Health of the LGBTI+ Population in Primary Health Care and the Insertion of Nursing

Objective: To reflect on the approaches to the health of the LGBTI+ population, Primary Health Care and Nursing in the care of this population. Method: The reflection is based on a brief characterization of the LGBTI+ population and their health, an analysis of the nurses' work in Primary Health Care (PHC), and a debate about particularities of the nursing care for the LGBTI+ population in the PHC. Results: The LGBTI+ population is composed of many populations defined by the diversity of gender identity and expression, sexual orientation, and biological sex. In Family Health teams, nurses must know the main demands of this population. The institutional reorientation of PHC imposes new challenges to the enjoyment of the right to health of the LGBTI+ population. Conclusion and implications for practice: Although the National LGBT Health Policy is seven years old, studies are still scarce, foremost in Nursing. Considering that the LGBTI+ population is also under the Nursing responsibility in the PHC, it is up to this professional category to provide integral assistance with a view to minimizing the inequalities suffered by this population.


INTRODUCTION
Gender identity is how a person identifies with the genders, whether male or female, or other non-binary identities, and sexual orientation relates to sexual, affective and emotional attraction to similar, different, or multiple genders. It is still necessary to understand the LGBTI+ population in order to recognize the diversity of gender expression, as in the case of the cross-dresser and queer populations, and the biological sex, as in the case of the intersex population. 1 Among the various acronyms available to characterize the lesbian, gay, bisexual, transgender, and intersex groups, and all other gender identities and sexual orientations, the acronym LGBTI+ will be used in this study to comprehend the multiple possibilities of existence other than cis-heteronormatives, in attention to the terms and definitions about gender and sexual diversities according to the LGBTI+ Communication Manual of the 2018 National LGBTI Alliance. 1 The right to health was recognized as a human right in the Universal Declaration of Human Rights in 1948 and it influenced the constitutional charters of postwar countries. This list includes Brazil, which incorporated health as a social right in the 1988 Constitution, with guarantees of universal and free access to health for the population. Nevertheless, it is observed that there are several problems that generate social exclusion in the field of public health between the legal provision and its effective materialization. 2 Regarding gender and sexual orientation, these have been recognized as human rights by the United Nations and by the Organization of American States, triggering a series of documents that treat the protection and non-discrimination of this population group. 3 Nevertheless, in the health care field, similarly to the case with the general population and after 30 years of the Brazilian Constitution being enacted, inequalities are observed in the access to this fundamental right, mainly for social minorities like the LGBTI+ population. 4 Health care services must have a welcoming environment, free from prejudice, and offer full attention to the LGBTI+ population, with recognition of their specificities in providing the corresponding actions and services. 5 However, the LGBTI+ population is marginalized in health care services because of the prejudice and the stigma imposed upon it which, together to the lack of knowledge on the part of the health care providers and their insensitivity to its needs, entails the provision of poor quality services. 6 In Brazil, the LGBTI+ population is also among the marginalized social minorities with the least access to health care services and does not receive proper assistance in the face of the opinions and value judgments of health care practitioners, whose discrimination exists in several areas of society and also in the places of health care production. 7 In a review study that analyzed productions from 2004 to 2014, non-heterosexual orientation was evidenced to be a determinant factor in the difficulties to access health care services, with recommendations to expand studies and debates on the subject matter, so that there is an appreciation of health care practitioners and of health care services for the LGBTI+ population. 8 Therefore, this article aims to reflect on the health care approaches of the LGBTI+ population, on Primary Health Care, and on Nursing in the care for this population.
