The training of Medical students to health care of LGBTI+ people

: Introduction: Brazil national public policy for the comprehensive healthcare of the LGBTi+ population consists of several guidelines and plans that include the training of health professionals. Through actions and strategies, it aims to minimize the effects of gender and sexuality discrimination on this historically marginalized population. Studies were found that show a lack of specific hours for gender and sexuality, a lack of transversality of the LGBTI+ topic and a lack of addressing the socioeconomic, political and racial aspects of LGBTI+ health in the curricula of Faculties of Medicine in Brazil and in the world. Objective: To compare the perception between admittedly LGBTI+ students and heterosexual students regarding the training of medical students on the health of sexual and gender minorities. Methodology: An in-depth qualitative study was carried out through two focus groups: one with LGBTI+ students and the other with non-LGBTI+ students. In addition, a semi-structured questionnaire was also applied. The analysis was made through the analysis of Spink’s Discursive Practices. Result: Current problems were identified: low number of programmatic hours on the topic; lack of transversality; addressing the topic through a pejorative and prejudiced look; association of LGBTI+ people with infectious or psychiatric diseases; lack of addressing socioeconomic, cultural and racial aspects; Primary Care as a space of greater openness to fight against the cisheteronormative hegemony; Conclusion: LGBTI+ health education is still insufficient, as students feel unprepared to address the issue of gender and sexuality, which directly impacts the healthcare of this population. Additionally, further studies on medical education in LGBTI+ health are needed.


