Opening the closets of access and quality: an integrative review on the health of LGBTT populations

The research aimed to study the situations that condition access and quality of health care to lesbians, gays, bisexuals, transvestites and transsexuals (LGBTT) in health services from an integrative review of national and international literature, whose sample of 41 papers was selected in PubMed, Lilacs and SciELO databases from 2007 to 2018. Access and health issues of LGBTT people were discussed in three dimensions: relational, concerning intersubjective relationships among users and professionals; organizational, concerning the organization of services and work processes; and contextual, which covers the effect of vulnerable situations enmeshed with social determinants on the conditions of satisfaction of health needs. The related data showed that LGBTT populations are the target of prejudice, violence, and discrimination, which, added to different social indicators, engender a context of vulnerabilities in access and healthcare. It is necessary to transform health institutions’ practices and social relationships. Otherwise, there is a risk of increasingly warding off those populations from health services.

introduction Access to health services is related to the ability of a group to seek and obtain health care, and accessibility conditions include political, economic, technical, and symbolic dimensions 1 . The quality of health services, on the other hand, is usually normatively assessed, and its theoretical framework consists of seven pillars: efficacy, effectiveness, efficiency, optimization, acceptability, legitimacy, and equity 2 . However, the idea of quality is also related to the subjectivity of health processes 3 .
In this context, inequalities in access and low quality of health care are issues pointed out in different health systems around the world, and primarily affect minority groups, such as lesbian, gay, bisexual, transvestite and transsexual (LGBTT) populations 4,5 . The social imaginary that institutes binary sexual patterns and promotes the alignments "woman-vagina-maternity-procreation-heterosexuality" and "man-penis-rationality-paternity-heterosexuality" 6 builds a non-place or a displaced place for those who fail to meet the standards. So, where and how would they be taken care of in their different health needs? In the closet?
The closet metaphor enacts how health services have been the scene of denials and concealments of the sociability of LGBTT populations. However, in this discussion, it is highlighted that the scientific literature on this topic has hardly had any visibility, thus the importance of underlining it as a large, expanded closet. Bringing this debate out of the closet is also promoting reflections, incursions, and criticisms in the field of knowledge.
Sexual orientation and gender identity are factors that must be considered in the debates on social determination in health. Subjects who escape sexual binarism are exposed to several situations of vulnerability, not only concerning health care but also employment, income, studies, safety, among others 4 .
The world of dissent from the heterosexual norm is very vast. Letters L, G, B, T, and T perceived only as an acronym can lead to the illusion of homogeneity. Each of these letters carries within itself an extensive and diverse set of experiences, as per situations and intersectional markers. However, the experiences of these communities are traversed by some common force lines, subjected to stigmas, prejudice, and violence that are also expressed in access and health care [4][5][6] . All of this pointed to a long path of political disputes, conflicts, and negotiations in the field of fundamental rights and citizenship 7 . In modern times, laws, norms, policies, protocols, among others, are relevant instruments in the enactment of these rights 8 .
This paper, through an integrative review of national and international literature, discusses conditionants and challenges to accessing and quality of health care for lesbians, gays, bisexuals, transvestites, and transsexuals in health services.

