Bioethical implications in health care for the LGBTT public

The aim of this study was to analyze academic publications regarding actions of health care for lesbians, gays, bisexuals, transvestites and the trans gender (LGBTT), in a focus of principialist bioethics. The methodology employed was trial design, in which the data gathered were divided into two sets: academic productions, and documents standardizing LGBTT health policy in the Single Health System (SUS). The studies showed that beyond the the actions aimed at the health of LGBTT, there exist prejudice and discrimination, requiring a new examination of ethical and bioethical interaction between the professional and the user. Thus professional performance based on principialist bioethics may be considered a way of overcoming values judgments on the part of health professionals, helping better pursue the integral nature of care.

Bioethical implications in health care for the LGBTT public http://dx.doi.org/10.1590/1983-80422015232078 Homosexuality is a question that is often discussed these days, but its socio-historic context springs from concepts and debates that date back to antiquity.The main focus of this discussion always fell upon masculine homosexuality, the reason being, perhaps, of the greatest social importance of the sex in ancient societies.
With the advent of Christianity, religion impregnated with Jewish-Hellenistic inheritance, sexual intercourse between two men was called "sodomy," coming to be understood as one of the sins contra naturam, in that it was against the nature fixed by God, along with masturbation and sexual intercourse with animals.In this classification, sodomy was the nefarious sin, the most serious of all 1 .
In the 19th century, with the discourse of psychology and psychiatry, the term "sodomy" is substituted for the name "homosexuality", which came to be seen as a psychiatric deviation, pathologic, mental disturbance or, in the words of Foucalt, a kind of interior androgyny, a hermaphroditism of the soul that should be treated 2 .It was only on the 17 th of May of 1990, that the World Health Organization (Organização Mundial da Saúde -OMS) removed homosexuality from the International Classification of Diseases (Catálogo Internacional de Doenças), reducing the pathological nature of homosexuality and adopting the nomenclature "homosexuality" 3 .
In contemporary times, homosexuality is many times thought of as an option, that is, of individual choice, whereas heterosexuality is analyzed as something innate and natural.Destabilizing such ideas requires a challenge capable of breaking with the heteronormative culture, to which the prerogative is given to establish the label of what is "certain" and "wrong" in the exteriorization of sexuality 4 .That is, such a challenge implies deconstructing the notions of "normal" and "abnormal", those which persist as elements of anchoring of the social imagery that attaches this new classification 2 , having seen that, at all times, and probably in every culture, sexuality was part of a constraints system [...] in consequence and degradation, between health and illness, normal and abnormal 5 .
In Brazil, one of the first organized movements that has been registered in the fight against prejudice in relation to homosexuals was the Homosexual We Are Affirmation Group (Grupo de Afirmação Homossexual Somos -SP), which had its first social participation in 1979 6 .In 1983, the Gay Group of Bahia (Grupo Gay da Bahia -GGB) was registered as a non-profit civil society 7 ; a decade later, in Rio de Janeiro, the Rainbow Group (Grupo Arco-Íris) 8 , was officially founded, and in 1985, the Support and Prevention of Aids Group (Grupo de Apoio e Prevenção à Aids -Gapa) 9 , was created in São Paulo, just to cite some very active groups in the period.Today there are 12 entities registered which act at the national level in the defense of human rights of lesbians, gays, bisexuals, transvestites and transgender (lésbicas, gays, bissexuais, travestis e transexuais -LGBTT), as well as another 92 regional institutions spread across the country 10 .
In these little over 30 years, the movements of the LGBTT population has been concentrated in the combat against discrimination and prejudice, especially homophobia, as well as the prevention of the incidence of Human Immunodeficiency Virus (vírus da imunodeficiência humana -HIV) and Acquired Immunodeficiency Syndrome (síndrome da imunodeficiência adquirida -AIDS) as much in the gay community as the in the general population.Apart from the combat against homophobia, also contributing to the consolidation of these groups was the rise of the HIV/AIDS epidemic, which in the 1980's struck this segment of the population in an accentuated manner.
Lately, such movements have intensified, in search of specific strategies for the promotion of health and prevention of grievances among these groups.Gradually, the claims of LGBTT concerning violence, civil union, sexual and reproductive rights, among others, are advancing and making history, so far as to be included in the set of actions of government agendas.In 2004, the program Brazil without Homophobia (Brasil sem Homofobia) was launched by the Ministry of Health, by the National Council on the Combat of Discrimination and by the Special Secretary of Human Rights (Conselho Nacional de Combate à Discriminação e pela Secretaria Especial dos Direitos Humanos -SEDH), the combat of violence and discrimination against GLTB and the promotion of homosexual citizenship 11 .Subsequently, the federal government signed the Decree of the 4 th of June of 2010, instituting the 17 th of May as the National Day against Homophobia (Dia Nacional de Combate à Homofobia) 12 .