INTRODUCTION
Sexual and gender diversity is defined by a range of experiences and expressions repeatedly formed by a combination of psychological, biological and social elements, and can be divided into three elements: biological sex, sexual orientation and gender identity.Biological sex, derived from medical knowledge, is defined by chromosomal genetic information, genital organs, reproductive capacity and secondary characteristics.The biological sex category is subdivided into "male" and "female" or "intersex", the latter when the individual has combined characteristics from both sexes.Sexual orientation is a categorization of the possible types of affective and/or sexual attraction that an individual has when relating to another, and is usually understood as heterosexual, homosexual and bisexual.Gender categorization differentiates the biological aspect from the social one and problematizes biological sex as being independent from cultural expressions.Therefore, the idea of gender identity encompasses the conception of the social reality to the detriment of the anatomical primacy of individual bodies¹.
The National Policy for the Comprehensive Healthcare of Lesbians, Gays, Bisexuals, Transvestites and Transsexuals (PNSILGBT, Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais, Travestis e Transexuais), established by the Ministry of Health in 2011, consists in a group of guidelines, contains health goals and plans aimed at guaranteeing healthcare for a historically marginalized population, respecting the individualities of gender, race/ethnicity, generation, orientation and affective and sexual practices².The LGBTI+ population, historically violated in their human rights, is often seen in situations of vulnerability due to social rejection of the existence of non-cisgender and heteronormative identities.From the constant struggles and tensions of social movements engaged with the agenda of free sexuality, the Ministry of Health recognizes gender identity and sexual identity as essential components to conceive a society free of discrimination and exclusion.Gender identities other than cisgenders, as well as sexual orientations other than heterosexuals, are subject to vulnerabilities such as the "violation of the right to health, dignity, non-discrimination, autonomy and free development"³.Thus, one of the PNSILGBT axes is related to the training of health professionals through actions and strategies aimed at fighting discrimination based on gender, sexuality, race, skin color, ethnicity or territory².
The new National Curriculum Guidelines (DCN, Diretrizes Curriculares Nacionais), regulations that guide the curricula of undergraduate medical courses in the country, encourage doctors in training to consider the spectrum of subjective diversity of individuals, respecting ethnic-racial, gender, sexual orientation, biological, socioeconomic, political, environmental, and cultural characteristics.The DCN also provides for human rights as a cross-cutting topic in the curricula of medical schools in Brazil 4 .However, both national and international literature points to a lack of knowledge about the health of the LGBTI+ population by medical professionals.
A study conducted by Moll in emergency residency programs in the United States of America on the prevalence of training and education in LGBTI+ health points out that in most of them there are no specific hours in the curriculum for the topic of LGBTI+ health, although there is a desire for inclusion.
This study shows that the greater the number of professors and residents who self-identify as LGBTI+, the greater the number of teaching hours dedicated to LGBTI+ health in the programs 5 .Donald proposes a report to qualify competencies and guide medical educators in teaching care aimed at LGBTI+ individuals.This reinforces the importance of considering socioeconomic factors to understand factors related to LGBTI+ health.Moreover, this report aims to develop quality education culminating in the guarantee of equity in the health system, since researchers consider medical education to be precarious regarding LGBTI+ health 6 .Salinas Urbina focuses her studies on dealing with sexuality in professional practice from the perspective of students in the last years of medical school in Mexico.The author reports a feeling of incapacity experienced by the students when dealing with issues of gender and sexuality in the face of sexual violence.They complain about the existence of a gap in theoretical knowledge regarding the care needs of the LGBTI+ population, in addition to highlighting the need to incorporate emotional and cultural aspects involved in the social construction of sexuality 7 .
Cronemberger Rufino finds an insufficient mandatory workload when teaching the topic "sexuality" in medical courses in Piauí, in addition to the lack of comprehensiveness and transversality of the topic in the course.Moreover, there is the pathologization of the LGBTI+ population, since there is an association between sexuality and organic and psychiatric diseases, as well as "sexuality disorders", "sexual violence" and in topics such as cancer, abortion, Sexually Transmitted Infections (STIs) and Acquired Immunodeficiency Syndrome (AIDS) 8 .Paulino 9 analyzed speeches by physicians from the Family Health Strategy (FHS) about care for the LGBTI+ population by grouping the statements into three speech categories: "Discourse of non-difference", "Discourse of not knowing" and "Discourse of not wanting".The author states that the analyzed discourses depreciate issues involving the health of the LGBTI+ population, moving it away from an equitable, comprehensive and universal ideal.This study concludes that questioning the cis-heteronormative view present in the subjective constitution and that crosses the relationship with the LGBTI+ population is essential for positive changes within the places of care for the LGBTI+ population.Cronemberger Rufino states that the challenge lies beyond overcoming the discrimination against the LGBTI+ population, but in understanding the complexity of the subject, elaborating on its socioeconomic, historical, political, cultural factors within the curriculum of medical courses, so that effective strategies can be developed to improve access and quality of comprehensive care to LGBTI+ health.
In addition to the lack of knowledge about the health of the LGBTI+ population, doctors in training reproduce prejudices in discourses related to sexual and gender diversity.In a study about prejudice against sexual and gender diversity in a medical course in Santa Catarina, Moretti-Pires concludes that at least 60% of the students showed some type of discrimination against the LGBTI+ population, but when considering veiled or subtle prejudice, 10,11 this percentage tends to increase.This study points out that the formal curriculum of the medical course does not include the LGBTI+ health topic, but there is a hidden curriculum as a driver and defender of discrimination.

