Health care provision in Brazil: A dialogue between health professionals and lesbian,gay,bisexual and transgender service users

Method

A group discussion between health professionals and LGBT service users was conducted on the topic of health care provision for the LGBT population. The meeting followed the dialogue facilitation model developed by the Public Conversations Project (PCP), a North-American institution that offers dialogue interventions in situations of social conflict and polarised opinions. The PCP provides an alternative structure to the conversational interactions that take place during a debate. A debate predominantly employs a rhetoric of argumentation and counter argumentation, questioning truths, using abstract arguments, homogenisation and simplification of points of view, and stereotyping differences. In contrast, the PCP strategy uses three main axes: (1) to focus on sharing personal stories to enable participants to understand each other’s perspectives about what is being discussed, (2) to explore ambiguousness and ambivalences about the theme and (3) to invite questions about divergent opinions expressed (PCP, 2011). It is possible to articulate the social constructionist discourse with the PCP methodology, as both understand dialogue as a characteristic of a conversation in which contrasting truths about the world can be appreciated and opinions can be regarded as cultural and historical social constructions.

The discussion involved two facilitators, a female heterosexual psychologist and a male homosexual psychologist, and seven participants, here described by the attributes they chose to present themselves to the group: Amanda, a 22-year-old homosexual and transvestite, currently unemployed and living in a community shelter; Carolina, a 27-year-old married transvestite, currently working as a sex-worker and living in a community shelter; Julio, a 42-year-old local General Practitioner; Bruno, a 21-year-old homosexual student, who is currently in a relationship; Tiê, a 20-year-old female transsexual, who is currently in a relationship; Juliana, a 35-year-old married nurse; and Marília, a 39-year-old primary care nurse.

Participants of the study were recommended by key informants within the local community: a vicar from an LGBT inclusive church, a transsexual coordinator of a shelter for transvestites and transsexuals, and a nurse and coordinator from a sexually transmitted disease (STD) clinic that provides advice and performs tests (Centro de Testagem e Aconselhamento – CTA).

The discussion took place in Maringa, a recently urbanised, relatively large city in the Brazilian state of Parana. The city’s economy is predominantly based on retail, and local health authorities have not yet properly implemented the National Policy for Integral Health of LGBT population. The local LGBT social movement has been putting pressure on the health services that tried to practice policy guidelines (e.g. by referring to users by their preferred name) to attend workshops and talks delivered by reputable professionals and academics in order to raise professional awareness about LGBT health issues.

Prior to the group discussion, each participant attended an individual interview, in which the purpose of the study and of the group discussion were presented, and in which they could explore how the topic of the discussion was experienced by them and potentially by others. During these interviews, ground rules were set, such as participants should only share their own personal experiences, thus avoiding abstract discourses, not to judge other participants’ opinions, not to interrupt when others are speaking, to speak within the allowed time, not to try to persuade others to change their opinion and to avoid making counter arguments.

To start the discussion, the facilitator asked the group what were the main challenges they faced when using or providing health services in the city. Participants were then invited to ask each other details of the experiences they described, with interest and respect. To conclude, the facilitators asked the participants, on the basis of their experiences, as well as on what they had learned during the discussion, to propose resources to improve health care provision to the LGBT population.

All participants signed a consent form. The study was one of the outcomes of a project that had been approved under reference number 01647512.5.0000.0104 by the Committee of Ethics in Research involving Human Beings from Maringa State University, institutional affiliation of one of the researchers. The discussion took place in one of the university’s classrooms.

The literal and complete audio transcript of the recorded discussion was analysed considering the meanings about improving the provision of LGBT care that were coproduced by the interactions within the group. These meanings are related to the third question raised during the discussion.

Results and discussion

The analysis of the discursive practices produced in the group interactions during the discussion indicates that health professionals need to be more attuned to the LGBT population. This resource was endorsed by most participants:

In the aforementioned transcripts, expressions such as ‘new to me’, ‘it seemed natural’, ‘new experience’, ‘shock’ and ‘used to’ indicate that the interactions between health professionals and LGBT service users is described as a novelty, as something unusual, that is uncommon in everyday working life. In the discourse, a distinction between they (the users) and us (the health professionals) is constructed, as well as reference to ‘the unusual sexuality’ as something exclusive to the users. According to the professional’s discourse, this division indicates the need for health professionals to be more attuned to those users with whom they have little to no contact. This lack of knowledge has also been found in other similar studies in Brazil (Terto-Junior, 2002; Moscheta, 2011) and abroad (Davy and Siriwardena, 2012).