In the recognition of these struggles for rights and acceptance of peculiarities in serving the LGBTT public specifically with regard to the health-disease process, there are the propositions of the 12 th and 13 th national health conferences, taking place in 2003 and 2007, respectively, which brought to the agenda issues related to the rights of the LGBTT population, in presenting sexual orientation and gender identity as themes for analysis of the social determination of health.It is worth noting the in-Bioethical implications in health care for the LGBTT public http://dx.doi.org/10.1590/1983-80422015232078troduction of the transexualization process, by the Ministry of Health, in the framework of the Single Health System (Sistema Único de Saúde -SUS) 13 .
In the year 2010, in line with the agendas of these conferences, the Ministry of Health presented the National Policy of Integral Health of Lesbian, Gay, Bisexual and Transgender (Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais, Travestis e Transexuais -LGBTT), laying down guidelines for integral care for these population groups 14 .Among these guidelines, it is worth mentioning the awareness of professionals in the process of continuing education regarding the rights of LGBTT; the guarantee of sexual and reproductive rights, and the establishment of the norms and protocols of specific services for lesbians and transvestites 15 .
In this context the struggles and achievements of the LGBTT groups -more precisely in relation to what was reached in the area of health -, an important issue emerges, which concerns the conduct of health professionals facing sexual diversity.Despite the influence of various secular philosophies on the exercise of health science professionals, a major part of their behavior is still based on values tied to their socio-historic context of socialization, which molds thinking and action in society.Just as with other forms of social discrimination, homophobia does not occur in an isolated manner; it walks alongside and is reinforced by machismo, by racism, by misogyny and by all related forms of intolerance 15 .
In contrast to these activist standards, professional codes of ethics prescribe that, in the exercise of his function, the professional must refrain from any kind of value judgment of the relationship between himself and the user 16 .Considering this maximum from the principlist bioethics model 17 , making evident the importance of training the health professional to introduce, in everyday practice, the four fundamental principles -beneficence, justice, non-malificence and respect for autonomy -, by making them indispensable in the encounter between those who provide service and those who use it 16 .
The literature review undertaken for the preparation of this article has demonstrated the scarcity of academic production concerning health care issues of the LGBTT universe, especially when taking into account its ethical aspects.It is necessary, thus, to deepen the knowledge of this line of reflection, as well as disseminate within the professional environment the instruments used to promote the guarantee of rights of this population, once this public is considered priority in the political strategies of the Ministry of Health.In this context of bioethical commitment to health care of the society and, specifically, the LGBTT population, this study aims to analyze the academic publications about the health care activities of LGBTT with a focus on principalist bioethics 17 .

Method
As a methodological resource, it was anchored in form of an essay, given the understanding that this methodology of academic work makes it possible to scrutinize and examine the issue at hand, in order to analyze it in depth and propose questions.Thus, it can characterize the test as a well-developed study, formal, discursive and conclusive, consisting of logical and reflective exposure and rigorous reasoning with a high level of interpretation and personal judgment 18 .
The issue that gave rise to this study grew out of discussions, experiences and involvement of the authors with the subject matter in the Study and Research Group on Gender and Sexualities of the Southwestern State University of Bahia (Grupo de Estudo e Pesquisa em Gênero e Sexualidades da Universidade Estadual do Sudoeste Bahia -Uesb), as well as the reflections within a Bioethics course in Graduate studies in Nursing and Health, of the same institution.For the development of the argument, it was necessary to address and analyze as much the academic production related to health care services for LGBTT, during the period from 2008-2012, as the Ministry of Health documents containing the prerogatives of the law and access to the health of this population.
As a first set of data (Table 1), 119 articles available in the Virtual Health Library (Biblioteca Virtual em Saúde -BVS) were selected.As criteria for inclusion, full texts were adopted in Portuguese, available in their entirety, published in the period of 2008-2012 and whose descriptors were "homosexuality", "health policies", "National Health System", "ethics" and "health" and combinations thereof.After the first assessment, which took into account the title and its relation to the theme, there were 50 articles remaining.In a second filtering process, by reading of the abstracts, there were 21 articles remaining, of which after a thorough reading of each text -guided, once again, by the proposed objective -, seven works were selected, which made up the body of this study.
