Brazilian Journal of Medical Education and the Health of Transgender People

Introduction: This research aims to understand the current knowledge on the health of the transgender population in the Brazilian Journal of Medical Education. Historically, the formation in medicine was consolidated in the Cartesian discourses: the figure of the white man, heterosexual and cisgender. Method: This is a qualitative and retrospective research, which also aims to problematize the medical education and the importance of Queer Studies. A documental analysis was carried out to identify the content in the conceptual constructs of the documents published between 2008 and 2017. The content analysis method according to Bardin was then chosen. Results: The methodological management indicated four categories for study: knowledge about the sexuality of medical students; gender as a research variable; gender and education; training and sexuality. Conclusion: The analyzed material indicates the lack of publications on the health of people whose gender identity is considered as dissident. The need for editorial opening is pointed out, with the purpose of providing visibility to the demands of the transgender population in the journal, aiming to broaden the discussions on the integral health of the LGBTTQIA+ population during graduation.


INTRODUCTION
In Brazil, the republican democratic state gives people, at birth, the aegis of attaining and consolidating the access to their rights, based essentially on the Federal Constitution, enacted in 1988. The social rights, inalienable to citizens, aim to ensure the fundamental right to live with dignity under egalitarian conditions 1 .
Understanding this perspective, the political movement of transgender people, queer, bisexuals, intersex, asexual individuals, lesbians, and gays (LGBTTQIA+), has sustained some antagonism caused by the acknowledgment and depathologization of sexualities and gender identities dissident to the hegemonies. Social achievements have been attained in recent years due to affirmative public policies, allowing greater visibility of the movement. However, this population continues to face difficulties regarding their access to health services. This article aims to reflect on the need to assess this topic in the context of medical training.
There is, in some way, a consensus in the academic universe regarding the dissatisfaction in the care of the population in general and the need to reformulate certain aspects of medical training, particularly through management based on the humanization principles 2 . This fragility is highlighted in the transgender population, for which the humanistic dimension is, above all, characterized by the need for identity recognition of being and existing in a condition different from what is stated as true in modern pedagogical discourses, that is, the binary opposition between sexes and genders.
This article aims to identify the current knowledge in medical education about the political context and the health of the transgender population, based on the analysis of publications in a national journal on medical education consolidated in the academy, the Brazilian Journal of Medical Education (Revista Brasileira de Educação Médica -RBEM).

Medical Education in Brazil
In 1808, with the arrival of the Portuguese royal family in Brazil, a Royal Writ was signed, with the authorization of D. João VI, guaranteeing the implementation of the first medical courses in the country. The first one was implemented at the School of Surgery of Bahia and the other at the School of Anatomy, Medicine and Surgery, in Rio de Janeiro, based on the European experience and modern science 3 .
In the first half of the 19 th century, the state of the art in medical education followed the French model, whereas in the last half of the same century, the influence of German medicine and education was increasing, being characterized by its propensity for the laboratory, the hierarchy and specialization in the emerging areas of experimental disciplines. The French anatomoclinical model presupposed teaching carried out through work and research in hospitals, specialized in the observation of the human body 4 .
Medicine considers the body as an object to be repaired and, the doctor, as occupying a position of a mechanic that repairs damaged parts 5 , a perspective that underlies the logic of modern medicine, which sequentially circumscribes the body as an organism, a living being unit, consisting of integrated parts that have different functions. Currently, the scientific heritage of these beginnings is still present in medical education and in the work of the professionals, in which the updating of curricula is still necessary.
The concept of health and disease assumes more complex dimensions in the 20 th century, but the medical-scientific discourse does not take significance as an object, given the impossibility of delineating it based on its descriptive references 6 . In 1910, medical schools in the United States and Canada took the lead regarding the teaching models. After the publication of a study entitled "A Report to the Carnegie Foundation for the Advancement of Teaching", known in the academy as the Flexner Report, which, on the one hand, organizes and regulates the functioning of medical schools, in addition to inaugurating the discourses on medical training excellence whereas, on the other hand, it starts affirming the health needs of the population as the point of arrival and not departure of medical education 7 . This formative model was appropriated by the Brazilian medical education and remains hegemonic in the country, showing a special impact on the health care of the most vulnerable populations, as they are unable to have their singularities recognized.