METHODS
This is a qualitative research, with in-depth discourse analysis, using the technique of Online Focus Groups (OFG) synchronously through online videoconferencing as suggested by Fricker 12 .It is noteworthy that the formation of face-to-face groups at the time when the research was carried out was prohibited, due to the Covid-19 pandemic.It was decided to include students in an advanced stage of the medical course, working in the clinical practice predicted during the course.Therefore, the OFG consisted of students between the seventh and twelfth semesters of the course.The difficulty in accessing the internet was established as an exclusion criterion, as it was essential to use the web conferencing system made available by the researchers.
Recruitment was carried out using an online form, which the interested parties could use to register and identify themselves for subsequent selection using the snowball method, as described by Bernard, considering gender and race/skin color for greater diversity and representativeness within the OFG 13 .The initial contact with the participants took place via virtual meeting, in which the researcher explained the topic, relevance and purpose of the research, as well as the possible destinations in terms of treatment and analysis of information, as well as the dissemination of results, following the current Legislation protocols on research with human beings, including the explanation of the Free and Informed Consent Form (ICF).Furthermore, the date and duration of the OFG were agreed upon.
The participants were divided into two groups, according to gender identity and sexual orientation, configured as LGBTI+ and non-LGBTI+ individuals.The OFG were conducted in December 2020 and had the participation of 10 students, with the Cis-LGB group consisting of five participants, as well as the Cis-Heterosexual group, both of which are described in Table 1.It is important to note that it was not possible to divide the groups according to the race/skin color criterion due to the insufficient number of participants for this purpose; however, we considered it relevant to characterize the participants also according to race/skin color characteristic in the data presentation.Moreover, at the time of the research, the medical course had only two trans students, who, because they were in the initial semesters of the course, did not participate in the present research.Therefore, the groups consisted only of cisgender people.The meetings lasted, on average, one hour, were recorded and fully transcribed for later analysis [12][13] .
The OFG were monitored by two researchers, one of which was responsible for moderation, mediating the participation of all participants.The second researcher acted as the rapporteur responsible for technical issues of the OFG, such as controlling the quality of the recording and getting in touch if any participant lost connection or left the online meeting without warning.
Triggering questions led the discussion and guided the topic, but the moderator researcher ensured that the group directed the conversation in the way that made sense to them.Silence was considered as agreement with the member's speech and informed to the participants; therefore, it was encouraged that divergences, as well as other relevant aspects were verbalized [14][15] .After the initial explanations, the focus group moderator asked the first guiding question: "I would like you to report what you learned about the health of the LGBTI+ population during your undergraduate course", while the others were asked as necessary for the progress of the discussion 12 .The few interventions made by the moderator occurred to offer explanations related to terminology, characteristics, events or specific meanings for the students.
With regard to the clarification of singular meanings brought by the students, unstructured questions were essential to confirm the moderator's understanding of what was being said by the participants 12-14-15 .
The OFG reports were later transcribed and for discourse analysis, the concept of discursive practices was used, as advocated by Spink.This concept is a theoreticalconceptual instrument used in studies that use language as an empirical research substrate; however, it does not intend to analyze structures or usual linguistic ways of working with content.For Spink, language is associated with casual and contextual meanings in bundles of fluid relationships, and allows understanding the diversity, dynamism and variability of linguistic devices when used to construct versions of actions, events and other phenomena.This concept becomes important for the analysis of the study, since it provides the opportunity to present the groups' perceptions in relation to each other 16 .

RESULTS
The conducted online focus groups showed a concern and an interest by students in being better technically trained with regard to LGBTI+ health, since little information is provided on the specific features of this population's health during the medical course.There are notes that LGBTI+ health, when addressed, in a few situations, is often associated with diseases, whether infectious or psychiatric conditions.
The participants pointed out that the biopsychosocial approach present in Health and Family Medicine contributes positively to thinking about how to clinically approach more vulnerable populations, since there are reports of experience in internships in Basic Health Units (BHUs), in which the embracement and the assumptions of this approach help to think about not pathologizing the LGBTI+ population.A difference was also noticed regarding the perception of the importance of discussing this topic in the classroom according to the conducted groups, since the Cis-Heterosexual group points out a concern with regard to technical training, while the Cis-LGB group, in addition to technical training, point out their personal experiences of discrimination and discomfort in the academic space and that the discussion of the subject can contribute to a better coexistence in these spaces.These data are described and exemplified with excerpts from the speeches that took place in the focus groups and will be further analyzed in the next section.
Considering the doctor's performance regarding the health of the LGBTI+ population, the focus groups showed that the undergraduate students were not presented systematically both in terms of data and work with the population in their health demands.Therefore, regarding the workload on LGBTI+ health or the teaching of sexuality and gender, the OFG pointed out an insufficiency: In this context, it is possible to infer, according to the perception of both OFGs, that in the few moments when the LGBTI+ topic is presented in the classroom, it contains a pejorative look.The association of psychiatric, infectious-contagious diseases to the LGBTI+ population is common, revealing a negative bias in the teaching of sexuality and gender: the LGBTI+ population as an object of study, not perceiving them as biopsychosocial beings.It is also interesting to point out that an optional subject, present in the curriculum focused on gender and human sexuality, was mentioned only in the Cis-LGB group: "so, many questions, of social sciences anyway, many questions like that don't get there in the course, they don't even come to us as an alternative for us to be able to go after, you know, we have to keep going after it and I think they are very different approaches like that, medicine, so, it sees (the LGBTI+ population) as an object of study, pathologizer, as if, pathologizing, as if that person had, still in the biomedical view, they remained that thing that has to be cured, treated or suppressed, it is not even thought about the social aspects of the person and how this can affect their health, for example.