The health of LGBTI+ population, Primary Health Care, and Nursing in the care for this population Discussing the particularities and health demands of the LGBTI+ population in Brazil is a big challenge. A review research done after the publication of the National LGBT Health Policy, covering the period from 2011 to 2016 concluded that the history of health care for this population has been linked to the prevention of Sexually Transmitted Infections (STIs). 9 This history contributed to the institutional discrimination and prejudice by the health care practitioners and, even after the Policy, articles on the advances in health care of the LGBTI+ population are scarce. 9 Knowledge of the main demands of the population should guide the practice. For instance, the high rate of violence suffered by this social group, as a result of the LGBTI phobia, should prompt the health care practitioner to investigate possible acts of violence the person may be suffering at family, school, work, or in their community. A study conducted in Italy with 1,000 individuals from the LGBTI+ group evidenced experiences of violence that indicate the need for improvements in the political initiatives to mitigate this situation. 10 Yet another research showed that, when laws on anti-discrimination of minority sex groups (LGBTI+) are applied, there is a synergy with the use of routine health care, which can contribute to the protection of lesbians' and gay men's health. 11 LGBTI+ people that show a gender expression and nonstereotypical behavior can go unnoticed inside the medical offices. Considering plurality and diversity, and that people do not follow a pattern, the anamnesis must be meticulous and expanded, paying attention to the possible human responses and life contexts of each person, and the entire therapy must be based on participation and on respecting the autonomy and the user's life projects by the interdisciplinary reference team and possible supporters. 12 The National Integral Health Policy for Lesbian, Gays, Bisexuals, Transvestites, and Transsexuals brings to the debate the importance of knowing the social determinants of health of the individuals that result directly in their quality of life. 5 However, it draws attention to the fact that the LGBTI+ population is reproducing their lives in the territories, but they are dying. A review study reports that the murders of LGBTI+ people evidence the maintenance of heteronormativity, and especially the elimination of transvestites shows a social cleaning up process, indicating that the public security policies for LGBTI+ need to consider the LGBTI phobic gender and culture categories to confront such crimes. 13

Nursing, LGBTI+ Population and Primary Care
Santos JS, Silva RN, Ferreira MA Regarding the data on the transsexual individuals in the country, there is underreporting of murders, and yet it is highlighted that Brazil occupies the first place in the ranking of deaths in this group, whose data between October 1 st , 2017 and September 30 th , 2018 reports 167 murders, followed by 71 deaths in Mexico, 28 in the US and 21 in Colombia in the same period. 14 Some of the proposals submitted by the Grupo Gay da Bahia to fight violence against LGBTI+ individuals are sexual and gender education for the general population and the creation of public policies in the health care area. 15 It is noteworthy that the life expectancy of transsexual people is 35 years, while for the general population it is generally 74.9 years. 16 Besides transphobia, non-violent deaths of trans people are related to complications due to HIV infection and to those due to body modifications without medical guidance. 16 Respecting the use the social name, an essential tool to diminish the discrimination of the trans population in the health care services, 17 and not understanding sexual reassignment as the only outcome this population wishes, 18 should also be observed. Added to this is the fact that the LGBTI+ population is more vulnerable to the use of substances, STIs, cancer, cardiovascular diseases, obesity, bullying, isolation, rejection, anxiety, depression, and suicide compared to the general population. 6 Unlike cis-heterosexual people, LGBTI+ individuals need to publicly assume themselves in various moments of their lives, asserting themselves in their sexual orientations and identities, both for themselves and for their family, friends, and co-workers, in every context that they be inserted. The bisexual population is often made invisible, even by the PHC professionals, 19 and among the specific demands of this population is the necessary diversity of prevention methods against STIs in the face of several sexual practices that this population may, even if not necessarily, adopt. 20 This process of personal, family, and social acceptance can trigger a variety of mental health issues. A survey conducted in the United States with 577 individuals from the LGBTI+ group revealed that prejudice and discriminatory experiences can contribute to the rise of mental disorders. 21 In Brazil, a study conducted with 19 homosexual youths evidenced that the psychological sufferings that affect them come from prejudices, heteronormative rules, stigmas, reclusions, losses, and loneliness, which several times lead them to suicidal ideation, and generates demands to the health care providers, regarding the mental health, in the face of suicide being a serious public health problem. 22 The National Health Promotion Policy (NHPP) challenges us to promote health considering the social determinants of the population's health. Some of its core values are respect for diversities, including sexual orientation and gender identity, justice, and social inclusion. 23 In Brazil, Primary Health Care (PHC), or Primary Care (PC), is implemented as a State policy, being the main and priority gateway to health care services, in the coordination of care and reference in the Health Care Network. The National Primary Care Policy (NPCP) was launched in 2006 and revised in 2011, with increased access, coverage and resolution, in a move towards PHC consolidation. Nevertheless, in 2017 there was a new revision of the NPCP with important changes, whose criticisms embrace the concern with the provision of minimum care, in the conception of selective PHC; however, the expectation of some specialists is that the interests converge towards an accessible and resolute PHC, with strengthening of the Unified Health System (Sistema Único de Saúde, SUS). 24 It is noteworthy that, as a State policy and supporter of the SUS, PHC should respect its fundamental principles, considering the singularity, cultural insertion, social determinants, and conditioning factors of population's health, whose actions must converge to the protection, prevention, recovery, and promotion of health. In this sense, efforts should be made to minimize the inequalities and the exclusion of social groups, considering human diversity and the LGBTI+ population is included in this group.