The National Curriculum Guidelines (2014) approved for medical courses in Brazil do not mention the discussion of sexualities or gender, but their importance is undeniable for the individual and collective health of individuals 8 . It is also observed that, in its overall organization, the education focuses on extensive clinical training, centered on the biomedical sciences -which reinforces the individualistic practice of Medicine, disregarding subjective questions -and a social approach, incapable of critically redefining this training and its different types of practice 2 .
Therefore, the need to promote, in the context of training, the construction of views on the differences that prioritize health care in its complex dimension and that can understand the person as a reflection of a territory of culture and singularities is highlighted.
Queer Studies: a challenge for a new look at gender The Queer category emerges from the encounter of the North-American philosophical thought and cultural studies with European post-structuralism, promoting a critical impulse in relation to the contemporary sexual order, associated with counterculture and the demands of new social movements. Queer studies overcome the centrality of social mechanisms of gender, associated to the operation of hetero / homosexual and male / female binarism for the organization and structuring of social life, placing greater emphasis on a policy of knowledge and differences. The association between Queer studies and the Brazilian education process is manifested in an attempt to make a critical sensitivity of our educators comprehensible in relation to the social forces that impose behavior models, identity patterns and moral grammars on students 9 .
For Butler (2010) 10 , "gender must not be merely conceived as the cultural inscription of meaning in a previously given sex". The author speculates that, "we must also designate the very apparatus of production by which the sexes themselves are established" (p. 25). For the hegemonic pattern, the social dynamics of gender produces a false notion of stability, in which the cis-heterosexual matrix is the model reference, establishing two linear and stable sexes: the male and the female.
On the contrary, the transgender identity is understood as a construct that allows the transition between bodies, through the non-conformity of gender recognition that was attributed -previously -at birth, based on the biological sex 11 . Therefore, the sex of birth is constructed as the natural form, derived from the conception of nature, and the gender from culture, derived from social relations. This "separation between sex and gender, being one opposite to the other, makes us fall into the trap of compulsory heterosexuality, which institutes that natural is superior to cultural, that is, sex is superior to gender" 10 (p.40) .
Still according to Butler' s thought, the concept of gender is contested as an immutable character of sex, breaking with the idea that sex and gender are reinforced for the institution that combines male and man; female and woman. In fact, modernity has consecrated the idea that gender is a restrictive marker for being a man/being a woman in legitimizing people' s performance, since the social aspect determines the standards of correction and acceptability of behavior through repressive and moralizing judgments.
Not infrequently, transgender people are affected by a diversity of psychological suffering that can take the following presentations: suicide attempts, depression, eating disorders and anguish in the most diverse ways, caused not only by the feeling of not belonging to their biological sex, but by conditions of social vulnerability, such as the difficulty in entering the formal labor market due to problems with documentation 12 or having access to the health system. Therefore, it is necessary to understand the concept of gender as relational and political, regardless of its biological basis, that is, biological sex and, as influential, among human beings, of roles that are exercised and constructed in society.
LGBTTQIA+ people health care Historically, the issue of transgenderism in Brazil has been placed by Medicine in the field of mental problems and as a pathological condition. In the 1970s, the AIDS epidemic explodes, the first associations with transgender people are created and, along with them, an even greater wave of prejudice is disseminated. It is only in the early 1990s that the category of transgender people -who were not even formally included in the so-called Brazilian Homosexual Movement -(MHB, Movimento Homossexual Brasileiro) start to more clearly present collective actions of which authorship referred to a kind of "federation" of different social categories in which they could find some space for political representation 13 .
The Federal Council of Medicine (CFM, Conselho Federal de Medicina) 14 , in 1997, through Resolution N. 1.4821, authorized the performance of sex reassignment surgeries in trans-people in the country, considering it to be therapeutic. This resolution is based on the principle that "the transsexual patient has a permanent sexual identity psychological deviation, with rejection of the phenotype and a tendency towards self-mutilation or self-extermination". Thus, surgical intervention gains legitimacy in Brazil.
