ABSTRACT

The article presents results of qualitative research carried out in Resende, a city located in the countryside of the state of Rio de Janeiro, on the implementation of the National Policy for Comprehensive Health for Lesbians, Gays, Bisexuals, and Transvestites and Transsexuals (PNSI-LGBT). It was carried out in order to contribute to the understanding of the process of developing public policies aimed at the LGBTQIA+ population, with an emphasis on the area of mental health, document analysis, and interviews with the management team of the municipality’s mental health program. The results showed that the PNSI-LGBT was not implemented in the health care network and that the majority of managers interviewed had little knowledge of the policy. Regarding concrete actions aimed at the LGBTQIA+ population, they are currently limited to the implementation in the city of an outpatient service focused on hormone therapy and transgenitalization of transgender people. The research made it possible to spark a discussion about the PNSI-LGBT and the incipience of its implementation in the municipality, highlighting the challenges to be faced by public management.

KEYWORDS
Sexual and gender minorities; Mental health; Health policy; Health management; Human rights

Introduction

Brazil is considered a dangerous country for the population of Lesbians, Gays, Bisexuals, Transgenders, Queer, Intersex, Asexuals, among others (LGBTQIA+). According to the dossier ‘Deaths and violence against LGBTI+ in Brazil’¹1 Acontece Arte e Política LGBTI+; Associação Nacional de Travestis e Transexuais; Associação Brasileira de Lésbicas, Gays, Bissexuais, Travestis, Transexuais e Intersexos. Mortes e violências contra LGBTI+ no Brasil: Dossiê 2022. Florianópolis, SC: Acontece, ANTRA, ABGLT; 2023. [acesso em 2023 dez 13]. Disponível em: https://observatoriomorteseviolenciaslgbtibrasil.org/.
https://observatoriomorteseviolenciaslgb... , there were 273 deaths of LGBTQIA+ people in 2022, observing an upward trend in the number of violent deaths in the last two decades. In Brazil and other parts of the world, homosexuality and sexual orientations and non-heteronormative gender identities or expressions are often stigmatized²2 Herek GM. A Nuanced View of Stigma for Understanding and Addressing Sexual and Gender Minority Health Disparities. LGBT Health. 2016; 3(6):397-399.,³3 Saraff S, Singh T, Kaur H, et al. Stigma and health of Indian LGBT population: A systematic review. Stig. Health. 2022; 7(2):178-195.,⁴4 Silva JCP, Cardoso RR, Cardoso ÂMR, et al. Diversidade sexual: uma leitura do impacto do estigma e discriminação na adolescência. Ciênc. saúde coletiva. 2021; 26(7):2643-2652., which leads many people to be targets of violence and mental suffering⁵5 Valentine SE, Shipherd JC. A systematic review of social stress and mental health among transgender and gender non-conforming people in the United States. Clin. Psychol. Rev. 2018; 66:24-38.,⁶6 Gomes M, Brum TG, Zanon BP, et al. A violência para com as pessoas LGBT: uma revisão narrativa da literatura. Braz. J. Health Rev. 2021; 4(3):13903-13924..

In relation to the health sector, in addition to LGBTphobia⁷7 Tagliamento G, Silva SSC, Silva DB, et al. Minha dor vem de você: uma análise das consequências da LGB-Tfobia na saúde mental de pessoas LGBTs. Cadernos GenDiv. 2021; 6(3):77-112., the majority of these people face barriers in accessing public services, prejudice and difficulties in communicating with health professionals, which contributes to the fear of revealing their orientation or gender identity, putting them in a place of exclusion and marginalization in care and health promotion practices, loneliness and psychological illness⁸8 Ferreira BO, Nascimento EF, Pedrosa JIS, et al. Vivências de travestis no acesso ao SUS. Physis. 2017; 27(4):1023-1038.,⁹9 Whitehead J, Shaver J, Stephenson R. Outness, stigma, and Primary Health Care utilization among rural LGBT Populations. PLoS One. 2016; 11(1):e0146139.,¹⁰10 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.. Stigmatization, discrimination and LGBTphobia make access difficult and have an impact on the morbidity and mortality profile of this population, highlighting a scenario of social inequality that places LGBTQIA+ people in situations that imply degrees of injustice and disadvantage in relation to the opportunity to be and maintain themselves healthy, which makes them a priority population for public policies.

