Systematic review on health care professionals’ competencies in the care of LGBT+ individuals

Abstract This review encompasses both national and international literature about training needs analyses for health care professionals working with the LGBT+ population. The descriptors “health professionals”, “health providers”, “LGBT”,“training needs analysis” were searched in the following databases: Academic OneFile, Academic Search Complete, Medical Literature Analysis and Retrieval System Online, Virtual Health Library, Cumulative Index to Nursing and AlliedHealth Literature, Complementary Index, Business Source Complete, Education Source, Gender Studies, National Center for Biotechnology Information, Scientifi c Electronic Library Online, SportDiscus, and PsycINFO. Inclusion criteria were:empirical articles, published from 2007 to 2017, in indexed and peer-reviewed journals, available in full text, in Portuguese or English versions. Of the 17 included articles, most were published in North American countries. There is a need for training and formal protocols within institutions. Training had positive results. No instruments about the competencies for health care professionals working with the LGBT+ population were identifi ed. Further studies should be conducted in the fi eld of health care professionals training to provide satisfactory health care services to this public.

Human sexuality is a subject that still has a small presence and little debate in the curricula and in the capacities of health care professionals, and this is further restricted when it involves the specific care of the LGBT+ (Lesbian, Gay, Bisexual, Transvestite and the + sign for other gender designations: Transsexuals, Transgender, Queer, and Intersex Individuals) population (Cesnik & Zerbini, 2017;Rowan & Beyer, 2017;Talan, Drake, Glick, Claiborn, & Seal, 2017). Influences on the lack of training offered in this topic may be due to the socio-historical context based on concepts and debates that go back to the heterosexual binary matrix, which remains a regulating system of sexuality and subjectivity (Chapman, Watkins, Zappia, Nicol, & Shields, 2012b).
Brazil leads the world ranking of murders and sexual violence against LGBT+. According to the report by Mott, Michels, and Paulino (2017), every 19 hours an LGBT+ person is murdered violently due to homophobia in the country. In 2017, 445 people were registered victims of homotransphobia, and there is an expectation that these statistics will rise. Leading a world ranking in the XXI century indicates that there are serious flaws in the education of the population. In the context of health care, there is a history of LGBT+ being verbally harassed by health care professionals, indicating a greater need for awareness-raising and training actions for these professionals (Rowan & Beyer, 2017).
In this sense, there is a need to promote learning opportunities and educational actions capable of raising awareness about sexual diversity and respect for the human being so that LGBTphobia is no longer part of the everyday life in the health care area. To ensure this, it is important to guarantee that professionals working in the context of health care and prevention are fully prepared to serve this population.
In addition to the increased risk of being murdered, there are other problems that people in the LGBT+ community experience at a variety of ages. Lesbian, Gay, Bisexual, Transvestite adolescents have a higher suicidal ideation, higher rates of suicide attempts, and suffer more sexual violence than heteronormative adolescents; homosexual men, along with other non-heteronormative individuals, are more vulnerable to depression and suicide; transsexual individuals have a high incidence of anxiety disorder, depression and higher rates of suicide attempts (Lerri et al., 2017;Lee, Oliffe, Kelly, & Ferlatte, 2017;Teixeira Filho & Rondini, 2012). In this way, health care professionals should focus on their care beyond Sexually Transmitted Infections (STIs) (Ferlatte, Salway, Oliffe, & Trussler, 2017). By recognizing the risk factors, stigma, invisibility, and vulnerabilities these people face in their daily lives, health care providers can properly conduct health care in preventing depression and suicide (Lee et al., 2017;Merryfeather & Bruce, 2014). This will be made possible through greater education actions on sexuality and gender diversity in the health care context, as well as advocating for change in the health care model for these minorities to effectively promote the health of this population (Harrell & Sasser, 2018).
Still a result of this socio-historical-cultural context, marked by prejudice and the pathologization of human sexuality, the provision of health care and daily clinical practices are most often guided by the psychiatrisation of homosexuality and transsexuality. The diagnosis of gender identity disorder, for example, can be considered a pathological and stigma vector, since it attributes a disease to the patient without questioning the historical, political and subjective issues of this psychiatrisation. Thus, a normative system of sex and gender is reproduced that does not correspond to the modes of subjectivation or the diversity of the gender-building forms in transsexuality, besides not letting patients express themselves (Arán, Murta, & Lionço, 2009;Moscheta, Souza, & Santos, 2016).