The second set of documents (Table 2) was composed of standardizing instruments of public policies for the LGBTT public, and other legal frameworks that address the rights of the SUS users.Principles of the application of the international legislation of human rights in relation to sexual orientation and gender identity

Results and Discussion
As it is known, we live in a patriarchal social structure, marked by values grounded in moral principles that do not take into account the autonomy of the human being.Among these values are those based on the exclusive acceptance of sexual inter-course that allows affective expression between people of the opposite sex.In this context, the homosexual appears to be destabilizing the current standard, occupying, in different scenarios, a marginal position in society, a place of abject, that is, that which is not subject: The abject designates here precisely those areas "inhospitable" and "uninhab-Bioethical implications in health care for the LGBTT public http://dx.doi.org/10.1590/1983-80422015232078itable" of social life, which are, however, heavily populated by those who do not enjoy the status of subject, but whose dwelling under the sign of "uninhabitable" is necessary so that the subject domain is circumscribed 30 .
For centuries, the Western world saw homosexuality as an abominable sin, perversion, deviance and crime, which subjected homosexuals to cruel and inhumane treatment 20 .Some recent historical facts contributed so that the practice of homosexuality would acquire yet more unfavorable connotations.Many times the world scene corroborated to consolidate the negative social imagery with regard to homosexuality and/or homosexual behavior.As an example relevant to this construction, is taken from the Second World War, in which the action that Hitler incited, among other things, the look of disgust upon homosexuals.Proof of this is that in the fall of 1933, many homosexuals were sent to Nazi concentration camps and, there, castrated and kept in the regime of forced labor 31 .As reported by Fry and MacRae, they were marked with a pink triangle sewn on their uniforms, they not only suffered persecution and violence of their captors, but also from other prisoners, and to this day, when talking about the victims of the concentration camps, they are systematically excluded 32 .
Decades later, already in the 1980s, the genesis of the emergence of HIV/aids, negatively associated with homosexuals, further contributed to the mistaken perception of homosexuality and health issues of this population.The "Guide to prevention of STD/AIDS and citizenship for homosexuals", from the Ministry of Health ("Guia de prevenção das DST/ aids e cidadania para homossexuais", do Ministério da Saúde), informs that since the emergence of AIDS in the early 1980s, homosexuals were the population group most affected by the epidemic around the world 33 .
Associating different factors, ranging from behavioral characteristics to lifestyle, the risk and the vulnerability of male and female homosexuals in the face of HIV infection were significantly accentuated by the lack of information, stigma and prejudice of society 34 , giving rise to a number of violations, including extra-judicial killings, torture and ill-treatment, sexual assault and rape, invasions of privacy, arbitrary detention, denial of employment and education ... and serious discrimination in relation to the enjoyment of other human rights 35 .
In this sense, it is worth noting the formulation, in 2006, of The Yogyakarta Principles, representing a milestone of the LGBTT population's rights inter-nationally.In this document, which deals with the application of international legislation of human rights relating to sexual orientation and gender identity, it is stated that all human beings are born free and equal in dignity and rights, that all human rights are universal, interdependent, indivisible inter-related 29 .
The recognition of the right to sexual orientation and gender identity is essential to the dignity and humanity of every person, and no difference should be the cause for discrimination or abuse.Based on the principle of autonomy -understood as the ability of a person to decide to do or to look for that which is judged to be best for himself -, all forms of discrimination can be seen as a violation of a person's rights (or the citizen/user) of making his choices 29,36 .
The Federal Constitution of 1988 states, in its 5th article, that all are equal before the law, without distinction of any kind, guaranteeing to Brazilians and foreign residents in the country the inviolable right to life, liberty, equality, security, and property 25 .Similarly, Law 8,080, or the Organic Health Law of 1990, subscribes that public health actions and services will be conducted in accordance with the principle of universal access to these services at all levels of care.Thus, both documents ensure non-discrimination of any nature in public health services 26 .
Silva e Nardi 22 draw up a counterpoint to the provisions of the Federal Constitution, when they affirm that there are people who, in providing and adopting a certain condition of existence and expression of sexuality, as in the case of sexual orientation, are treated unequally, if compared to others in the same situations and locations -making them victims of discrimination.This analysis leads to reflection on the principle of justice, which, according to the authors, is guided by fairness and the sharing of common goods and resources.Such a conception of justice implies the guarantee of the same opportunities for access to public goods such as health services, for example 25,26 .