As a result of the historical struggle of social movements, the National Policy for Comprehensive Health for Lesbians, Gays, Bisexuals, Transvestites and Transsexuals (PNSI-LGBT)¹¹11 Ayhan CHB, Bilgin H, Uluman OT, et al. A systematic review of the discrimination against sexual and gender minority in health care settings. Int. J. Health Serv. 2019; 50(1):44-61. was established with the aim of promoting the integral health of this population, in an attempt to eliminate prejudice and reduce inequalities in health care. This is because multiple expressions of gender and sexuality affect mental health as a result of social processes of violence, oppression, exploitation, domination, subjugation, policing, silencing and colonization. According to several studies, problems and illnesses such as alcohol and drug abuse, anxiety and depression manifest themselves as reflections of the exclusions that this group suffers on a daily basis¹²12 Medeiros LL, Facundes VLD. Sexualidade, identidade de gênero e as interferências na saúde mental. Res., Soc. Dev. 2022; 11(6):e5911628414.,¹³13 Clemente A. Diálogos entre saúde mental e homossexualidade: Notas sobre produção de subjetividade, sofrimento e opressão. REBEH. 2019; 2(5):42-58.,¹⁴14 Silva BL, Melo DS, Mello R. A sintomatologia depressiva entre lésbicas, gays, bissexuais e transexuais: um olhar para a saúde mental. Rev. Enferm. UERJ. 2019; 27:e41942.,¹⁵15 Moraes MA, Borges JLJ, Santos JEDS. Saúde mental da população LGBTQIA+: violências, preconceitos e suas consequências. Braz. J. Develop. 2021; 7(6):57836-57855..

The article presents research results originating from Costa’s master’s thesis¹⁶16 Costa LF. Implementação da PNSI-LGBT no Município de Resende, RJ. [dissertação]. Rio de Janeiro: Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz; 2022. [acesso em 2023 dez 10]. Disponível em: https://www.arca.fiocruz.br/handle/icict/57273.
https://www.arca.fiocruz.br/handle/icict... , which aimed to analyze the implementation of the PNSI-LGBT, with an emphasis on mental health, from the perspective of municipal health managers in Resende, in the state of Rio de Janeiro.

Methodology

This is exploratory research, with a qualitative approach, which incorporates social phenomena considering meanings, attitudes, intentions, beliefs, values and human aspirations to understand and interpret reality¹⁷17 Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. São Paulo: Hucitec; 2004.,¹⁸18 Minayo MCS. Análise qualitativa: teoria, passos e fidedignidade. Ciênc. saúde coletiva. 2012; 17(3):621-626.. To process the data produced, the Content Analysis method was used, in the thematic perspective of Minayo¹⁷17 Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. São Paulo: Hucitec; 2004.. The author proposes another way of carrying out content analysis that does not focus so much on quantitative aspects, but rather on qualitative ones, valuing more the themes that appear in the discourse, organizing them in a way that allows their interpretation.

The notion of the Unified Social Assistance System (SUAS), from 2008, was adopted, cited by Ferreira¹⁹19 Ferreira SS. NOB-RH Anotada e Comentada. Brasília, DF: MDS; Secretaria Nacional de Assistência Social; 2011.⁽³⁵⁾, for whom management “is composed of the association between the domain of technical knowledge and the capacity for innovation, aligned with democratic principles of public management”.

Carneiro and Menicucci²⁰20 Carneiro R, Menicucci TMG. Gestão pública no século XXI: as reformas pendentes. Rio de Janeiro: Fiocruz, Ipea, Ministério da Saúde, Secretaria de Assuntos Estratégicos da Presidência da República; 2013.⁽¹³⁶⁾, state that public management

The National Labor Management Policy (NOB/RH-SUS)²¹21 Brasil. Ministério da Saúde, Conselho Nacional de Saúde. Princípios e diretrizes para a gestão do trabalho no SUS (NOB/RH-SUS). Brasília, DF: Ministério da Saúde, Conselho Nacional de Saúde; 2005. states that it is the function and responsibility of the management team, be it made up of secretaries, superintendents, directors and/or coordinators, to think about the dimensions of public policies, prepare diagnoses of demands of the population based on the data produced by the services, plan, execute, monitor and evaluate the actions developed by these services, in a dynamic and integrated way.