Although there have been some changes in society, such as the insertion of laws that guarantee the use of the individual's chosen name, there are still many barriers in the health system, which limit an improvement in the results of non-heterosexual young individuals, i.e., essential services such as hormonal drugs and sex reassignment surgeries (Dowshen et al., 2016). In order for prejudice and violence towards LGBT+ individuals to cease to exist, and for adequate health care be offered, it is necessary to review the current cultural concepts of the health care team through training in this subject so that these problems can be minimized or even extinguished, providing positive results in health care for the LGBT+ population (Merryfeather & Bruce, 2014).
And how to assess what aspects are really needed to be worked on in training? The Training Needs Assessment (TNA) area is part of the Training, Development and Education (TD&E) system and anticipates the educational event itself, by conducting an assessment of the existing or unsatisfactory competencies in the group of individuals that will be the target of the training (Meneses, Zerbini, & Abbad, 2010). This step allows the collection and analysis of information, technical and/or behavioral skills that must be transmitted, as well as differentiating the professionals which really need to deepen their knowledge.
Given this scenario, which highlights the need for LGBT + people and the gap in the context of training health care professionals about the health care of this population, this article aims to describe what Brazilian and foreign literature have produced of empirical knowledge that indicate which are the training needs of health care professionals in assisting LGBT+ individuals.

Method
A systematic review is a research method that presents a rigorous and judicious process of collection and critical evaluation of research results, as well as reducing bias by identifying, evaluating, and synthesizing all relevant studies of the research topic, and not only those compatible with the researcher's hypotheses or theoretical-methodological perspectives (Costa & Zoltowski, 2014;Uman, 2011).
It involves a detailed and comprehensive plan, and uses research strategies to analyze the production of knowledge in the scope of study. According to the guidelines of Rojon, McDowall, and Sounders (2011), the systematic review is developed in three stages, with pre-established criteria, so that there is an adequate search of the publications in the databases, which are: (1) transparency, specificity, and repetition of the study compared with the narrative review; (2) the process of constructing the research question must be carried out with the guidance of professionals of the area, a fact that offers theoretical rigor and practical relevance when carrying out the review; and (3) the research must use concise inclusion and exclusion criteria.
In this work, the systematic review protocol proposed by Cronin, Ryan, and Coughlan (2008) was adopted, which is composed of the following steps: (1) formulation of the question used for searching; (2) establishment of a set of inclusion and exclusion criteria; (3) literature selection and access; (4) evaluation of the quality of the literature included in the review; and (5) analysis, synthesis and dissemination of results.
The article search used the descriptors "health professionals" OR "health providers" AND "LGBT" AND "training needs analysis" and their Portuguese language correspondents: "profissionais de saúde" OR "provedores de saúde" AND "LGBT" AND "análise de necessidades de treinamento"; the inclusion criteria consisted of the search for empirical articles that addressed the subject of interest, with qualitative and quantitative delineations, published in the last ten years (2007)(2008)(2009)(2010)(2011)(2012)(2013)(2014)(2015)(2016)(2017) in indexed and peer reviewed journals, available in full text, and of free access, in Portuguese or English. The exclusion criteria were duplicate publications in the databases, and those that addressed the issue of sexual minorities, but not the analysis of training needs, simultaneously.
The databases consulted for this systematic review were: Academic OneFile, Academic Search Complete, MedLine, Bireme (Latin American and Caribbean Center for Health Sciences Information), CINAHL (Cumulative Index to Nursing and Allied Health Literature), Complementary Index, EBSCOhost, Education Source, Gender Studies, NCBI (National Center for Biotechnology Information), SciELO (Scientific Electronic Library Online), SportDiscus/EBSCOhost and PsycINFO (American Psychological Association).
When searching the databases, firstly, the title and the summary of the articles found were read in order to verify if they related to the research subject; after performing this first screening, the articles collected were read in full to deepen into the subject described and to check the framing of the article in relation to the topic of interest. A total of 17 articles were selected to compose the present review. Figure 1 shows the results, in quantitative terms, of the searches performed in the abovementioned databases. In the SciELO, EBSCOhost and PsycINFO databases, no articles were found according to the inclusion criteria established for this review. Total studies included in this articles N = 17 Articles removed for not being empirical or for not addressing e the subject of interest, dissertations, or thes s N = 170 Table 1 presents the following information about the studies that make up this literature review: authors, place, country and year of research, objective, method, number of participants, and main results obtained.  There is a moderate significance by students regarding negative attitudes toward gay people, since the analyzes demonstrate how American students behave negatively with gay men, but they do not characterize their perceptions of lesbian, bisexual, transgender, or intersex individuals; Negative attitudes towards gay individuals are linked to normative conceptions of the masculine gender or how society imposes that the masculine gender should act, the attitudes played by men at young age.

