Nome, acesso à saúde e sofrimento social entre pessoas transgênero. Interface (Botucatu). 2022; 26:e210017. discuss the pathologizing concept that permeates trans people’s access to health services, which has already been challenged by social movements and national and international organizations. The authors point out that ‘depathologization’ has been one of the axes of political advocacy of the trans social movement in discussing and reclaiming the notion of existence as ‘not sick bodies’. According to the authors, the fulfillment of this demand in Brazil depends on the expansion of public policies to provide access to the transsexualizing process in the SUS and, above all, the massive recognition of trans citizenship. In this context, depathologization has been an important political tool in the resistance and claims of trans bodies in search of integral and welcoming healthcare.

Dornelas et al.¹⁴14 Dornelas R, Silva K, Pellicani AD. Atendimento vocal à pessoa trans: uma apresentação do Protocolo de Atendimento Vocal do Ambulatório Trans e do Programa de Redesignação Vocal Trans (PRV-Trans). CoDAS. 2021; 33(1):e20190188. raise the prospect of access quality for the LGBTQIA+ population, which is directly linked to welcoming practices. Implementing this guideline requires recognizing the health needs of others through

Barriers and facilitators of access to healthcare for the LGBTQIA+ population in PHC

All the analyzed articles address in different ways the barriers faced by the LGBTQIA+ population in accessing PHC, whether objectively or subjectively. Brigeiro and Monteiro¹⁵15 Monteiro S, Brigeiro M. Experiências de acesso de mulheres trans/travestis aos serviços de saúde: avanços, limites e tensões. Cad. Saúde Pública. 2019; 35(4):e00111318.(⁴4 Butler J. Bodies that matter: on the discursive limits of “sex”. New York: Routledge; 1993.) highlighted that

Other texts also address the issue of stigmatization of the LGBTQIA+ population with HIV. In this regard, Sevelius et al.¹⁶16 Sevelius J, Murray LR, Martinez Fernandes N, et al. Optimising HIV programming for transgender women in Brazil. Cult. Health Sex. 2019; 21(5):543-558. state that institutional environments, due to the introjection of rigid categories of gender and sexuality, link and interconnect stigma and discrimination related to HIV and transgender people:

Thus, it can be observed that access to healthcare for the LGBTQIA+ population is still linked to their sexual behavior, meaning that the first offer of service is associated with HIV testing, preceding any other health need for these users. This may be related to the representation of HIV, permeated by stigmas and misinformation about various epidemiological scenarios, which are determinants to discrimination and contribute to perpetuating access barriers for this population¹⁷17 Farias OO, Guedes DS, Freitas PC, et al. Análise das necessidades de ajuda de homens com HIV que fazem sexo com homens. Rev. Esc. Enferm. USP. 2020; 54:e03650.. The blaming and association of the LGBTQIA+ population as disseminators of Sexually Transmitted Infections (STIs) by health professionals is characterized by Guimarães et al.¹⁸18 Guimarães NP, Sotero RL, Cola JP, et al. Avaliação da implementação da Política Nacional de Saúde Integral à população LGBT em um município da região Sudeste do Brasil. RECIIS. 2020; 14(2):372-385. as acts of violence and discrimination, which result in one of the main barriers to accessing healthcare. Parente et al.¹⁹19 Parente J, Silva C, Magalhães B, et al. LGBTQIA+ health in light of principlist bioethics. Rev. Bioét. 2021; 29(3):630-640. also highlight institutional violence as the main barrier to accessing health services. For these authors, the violence is materialized by inadequate assistance, the non-adoption of the social name, which is a legal right, and disrespectful comments leading to anger and emotional instability in users.

Despite regulations covering policies to ensure access to healthcare in PHC for those social groups, Mota et al.¹³13 Mota M, Santana ADS, Silva LR, et al. “Clara, esta sou eu!” Nome, acesso à saúde e sofrimento social entre pessoas transgênero. Interface (Botucatu). 2022; 26:e210017. say that they are not enough to guarantee full citizenship. The authors mention as an example the failure to comply with Provision No. 73, of June 28, 2018, which addresses the rectification of the birth registered name. In the routine of the services, the rectified name of trans people and transvestites is often not formalized at the time of care attendance. There is a double denial: of the human condition and of trans people’s citizenship. Rocon et al.²⁰20 Rocon PC, De Barros MEB, Rodrigues A. A formação dos(as) trabalhadores(as) da saúde na construção de um acesso à saúde integral, equânime e universal à população trans. Pro-Posições. 2022; 33:e20190083. highlight the barriers to access pointing out that there is a chain reaction which produces suffering and illness among the trans population: the notion of ‘institutional trans-travestiphobia’ the main access barrier leading to the interruption of treatments with consequences and sequelae for this population’s health who does access healthcare services, but find it hard to remain.