We chose to interview managers and collect public municipal management documents as methodological strategies as they were considered key elements in the implementation of the PNSI-LGBT. Document analysis allowed the political agenda to be taken into account and, through interviews, to obtain the vision of the implementers. In addition to these professionals being responsible for developing policies, they must also encourage the production of data for their preparation; and, even more, they need to organize care and provide training for professionals who will transform political guidelines into actions.

The following documents were collected: Municipal Multi-Year Plan and Action Plan prepared in the periods 2014-2017 and 2018-2021, seeking to identify programs, projects and actions with LGBTQIA+ themes. The interview script was divided into three blocks: the first comprised questions regarding the sociodemographic and occupational characteristics of the interviewees; the second covered knowledge about PNSI-LGBT, information about the profile of the LGBTQIA+ population, health care network and service data; and the third dealt with the operational plan, municipal actions and resources, policy dissemination and ongoing education to qualify the network.

The interviewees were municipal managers in charge of the following positions and functions: two nurses from the Mental Health Superintendency and five mental health service coordinators. They worked in the following sectors: Mental Health Outpatient Clinic, Psychosocial Care Center (Caps), Psychosocial Care Center for alcohol and other drugs (Caps-ad), Psychosocial Care Center for Children and Youth (Capsi), Mental Health Bed, Therapeutic Residence and LGBTQIA+ Comprehensive Health and Outpatient Clinic (ASI-LGBT).

An individual meeting was held with each participant, with the duration of the interviews varying from 20 to 50 minutes. In order to preserve anonymity, to publish the results, the names of the participants were coded by the names of Non-Governmental Organizations representing LGBTQIA+ social movements in Brazil: Brazilian Association of Gays, Lesbians and Transvestites, Transsexuals and Intersexes (ABGLT); Bahia Gay Group (GGB); Pink Triangle Group (Triângulo Rosa); Rainbow Group (Arco-Íris), Art and LGBTI+ Politics Happens (Acontece); National Association of Transvestites and Transsexuals (Antra) and Volta Redonda Without Homophobia (VRSH).

The study followed the parameters and guidelines for carrying out research involving human beings, approved by the Research Ethics Committee of the Sergio Arouca National School of Public Health, in accordance with opinion nº 5,269,609.

Based on the assumption that the PNSI-LGBT had not been implemented in the municipality, the interpretation of the results sought to interrelate the document analysis, the interviews and the theoretical framework. The analysis was based on two main thematic categories: i) knowledge about PNSI-LGBT, access and mental health care for the LGBTQIA+ population; ii) continuing education for mental health professionals.

Results

The ‘Little Princess of the Valley’: from coffee barons to the birthplace of Aman

Resende is the oldest municipality in the South Fluminense region. Originally inhabited by the indigenous Puris, in the 18th century, São Paulo colonel Simão da Cunha Gago obtained a license to explore the region in search of gold and precious stones. In 1801, the town became ‘Vila de Resende’, named in honor of the Count of Resende, who was the Viceroy of Brazil at that time. During the 19th century, it became a reference in coffee production; and, in 1848, the town was emancipated as a city²²22 Prefeitura de Resende. História da cidade: conheça Resende. Resende: Prefeitura Municipal; 2023. [acesso em 2023 dez 13]. Disponível em: https://resende.rj.gov.br/historia.
https://resende.rj.gov.br/historia... .