The LGBTI+ population's vulnerability, the right to universal and free access to health guaranteed by the Constitution and the function of PHC are aspects to be considered in the care of this population group. However, despite the expectations mentioned above, the changes in the NPCP threaten this achievement, given that the review of the new policy text indicates a relativization of the coverage, as it does not commit to the adoption of parameters to favor a more qualified process of progressive attention. 25 In Brazil, the landmark of public health policies focused on LGBTI+ population is the 1980s, based on the AIDS epidemic that facilitated the fights in defense of sexual rights, with the inclusion of this population as a risk group vulnerable to STIs and AIDS, and with further advances towards health care with a view to integral care. 9 Given this care, the Brazilian PHC structure comprises the work of a multidisciplinary team within a Basic Health Unit (BHU). Among the various compositions that a PHC working team can have, the Family Health team (FHt) stands out, which is the priority strategy of the organization of the Brazilian PHC teams. The FHt is made up of a doctor and a nurse (preferably experts in Family Health), a nursing assistant and/or technician, community health agents, being able to join this composition, endemic disease combating agents and oral health professionals. 26 The work of a nurse in the PHC as a Family Health team member implies the performance of functions based on the principles of the SUS that, as a matter of principle, does not allow exclusions of any kind and has the duty to promote equality. In the meantime, according to the NPCP, the nurse is responsible for performing and supervising the reception, as well as for executing risk stratification, at any stage of the individual's life cycle, very often being the first professional with a bachelor's degree that the user has contact with when they seek for health care at a Basic Health Unit.
In the PHC context, besides the program's demands that compose the booked consultations, work is also done with the spontaneous demand that may be one related to an acute health condition or to a complaint that the user considers important at that moment. In both types of demands, the nurse is able to act Nursing, LGBTI+ Population and Primary Care Santos JS, Silva RN, Ferreira MA autonomously, with resolution and completion of care, or can refer the user to another professional.
Regarding nursing, two important activity fields stand out: nursing consultation and the development of educational groups, be them in the BHU as well as in other spaces available in the territory, such as churches, schools, and neighborhood associations. Nevertheless, within the scope of nursing consultation in the Family Health Strategy, studies are very limited to lines of care such as hypertension, diabetes, women (heterosexual) and children health, although there are a few studies about the LGBTI+ population. 27,28 Despite the report of the specificities, social determinants of health and inequities, debating the nursing care for the LGBTI+ population within the Brazilian PHC is important in the set of actions that aim to give visibility and legitimize the space of this professional in welcoming and caring for the LGBTI+ population.
In this context, PHC is characterized as a fundamental tool for the education process and the dissemination of qualified information that assist in the process of awareness of the population. Nurses can occupy a prominent place in this investment, by means of education in health in educational groups in the community and within the schools, approaching among many themes such as the culture of peace and human rights.