Therefore, the analyzed production makes it clear that the existence of a national policy that advocates access to health services for the trans population is not enough to ensure that the structures of the services welcome and monitor the PHC as established. The heteronormative practice used by health professionals to care for the LGBTQIA+ population was highlighted by Lazcano and Toneli²¹21 Lazcano CL, Toneli MJF. Producción de sentidos sobre asistencia transespecífica en salud, derechos y ciudadanía trans*. Psicol. Ciênc. Prof. 2022; 42:1-12.; the authors point out that even when the regulations establish a line of care for transvestites and transsexuals as part of Brazilian public health system, this is strongly impacted by heteronormativity and gender binarism, which combined with the pathologization of transsexualities, end up accentuating the precariousness of transexistences. Parente et al.¹⁹19 Parente J, Silva C, Magalhães B, et al. LGBTQIA+ health in light of principlist bioethics. Rev. Bioét. 2021; 29(3):630-640.(636-637) observed that

Silva and Gomes²²22 Silva AN, Gomes R. Acesso de mulheres lésbicas aos serviços de saúde à luz da literatura. Ciênc. saúde coletiva. 2021; 26(supl3):5351-5360. have analyzed the issue of the personal values of health professionals which are intertwined in the assistance given to lesbian women. Religious beliefs held by a portion of health professionals who reaffirm heterosexuality as the only acceptable conduct become embedded in their practice, creating difficulties for these women to access healthcare services. In other words, “naturalized heterosexuality is present - explicitly or implicitly - in healthcare practice in general and in the attitude of professionals”²²22 Silva AN, Gomes R. Acesso de mulheres lésbicas aos serviços de saúde à luz da literatura. Ciênc. saúde coletiva. 2021; 26(supl3):5351-5360.(53-54).

Ferreira and Bonan⁹9 Ferreira BO, Bonan C. Abrindo os armários do acesso e da qualidade: uma revisão integrativa sobre assistência à saúde das populações LGBTT. Ciênc. saúde coletiva. 2020; 25(5):1765-1778. have also indicated the existence of barriers in the management and operationalization of the PNSI-LGBT as well as a fragile dialogue between federal, state and municipal administrations in which normative and legal agreements are not established in a precise manner. The authors also indicate as a barrier the knowledge of health professionals in relation to the sexual orientation and/or gender identity of people who access health services. The majority of professionals report they adopt a single approach when dealing with the general population. However, they choose to standardize care without considering the expressions, desires, and health needs of users. The identification of gender identity and/or sexual orientation was indicated in the professional’s rhetoric as something of little relevance to healthcare assistance²³23 Ferreira B, Bonan C. Vários tons de “não”: relatos de profissionais da Atenção Básica na assistência de lésbicas, gays, bissexuais, travestis e transexuais (LGBTT). Interface (Botucatu). 2021; 25:e200327..

Guimarães et al.¹⁸18 Guimarães NP, Sotero RL, Cola JP, et al. Avaliação da implementação da Política Nacional de Saúde Integral à população LGBT em um município da região Sudeste do Brasil. RECIIS. 2020; 14(2):372-385. support this view in their research with health professionals. There were only approaches to the population’s sexual orientation and gender identity during academic training, and even then, they were linked to the subject of STIs. Along the same lines, Silva and Gomes²²22 Silva AN, Gomes R. Acesso de mulheres lésbicas aos serviços de saúde à luz da literatura. Ciênc. saúde coletiva. 2021; 26(supl3):5351-5360. highlighted this weakness in the training of health professionals, which has contributed to their discomfort and unpreparedness when it comes to welcoming lesbian women, for instance, making their demands and specificities invisible.