" (OFG Cis-LGB) "the teachers, I don't feel that they are prepared to deal with this subject and I also don't feel they are respectful people" (OFG Cis-Heterosexual)
"There is a course, which is about gender and sexuality, an elective discipline" (OFG Cis-LGB) We found reports in the OFG Cis-LGB that there is a greater demand for knowledge about LGBTI+ health by people who identify themselves as part of this population or who are part of a context that welcomes the topic with greater appreciation.
"generally those who are interested are those who already are, or already identify as LGBT" (OFG Cis-LGB) "usually, those who seek these elective subjects, this content outside the course like this, aimed at LGBTI health, are the ones who would need it the least, would least need it, as an advantage, because they are already well included and well on their way in this regard, because the people who really are, there would be a difference, they don't care about it like that."(OFG Cis-LGB)

OFG Cis-LGB participants report the tendency that
LGBTI+ medical students have to group together and maintain close relationships as a strategy to create a safe and embracing environment, thus facing the prejudice suffered within the course in general.
"I think that one characteristic that I see at least among LGBT people in medicine is that we get together, like, the LGBTs, generally, they are friends, we have our little group, sometimes there is one or two heterosexual "pets" like that, but in general, like, we relate to ourselves, you know, so I always felt welcomed because I always had people by my side who went through the same things I did, or who could understand the things I had to go through, I always had my group of friends, still, I never felt alone in medicine, but I cannot say that I feel welcomed by the rest of the course" (OFG Cis-LGB)

"I think it affects the way groups are formed like this, LGBTs end up together and it's very much a matter of personal identification" (OFG Cis-LGB)
Reports of discrimination in health care were brought in the OFG Cis-LGB: "I think it completely changes the approach that a doctor has with you from the moment you reveal yourself as LGBT" (OFG Cis-LGB) "I was treated in a horrible way, from the attendant at the health center that said discriminatory things in relation to sexual health, in relation to my being LGBT, like, well, for "n" questions, to a doctor who attended me and I was treated with a certain disgust, like, questions about being LGBT, the questions I had about anal health, or things they didn't want to face" (OFG Cis-LGB) The OFG Cis-Heterosexual points out that a greater number of LGBTI+ individuals within a group of people contributes to confronting the violence against LGBTI+ people.
Although there is no consensus regarding the reduction of violence directed at LGBTI+ people, there is recognition that there is respect for these people, whether through coercion exerted by a significant number of LGBTI+ people or as a matter of knowledge or awareness of different gender identities and sexual orientation.It is important to emphasize, however, the existence of discursive violence regarding LGBTI+ people, since the word "contaminated" is used to describe LGBTI+ people in the classroom, related to a pathological perception: "In my classroom, it is even a little contaminated, because I think there is an above-average number of LGBT colleagues, so I believe there are people who make jokes, but in my viewpoint, it is a more respectful environment than I believe is on average, due to the number of LGBT colleagues in the room."(OFG Cis-Heterosexual)

"But I don't think it's a respect like that, out of awareness or knowledge, I think it's a respect out of fear of coercion on the part of other colleagues, because numerically, let's say, heterosexual people who tend to have more aggressive behaviors are in the minority, so I don't think it is, this environment of respect, I don't think it is a matter of awareness, it would be a matter of the rest of the class reacting very badly." (OFG Cis-Heterosexual)
It is noteworthy that only the OFG Cis-LGB discussed the social class aspect and income markers regarding the power to choose a professional and the difference between public and private health service.The possibility of choice is pointed out as a possibility to seek spaces and professionals that respect often than the others, some I don't even see addressing it, in fact, so if the family medicine is the only one that will, that will tackle this issue, as it has clashed with so many others, and the professionals who are being trained (...) are managing to change this view, perhaps, of the people" (OFG Cis-Heterosexual) The results indicate that although both groups problematize the importance of discussing and being technically trained regarding the health of the LGBTI+ population, the OFG Cis-LGB raises a debate that goes beyond instrumental training, but the violence that this population is subject to, either in university spaces or in healthcare spaces.