But it is necessary to consider that, to be effective, professional performance needs to overcome challenges and barriers that prohibit care. In relation to the health care professionals, studies show that one in five LGBTI+ individuals does not reveal their sexual orientation to the health care practitioner during the consultation, transsexual people tend to avoid seeking health care even when ill and there are even reported cases of denial of consultation to the LGBTI+ group, all of which a result of the fear of discrimination by the health care practitioners and services. 29 A study conducted with 14 basic health unit doctors from a capital in the Brazilian Northeast Region revealed that none of them received training to deal with the health of the LGBTI+ population and that the Curriculum Guidelines of the Medical School do not consider the most expressive aspects of this population group's health. 30 In a review study on the nursing care for the trans population 11 publications were found in the 2005-2001 period, most from abroad, with only one Brazilian publication. 31 The results show that few nurses feel able to serve this population and that there is lack of knowledge and competency for the interaction with trans people and for dealing with gender diversity in the professional practice; thus, it is necessary to increase or to include contents in the nursing curricula. 31 Corroborating with this data, a study with 19 students from a federal university in the Brazilian South Region evidenced weaknesses in their knowledge, both about their concepts of homo and bisexuality as well as about the training on the care for this group, with a superficial approach in classrooms, leading them to search for extracurricular activities. 32 Homo and bisexual women have fewer chances of being offered to undergo a cytopathological cervical examination and are exposed to acts of violence during the procedure, such as the use of a speculum of an inadequate size and without the necessary lubrication. 33 To assess the knowledge, attitudes, and cultural competency of undergraduate nursing students in serving the LGBTI+ population, researchers performed an educational intervention and applied an Attitude Scale Concerning Lesbian and Gay Men before and after the intervention. The results evidenced a statistically significant increase in the students' positive attitudes and knowledge level and showed that the inclusion of the contents about health care for the LGBTI+ population in the curricula contributes to the promotion of the students' cultural competency and sensibility to the subject. 34 In receiving health care by the nurse, the implementation of the Nursing Process implies a careful collection of the individual's history so that the Nursing Diagnosis and the Care Plan are well instructed, taking into account the user's specificities. Regarding the care actions, their practice requires an understanding of the social context, identification of the health needs and the expectations of the people are under the nurse's professional care. 35 Therefore, it's necessary that the professional is well trained for an open and enlarged approach of the individuals who seek care.
The specific needs and the challenges faced by the LGBTI+ population require preparation and lack of training can perpetuate prejudice and discrimination, resulting in poor quality health care actions and in an increased incidence of diseases and their risk factors; therefore, there must be investments in professional education and practice guidelines, so that there is a wide, comprehensive, scientific, and human offer to this population group. 6 About the clinical guidelines for the provision of primary care and family planning services to the LGBTI+ population, a review study shows that there are important advances. 36 In this sense, there is the need to reflect on this matter and to place it on the debate agenda, both in the training as well as in the permanent education activities in health care services, and also in the scientific events of the area, facilitating to consider the specificity of the health context and the lives of the LGBTI+ people, expanding dialog and sharing the knowledge needed for the health care practices to be incorporated in the PHC daily routine.
The data and the discussion contained in this study lead to reflect that thinking and practicing the care for the LGBTI+ population professionally necessarily implies considering their existence and expression, knowing their specific needs and the proper approaches in the professional training. Considering human plurality in its varied possibilities of expression is the primary condition for the practice of health care, despite the complexity inherent to these fields: health, nursing, care.

Nursing, LGBTI+ Population and Primary Care
Santos JS, Silva RN, Ferreira MA

CONCLUSION
Despite existing, resisting, and occupying the spaces of society, the LGBTI+ population finds itself invisible in the implementation of public policies. As biological bodies and immersed in multiple social contexts, they need attention that involves health in its broadest concept. Although the LGBT National Health Policy exists for seven years and one of its objectives is to identify the health needs of the mentioned population, we are facing the necessity to expand studies, especially in Nursing, which outline the profile of this population group in respect not only to the field of bio-clinical needs, but also to defining the sociodemographic profile of this population and the social determination of their health.
The LGBTI+ community as a whole has particularities, but each population group that composes it has specificities that differentiate them from each other. There are differences in gender identity, gender expression, sexual orientation, and biological sex. Nursing, science and art of caring for human beings in all vital cycles and life contexts that in Brazil occupies half of the jobs in health care services, have as primary function to establish a helping relationship for all who are under their care responsibility. The LGBTI+ population, as a group of citizens using the SUS, is also under the responsibility of Nursing in the scope of Primary Health Care and, thus, it is this professional category's responsibility to provide integral assistance aiming to minimize the inequalities suffered by this population.
Nursing professionals must assume the expressed responsibility, in principle and in nature, not only in the political dimension, but also in the ethical and legal dimensions of care, calling on educational institutions and scientific associations, to promote a debate over technical, scientific, cultural, and political developments in favor of sexual and gender minorities.