Gomes and Sauthier¹²12 Gomes DF, Teixeira ER, Sauthier M, et al. Restrição de políticas públicas de saúde: um desafio dos transexuais na atenção básica. Esc. Anna Nery. 2022; 26:e20210425. suggest that, in addition to restrictions on access to health services, there is a fundamental issue which is the low level of resolution in specific care provided to the transgender population. According to them, this population is dissatisfied with the lack of specific services in the Basic Health Units (UBS), “characterizing itself as a restriction on transsexuals’ access to public health policies that meet their demands”¹²12 Gomes DF, Teixeira ER, Sauthier M, et al. Restrição de políticas públicas de saúde: um desafio dos transexuais na atenção básica. Esc. Anna Nery. 2022; 26:e20210425.(³3 Vieira TR, Paiva LAS. Identidade sexual e transexualidade. São Paulo: Roca; 2009.), reinforcing the conditions of vulnerability of this population to specialized services that should be referred by the primary level of care.

Leite et al.²⁴24 Leite BO, Medeiros DS, Laio M, et al. Association between gender-based discrimination and medical visits and HIV testing in a large sample of transgender women in northeast Brazil. Int. J. Equity Health. 2021; 20(199). argue that although Brazil has a universal health system, there is still no effective strategy to link those people to the system and there are still many barriers to access resulting from discrimination by health professionals and users, disrespect for their social name and gender identity, and failure to meet the necessary health demands.

Based on their research, Paulino et al.²⁵25 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:e180279. bring up the perspective of the ‘discourse of not knowing’ about the demands of the LGBTQIA+ population by health professionals. In other words, a lack of knowledge structured around blaming the system, and justified due the lack of training on the subject during graduation or because the municipal management did not offer continuing education on the issue. The authors point out to this process as a strategy that also conceals irresponsibility, i.e. “I don’t know and I can continue not knowing”²⁵25 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:e180279.(⁸8 Brasil. Ministério da Saúde, Agência Nacional de Vigilância Sanitária. Resolução da Diretoria Colegiada - RDC nº 34, de 11 de junho de 2014. Dispõe sobre as Boas Práticas no Ciclo do Sangue. Diário Oficial da União. 16 Jun 2014. [acesso em 2022 nov 15]. Disponível em: https://saude.rs.gov.br/upload/arquivos/carga20170553/04145350-rdc-anvisa-34-2014.pdf.
https://saude.rs.gov.br/upload/arquivos/... ). It is therefore possible to note that primary healthcare for the LGBTQIA+ population is compromised by deficiencies in specific knowledge and skills among healthcare professionals. However, lack of responsibility is a widespread strategy. Other issues also keep the LGBTQIA+ population away from healthcare services such as: inhospitable environments in health services that stigmatize those patients and the lack of policies and parameters for better practice.

Regarding the facilitators that enables the access for the LGBTQIA+ population in PHC, 19 out of the 29 analyzed articles addressed this aspect.

Most of the articles that discuss facilitators of access to health services for the LGBTQIA+ population mention PHC as a powerful level of care for increasing the access. Ferreira et al.⁹9 Ferreira BO, Bonan C. Abrindo os armários do acesso e da qualidade: uma revisão integrativa sobre assistência à saúde das populações LGBTT. Ciênc. saúde coletiva. 2020; 25(5):1765-1778., Mota et al.¹³13 Mota M, Santana ADS, Silva LR, et al. “Clara, esta sou eu!” Nome, acesso à saúde e sofrimento social entre pessoas transgênero. Interface (Botucatu). 2022; 26:e210017., Guimarães et al.¹⁸18 Guimarães NP, Sotero RL, Cola JP, et al. Avaliação da implementação da Política Nacional de Saúde Integral à população LGBT em um município da região Sudeste do Brasil. RECIIS. 2020; 14(2):372-385. and Parente et al.¹⁹19 Parente J, Silva C, Magalhães B, et al. LGBTQIA+ health in light of principlist bioethics. Rev. Bioét. 2021; 29(3):630-640. mention legal frameworks as facilitators of access, such as the creation, in 2014, of the Programa de Combate à Violência e à Discriminação contra GLTB e de Promoção da Cidadania Homossexual (Program to Fight Violence and Discrimination against LGBT People and Promote Homosexual Citizenship), and the Ordinance No. 2,836/2011 which established the PSNI-LGBT. These regulations are highlighted as tools to improve access to healthcare for social minorities such as the LGBTQIA+ population.