Methodological route
This is an integrative review of national and international literature, a research method that aims to gather, synthesize and critically evaluate results from previous studies on a given topic/issue, allowing the construction of an overview of the current state of knowledge and the identification of gaps and directions for future research 9 . The issue to be discussed in this study is situations that condition access and quality of health care for lesbians, gays, bisexuals, transvestites, and transsexuals in health services.
The survey of scientific publications was conducted in January 2019 in the following databases: U.S. National Library of Medicine (PubMed), Latin American and Caribbean Literature in Health Sciences (Lilacs), and Scientific Electronic Library Online (SciELO). Health Sciences Descriptors (DeCS) were used in both Portuguese and English, combined by the Boolean operator "and". In the PubMed advanced search, descriptor "sexual and gender minorities" was combined with "access to health services", "health care" and "quality of health care", separately. The same combinations were performed in Lilacs and Sci-ELO, resulting in a small number of papers. We also used the terms "homosexuality", "transsexuality" and "transgender people", in isolation, to broaden the search on these two databases, and new papers were compiled.
The following inclusion criteria were defined: original papers, available in full in electronic format, in Portuguese, English or Spanish, and published from January 2007 to December 2018. Exclusion criteria were: editorials, letters to the editor, dissertations and theses, papers with an exclusively clinical-epidemiological focus, review papers, essays, and experience reports. The Yogyakarta Principles 10 were launched in late 2006. They are a fundamental document for the fight against prejudice and discrimination against LGBTT populations in the world. Thus, the starting date considered in this search was 2007.
The first survey returned 3,428 papers. After reading the titles or abstracts, 448 studies were eliminated as they were duplicates, and 2,916 due to the exclusion criteria. As a result, 64 publications were left out for full-text reading. Of these, 23 were excluded because they did not discuss issues related to access or the quality of health care for LGBTT populations. In the end, 41 papers were included in the study and identified by an alphanumeric code. We present the search strategies schematically by the specificity of each database in Figure 1.
A more descriptive analysis of the material found was carried out after some reading sessions. Some of this information was synthesized in a synoptic table (Chart 1) containing the following items: code accompanied by the reference number, title, first author, journal, and year. Then, we conducted a content analysis guided by the discussion of the integrative review, where the categories access and health care of LGBTT populations were discussed in three dimensions: relational, which concerns the intersubjective relationships between users and professionals; organizational, which refers to ways of organizing services and work processes; and contextual, which encompasses how situations of vulnerability interwoven with social determinants affect the conditions for satisfying health needs.

results and discussion
What did we find in the closets?
The issue of access and quality of health care for LGBTT populations has been the subject of growing interest in national and international literature. From 2009 to 2014, five publications on the theme were identified, and 36 were found   (16), United States (7), South Africa (5), Canada (4), New Zealand (2), Argentina (2), Portugal (1), Sweden (1), Colombia (1), India (1) and Germany (1). The 41 works were published in 30 journals, sixteen of which were from the U.S., ten Brazilian, two Colombian, one Argentine and one Portuguese. Among Brazilian journals, Ciência & Saúde Coletiva had a higher frequency of papers (4), followed by Physis (2), Interface (2), Cadernos de Saúde Pública (2), Tempus Actas (2), and the remaining ones appeared with a single publication. In Brazil, this scientific production has found space in indexed journals of national circulation that stand out in the dissemination of social sciences and humanities in health studies. Almost all national publications were from journals rated A2, B1 or B2, in the area of collective health by the periodical evaluation system of the Coordination for the Improvement of Higher Education Personnel (Qualis/CAPES). Most foreign journals were rated A1, A2, and B2 for the same area of knowledge.
The professional background of the first authors of the papers was, mainly, in Psychology (12), Nursing (10), and Medicine (9). Four papers had a single author, and a large contingent of three or more authors, expressing strong interaction between different research centers and interdisciplinary dialogues.
Twenty-nine papers used a qualitative approach, nine were quantitative, and three were quantitative-qualitative studies. Previous reviews 4,5 also pointed out the predominant qualitative approach in studies on LGBTT health, perhaps because they are more conducive to understanding complex issues, such as gender, sexuality, production of subjectivity and human rights relationships in the area of health. Many used techniques of content analysis or analyses based on hermeneutic-dialectic assumptions in the interpretative process. In quantitative publications, descriptive studies with sociodemographic and clinical information from LGBTT populations prevailed.
As for the participants, the surveys include both LGBTT groups and health professionals, especially doctors. Most of the studies use the recruitment of LGBTT participants through convenience sampling, using the Snowball technique.
Noteworthy is the incorporation of participants through online recruitment or with the support of crucial informants from LGBTT social movements. The main advantage of methods that use chains of reference is that, in complex, difficult access social networks, such as LGBTT populations, it is easier for a group member to know another member than researchers to identify them.
Nineteen papers discuss LGBTT populations as a single group, considering the nuances in their analysis. Twelve studies use only the categories transvestite, transsexual, or transgender man/woman or trans people. They discuss the biomedical conditions arising from the process of body transformation, such as the use of hormones, plastic surgery, silicone applications, and even sexual reassignment.
Nevertheless, these analyses transcend the hegemonic and pathological perspective, and the authors seek to unveil the challenges for health promotion, legal assurance of these processes, the strengthening of rights, recognition, and autonomy of these subjects in health services. Eight papers address the quality of health care for lesbians and bisexual women in public and private services. Exclusive gay men studies were found only in two publications, one national and the other international. No paper analyzed only the bisexual condition.
The theme has been concealed in the different studies, suggesting that bisexuality holds a vulnerable place socially, politically and scientifically, and is still perceived as "questionable" sexuality, which hinders the possibility of real inclusion of these subjects. A review of papers published in the United Kingdom also noticed the limited production concerning bisexuals 5 . Despite the importance of the topic, issues related to the health needs of adolescent and young LGBTT were discussed in only three papers. In some studies (5), the researchers -gays, lesbians, and a trans man -explained, in the paper, their sexual orientation or gender identity.