In an attempt to broaden and strengthen the exercise of citizenship in Brazil, the federal government, through the Ministry of Health, launched in 2004 the aforementioned program Brazil without Homophobia 11 , recognizing the trajectory of thousands of Brazilians who, since the late 1970s have dedicated themselves to the struggle to ensure the guarantee of human rights for homosexuals.This program can be considered a milestone in the fight for the right to dignity and respect for differ-Bioethical implications in health care for the LGBTT public http://dx.doi.org/10.1590/1983-80422015232078ence.Two years later, in 2006, another instrument which prohibits and/or inhibits various forms of discrimination, including sexual orientation, in health services was approved: the Charter of SUS User's Rights (Carta dos Direitos dos Usuários do SUS), which in its third principle ensures the citizen friendly service, free from discrimination, aiming at equal treatment and for a more personal and healthy professional-user relationship 28 .Subsequently, in 2008, in discussing care for the LGBTT population, the Ministry of Health stressed the importance of addressing the factors that act negatively on the determinants of health 15 .
According to this last document, the country's population will only reach adequate levels of health through the articulation of all sectors committed to the fostering and promotion of social policies, in such a way as to generate an effective interference on the determinants of the health-disease process.Facing the complexities of these factors of life and health of people and communities requires intervention in situations like social exclusion, unemployment and access to housing and food.For this, it is also necessary to recognize the factors that intersect, maximizing the vulnerability and suffering of specific groups 15 .
Considering this perspective, in 2010, the Brazilian government created the National Integral Health Care Policy of LGBTT (Política Nacional de Saúde Integral de LGBTT), which, in addition to seeking to transcend the paradigm of non-acceptance of inequalities in health care services, intended to address SUS principles, that is, promote integral health care for lesbians, gays, bisexuals, transvestites and transgender, eliminating discrimination and institutional bias, and contributing to the reduction of inequalities and the consolidation of SUS as a universal system, integral and equitable 14 .This proposal, proved as admitting the existence of prejudices and limitations in the treatment of SUS professionals in dealing with their relations with the LGBTT public, stimulates changes in all levels of care services.
Based on the analysis of this government policy, it seems that its genesis lies beyond the issues that guide health actions or services to this population.It can be affirmed that its most significant consequence is in the transformation of social image, in the overcoming of prejudices that permeate life and social relations and markedly befall this public.According to Lionço, comprehensive health care for this population requires the redimensioning of sexual and reproductive rights, demanding the denaturalization of sexuality and its manifestations, as well as the refusal of the medicalization of sexuality that tends to regulate the expression of human sexuality according to heteronormative logic and linearity in the determination of sex on gender 37 .This perspective assumes that any form of discrimination is a limiting factor of health and promoter of disease, including homophobia itself.Borrilo 38 affirms that homophobia is understood as contempt for and rejection of not only people who identify themselves as homosexuals, but also homosexuality itself and other expressions of sexual and gender diversity (such as bisexuality, transvestitism, and transgender) which flee from the so-called norm and "natural order" (heterosexuality), hence seen as threatened or destabilizing.In contrast, heteronormality is considered as a principle comprising heterosexuality as a legitimate, true and natural expression of sexuality.
Miskolci 39 and Valadão and Gomes 21 claim that these prejudices, historically widespread in Western societies, contribute to consolidating the unpreparedness of health care professionals to deal with sexual diversity, since, throughout their training, they are not taught how to deal with the subject in an open and unbiased way.This deficiency impairs the professional-user relationship, because it inhibits free expression of gays and lesbians when talking with these specialists about their sexual orientation and, with that, ultimately creates barriers in care production relationships 21,39 .Thus, producing the change proposed by the National Integral Health Care Policy of LGBTT requires a rereading of the thoughts and ethical attitudes of the health care professional, with the aim of guaranteeing proper health care to the population, among which is the LGBTT community 33 .In this sense, taking discrimination as an illness factor, the acting of health care professionals should be guided by the principle of non-violence, in other words, not causing intentional prejudice against users, even considering the presupposition that, in any diagnostic or therapeutic action, there is a risk of generating some harm 36,40 .
When analyzing the professional action from the principle of autonomy, it is possible to understand that this notion contradicts forms of coercion and repression.Such a principle is ethically based on the dignity of the human being 16 , in such a way that disrespecting the autonomy of the people means to disregard their judgments, denying them the freedom to act according to their principles 40 .Thus, the imposition of heterosexuality as a social standard of sexual behavioral can hurt the autono-Bioethical implications in health care for the LGBTT public http://dx.doi.org/10.1590/1983-80422015232078my of the other, as it already impedes the person from acting according to what he judges as best for himself, even when what it is about an aspect of his life considered intimate, obligating him to adopt the standard that the culture and society understand as "correct".