From 1870 onwards, the locality suffered from the exodus of coffee producing families for two reasons: prohibition of the slave trade in 1850 and low land production due to excessive use, making cultivation expensive. Thus, there was a devaluation of real estate that attracted immigrants from Minas Gerais who settled with their cattle in abandoned coffee plantations. At the beginning of the 20th century, the livestock cycle began in the region, which led Resende to produce a third of the dairy production, becoming the second producer of cheese and butter in the state of Rio de Janeiro²²22 Prefeitura de Resende. História da cidade: conheça Resende. Resende: Prefeitura Municipal; 2023. [acesso em 2023 dez 13]. Disponível em: https://resende.rj.gov.br/historia.
https://resende.rj.gov.br/historia... .

The 1940s and 1950s were important for the municipality, not only due to the expansion of industrialization, but due to two events: the installation of the Agulhas Negras Military Academy (Aman) and the inauguration of the Presidente Dutra Highway. Resende is located at a strategic point on the stretch that connects the capital of Rio de Janeiro to the state of São Paulo. Furthermore, if the city was historically inhabited by masters and slaves, after the installation of Aman in 1944, the municipality became known for the arrival of the military²²22 Prefeitura de Resende. História da cidade: conheça Resende. Resende: Prefeitura Municipal; 2023. [acesso em 2023 dez 13]. Disponível em: https://resende.rj.gov.br/historia.
https://resende.rj.gov.br/historia... .

Resende then became divided between military and civilians, with the military now having better salaries, better homes, greater access to goods and services and public policies in relation to the majority of the population. The municipality currently has 129,612 inhabitants and a total area of 1,099.336 km², of which 67 km² belong to the Brazilian Army²³23 Instituto Brasileiro de Geografia e Estatística. Resende. [Rio de Janeiro]: IBGE; 2023. [acesso em 2023 mar 13]. Disponível em: https://cidades.ibge.gov.br/brasil/rj/resende/panorama.
https://cidades.ibge.gov.br/brasil/rj/re... . Currently, GDP per capita is R$61,373.00; and the city’s economy is based on industrial activities, with emphasis on the metalworking and chemical-pharmaceutical sectors. In addition, the city is home to the only uranium enrichment factory and is the second largest automobile hub in the country²²22 Prefeitura de Resende. História da cidade: conheça Resende. Resende: Prefeitura Municipal; 2023. [acesso em 2023 dez 13]. Disponível em: https://resende.rj.gov.br/historia.
https://resende.rj.gov.br/historia... ,²³23 Instituto Brasileiro de Geografia e Estatística. Resende. [Rio de Janeiro]: IBGE; 2023. [acesso em 2023 mar 13]. Disponível em: https://cidades.ibge.gov.br/brasil/rj/resende/panorama.
https://cidades.ibge.gov.br/brasil/rj/re... .

The brief history of the city and its mode of development sought to demonstrate that Resende is a municipality marked by ‘militarization’ with the implementation of the Army Higher Education School. Therefore, it is important to emphasize the conservative culture that characterizes local society, with a preponderance of traditional moral values and cis-heteronormative principles.

The context: the mental health care network and the research subjects

The municipality of Resende has a health network formed by two Emergency Care Units (UPA 24h), three urgent and emergency care services and a municipal hospital specialized in emergency care with nine ICU beds and a hemonucleus, 35 units of basic care services, including 32 Basic Family Health Units, a Health Academy, a Street Clinic and an Adolescent Assistance Center, in addition to 12 specialized care services.

The city has a total of 301 hospital beds, 195 of which are public and 106 private. However, of this total, only 10 beds are intended for people undergoing treatment for mental disorders, 5 of which are male, 4 female and 1 bed for children and adolescents. Regarding the network of specialized mental health care services, there is a Mental Health Outpatient Clinic, a Caps-ad, a Capsi, a Caps, a Therapeutic Residence and 10 beds for patients in crisis in the municipality.

During the development of the research, ASI-LGBT was inaugurated, a municipal service currently administered by the mental health superintendency that offers hormonal and gender reassignment treatment for transgender people. The service’s technical staff was made up of five professionals: two social workers, two psychologists and an endocrinologist. All professionals are assigned to other services and share their workload in the outpatient clinic. Furthermore, the physical space is also shared with another service. According to the managers, because it was an outpatient clinic in the implementation phase and because it did not receive funding beyond the municipality, it did not yet have administrative workers, a contact telephone number, and appointments needed to be made via email.