Are the rights recognized to LGBTT populations on the shelves of closets?
Human rights are born as universal natural rights. They develop as positive private rights, to finally find their full fulfillment as universal positive rights 8 . In the revised papers, reflections on LGBTT rights claim legitimacy in a set of normative documents, from the 1948 Universal Declaration of Human Rights to the 1994 International Conference on Population and Development in Cairo. The 2007 Yogyakarta Principles -a document that synthesizes a set of principles for the application of international human rights legislation concerning sexual orientation and gender identity -were fundamental to guide States in adopting measures to protect LGBTT populations. The analyses on access conditions and the quality of health care, in most cases, were included in these milestones [11][12][13][14] .
Removing homosexuality from the section of pathology was a relevant fact to address abuse, restrictions, and denials of rights to LGBTT populations. However, the process of deconstructing the pathological perspective has been long and non-linear. The papers 12-15 mentioned the role of international normative frameworks when, in the mid-1970s, bodies such as the American Psychiatric Association and the American Psychological Association stopped classifying homosexuality as a disease and, in 1990, the World Health Organization followed the same path, removing it from the list of mental illnesses.
The approval of laws that prohibit crimes against sexual orientation and gender identitysuch as U.S. Matthew Shepard Law and the law regulating LGBT marriage in Canada -are taken as examples of legal initiatives that enhance the enforcement of rights 13,16,17 . The papers discuss the case of South Africa, which, despite being surrounded by countries averse to LGBTT rights, opened space for the consolidation of one of the most "progressive" laws in the world; its Constitution was the first to prohibit sexual, and gender discrimination and, currently also protects LGBTT refugees, which is why it concentrates a large number of "sexual asylum seekers" of the continent 11,18,19 . In Portugal, the Gender Identity Law allows and assists body changes and modification of civil records since 2011, and is a reference for discussing LGBTT rights 14 .
In discussing LGBTT health care aspects, many papers 17,20,21 , mainly from the U.S., refer to documents such as protocols, technical manuals, conduct guidelines, recommendations, and others. Mostly, they point out gaps between the theoretical-logical models of policies and programs and the reality of clinical practice.
In the Brazilian scenario, many publications mention the 1988 Federal Constitution that established the universal right to health 15,22,23 , the 2004 "Brasil sem Homofobia" (Brazil without homophobia) program, and the 2008 First National Conference of LGBT Public Policies and Human Rights 12,15,24 . In the discussion on depathologization, Resolution 001/99 of the Federal Council of Psychology, which prohibits psychologists from participating or proposing events and services that aim to "treat" and "cure" LGBTT people 15,23 , is often cited. In the discussion about the transsexualizing process in the SUS, the landmark is Ordinance N° 2803/13, from the Ministry of Health, pointed out as a watershed in the perspective of health equity 4,25 . Ministerial Ordinance N° 2.836/11 that launched the National Comprehensive Health Policy for Lesbians, Gays, Bisexuals, Transvestites, and Transsexuals is a reference for discussions on access and quality of health care for these populations 12,23,24 .
Studies show how historical and structural problems in health services and systems, linked to political, economic, and cultural contexts, affect the health production of individuals with multiple stigmatizations -by gender, skin color/ethnicity, socioeconomic status, among others 11,16,26,27 . In the Brazilian reality, despite the existence of health policies for LGBTT populations, health managers face difficulties in operationalizing, monitoring, and evaluating them, and weaknesses are identified in the coordination and dialogue between representatives of the federal, state, and municipal governments 12,23 .
If national and international literature shows how normative and legal instruments are essential for the guarantee of LGBTT rights, it also reveals that they are not sufficient for changes. For its actual effectiveness, other pacts that are not normative and legal and traverse circuits other than those macro-political and macro-institutional must be established. The political struggles that cross the authorities that design, implement and manage public policies are translated and re-enacted in the health services, in the corridors of the units, within offices, in meetings, and in the sociabilities that are woven there daily.