Still from this perspective, Ferreira and Bonan⁹9 Ferreira BO, Bonan C. Abrindo os armários do acesso e da qualidade: uma revisão integrativa sobre assistência à saúde das populações LGBTT. Ciênc. saúde coletiva. 2020; 25(5):1765-1778. also point out that the removal of homosexuality as a pathology in the 10^th Revision of the International Classification of Diseases (ICD-10) was fundamental for tackling abuses, restrictions, and denial of rights to LGBTT populations. However, some authors also warn that the existence of legal frameworks, although important, is not enough to guarantee the LGBTQIA+ population access to health services in PHC. Borba²⁶26 Borba R. Sobre os obstáculos discursivos para a atenção integral e humanizada à saúde de pessoas transexuais. Sex., Salud Soc. (Rio de Janeiro). 2014; (17):66-97. mentions the Ordinance 1,707/2008 which establishes the transsexualizing process and defines humanized care as the ones free from discrimination. The author underlines that the humanization of care provided for in that Ordinance is not deeply explored. It is part of broader reflections and propositions within the HumanizaSUS movement, in the Política Nacional de Humanização do SUS (PNH) - SUS National Humanization Policy). Nevertheless, these discussions are still not enough to ensure that trans people are welcomed in health services as confirmed by Ferreira and Bonan⁹9 Ferreira BO, Bonan C. Abrindo os armários do acesso e da qualidade: uma revisão integrativa sobre assistência à saúde das populações LGBTT. Ciênc. saúde coletiva. 2020; 25(5):1765-1778., Mota et al.¹³13 Mota M, Santana ADS, Silva LR, et al. “Clara, esta sou eu!” Nome, acesso à saúde e sofrimento social entre pessoas transgênero. Interface (Botucatu). 2022; 26:e210017., and Oliveira and Romani²⁷27 Oliveira I, Romanini M. (Re)escrevendo roteiros (in)visíveis: a trajetória de mulheres transgênero nas políticas públicas de saúde. Saúde Soc. 2020; 29(1):e170961..

Bringing in humanization as an ethical and political guideline is an important change for the transgender population’s access to healthcare. However, according to Rocon et al.²⁸28 Rocon PC, Wandekoken KD, Barros MEB, et al. Acesso à saúde pela população trans no Brasil: nas entrelinhas da revisão integrativa. Trab. Educ. Saúde. 2020; 18(1):e0023469., there is still a need for more studies on the health of trans people based on the propositions, contributions, and ethical and political movements of the PNH.

Rocon et al.²⁸28 Rocon PC, Wandekoken KD, Barros MEB, et al. Acesso à saúde pela população trans no Brasil: nas entrelinhas da revisão integrativa. Trab. Educ. Saúde. 2020; 18(1):e0023469. noted that another facilitator of access for the trans population is the removal of the requirement for surgery to change the names on documents. In line with this analysis, Guimarães et al.¹⁸18 Guimarães NP, Sotero RL, Cola JP, et al. Avaliação da implementação da Política Nacional de Saúde Integral à população LGBT em um município da região Sudeste do Brasil. RECIIS. 2020; 14(2):372-385. emphasize that the presence of a field intended for the social name in health documents and medical records expresses the respect that professionals have for the names users have chosen. Adopting the name of choice in the records not only de-characterizes violations of established rights, but also brings the professional practice closer to the SUS’s principles of universality and equity¹⁸18 Guimarães NP, Sotero RL, Cola JP, et al. Avaliação da implementação da Política Nacional de Saúde Integral à população LGBT em um município da região Sudeste do Brasil. RECIIS. 2020; 14(2):372-385..

Ferreira and Bonan⁹9 Ferreira BO, Bonan C. Abrindo os armários do acesso e da qualidade: uma revisão integrativa sobre assistência à saúde das populações LGBTT. Ciênc. saúde coletiva. 2020; 25(5):1765-1778. mention educational actions as facilitators for professionals, managers, administrators, and also for the general community with the aim of discussing historically constructed concepts and stigmas with positive effects on both the relational and organizational dimensions. These recommendations, drawn up since the 12^th National Health Conference, range from raising awareness among professionals about the rights of the LGBTQIA+ population, including the issue of free sexual expression in the SUS continuing education policy, to increasing the representation of this population in the decision-making levels such as in the health councils. Some official documents include the establishment of specific protocols for the assistance of lesbians and transvestites, the encouragement and sharing of technological innovations that increase the effectiveness of interventions and the guarantee of the sexual and reproductive rights¹⁸18 Guimarães NP, Sotero RL, Cola JP, et al. Avaliação da implementação da Política Nacional de Saúde Integral à população LGBT em um município da região Sudeste do Brasil. RECIIS. 2020; 14(2):372-385..