In this research, seven mental health professionals were interviewed: six were in the role of managing mental health services, and one was in the role of managing the ASI-LGBT. The interviewees were a nurse managing the mental health superintendence; and six professionals at the service management/coordination level – four psychologists, a social worker and a nurse. The sociodemographic and occupational characterization of the interviewees is presented in table 1.

The coordinators participating in the research entered, for the most part, through a public exam and had worked for more than two years in a management position (taking into account previous experiences), with the aim of acquiring qualifications and differentiated profiles to work in their professional field. All professionals interviewed took postgraduate courses, and two/two had a master’s degree. It was possible to observe that female, white professionals predominated, with an average age of 47 years (minimum of 37 years and maximum of 58 years), and only three of the seven interviewees declared that they had a religion.

As seen in table 1, all interviewees reported being cisgender men or women, the majority of whom had a heterosexual orientation. The fact that there is no coordination with non-binary gender identity or non-heterosexual sexual orientation deserves consideration. In this context, the lack of people occupying management positions with a different gender identity or sexual orientation could signal barriers to accessing a career in the public service, reinforcing evidence about prejudice and/or schooling difficulties faced by the LGBTQIA+ population, making so that the vast majority do not even complete primary or secondary education.

Several studies address the main reasons that lead Brazilian LGBTQIA+ students to interrupt their studies, such as social inequalities, rights violations, negligence, violence, social, economic and emotional vulnerability, as well as discrimination²⁴24 Alves CER, Moreira MIC. Do uso do nome social ao uso do banheiro: (trans)subjetividades em escolas brasileiras. Cad. Psic. 2015; 19(3):59-69.,²⁵25 Lima T. Educação básica e o acesso de transexuais e travestis à educação superior. RIEB. 2020; (77):70-87.,²⁶26 Associação Brasileira de Lésbicas, Gays, Bissexuais, Travestis e Transexuais, Secretaria de Educação. Pesquisa Nacional sobre o Ambiente Educacional no Brasil 2015. Curitiba: ABGLT; 2016.. In 2016, the National Survey on the Educational Environment²⁷27 Abramovay M, Castro MG, Waiselfisz J. Juventudes na escola, sentidos e buscas: Por que frequentam? Brasília, DF: Flacso - Brasil, OEI, MEC; 2015., carried out by ABGLT, revealed that 60.2% of Brazilian students of both sexes said they felt unsafe at the educational institution because of their sexual orientation, and 42.8% felt unsafe due to the way they expressed gender.

A fifth of LGBTQIA+ students (21.7%) who used to hear LGBTphobic comments at the educational institution reported that these comments were made by the majority of their peers. More than two-thirds (69.1%) of students reported that they had heard LGBTphobic comments made by teachers or other staff. Moreover, the survey ‘Youth at school, meanings and searches: why do they attend?’²⁷27 Abramovay M, Castro MG, Waiselfisz J. Juventudes na escola, sentidos e buscas: Por que frequentam? Brasília, DF: Flacso - Brasil, OEI, MEC; 2015. indicated that 19.3% of public school students would not like to have a transvestite, homosexual, transsexual or transgender classmate.

Knowledge of mental health managers about PNSI-LGBT, actions and practices

Regarding the difficulties of implementing the PNSI-LGBT in Brazil, studies highlight the lack of knowledge about the policy, LGBTphobia, stigma, prejudice and discrimination, in addition to the lack of preparation of health professionals to welcome and serve this population²⁸28 Avellar CCC, Rodrigues FB. Avanços e barreiras na implementação da política nacional de saúde integral da população LGBT: uma revisão integrativa. J. Educ. Sci. and Health. 2023; 3(3):1-11.,²⁹29 Oliveira RP, Souza Júnior MAF, Silva IFP, et al. Política Nacional de Saúde Integral LGBT e sua instrumentalização na atenção primária do SUS: uma revisão sistemática. Braz. J. Health Rev. 2023; 6(1):3907-3927.,³⁰30 Prado EAJ, Sousa MF. Políticas Públicas e a saúde da população LGBT: uma revisão integrativa. Tempus (Brasília). 2017; 11(1):69-80.. Corroborating this statement, the majority of municipal mental health managers in Resende reported that they did not know PNSI-LGBT in depth. Only GGB, Antra and VRSH stated that they were studying the policy with the aim of implementing it in their services. In the understanding of the other participants, this task would be more the responsibility of the ASI-LGBT coordination, and this, in turn, would have the function of disseminating it to the other services.