DISCUSSION
The speeches presented herein are in line with studies that report a gap in the formal curriculum of the medical course, either due to absence or a low workload on topics related to LGBTI+ health 5-7-8-10 .This gap goes against the studies that show the importance of introducing content related to gender identity, sexual orientation and sexuality in medical training as a key element to promote public health policies aimed at gender equality and the promotion of human rights [17][18] .We realize this importance when we associate these studies with the findings of Cronemberger Rufino 8 , which reveals an approach with a negative bias in the teaching about sexuality and gender in medical courses in the state of Piauí, as it is common to associate psychiatric, infectious and contagious diseases to the LGBTI+ population.This perception was also mentioned in the OFG conducted in our research, when the participants point out that in the few moments when the LGBTI+ topic is presented, it contains a pejorative look.
We understand that discrimination and lack of debate on gender and sexuality issues in medical courses contribute to a feeling of non-belonging and, in some cases, to the existence of discrimination or violence experienced by the LGBTI+ undergraduates.As a way to build a support network among students, OFG Cis-LGB participants reported the grouping of LGBTI+ medical students as a strategy to create a safe and welcoming environment, thus facing prejudice.Moreover, together with other studies, this is also a way to identify and understand the LGBTI+ experience [10][11][12][13][14][15][16][17][18][19][20][21][22][23] .These reports may be one of the justifications for studies that associate the presence of LGBTI teachers and residents with a greater workload available in health education for this population 5 , because we perceive that LGBTI+ people, through their experiences, understand the potential impact of these discussions on interpersonal relationships and the creation of spaces of belonging beyond technical training.their particularities, and, in matters of gender and sexuality, it is essential for professionals to understand the specific demands of the LGBTI+ population.
"I think that when you can choose your doctor, when you are not part of the public service, when you don't depend on it, I think that even you can live inside a bubble like that, maybe you only live with doctors who treat you well".(OFG Cis-LGB) The OFG Cis-Heterosexual addressed the issue of discrimination against LGBTI+ people and the gap in teaching about the patients' gender and sexuality-related health demands from an external and instrumental perspective on how to approach patients: "During undergraduate school, we are not trained to know the type of approach, so no matter how much it is mentioned at some point in semiology, we are not trained and encouraged to address these issues (of gender and sexuality)" (OFG Cis-Heterosexual) "It seems that this part (gender and sexuality), which is a very important part of a patient's life, we are not, we are not encouraged to talk about it, ask about it, to seek this bond too, right, with the person that we are assisting" (OFG Cis-Heterosexual) Both groups discussed the discrimination suffered by the LGBTI+ population, but it is important to emphasize the difference in the discussions between them.In the OFG Cis-Heterosexual, the discussion took place in a more technical way, on how to deal with LGBTI+ patients and in the OFG Cis- LGB, the importance of a broader discussion was emphasized, beyond the clinical practice, but also as a social formation, being common for them to bring their personal stories.We understand that the discussion on the subject is also a way to create a space of belonging and the existence of these people within the space that is the University.
Regarding the Primary Health Care (PHC), both groups mentioned it as a positive experience, in which family and community medicine acts as an instrument for addressing gender and sexuality in health care.
"I arrive at a meeting of the family health team at the BHU where I carry out community interaction, and there is already a greater commitment to discussing pathologization, about the social aspect, a more psychosocial approach in relation to transgender people, you know, and multidisciplinary too, not simply restricted to the DSM V itself, or the criteria that basically try to classify these people as ill" (OFG Cis-LGB) "I think it will change through family medicine, you know, when we have more of it, because it is the only specialty nowadays that I see that addresses this more DOI: https://doi.org/10.1590/1981-5271v47.Despite the fact that there are studies describing the importance of defining class and addressing socioeconomic factors as essential for a complete understanding of LGBTI+ health 6,9 , this perception was not very evident in the focus groups.
It is important to emphasize that Brazil has socioeconomic and racial inequalities that cause severe disparities in access to the university, evidenced mainly in more prestigious courses, such as Medicine, still predominantly attended by white, rich and upper middle class individuals 24-25-26 .In this context, the non-appearance of skin color/race and class emphasizes the absence and/or precariousness of the intersectional debate in medical training 27 , since different social markers (social class, gender, race/ethnicity, skin color, sexualities, among others) interrelate, thus contributing to the existence of inequalities and injustice.We emphasize this aspect because there are studies demonstrating the interrelation of systemic oppressions as individual identities intersect 28,29 .It is worth mentioning that this research was carried out in a federal public university, consisting of students that entered University through social and ethnic-racial quotas.
Considering studies that affirm the need for an approach to the biological, sociocultural and psychological aspects of individuals for the adequate teaching of gender and sexuality 19-20-21-22 , we can understand the potential of PHC to consider the embracement of the LGBTI+ population.PHC understands health from its social determinants and constraints, becoming a place for vulnerable populations, such as the LGBTI+ population.It is the main gateway to the health system and a reference in the Health Care Network and works to minimize the inequalities and exclusions experienced by social groups 30 .This perception corroborates the study reported by Pereira concerning the feeling related to health care for the trans population in the context of PHC in Florianópolis 31 .However, the review of the National Primary Care Policy (PNAB, Política Nacional de Atenção Básica) in 2017 threatens the potential of PHC care and embracement, since its alteration allowed the relativization of territory coverage and has selective health care that prioritizes the provision of minimal care 32 .This, combined with the gap in the training of physicians found in our research, places us at the forefront of a critical scenario regarding the health of the LGBTI+ population.
The absence of trans people in the universe of this research portrays a reality marked by intense inequities, being one of the social groups that most experience prejudiced, discriminatory and violent practices, known as transphobias 33 .
The low number of trans people at the university also highlights the difficulty of access to education, probably due to the impossibility of this population's existence in society.This context is more evident when we are faced with the fact that Brazil is the country that leads the world ranking of deaths due to transphobia, with 980 deaths recorded between 2011 and 2016, and at least 175 murders of trans people in the year 2020 34 , whereas until 2021 an average of 123.8 murders were recorded from 2008 to 2021.It is important to note that the data presented herein are not official data, since the country does not have a census that considers gender identity that allows data related to murders to be necessary.Additionally, life expectancy is only 35 years old 34 , 82% of trans women leave high school between the ages of 14 and 18 35 and 90% of them have sex work as their only possibility of survival, exclusively or mainly [34][35][36] .