According to Pelegrin & Bard (2017) 15 , regarding gender identity and sexuality, we have part of the psychiatric literature, whose thinking is based on prejudice and orthodox ideals, which has referred to them as disorders since the 19 th century, including the "psychiatric" logic of homosexuality; then gender identity as a disorder, as in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM III) and, subsequently, as gender dysphoria in the 1987 revised version of DSM III. In 1994, in the DSM IV, gender dysphoria started to be considered a gender identity disorder and, in 2013, it was once again treated as gender dysphoria in DSM V.
On the other hand, the Federal Council of Psychology (CFP, Conselho Federal de Psicologia) 16 has been acting in relative agreement with the social movements linked to the belonging to LGBTTQIA+. On January 29, 2018, the council established rules of action for psychologists related to transgender people: Art. 1 -Psychologists, in their professional practice, will act according to the ethical principles of their profession, contributing with their knowledge to a reflection aimed at eliminating transphobia and prejudice towards transsexual and transvestite individuals.
In 2019, the LGBTTQIA + movement celebrated two achievements: the first was the removal of transsexuality from the list of mental illnesses or disorders and the second is related to the progress of the process aimed at criminalizing LGBT-phobia in the country. In May of the same year, the World Health Organization (WHO) published the 11 th edition of the ICD (International Statistical Classification of Diseases and Related Health Problems), which no longer included the so-called "sexual identity disorder" or "gender identity disorder". In the ICD, transsexuality remains as "gender incongruence"; however, in a different category, now related to sexual health conditions. Also in 2019, the Senate advanced the proposal to include discrimination based on sexual orientation or gender identity into the Brazilian anti-racism law. Bill 672/2019 was approved on a terminative basis by the Constitution and Justice Commission (CCJ, Comissão de Constituição e Justiça). However, as the approved text is a substitutive one, it will still need to go through an additional approval at CCJ.
The current discourse on "transsexualism" by the academy, is anchored in modern psychiatry and the political reading based on an orthodox psychoanalysis, maintaining transgenderism as a pathological experience -an "identity disorder" -given the nonconformity between the biological sex and the gender. It is observed that what defines this diagnosis is a normative conception of sex-gender systems, based on a heterosexual binary matrix, which becomes a regulatory system of sexuality and subjectivity, a model without any foundation, in Queer studies or in the statements of the involved subjects.
However, as observed by Foucault (1988), issues related to sexuality and the body generate mechanisms and systems aimed at regulating the practices and ways through which individuals can and must recognize themselves as sexual and social subjects 17 . And it is up to us to question how medical training has identified itself with this dimension of social control to the detriment of ensuring health care for transgender people.
Therefore, this investigation analyzes the knowledge disseminated in Revista Brasileira de Educação Médica (RBEM) regarding the political and health context of the transgender population based on the content analysis of academic productions on the thematic axes of sexuality and gender.

METHOD
This is a qualitative study of documentary analysis, consisting of primary data obtained from retrospective and descriptive research. This methodological resource was chosen because it allows adding the dimension of time to the understanding of the social. The documentary analysis favors the observation of the maturation or evolution process of individuals, groups, concepts, knowledge, behaviors, mindsets, and practices, among others 18 .
Considering the research objective, Revista Brasileira de Educação Médica was chosen because it is an important vehicle for the dissemination of knowledge in medical education in the country, which has allowed, in recent decades, the circulation of political and economic contents articulated with the medical teaching process, and because it is currently the only Latin American journal to focus, with an affirmative emphasis, on such perspective.
The choice of this journal was justified by the continuity of publications, considering its historicity: it has been published for 39 years. The sources used for the development of this study consisted of the scientific articles published in the period of 2008 to 2017 (ten years), since it comprises the period of greatest inclusion of discussions focused on the movements of LGBTTQIA+ people. A total of 42 issues were identified as being related to the study period.