There was no perceived concern on the part of the management team with the dissemination of the PNSI-LGBT, since, at the time of the interview, the policy established in 2011 had not been publicized, not even to mental health service professionals. Triângulo Rosa reported that a conversation took place with the professionals who would be part of the ASI-LGBT, with the aim of introducing the topic and discussing the new outpatient clinic with the team. However, there was no continuation of the action. Antra stated that, on its own initiative and at the request of the team under its coordination, a conversation took place with an external professional about assistance to the LGBTQIA+ population, but there was no continuity either.

The literature indicates the need to disseminate policy, raise awareness and educate professionals regarding the health and rights of LGBTQIA+ people; the inclusion of gender identity and sexual orientation requirements in forms, medical records and information systems; the establishment of specific standards and service protocols for lesbians, transsexuals and transvestites; the guarantee of sexual and reproductive rights; the implementation of protocols for reception and care for mental health and against violence, among other actions³¹31 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.,³²32 Silva ACA, Alcântara AM, Oliveira DC, et al. Implementação da Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais, Travestis e Transexuais (PNSI LGBT) no Paraná, Brasil. Interface (Botucatu). 2020; 24:e190568.,³³33 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. Rev. Eletrôn. Comun. Inf. Inov. Saúde. 2020; 14(2):372-385.,³⁴34 Sacramento I, Ferreira V. As identidades LGBT no Brasil: entre in/visibilidades e in/tolerâncias. Rev. Eletrôn. Comun. Inf. Inov. Saúde. 2019; 13(3):444-44 9..

Participants were asked about other activities recommended by the National Mental Health Policy, since the ASI-LGBT is focused only on the process of hormoneization and transsexualization³⁵35 Popadiuk GS, Oliveira DC, Signorelli MC. A Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais e Transgêneros (LGBT) e o acesso ao Processo Transexualizador no Sistema Único de Saúde (SUS): avanços e desafios. Ciênc. saúde coletiva. 2017; 22(5):1509-20.. Questions were asked about action planning for other LGBTQIA+ actors, and not just trans people, as well as about care across the entire health network and specialized mental health services.

After reading and analyzing the Multi-Year Plan and the Operational Plan, no issues related to the health of the LGBTQIA+ population were identified in the political agenda in the last eight years. In addition to the absence of the topic on the municipality’s agenda, it can be said that there is no information on how many people from this community are served by the Unified Health System (SUS) in the city of Resende. Besides, there are no projects or programs nor mention of allocation of resources to carry out specific actions for this population. Through the interviews, it was possible to identify that not even mental health services have specific data and information about the LGBTQIA+ population.

The coordinators of ABGLT, GGB and VRSH informed that this data is only recorded by the recently opened ASI-LGBT service, but that they do not have data from other mental health services. Triângulo Rosa, Grupo Arco-Íris and Acontece Arte e Política reported that there is no information on the patients’ gender identity and sexual orientation in the medical records. Antra stated that there is a gender identity variable with the options ‘male’, ‘female’ and ‘others’. However, the ‘other’ option was never selected by the team’s professionals, therefore, this information remains unknown.

No specific laws, programs or municipal projects were identified to serve the LGBTQIA+ population. When questioning the coordination about the existence of a municipal Operational Plan that included projects and actions aimed at this population and what investments the municipality has made to implement the policy, the majority of interviewees summarized the development of the PNSI-LGBT to the implementation of the ASI-LGBT. According to the participants, the positive side in the city’s current scenario is to transform the outpatient clinic into a service and officially establish it, which will enable the direct transfer of resources and strengthen its operations more fully.