Results and Discussion
The need to revise the curriculum and add more disciplines on the health care of sexual minorities.
Meyer & Johnston (2014)  Further studies are needed to identify interdisciplinary patterns such as theoretical models for practical guidelines. There is no exclusive course to teaching in the context of LGBT health. Health care students should understand how social exclusion, stigma, and discrimination affect the health of LGBT individuals, and change their attitudes and assumptions so that they do not become "prejudiced" health care professionals.
LGBT health should be incorporated into the existing curriculum to prepare health care students for providing decent care practices for LGBT individuals.

Pelts & Galambos (2017) / Mississippi / USA
To make an intervention to the members of the team who provide health care services to the residents of nursing homes / Mixed / 60 professionals.
After the intervention, there was a significant increase in positive attitudes towards assisting residents who identified themselves as lesbian and gay individuals. Women showed lower negative attitudes than men. Attitudes regarding SGM and gender differences were more positive after the training compared to the pre-training data; after the primary intervention, the professionals performed different interventions in the workplace or in the following GSD training programs.
The evaluation of longitudinal studies and online or short-term training studies should be assessed to verify the impact of these courses on health care professionals.

Rutherford, McIntyre, Daley, & Ross (2012) / Toronto / Canada
To explore how caregivers with practices focused on the LGBT public have developed their capacities regarding this population / Qualitative / 08 health care professionals.
Professionals had identified themselves as members of the LGBT community, but membership is not equal to providing adequate support or care for LGBT individuals Knowledge gaps have been clarified through workshops and training materials, either independently or in a groups of professional colleagues working with the LGBT population.
There is a lack of training opportunities in the LGBT field, as well as specific resources to promote awareness of mental health services in this field.

Mandatory introduction of the
LGBT health care context in medical schools: terminologies, appropriate intervention issues, minimizing disclosure of sexual orientation and gender identity, information on the impact of heterosexuality and homophobia, and the need for a specific health care practice oriented to gender and sexual identity. It shows that the predominance of the method used in the research is qualitative, followed by quantitative and mixed methods; the participants are mostly health care professionals, due to the use of the descriptors, but there are also studies carried out with students from health courses or LGBT+ individuals -on perceptions or opinions about the health care provided by professionals. The studies show the need to provide training to health care professionals to provide a better care to the LGBT+ public, since there are barriers in the humanized care of this group. The curricular base for graduating in the health care field shows a low number of hours, or the lack of disciplines on this type of health care; besides the presence of stigmas, discrimination, and prejudices of the health care students as for the non-heteronormative individuals.
Although these studies point out the need to offer training and development of these professionals considering their university and career formation, no reference in literature was found regarding a movement in the direction of identifying the knowledge, skills, and attitudes required for the specific care of LGBT+ people. Thus, it is difficult to propose training actions capable of supporting health care professionals in terms of technical-scientific capabilities and adequate behavioral repertoire in the provision of health care to the LGBT+ population. Therefore, the publications seem unanimous about the importance of the qualification of health care professionals to provide a better care for the LGBT+ population, and the concern about the lack of attention to the subject in curricula and in continuing education, however, there is no indication in the literature about which are the competencies to be developed, that is, it does not address training needs analysis, a stage prior to the planning and execution of educational events, pertinent to developing fixes to skills gaps for the appropriate performance of health care practices. It is necessary to train and change the policies of the health care services agencies; training of professionals on guidance of cultural diversity was considered as the main aspect to provide the access to health care services for LGBT young individuals.   Figure 2 shows the countries that published the surveys that integrated the corpus of this review. It is noted that the number of publications has been rising in recent years, with the United States leading the ranking in publications.
This literature review describes the publications of the last ten years on training needs analysis of health care professionals regarding LGBT+ care. It was found that there is a gap on this topic, although there are studies that indicate that some trainings have been performed by health care professionals so that there are changes in the care services offered to this public.