Similarly to how it has been described in a study on primary care in Brazil (Moscheta, 2011), in our study, health professionals mentioned different examples of the difficulties they experience concerning how to refer to users (preferred name) and enquire about their sexual life during consultation. These concerns show us how much differences, such as sexual orientation, behaviours and manners of dress, are still a taboo in the relations between professionals and patients, therefore something that needs to be addressed very carefully. While trying not to act with prejudice, health professionals become distant, less spontaneous and resent providing inadequate care to their users. Against such level of cautiousness, Tiê suggested a resource that is simple and yet disruptive:

Not because I am effeminate, almost transvestite, or if I was a lesbian, or looked like a girl, or if I looked like neither, not even a human being. The most polite and respectful way is to ask ‘How should I call you?’ Then, for example … you need to establish the number of sexual intercourses, you can ask ‘how often do you have sex?’ There is no need to ask about the gender of the sex partner or partners, you know? (Tiê)

This resource is simple because it allows potentially uncomfortable situations to be resolved by asking users what would make them feel comfortable during a consultation. However, it is disruptive because it opposes the biomedical model, which assigns to the professional in their specialist capacity the responsibility of knowing what is best for the user (Souza and Santos, 2014). In this model, the professional asks how best to act so that instead of being positioned as the ‘one who knows about the other’, an opportunity is created to ‘know with the other’. The idea of dual responsibility for the quality of the professional–user relationship is still not well understood by health professionals outside the mental health field, often because they do not see the emotional experiences of the users as objects of the care they provide (Souza and Santos, 2013).

Tiê’s discourse must be seen from the perspective of her social context, as a graduate student of the humanities who participates in discussions about sexual diversity, feminism and gender policies. Derived from her knowledge of discourses reporting sexual discrimination, she points that professionals should treat LGBT service users in the same manner they would treat any other human being, or even to those who ‘do not look human’, as she humorously stated. Tiê defends that professional should not change the way they interact with service users because of the way they look, and that this is a way of demonstrating respect. This resource could reduce the widespread dissemination of social prejudice suffered by LGBT service users in the consulting rooms (Macdonnell, 2014).

To address the gaps in professional training, described in the beginning of the study, professionals and users highlighted that it was important to have a high number of LGBT service users coming in for consultation in order to improve the quality of the service provided. The contact between professionals and LGBT service users, limited to STD clinics, indicates the ineffectiveness of basic care services with respect to the provision of access to the LGBT population, which is also seen in other countries (Macdonnell, 2014). It also indicates a gap in the higher education curriculum given that this type of care is not covered by most courses.

During the group discussion, Tiê presented her opinion about how the lack of understanding of sexual diversity displayed by health professional should not be replaced by closed definitions of what it means to be transvestite, transsexual, transgender or cisgender, as such definitions also imprison people into definitive forms of being in the world, something that Tiê would rather avoid:

Never to assign a gender, you know? If, for example, you see a very feminine figure … or that you judge by her features that she is female … Always ask how she wants to be treated. Because when I am dressed up and have my make up on, I like to be treated like a woman. I may say to the professional ‘Darling, what do you see? What do you think makes me feel comfortable?’ ‘Ah, I see a woman’ ‘So, this is the message I want to express’. (Tiê)

Tiê appears to defend a notion of self that is dynamic, plural and changeable. This dynamism becomes evident when we consider the possibility of approaching health professionals in different ways, dressed like a woman or like a man, for example. Therefore, the way in which health professionals treat users should be equally fluid. This relational form proposed by Tiê is contrary to the need for static definitions, as asked by Julio, who thought it to be helpful in avoiding mistakes being made when interacting with service users:

This so-called indifference … I think of those who do not want us to discuss the matter [of sexuality]. For example, a user comes in for treatment thinking ‘Please I do not want to talk about this, I came here to receive treatment for a disease, my sexual behaviour is not the objective of this treatment’ So, what can one do? It is this fine-tuning that I have not worked out yet: do I go straight to the point, or do I let the user come forward … because, it is easy for me to tell yours [identity], but it is hard to tell some people’s. (Julio)

The impression that the user would not feel comfortable to discuss his or her sexual orientation reproduces much of the social prejudice according to which differences should be concealed. To assume that sexual orientation should not be discussed propagates the belief that there must be something wrong with being LGBT, that it cannot form part of the conversation between health professionals and users. This becomes even more significant when considering that interactions happen within a place of care provision, including sexual care, particularly relevant in the case of STD treatment (Wheldon et al., 2013). Julio mentioned that the group participants were clear when expressing their sexual orientation, but this was not so clear in his work setting. He was referring specifically to the concern of failing to define a user’s sexual orientation, insulting him or her instead. Marília also referred to this issue when she mentioned concerns about assuming incorrectly that someone was homosexual, offending the person by doing so. The idea that a service user will feel insulted by being thought to be homosexual is the result of prejudice, as if homosexuality was something bad. Therefore, the caution of health professionals in applying the correct definition can propagate prejudice. The concern about incorrectly assuming that a service user is homosexual leads health professionals to take the opposite position. However, their assumptions are not seen as reservations or having the potential to offend a service user who declares himself or herself as homosexual. Assuming heterosexuality, when in doubt, is like maintaining the privileges attributed to those seen as heterosexual while concealing alternative sexual preferences within the health system.