The management team did not seek to adopt the PNSI-LGBT guidelines since, to date, it has not realized the need to produce data to formulate monitoring and evaluation indicators on morbidity and mortality, as well as access for this specific population to comprehensive care, considering establishing priorities and goals in state and municipal health plans. In this sense, the absence of such information makes it difficult to diagnose the health situation, not allowing strategies to be drawn up to combat and eradicate health inequalities, in addition to making intra and intersectoral planning impossible, which could, in this case, add greater effectiveness to actions aimed at equity.

All these problems point to the persistent challenges of implementing the PNSI-LGBT in municipalities³⁶36 Lima RAF, Salgueiro CDBL. Atenção à saúde da população LGBTQIA+ visando o acesso integral aos serviços de saúde. Res., Soc. Dev. 2022; 11(12):e376111234597.,³⁷37 Melo IR, Amorim TH, Garcia RB, et al. O direito à saúde da população LGBT: desafios contemporâneos no contexto do Sistema Único de Saúde (SUS). Rev. Psicol. Saúde. 2020; 12(3):63-78.,³⁸38 Gouvêa LF, Souza LL. Saúde e população LGBTQIA+: desafios e perspectivas da Política Nacional de Saúde Integral LGBT. Periódicus. 2021; 3(16):23-42.,³⁹39 Sena AGN, Souto KMB. Avanços e desafios na implementação da Política Nacional de Saúde Integral LGBT. Tempus (Brasília). 2017; 11(1):9-28.. This apparent lack of interest and discontinuity of actions contributed to non-compliance with the SUS precepts of universality and equity, perpetuates the violation of rights at the institutional level, discourages respect for diversity, leaving it up to common sense and the interest of professionals in seeking knowledge to offer a qualified welcome, without discrimination and prejudice, respecting the individualities of each LGBTQIA+ user. Furthermore, not even managers are aware of the need to meet the specificities of this group in the services under their management, and the majority simply believe that the opening of a specialized service corresponds to the implementation of the policy.

Development of continuing education actions for mental health professionals on LGBTQIA+ topics

A systematic review study⁴⁰40 Bender MS, Sott MK, Gonçalves IF, et al. Saúde da população LGBTQIA+ durante a pandemia da Covid-19. Cadernos GenDiv. 2022; 8(2):166-203. revealed the effects of the COVID-19 pandemic on the LGBTQIA+ population. In addition to increasing barriers to accessing existing health services, the health and humanitarian crisis has increased vulnerability to infection by the new coronavirus. The pandemic context has led to the weakening of social bonds and worsened problems related to mental health, with an increase in rates of psychological distress and mental disorders, such as depression and anxiety, and the use of legal and illicit substances. Thus, the lack of care and respectful reception for these people and the lack of preparation of professionals to meet their particularities and offer qualified care only reaffirm the need for the training of health workers to be prepared to deal with these issues.

Research participants were asked what continuing education actions have been developed for mental health professionals regarding LGBTQIA+ health policy. The professionals’ response was that, for some years, there has been no permanent education policy for the mental health network on the part of management, with service coordinators being responsible for these initiatives in isolation, depending on the needs and difficulties presented. This fact can be noted in the speech of Acontece, when asked ‘How often does mental health management carry out ongoing education actions for service professionals?’.

Furthermore, he added that, even previously, when there was greater investment in continuing education, the health of the LGBTQIA+ population was not addressed in these processes, being only included in isolated actions, such as lectures or seminars. He also stated that now, after the operation of the ASI-LGBT, there is greater visibility of this issue.

It is known that health professionals have little information related to the historical, political and social context that involves the health-disease-care process of the LGBTQIA+ population. Moreover, there is a stigmatizing rationality⁴¹41 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., influenced by the pathologization of sexuality by professionals, which links the identity of LGBTQIA+ people to the notion of a risk group and associates this with a condition that causes diseases, especially STIs/ AIDS and mental disorders, in addition to morally reprehensible behaviors, reproducing in services the prejudice and discrimination present in everyday life.