Oliveira and Romanini²⁷27 Oliveira I, Romanini M. (Re)escrevendo roteiros (in)visíveis: a trajetória de mulheres transgênero nas políticas públicas de saúde. Saúde Soc. 2020; 29(1):e170961. stress the articulation of health services as a way of increasing access. Primary care and specialized services need to converge their efforts to increase the care provided to the LGBTQIA+ population. They also consider the importance of community health workers as professionals located in the closest units to the users of health services. In this sense, it is essential that these professionals are well trained to welcome the LGBTQIA+ population.

Silva and Gomes²²22 Silva AN, Gomes R. Acesso de mulheres lésbicas aos serviços de saúde à luz da literatura. Ciênc. saúde coletiva. 2021; 26(supl3):5351-5360. observe that creating a welcoming environment encouraging bond-building and an open professional/user relationship can help to break down a context marked by stigma, discrimination and fear, as well as helping to reduce institutionalized violence. In the case of women, the authors advocate for maintaining an environment that respects their uniqueness and deconstruct forms of violence that lead to the exclusion and discrimination against lesbians. That constitutes an inclusive, comprehensive and humanized healthcare service.

Another initiative, as described by Lazcano and Toneli²¹21 Lazcano CL, Toneli MJF. Producción de sentidos sobre asistencia transespecífica en salud, derechos y ciudadanía trans*. Psicol. Ciênc. Prof. 2022; 42:1-12., was a training course involving transactivists and UBS staff. The project was intended to provide a sensitive reception for users. They believe that the communication relationship between the human rights movements proved to be powerful in the joint work undertaken with the medical team that assisted transgender people²³23 Ferreira B, Bonan C. Vários tons de “não”: relatos de profissionais da Atenção Básica na assistência de lésbicas, gays, bissexuais, travestis e transexuais (LGBTT). Interface (Botucatu). 2021; 25:e200327.. For Guimarães, Lorenzo and Mendonça²⁹29 Guimarães RCP, Lorenzo CFG, Mendonça AVM. Sexualidade e estigma na saúde: uma análise da patologização da diversidade sexual nos discursos de profissionais da rede básica. Physis. 2021; 31(1):e310128., health professionals’ knowledge of sexual orientation is both related to a better quality of the services and also in the increase of promotion and prevention actions for the LGBTQIA population.

The approach to professional training on access to healthcare for the LGBTQIA+ population in PHC

In relation to professional training to assist the LGBTQIA+ population in PHC, it was found that most of the analyzed articles approached this issue briefly and did not delve deeper into it. Only four articles specifically addressed professional training focused on serving the health needs of the LGBTQIA+ population²⁰20 Rocon PC, De Barros MEB, Rodrigues A. A formação dos(as) trabalhadores(as) da saúde na construção de um acesso à saúde integral, equânime e universal à população trans. Pro-Posições. 2022; 33:e20190083.,²³23 Ferreira B, Bonan C. Vários tons de “não”: relatos de profissionais da Atenção Básica na assistência de lésbicas, gays, bissexuais, travestis e transexuais (LGBTT). Interface (Botucatu). 2021; 25:e200327.,³⁰30 Fernandes NFS, Galvão JR, Assis MMA, et al. Acesso ao exame citológico do colo do útero em região de saúde: mulheres invisíveis e corpos vulneráveis. Cad. Saúde Pública. 2019; 35(10):e00234618.,³¹31 Santos L, Fontes W, Oliveira A, et al. O Acesso ao Sistema Único de Saúde na percepção de homossexuais masculinos. Rev. Bras. Enferm. 2020; 73(2):e20180688., either as a barrier or as a facilitator of the access to healthcare for the LGBTQIA+ population. According to Rocon et al.²⁰20 Rocon PC, De Barros MEB, Rodrigues A. A formação dos(as) trabalhadores(as) da saúde na construção de um acesso à saúde integral, equânime e universal à população trans. Pro-Posições. 2022; 33:e20190083., professional training strategies based on political awareness, technical information and the transmission of representations of transsexuality have not been enough to intervene in a way that guarantees the quality of access and welcoming of the transsexual population in PHC. The authors state that the training of health workers, whether technical or in raising political awareness of the trans population’s rights, is not enough to overcome the problems of access to health services. The emphasis on technicality, transmission and accumulation of information are not enough to tackle barriers regarding access.