All abstracts of articles published during the study period were read. The ones that did not mention the words gender, sexuality, transsexuality and / or transgender and its variations were excluded. Of the 812 abstracts read, 25 met the inclusion criteria: being a study carried out on the topic with a focus on Medicine and including the words gender, sexuality, transsexuality, transgender; in the title, abstract or keywords or descriptors. After the identification of the abstracts, the second phase started, which consisted in reading all the selected articles that had been published as trials, reviews, theses, study outcome, experience reports or literature reviews. Then, the content analysis technique was used 19 .

RESULTS
RBEM is characterized as a generalist journal, since the published contents do not have an immutable and regular character thematic axis, implementing an identity narrative link: medical education.
The obtained results are shown in Table 1, which depicts: article titles, year of publication, volume and authors (s). Of the 25 articles selected using the inclusion criteria: two of them made an exclusive mention of the word sexuality; 16 referred to the term gender; and 07 articles included both descriptors.
The analysis of the material was carried out through critical, reflective and qualitative reading aiming to identify the content in the conceptual constructs, which allowed us to identify convergences, permitting the analytical grouping into four thematic axes: knowledge of medical students' sexuality; gender as a variable; gender and education; training and sexuality.

Gender as a sociodemographic research variable
Considering the four exposed categories, there is a higher concentration of articles on the thematic axis: gender as a sociodemographic research variable, with ten published articles. Of this total, five of them aim to identify the profile of researchers in scientific productivity within the medical field. "Initially, for the data analysis, the analysis variables of the problem situations, such as: gender; age; occupation, were determined" 20 . Also in this area, the use of the term 'gender' assumes the meaning of the category in the identification of what was imposed on us from the perspective of the hegemonic binary, that is, as man and woman -"Of the 383 CNPq fellows in the analyzed medical area, 253 (66.1%) were males and 130 (33.9%) were females (1.94: 1)" 21 .
During the analysis of this category, we observed the substitution of the traditional term 'sex of birth' , which refers directly to the human genitalia, by the genital anatomical conformation that has a social comprehension of being and existing as an identity. Additionally, there are three publications in 2017, which leads us to believe in a change in the conception of more modern researchers; although the term is used aiming only at biological characteristics -"The analyzed variables were: gender, researcher' s original institution, time of doctorate, doctoral institution, scientific initiation, master' s and doctoral degree advisory, and publications in journals" 22 . Knowledge of medical students' sexuality This category promotes the identification of students' knowledge about human sexuality. In addition, it was observed, in a secondary way, a comparison of sexual behaviors without differentiating sexual practice from orientation of the same sample through a hegemonic bias, that is, without taking into account non-binary identities and / or those considered to be abject -"Regarding their sexual life, the men reported having had their first sexual intercourse earlier and a smaller number of them had not yet had sexual intercourse, when compared to the women" 23 . There were four articles that addressed this perspective.
Furthermore, during the analysis, there was a strong trend towards the association of knowledge of sexualities to sexually transmitted infections -"The majority stated that the first knowledge in relation to HIV / AIDS came from information received before starting collegeduring the school period, through the media, internet research and family guidance" 24 .
In brief, most articles infer the students' lack of knowledge about sexuality and the lack of capability to apply this knowledge in the work practice -"Among medical students there is still a lack of information about specific aspects of human sexuality. Medical education needs to encompass sexuality in its multiple aspects, enabling professionals to deal with the sexuality of their patients" 23 .

Gender in Academic circles
This category is characterized by the presence of five articles. The analysis allowed, in this case, evoking the discourses about the inclusion of women in the undergraduate scenario, from the selection process for university entrance exams, university hazing, up to the guarantee of academic and workspaces. Moreover, it is possible to notice the introduction of this content as of the year 2008, in volume number four.
It is remarkable the progressive and quantitative increase of women in medical schools and the tensions in relation to gender violence. The prevalence of the analyzed content permeated the feminization process of the medical course linked to the reproduction of stereotypes, sexist and discriminatory behavior towards women -"Investigations dedicated to studying and comparing the educational process of men and women in medical school conclude that female doctors suffer a significant negative impact caused by sexist stereotypes and gender discrimination during the formative years" 25 .