It is mainly the North American countries that publish studies on health care professionals and the LGBT+ public, showing a concern to provide higher quality health care for this population. This concern may be due to the cultural model that governs local society, which is driven by cultural diversity, resulting from minority group claims that have triggered modifications, which can be seen nowadays. On the other hand, there are no publications on this subject in the South American countries, evidencing the neglect of the discussion, and its reflection on health care conditions to the LGBT+ community, disregarding their specific needs, required in medical care, as well as the various forms of violence to which this public is exposed, also in the health care context.
Although there are tools such as "Gender & Sexual Diversity (GSD)" (Poteat et al., 2017) and "Lesbian, Gay, Bisexual, and Transgender Development of Clinical Skills Scale (LGBT-DOCSS)" (Bidell, 2017) created to guide the training of health care professionals, the process that precedes the training program itself, in other words, training needs analysis, has not yet been described. Similarly, the international literature provides restricted information on training models, covering only aspects about the culture and the ideology of the professional regarding their professional care to the individual (Costa et al., 2018;Grigorovich, 2016;Moe & Sparkman, 2015;Travers et al., 2010).
Failure to carry out the stage of training needs analysis makes it impossible to visualize the most important skills and the ones health care professionals are most comfortable with (or not) in the care of LGBT+ individuals. If training gaps in the technical and behavioral repertoire of professionals were identified, they could trigger the offer of specific training and improve their quality, influencing the subsequent effective performance of these professionals. However, failure to carry out the stage of training needs analysis can lead to a waste of resources, such as training competencies and people who already have them, or failing to train competencies which are of high priority for the adequate performance of these professionals. Both options are considered irresponsible because they directly affect the care of patients according to what is recommended by the World Health Organization.
The GSD scales (Poteat et al., 2017) and the LGBT-DOCSS (Bidell, 2017), which can be used to assess the clinical development of the LGBT+ public, explore specific clinical characteristics, develop or test various training programs and methods related to LGBT+ public, demonstrate to be effective after the training of health care professionals, besides assisting in the identification of other procedures to verify which subject should be emphasized when training professionals regarding the health care to the LGBT+ public.
Although there have been no studies that deal with the stage of training needs analysis for health care professionals in the LBGT+ public service in the literature, there is a description of some interventions performed to health care professionals such as training courses, workshops, and application of scales (Bidell, 2017;Meyer & Johnston, 2014;Rutherford, McIntyre, Daley, & Ross, 2012), as well as observations of the changes in the professionals' post-test health care attitudes (Meyer & Johnston, 2014;Pelts & Galambos, 2017).
From the standpoint of health care system users, they feel invisible to professionals and report that the discrimination based on their sexual orientation is a barrier to obtaining adequate health care (Moe & Sparkman, 2015). The existing stigma in the context of care and discrimination, practiced by professionals, broaden the chasm for the humanized care this public seeks (Ash & Mackereth, 2013). The provision of care to individuals with equality, dignity, and humanism, regardless of their sexual orientation, affects the performance of the professional and, therefore, impacts on the care of the health system user (Beagan, Fredericks, & Bryson, 2015).
The articles have shown that discrimination and stigma to the LGBT+ public prevails in the health care and academia fields, where homosexuality education still remains a psychiatric concept (Beagan et al., 2015;Snelgrove, Jasudavisius, Rowe, Head, & Bauer, 2012). On the other hand, homoaffective couples reported experiencing barriers and discrimination of health care professionals in the care of their children, demonstrating the need to sensitize these health care professionals to care for this population and the prevalence of heteronormativity in health care (Chapman, Watkins, Zappia, Combs & Shields, 2012a). There have been reports by health care professionals about the unfriendly environment for this public and the lack of training in this issue in their work institutions, but they also recognize the need to carry out training in the fields of sexuality and gender diversity for providing the population with adequate health care services.
In view of this evidence, there is a need for health care students to understand how the negative behavior of professionals affects the LGBT+ individuals (Müller, 2013). The study by Pelts and Galambos (2017) showed that a teaching intervention in health care for LGBT+ individuals aimed at health care professionals resulted in changes in their attitudes towards residents who did not identify themselves as heteronormative individuals. This shows that education plays a decisive role in providing adequate information to health care professionals, a fact that assists in the care provided to individuals in this group. Therefore, providing training to health care professionals would trigger a contribution of congruent knowledge to professionals so that they can perform appropriate health care practices.