Dismantling the closets of access and quality of LGBTT health care
In this topic, we analyze the discussions in the literature on the conditions that influence access and quality of health care for LGBTT populations. A vast national and international theoretical production has invested in categories and models of analysis for the study of access and quality in health, under varied perspectives, ranging from normative evaluative to more sociological studies. Without intending to delve into more technical issues in the area of health assessment, in this review, the themes and discussions found in the papers were organized into three main dimen-sions: relational, which concerns inter-subjective relationships between users and health professionals; organizational, which refers to strategies for organizing services and work processes; and, finally, contextual, which shows how different issues of vulnerability affect health situations. The distinction between these dimensions is merely to operationalize the analysis; in publicationsas well as in real-life interaction flows -they are complex and interwoven.

The relational dimension
In the dimension called here "relational", the relationships between LGBTT people and health professionals were identified as a central condition to the quality of care, like reception, which implies building bonds, respect, non-discrimination, and non-judgment, that is, the practice of a clinic committed to citizenship 25,28 , depends on them.
The literature on conditions of access to health services shows that a good user-professional relationship requires active and qualified listening 1,3 . In the reviewed papers, this qualification of the relationship was pointed out as a condition for the disclosure of sexual orientation or gender identity in health services -an indispensable condition for resolute care and the establishment of care lines 22,29 . The LGBTT populations showed different concerns regarding whether or not to reveal themselves to health professionals [29][30][31] .
Research with lesbians in São Paulo showed that the main barrier in the search for health services is related to the fear of revealing their sexual orientation and homoerotic practices, and the expectation of suffering prejudice 30 . In a study carried out in Germany with 766 lesbians, only 40% revealed their sexual orientation to health professionals, although 89% of them had a referral doctor for PHC 31 . Non-disclosure can make lesbian more vulnerable to sexually transmitted infections (STIs) and AIDS, because, despite their varied sexual practices, they hardly use condoms 32 .
In South Africa, LGBTT populations described experiences of disrespect by health professionals or administrators, when revealing sexual orientation or gender identity in health services, with scenes of verbal and sexual harassment 19,20 . In expressing their desire for pregnancy, lesbian in New Zealand felt harassed through pejorative reactions by health professionals 33 . Another study showed that users who revealed themselves were 2.5 times more likely to suffer prejudice 34 .
The disclosure of sexual orientation or gender identity can cause embarrassment in health professionals who are barely sensitized or trained to serve these populations. Research 29,33 showed that after the verbalization of LGBTT identity, users realized that the professionals became uncomfortable, with a rapid change of subject, not knowing how to continue the communication, or else, incredulous at the revelation of sexual orientation or gender identity. In the visits, some users also noted inadequate curiosity from health professionals, where issues and details of sexual practices were questioned, without these concerns being relevant to the historical revival, diagnosis, or treatment in health 19,20 . They also highlighted that the professionals' religious beliefs, when imposed, weakened the bond 18,22 .
The violation of information confidentiality in LGBTT health care was a topic widely addressed in the investigated literature and other reviews 4,5 . Users reported that their sexual orientation or gender identity was shared with other professionals, indiscriminately and unnecessarily, as well as with other people in the community 35,36 . In the U.S., users reported fear that their information would be passed on to health insurers, and higher fees would be charged, associating LGBTT identity with the risk of contracting HIV 17 . Canadian trans people had difficulties in adhering to health insurance, being on separate lists waiting for more than a year to take out insurance 13 .