Training and sexuality
In this modality, five articles aimed at expanding on the Education through the Health Work Program (PET) were identified, articulating the topics of human sexuality and gender during the undergraduate school period -"This article reports an experience of health education on sexuality, conducted by monitors from the PET-Saúde program of the University of Brasília, from the Family Planning subgroup" 26 .
The publications that comprise this category appeared as of the year 2012, with a total of three articles published in a single volume, suppli1. After that, it is relevant to inform the publication of two more articles, in the subsequent year, both included in the first volume. Therefore, this period is understood as fertile for these discussions.
Thus, they evoke the accomplishment of PETs as an important factor in the construction of intrapersonal relationships, promoting the work process recycling. They also address educational practices based on play, making it a mutual learning, the student and an assisted population: Dynamics, comedic performances and quizzes were carried out, with sexuality being the main topic. Subsequently, the creation of multiplying tools by the adolescents, such as videos and plays, was stimulated, making them protagonists of the teachinglearning process 27 . Thus, the importance of PETs is repeated and understood as an essential vehicle in the training of medical students, aiming to fill a gap in the curriculum of several educational institutions: The importance of research and extension projects is also emphasized, especially PET-Saúde, focused on the topics of education and health promotion, considered in their complexity and comprehensiveness and with the potential for transformation, and their inseparability from teaching and health care activities 28 .
What about the knowledge about the transgender population?
Regarding the transgender and / or transsexuality descriptors, no publications were identified in the journal during the assessed period. Considering the exposed absence, we will address the discussions on this topic. Hence, previously, what is apprehended is the resistance by the researchers to address the discussions on the issues of transpeople reinforcing the neglect and inattention inflicted on this vulnerable population.
The results inform that the knowledge about the political universe and the health of the transgender population is an invisible one. This finding, considering the assessed sample, mentions a possible impact on medical courses in the country. Moreover, it is possible to identify a substitution of the biological sex terminology by gender, recognizing maturation while men and women as a social construct and not restricted to the anatomical conformation of the genitalia.
Thus, it can be affirmed that gender discussions, from a binary perspective, have gained strength in academic circles because of the women' s rights movement that aim to question the place to which they are designated by the dominant classes and the implications of the violence inflicted to them because they are women. Finally, it recognizes that the researchers who published in RBEM tend to identify sexuality and its teaching, during undergraduate school, through the biologizing perspective, linking trans experiences to STIs.

DISCUSSION
Scientific publications aim to disseminate to the community the possibility that other people can use and evaluate them under different perceptions. Academic journals still assume the fastest model for researchers to circulate and obtain visibility for their work results. It is through a scientific publication that society becomes aware of the results of a research work and what it represents for the community 29 .
In this perspective, the lack of content about the transgender population in one of the most important medical journals in Latin America demonstrates the social invisibility and the perpetuity of vulnerability regarding the delivery and guarantee of human social rights, including access to public health services.
The Ministry of Health recognizes that dissident gender and sexual identities are part of a complex process of discrimination and exclusion, from which vulnerability factors are derived, such as "the violation of the right to health, dignity, non-discrimination, autonomy and free development" 30 (p. 571).
Although homosexuality is no longer considered a pathological factor in health area, it can be observed that the same process did not occur with the transgender people category. Thus, Lionço (2008) 31 emphasizes that it is necessary that health professionals get better acquainted with public policies and the specific problems of the transgender population for the improvement of the services provided by the different areas, considering the singularities and specificities of this population segment.
Thus, the depathologization of trans identities emerges as the foundation that dialogues with the abolition of gender as a diagnostic category. This premise is practically non-negotiable and indicates its own internal complexity 32 . Additionally, Foucault advocates that the construction of scientific knowledge is not something intrinsic to the subject, but that it is invented. The abjection to the social invisibility towards transgender people, constructed by the discourse of a dominant class, entails a series of consequences that affect the lives of these people. The data released by the non-governmental Austrian organization, Transgender Europe, informs that Brazil is the country that kills the most transgender people in the world. According to the report by the Gay Group of Bahia (2017), every 19 hours an LGBTTQIA+ individual dies violently, victim of LGBTphobia, which makes Brazil the number one country in crimes against sexual minorities.