The restriction on obtaining references, in the dominant scientific literature itself, with quality to support LGBT+ health care, as well as the restricted terminology of "binary medicine" make it difficult to assist these users in the health care system (Snelgrove et al., 2012). Contrary to this perspective, the professionals who were able to identify the aspects that interfered in their field of action, modifying the context and their own behaviors, are precisely those that had obtained some training in the LGBT+ field or that had already provided health care services for this public (Moe & Sparkman, 2015).
To increase the quality of care provided, health care professionals need to obtain a greater theoretical and technical base, as well as to develop behavioral skills to facilitate LGBT+ user health care. For this, there is a need to train both students and professionals who are already working in the health care field. In relation to the first group, it is suggested to add specific disciplines in this area to the undergraduate curriculum of health care professionals, since there is only an average of 10 hours (North American context) for a four-year curriculum (Matharu et al., 2012;Müller, 2013). Regarding the second group, it is extremely important to invest in continuing education of these health care professionals who are already working in the area (Ash & Mackereth, 2013;Carabez et al., 2015;Rutherford et al., 2012).
The suggestion to offer more training opportunities to health care professionals with relevant information regarding the health care context of the LGBT+ community is emphasized in these studies, demonstrating that it is essential to promote teaching and learning accessibility (Czaja et al., 2016;Rutherford et al., 2012). It should be noted that the basic contents, such as the terminology or the use of the proper article and social name, are interventions that culminate in a humanized health care for the individual (Rutherford et al., 2012). Training processes for health care professionals should be maintained for as long as it takes until the existing barriers in the health system are extinguished (Ash & Mackereth, 2013), and if these barriers stem from the lack of knowledge, skills, and attitudes, i.e., skills gaps, formal actions must be taken within the organization, such as training courses.
Regarding the ideal format for continuing education in this subject, there is a divergence of opinions among health care professionals about the strategies to carry it out and how to prepare future professionals to work in this field. Some suggest revising the undergraduate curriculum; for those professionals who are working, there are suggestions for conducting face-to-face training; others describe the provision of online training as opportune; and also, there are those who suggest the implementation of health care guidelines for the LGBT+ population, so that further training in this context are developed (Ash & Mackereth, 2013;Beagan et al., 2015;Carabez et al., 2015;Chapman et al., 2012a;Rutherford et al., 2012;Snelgrove et al., 2012). Regardless of the best teaching method or the most opportune moment (during graduation or during the professional activity) to carry out this kind of training, they are necessary to fill skills gaps that allow more effective and humanized interventions, being a concern in the literature. Therefore, the more educational actions are implemented, the better.
The study by Meyer and Johnston (2014) confirms the importance of training for health care professionals and their positive impact in assisting LGBT+ individuals. The report of a paperback pocketbook for Queer individuals (Beagan et al., 2015), which addresses issues such as providing efficient health care to transgender individuals, reinforces the real need for continuing education for health care professionals so that it may result in the adequate quality of care for the users of the health care system. The individuals' own reports on the need to sensitize professionals about the LGBT+ context for a better health care are also presented, reinforcing the need for professional training (Chapman et al., 2012a).
It is fundamental to provide protocols, theoretical models, and guidelines to assist health care professionals in the care of these individuals; in addition to performing training needs analysis, offering health care professionals training in this subject and evaluating the results of the interventions. The DOCSS and GSD scales are indicated as tools to train professionals and verify the effectiveness of these actions, but they have not yet been validated in the Portuguese language, a fact that reinforces the need to create a validated instrument in Portuguese to be used in the Brazilian context. In addition, the curriculum for undergraduate health courses need to be revised to include education regarding the health care for the LGBT+ public.
Further studies to be carried out in the field of health and sexual diversity care should involve innovative and rigorous evaluations, with different users of the health care system and its professionals, as well as linking it to the political layer, so that politicians can be engaged in public health policies and processes that result in a better performance in the health care system access, and in the care of the LGBT+ public (Jabson et al., 2016).

Conclusion
It is concluded that the scientific literature lacks studies on the training of health care professionals to care for the LGBT+ people in a competent and humanized way. Some of the findings reinforce the need to provide training to health care professionals, as well as demonstrate positive aspects resulting from short-term interventions. Cultural and educational factors, stigmas, and discrimination present themselves as barriers to the humanized care, as well as they negatively intensify the mental health of individuals who face them everyday in the context of today's health care environment.
It is recommended that future studies evaluate the health care practices of these professionals, review university curricula, promote training to professionals, and develop manuals to guide practitioners in the exercise of their functions, so that the appropriate access to health care is provided with dignity and humanization for all individuals who require it.