The organizational dimension
How the services are organized, the work processes and the effects concerning access and quality of health care for LGBTT populations have been debated in the literature. The inadequate reception was evidenced in several situations, such as the non-recognition of the social name in the medical records and the communications at the counters, in the waiting rooms and the offices, reported by Brazilian transvestites 37-39 the routine dispensing of male condoms to lesbian, without considering their sexual practices 40 ; the confusion between transsexuality and homosexuality 15 ; exposing LGBTT teenagers to vexatious situations or breach of privacy before parents or guardians 20,41 .
The heteronormative organizational logic and its effects on the work and communication processes in health services were perceived by the subjects participating in the reviewed studies, as well as they were highlighted in other previous reviews 4, 5 . In the ambiance of the services, espe-cially in the waiting rooms, users highlighted the lack of activities and informative and educational resources -posters, leaflets, booklets, lecturesregarding the health of LGBTT populations 12,[42][43][44] . The creation of a favorable environment for these populations in services requires, among other things, the institutional promotion of educational processes that include respect for sexual and gender diversity and fosters a culture of valuing human rights. Thus, some essential weaknesses are identified in health institutions regarding this educational role 23 . One work showed that the educational materials used in the services had a very technical language, not LGBTT-friendly, which did not come close to the communities' dialects and slang 33 .
LGBTT people also realized that they were being judged by workers in the cleaning, security, and administration services of health institutions, due to their way of speaking, their clothing, or ways of expressing themselves 24 . Others reported that they felt rejected by other users of services in the waiting room 23 . In several works 18,43 , users suggested carrying out educational actions for managers, administrators, health professionals, and others working in support services, as well as for the community in general, in order to demystify historically constructed concepts -which could have positive effects on both the relational and organizational dimensions.
The transformation of work processes in health institutions requires professionals to be more sensitive and understand the rights and specificities of care to LGBTT populations, especially transgender people 12 . In the United States, LGBTT populations in rural areas report difficulties in finding available and trained health providers 27 . In Portugal, these populations were better assisted by professionals who had LGBTT relatives, indicating a sensitivity generated from the systemic experience itself 14 .
Besides its pedagogical dimension, permanent education -capacity building and training, the most discussed modalities in the literaturefocused on LGBTT health was mentioned as an essential strategy for changing the operational logic of services 23,44 . Initiatives promoting this debate, such as that of the Association of American Medical Colleges, which has made videos, guides, and informative manuals available to health professionals, were discussed 17 . Likewise, initiatives by the Ministry of Health of Brazil were discussed, which, in partnerships with public universities, have promoted courses and training on the LGBTT theme, in the distance mo-dality 22,25 . The inclusion of the issue of LGBTT rights in academic education was another theme highlighted. Health professionals interviewed pointed out weaknesses in the teaching offered at colleges; considered that the curricular contents referring to LGBTT health convey an exclusively technical and biomedical conception, focusing on STIs and associated risks 12,25,31 .
The meanings assigned to the needs and health care of LGBTT populations are immersed in a continuous network of confrontations, negotiations, legitimations, and transformations, which can bring these subjects closer to or move them away from services, and that is why a broader and permanent discussion on the training devices and in-service education processes is necessary.