In the Queer perspective, intelligible genders are those that maintain a continuity between sex, gender, sexual practices and desire, through which identity is recognized and acquires a substance effect. The spectra of discontinuity and incoherence that turn into a pathology are, therefore, only conceivable according to this normative system. Therefore, "certain types of gender identity seem to be mere developmental flaws or logical impossibilities, precisely because they do not conform to the norms of cultural intelligibility" 10 (p.39).
The National Curricular Guidelines for the Medical courses (2001 and 2014) and the pedagogical project should guide the undergraduate curriculum aiming to establish criteria for the academic and professional profile of the graduate. This curriculum should contribute to the understanding of the plural context and cultural diversity, including ethical and humanistic dimensions, training doctors with attitudes and values that are oriented towards citizenship and capable of leading to the understanding of social, cultural, behavioral, and psychological determinations, at the individual and collective levels of the healthdisease-care process.
Although the National Curriculum Guidelines approved for the medical education course do not explicitly mention sexual issues and dissident identities, their importance is undeniable from the point of view of individual and collective health.
Moreover, the knowledge in medical education, based on the analysis of publications in RBEM, shows the presence of reductionist concepts. The absence of diseases, sexually-transmitted infections and difficulties in having access to medical appointments are emphasized as important conditions for the association between sexuality and medical education.
The results confirm the situation of vulnerability of this social group due to their constant fight against several obstacles to their social rights and instigate reflection on the health of the target population of this research, mainly in relation to the quality of care at all healthcare levels 34 .
The (in)existence of very little research about the current demands of the transgender community, whatever they may be, it is not only evidenced by the stigmatizing opinions of the professionals, but also because there is no investment by the Government in gender studies, even more in this specific study population. Thus, there is no interest from private institutions, or not, in knowing and caring for this group of people, a position justified by the lack of financial resources for this minority of rights 32 .

FINAL CONSIDERATIONS
The Brazilian Journal of Medical Education (RBEM-Revista Brasileira de Educação Médica) is a relevant medical journal in the training process, as it is a democratic vehicle that encompasses contents covering different topics and theoretical approaches committed to human rights and the social coverage of differences. Thus, the affirmative creation of a volume, perhaps an issue, is suggested, aimed at focusing on the health care of people whose affective-sexual and gender identities are not included in the binary cis-heteronormative norm, contemplating, with distinctive emphasis, the transgender people.
In the academic circles, the debate on gender issues must be broadened and implemented in the curricular matrix; additionally, it must be understood through the nuances of diversity, encompassing the plural forms that involve the process of subjectivation as an individual, abhorring the knowledge that tends to pathologize and punish certain behaviors, ways of being and existing, as well as the identities that differ from gender binarism.
As a prospective action, we suggest reapplying this same study, in the years 2018 and 2019, aiming to identify possible transformations in academic knowledge, considering the effects of the government management on the country' s academic production and its consequences for the social movements' struggles. Furthermore, taking into account the identity intersectionality of transgender people, an analytical in-depth analysis of the categories, ethnicity, class, generation, religiosity and territoriality is necessary.
In an attempt to overcome prejudices of this kind, advances in the construction of strategies that guarantee greater visibility for this group are more than necessary, considering the creation and implementation of public policies aimed at the concession to ensure basic social rights, survival of transgender human beings and that, therefore, remove Brazil from the top of the ranking of LGBTTQIA+ phobia.
Hence, the academic circles are a strategic territory for the production of affirmative knowledge for the reaching of and political representation of the marginalized social segments of public and private narratives. Thus, it is recommended that medical journals establish communication boundaries with the unique health universe of transgender people for an inclusive interdisciplinary analysis and practice. It is suggested, in particular, an approximation with the Social Psychology framework, which has been assuming a counter-hegemonic political role, showing a position in favor of the visibility and identity circularity of subservient groups as a mechanism of access to the social strata of power.
It is crucial to build editorial policies for the dissemination of Queer content based on voices belonging or committed to this perspective of studies. The speech of those who associate identity belonging reflects a place of speech that, when mediated by oriented academic language, combines science, subjectivity, discursive authenticity and a broad and complex health perspective, which includes singularities and differences.