CONCLUSION
This research concludes that medical students are insecure about medical care and clinical management of LGBTI+ health.In addition, the curricular programmatic content is insufficient in approaching and identifying LGBTI+ people and in handling their specific demands.This shows a deficiency in the discussion of LGBTI+ health in the classroom, which denotes an important gap in the training of future doctors to meet the demands of a population that, although called a minority, is a significant part of the Brazilian population.Considering the literature on the subject, it points to the need to include the topic of gender and sexuality in the formal curricula of medical undergraduate school, and the interest shown by the students in our study, as well as the insecurity they reported regarding the health care of LGBTI+ people, points to the need to discuss this curricular gap in the medical course.We emphasize that, as a result of insufficient discussion of the topic, students independently seek to acquire qualification in it, and those who identify themselves as people from the LGBTI+ group are more interested in the discussion because they are aware of the potentially violent context that a health service can be for an LGBTI+ person.

Finally
, Moretti-Pires suggests that these gaps play a central role in maintaining discriminatory structures against the LGBTI+ population within the environment of the undergraduate medical course 10 .Given the abovementioned facts, this research aims to compare the perception of openly LGBTI+ students and heterosexual students in relation to the training of doctors on the healthcare of sexual and gender minorities.

Table 1 .
Characteristics of the participants of the Online FocusGroups.
Source: Prepared by the authors.