Negreiros et al.⁴²42 Negreiros FRN, Ferreira BO, Freitas DN, et al. Saúde de lésbicas, gays, bissexuais, travestis e transexuais: da formação médica à atuação profissional. Rev. Bras. Educ. Méd. 2019; 43(1):23-31., in a recent study with primary care doctors, highlighted the deficiencies in the curriculum of health courses and the indispensability of training related to LGBTQIA+ themes. Albuquerque et al.⁴³43 Albuquerque GA, Garcia CL, Alves MJH, et al. Homossexualidade e o direito à saúde: um desafio para as políticas públicas de saúde no Brasil. Saúde debate. 2013; 37(98):516-524. also revealed this difficulty by emphasizing that the topic remains excluded from academic spaces and primary care. It is noteworthy that strategies that aim to discuss health care for these groups must be encouraged to qualify care.

With the implementation of ASI-LGBT, there was an initiative to train the team and other professionals coordinating mental health services with the aim of becoming multiplier agents for other SUS services. Despite there not being an Action Plan, the interviewees reported that dialogue had begun with the municipality’s primary care network through matrix support and conversation circles, but, until that moment, it was not possible to reach the professionals who work in the services specific for mental health.

Disseminating information, raising awareness and training on the health of the LGBTQIA+ population should constitute strategic actions and contribute to the formulation of the PNSI-LGBT municipal operational plan³⁰30 Prado EAJ, Sousa MF. Políticas Públicas e a saúde da população LGBT: uma revisão integrativa. Tempus (Brasília). 2017; 11(1):69-80.,³⁹39 Sena AGN, Souto KMB. Avanços e desafios na implementação da Política Nacional de Saúde Integral LGBT. Tempus (Brasília). 2017; 11(1):9-28.,⁴⁴44 Calazans GJ, Amador SM, Beretta GR, et al. A experiência de implantação da Política de Saúde Integral para Lésbicas, Gays, Bissexuais, Travestis e Transexuais (LGBT) no município de São Paulo. BIS, Bol. Inst. Saúde (Impr.). 2018; 19(2):105-115.. It is understood that continuing education is essential for the quality of services provided to the population, making it necessary for management to promote educational practices for managers and health workers and for social control. Education must be included in the routines of health services to end prejudice against LGBTQIA+ people, always with the concern of combating oppression and discrimination based on gender, sexual orientation, race and other social markers.

Despite stating that the ASI-LGBT team will be the multiplier of health actions for other services, no intra or intersectoral proposals were identified to fulfill the policy’s objectives, observing isolated actions. In addition to the absence of an Operational Plan, the lack of intersectoral committees whose objective is to think about and develop municipal projects or programs for the LGBTQIA+ population in the government structure is highlighted, the first step towards implementing a public policy in the municipality⁴⁵45 Ferreira BO, Nascimento M. A construção de políticas de saúde para as populações LGBT no Brasil: perspectivas históricas e desafios contemporâneos. Ciênc. saúde coletiva. 2022; 27(10):3825-3834.,⁴⁶46 Souza MBCA, Helal DH. Política nacional de saúde integral de lésbicas, gays, bissexuais, travestis e transexuais: análise descritiva e utilização de dados secundários para pesquisa e prática. Bagoas. 2015; (13):221-251.,⁴⁷47 Cardoso MR, Ferro LF. Saúde e população LGBT: demandas e especificidades em questão. Psicol. Ciênc. Prof. 2012; 32(3):552-563..

Final considerations

The suffering and mental illness of the LGBTQIA+ population is a topic of great relevance, already demonstrated by several studies. Twelve years after it was established, a low level of implementation of the PNSI-LGBT was identified in the municipality of Resende, today reduced to the implementation of an outpatient clinic responsible for the hormone therapy and transgenitalization process. In general, the bet is that, with the functioning of the ASI-LGBT, its institutionalization and greater contribution of resources, it will be a driver of policy.

Although it was not the object of the study, talking about social control is essential for the defense of rights and emancipation of subjects. The actions of LGBTQIA+ movements in Health Councils and other spaces for social participation could put pressure on public management to include diversity in the political agenda. In this way, it is expected that this study will contribute to the reflection of managers, health workers and the general population on the importance of implementing the PNSI-LGBT in the municipality of Resende, strengthening the fight for LGBTQIA+ people to have the right to full citizenship.

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