Other articles only briefly touch on this aspect⁹9 Ferreira BO, Bonan C. Abrindo os armários do acesso e da qualidade: uma revisão integrativa sobre assistência à saúde das populações LGBTT. Ciênc. saúde coletiva. 2020; 25(5):1765-1778.,¹²12 Gomes DF, Teixeira ER, Sauthier M, et al. Restrição de políticas públicas de saúde: um desafio dos transexuais na atenção básica. Esc. Anna Nery. 2022; 26:e20210425.,¹³13 Mota M, Santana ADS, Silva LR, et al. “Clara, esta sou eu!” Nome, acesso à saúde e sofrimento social entre pessoas transgênero. Interface (Botucatu). 2022; 26:e210017.,¹⁸18 Guimarães NP, Sotero RL, Cola JP, et al. Avaliação da implementação da Política Nacional de Saúde Integral à população LGBT em um município da região Sudeste do Brasil. RECIIS. 2020; 14(2):372-385.,¹⁹19 Parente J, Silva C, Magalhães B, et al. LGBTQIA+ health in light of principlist bioethics. Rev. Bioét. 2021; 29(3):630-640.,²¹21 Lazcano CL, Toneli MJF. Producción de sentidos sobre asistencia transespecífica en salud, derechos y ciudadanía trans*. Psicol. Ciênc. Prof. 2022; 42:1-12.,²⁵25 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:e180279.,³²32 Peixoto MF, Conceição VM, Silva SED, et al. Compreensões hermenêuticas sobre as vulnerabilidades femininas pertencentes ao coletivo de lésbicas, bissexuais e transexuais. Rev. Gaúcha Enferm. 2021; 42:e20200133.,³³33 Torres JL, Gonçalves GP, Pinho AA, et al. O Inquérito Nacional de Saúde LGBT+: metodologia e resultados descritivos. Cad. Saúde Pública. 2021; 37(9):e00069521.. According to Silva and Gomes²²22 Silva AN, Gomes R. Acesso de mulheres lésbicas aos serviços de saúde à luz da literatura. Ciênc. saúde coletiva. 2021; 26(supl3):5351-5360., there is a weakness in the training of health professionals, which makes them uncomfortable in dealing with issues of sexual orientation and diversity and with the LGBTQIA+ population. Therefore, there is the need to advance in professional training and qualification for health professionals, and they should be based on humanization and breaking with the heteronormative and cisgender logic. Certainly, it does not suggest that professional training may be the only solution to ease the access barriers faced by LGBTQIA+ people in PHC, but it does encourage discussion and opportunities for reflection and for the deconstruction of heteronormative principles.

Final considerations

The purpose of this article was to conduct a scoping review of the LGBTQIA+ population’s access to PHC services in Brazil. The review, which covered five databases spanning from 2017 to 2022, found a low number of publications on the subject, specifically concerning the access of the LGBTQIA+ population to this level of care, indicating that this issue has not been prioritized in the research agenda of the Brazilian scientific production.

Considering the objectives of the research, it was observed that access to health services for the LGBTQIA+ population is characterized by inequalities, permeated by stigmas and prejudices in which these groups are cared for based on the centrality of heteronormativity and the pathologization of trans people, disregarding this population’s specific demands.

Improvements in the legal framework were also highlighted, bearing in mind their impact on the assistance granted to the LGBTQIA+ population, such as the PNSI-LGBT with its guarantee for using the social name and the transsexualization process. These advances were deemed foundational in consolidating access to these groups to PHC as they promote the inclusion and visibility of this population’s historical agendas in the health sector. However, despite the achievements of LGBTQIA+ movements in the healthcare agendas, it can still be perceived as a challenge to effectively implement policies promoting sexual and gender diversity in public health facilities.

The results presented here confirm the recognition that healthcare facilities are organized based on the heteronormative logic, disregarding gender identities and their expressions. In this sense, there is a lack of professional training to deal with the LGBTQIA+ population’s health, which goes beyond academic formation and which is perpetuated in in-service training that is also scarce or disconnected from the needs of both the professionals and the target audience.

The importance of this issue is reaffirmed as well as the need for more in-depth reviews and studies capable of identifying more robust evidence on the findings outlined here. In particular, the dimension of this population’s access to the main gateway to the SUS definitely requires a more systematized approach and reflections upon a new sociability in relation to gender and sexuality issues by the planners and enforcers of health policies in the SUS. By confronting this agenda, greater visibility will be conferred upon the LGBTQIA+ population in the health sector and the historical gap of their suppressed social rights will be confronted.

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