In this regard, it should be noted that any change in the symbolic structures of society involves the perception, by understanding and acceptance of otherness.Understanding is a crucial factor in the relations between human beings.Morin 41 highlights the importance of working on the ethics of understanding as a way of broadening the possibilities of understanding among men.For the author, understanding necessarily includes a process of empathy, identification and projection.It is always inter-subjective and demands openness, sympathy and generosity 42 .With the information broadcasting devices for the media, it was never as easy as today to have available so many channels of promotion of dialogues.It is necessary, therefore, to take advantage of these means to foster changes, rather than consolidate stereotypical and discriminatory views.
The analysis of the Charter of Rights of the Users of SUS makes evident the guarantee for all citizens the right to health care in the network of health services.This implies providing humanized assistance, free from any discrimination, restriction or negation in relation to age, race, color, ethnicity, sexual orientation, gender identity, genetic characteristics, socio-economic conditions, health status, being a carrier of an infectious disease or a person living with a disability 28 .The document also indicates the need to promote transformations in the way of thinking and acting of health care professionals, which, given their importance and function in all levels of the healthcare network, are a natural multiplier of these notions for society.
Considering that the reformulations of the health care networks for better service to the LGBTT population depend on the transformations of the attitude of the professionals that act on them, Cardoso and Ferro 24 claim that one of the ways to promote such changes in health care services is the questioning of heterosexuality as standard sexual orientation.According to the authors, the SUS, is in its search for universality, embraces new specifications of population segments every day.It is in facing this diversity that the principle of beneficence is rendered by the actions of health care professionals, once its adoption implies contributing to the well-being of the patient, acting on behalf of the user 36 .
From an ethical point of view, it is known that health care professionals must refrain from expressing any form value judgment in their relationship with the user.In this sense, moral and religious character of judgments, as well as being counterproductive in clinical work, especially (but not only) with the LGBT population (...) generally inciting stigmatization and discrimination, thus constituting another form of prejudice; with the difference that come masked behind a pseudo-scientific-neutrality 43 .
Homosexuality, in breaking with that which is taken as normal and socially acceptable always raises questions, not only in academia, in search of understanding of its genesis, but also in the relation of this realm to society in general.Perceiving and accepting the different causes some destabilization in people's ideas, especially when it is cast by cultural and social patterns without the worry of launching a new examination of what is simply considered different.Thus, service to the LGBTT community in health services is permeated by socio-cultural dilemmas, given the relationship between the professional and the user represents -a meeting of two different worlds -a fact that would be mitigated by a professional practice based on ethical principles.

Final Considerations
The studies analyzed warn about the existence of situations in which the LGBTT population does not find the due care, which is verified by the judgments and value judgments expressed by health care service professionals.They also signaled that discrimination by sexual orientation is a fact that is manifested in various spaces in society, co-existing institutionally in places of the production of care.These prejudices can be seen as triggers for ethical conflicts in relationship between the professional and the user.The professional practice based on patterns of heteronormativity is presented as a limiting factor in the quality of care, and even associated with illness, the reason for which also it should be considered as the starting point of ethical dilemmas.
Consequently, professional performance based on principalist bioethics can be interpreted as a strategy for the overcoming of value judgments in the conduct of health care professionals, which will contribute to the actions that enable a targeted action for achieving integrality of care for the LGBTT public.
In the present study, while there are articles and legal milestones that address the health of the

Research article
Bioethical implications in health care for the LGBTT public http://dx.doi.org/10.1590/1983-80422015232078 LGBTT population in the Brazilian context, domestic production of experiences that would analyze the questions and/or ethical conflicts in the practice of professionals with regard to the manifestations of sexual diversity could not be found.Thus, it reaffirms the necessity to employ more academic studies about behavioral ethics before the demands of this public in public health services.
Work produced within the framework of the Studies and Research Studies in Gender and Sexualities of the State University of the Southwest of Bahia, Jequié/BA, Brazil.(Universidade Estadual do Sudoeste da Bahia -UESB).

Table 1 .
Description of articles by author, year of publication, objective and research method.

Table 2 .
Description of standard-setting documents, by name, year of publication and feature by level of interest of the LGBTT population 26e Federal Constitution defines, in its 5th article, that all are equal before the law, without any type of distinction, guaranteeing Brazilians and foreign residents in the country the inviolable right to life, freedom, equality, security and property Law 8.080/199026In its Chapter II, "The principles and guidelines", in Section I of the 7th Article, it is stated that the actions and public health services will be conducted according to the principle of universal access to health services at all levels of care