The contextual dimension
In a series of studies, situations of vulnerability and social determinants that affect the conditions of satisfaction of the health needs of LGBTT populations are discussed. The ideas of vulnerability and social determination in health refer to the intertwining of material, psychological, cultural, moral, legal and political conditions that strip rights, autonomy, recognition, and participation from people in varying degrees, exposing them to situations of illness and exclude them from the resources available to health [41][42][43][44][45][46][47][48] . What is called the LGBTT universe here is a heterogeneous cluster of people, who are distinguished not only by their sexual or gender identities but by class, skin color/ethnicity, origin, and other markers.
The situations of poverty, violence, discrimination, and stigmatization are essential components of contexts that make vulnerable and precarious the health conditions of LGBTT people, although not always in the same way 15,26 . Some studies have shown that immigrants, indigenous people, people deprived of their liberty, blacks, and rural residents suffer even more pronounced vulnerabilities in their attempt to access health services 27,43 .
A study with the LGBTT populations of New Jersey showed that, among the difficulties of access to health services, is the cost of private insurance 21 . In the Brazilian and South African realities, LGBTT populations in situations of poverty face weaknesses in accessing health services and actions due to the difficulty, for example, of paying for transportation to travel to health units 11,28 . In the case of trans people, in an attempt to become intelligible, the scarcity or lack of provision of specific technologies and specialized procedures in public services causes them, many times, to undergo the processes of forging their bodies in clandestine, unsafe services and end up experiencing near-death experiences constantly [37][38][39] .
LGBTT-phobia, a term that denotes discrimination and the most varied forms of violence suffered by LGBTT populations, extends and reproduces in the chain of events ranging from abuse and battering within families, on the streets or at work, and even the institutions where they seek support, such as police stations and health services 16 . Trans people, a group for which the search for health services is often associated with these events, reported the non-purposeful use of the social name, teasing, and vexing games in emergency rooms 12,14,19 . Institutional violence generates mistrust of professionals, hinders bonds, and produces the stance of avoiding health services in other situations 38 .
Another aspect discussed is how discrimination and violence condition access and the quality of health care, and are also factors of illness. These situations are associated with anxiety, depression, suicide attempts, abuse of psychoactive substances, and must be considered by health services 17,47 .
With the AIDS epidemic, homosexuality and other sexualities and genders diverging from the norm became perverse to illness, transforming one's sexual identity into a synonym for AIDS. Some papers discussed how the dual stigmatransgressing heteronormativity and AIDS -in their various crossings, also traversed health services in Latin America 48 , Canada 49 , and the United States 25 , operating in both primary and specialized care. In India, with the increased HIV incidence among transgender people, this dual stigmatization has been further reinforced 47 . An Argentine study showed another way of stigma: users assessed transgender health professionals as HIV-infected, pedophiles or sex offenders, unethical or not very competent in their profession 50 .
The recognition and protection of human rights are the supporting pillars of democracy 8 . In the reviewed publications, the importance of LGBTT activisms was discussed in the struggles for human rights in the health field and, therefore, in the struggles to transform positively the very contextual conditions and intrinsic to the services and professional practices that influence access and quality of LGBTT health care 45,46,51 .

Final considerations
The instituting imaginary of society is not a mere mental image of something. It is an unceasing "social-historical and psychic" creation of ways of relating, acting, and thinking that produce realities and rationalities 7 . National and international literature shows us how the imaginary that created heteronormativity has permeated, especially, practices in health services -whether in waiting rooms or inside offices -and affected the conditions of access and quality of health care for LGBTT populations. People whose gender identity and sexual orientation are different from what sexual binarism proposes are subject to prejudice, violence, and discrimination, which, added to class, skin color/ethnicity and origin markers, generate a context of vulnerabilities in the health field.
Advances in human rights laws, norms, policies, and programs, and especially concerning the health of LGBTT people, are recognized. However, besides these essential regulatory frameworks, there is a need to think about strategies for transforming practices and face-to-face interactions that occur in the interstices and the daily lives of health services. Otherwise, there is a growing risk that LGBTT populations will be increasingly removed from these institutions. Legal regulations are only realized when translated into local dynamics, that is, incorporated and shared by managers, professionals, and users of the services.
It is necessary to link, within the same principle of justice, the space for the recognition of gender injustices (social and cultural field) and the space for inequalities linked to the exploitation and redistribution of resources (economic field) 52 . This perspective imposes the reflection that the barriers faced by LGBTT populations in health services are the product of the devaluation or lack of recognition of their identities that, in a circular logic, produce or enhance restrictions regarding access to social goods and resources, including health care.
The fact of whether or not to reveal themselves to be LGBTT in interactions with health services emerged in the literature as a matter of high relevance in the health production processes of LGBTT populations. We could ask ourselves here about the "place of speech" 53 of sex-gender dissidents and the power hierarchies established in the field of health. The word "place" comes in handy. We can derive from the literature that health services have been extensions -drawers and shelves -of that invisibility and denial that has been referred to with the closet metaphor. Therefore, revealing oneself is an unavoidable part of the break with this logic. It is an operation necessary to open the "lockers", so that LGBTT people's rights are recognized, accessed, and realized.

collaborations
BO Ferreira and C Bonan contributed equally to all stages of the construction of the manuscript.