As a positive resource to improve LGBT care, Juliana mentioned the initiative by the management of the health service where she works to suggest the use of the preferred name (as opposed to the name in the ID document):

Now there is this thing about calling service users by their preferred name, there was even a meeting about it at work, in the general meeting, for us [professionals] to be careful with the issue of the preferred name. It was some time until we spoke to the receptionists about it: ‘Oh, be a little careful, look this is your name, but what would you like to be called?’ (Juliana)

During the group discussion, Julio mentioned the importance of clarifying with each service user the reason for seeking medical advice, instead of professionals drawing their own conclusions about it:

And we try to find out what they [LGBT] want, what they need, so we can arrange and provide it […] I noticed [here in the group] that we need to be more direct, and avoid drawing so many conclusions, I used to before [draw conclusions about sexuality], I used to try to figure out a lot by myself, but I think I am going to be more open and see how the users feel, right? (Julio)

What may seem obvious for many, to be able to count on the service user to state what he or she needs, was a new finding for Julio. This illustrates the power of the biomedical discourse of specialisation that shifts the focus from the person being treated to the technical and academic knowledge held by the expert. We believe it is significant that what Julio learned happened in a group setting, through a methodology that facilitates dialogues, and which enabled him to practice what he had just discovered. By asking Tiê how he should interact with health care users, he learned about the value of asking more questions.

To be ‘more open and see how service users feel’ requires allowing time to listen to them during consultation. The focus is no longer the content of the conversation (aimed at producing a diagnostic and recommending treatment), but the relational process experienced by both parties (Moscheta et al., 2011). This shift in focus assumes that the health professional must be willing to listen to criticism about the relationship, to reflect and be flexible in order to improve it. Under this new perspective, the fear of making mistakes, as seen in Julio’s discourse, is replaced by the possibility to making mistakes and rectifying them. The horizontalisation of the professional–user relationship, target of public policies about the humanisation of health care relationships in Brazil (Brasil, Ministério da Saúde, 2004), is a win-win situation, as users benefit from receiving a better service while health care professionals benefit from not having to carry the burden of being superhuman and committing no mistakes.

Another topic extensively discussed in the group concerned the resources needed to improve the process of hospital admissions by transvestites. The discussion was centred on which, an all-male or all-female ward, would be best suited to care for transvestites. It was argued that in Brazil, most people are prejudiced against transvestites, and that both men and women find it hard to share a hospital ward with a transvestite, particularly to undress in front of a transvestite.

Regarding his difficulty, Carolina suggested that it would be helpful if health professionals did not isolate transvestites as otherwise it would reinforce this preconceived judgement. Instead, Carolina argued that people need to get closer to transvestites so as to challenge their preconceptions:

If the health professional puts a barrier between the transvestite and the ward, there will be prejudice. (Carolina)

The need for developing more familiarity was justified by the simple fact that generally the population has little or no contact with people who identify themselves as transvestites (Moscheta, 2011). In face of this challenge, the group identified the need to ask what would make her feel more comfortable, as described in the fragment below:

This dialogue would be fundamental not only for hospital admissions but for all other health care service offered:

Amanda warns about how careful we must be not to reproduce in the hospital the segregation experienced by many transvestites in society. In the hypothetical situation presented by Amanda, the health professional, by asking the women in the ward whether they would mind sharing the ward with a transvestite, would be allowing the transvestite to be excluded in a moment, instead reassurance is needed, such as during illness (‘… is already ill’).

Joining the conversation, Tiê stated that making people come closer to transvestites in hospitals should happen despite feelings of awkwardness and discomfort, as these could be overcome by bringing people closer:

when a bed in a hospital ward is assigned to a transvestite at her request, this may cause discomfort to the other service users, but I think that this has to happen, even if … it creates an atmosphere. (Tiê)

The resource suggested by Carolina to prevent conflicts from arising between professionals and transvestites in various situations was for the latter to adopt a more respectful attitude towards themselves and towards health professionals:

It has happened that I went into the ladies room and the guard said ‘You can not go in there’ ‘But why not, because I am not female?’ ‘I am a feminine man, it is like being a woman, I told him’. When something like this happens they [security guards] seem unsure, but I talk to them in a respectful manner. Because from the moment they raise their voices, that is a whole new story. (Carolina)

Even so, we do not propose to ignore the differences in social class and authority between health professionals and users within the context of health care provision, Carolina’s suggestion refers to the possibility to treat the conflicts between professionals and users as a relational product so that transvestites might also develop the relevant skills to better relate to health professionals, thus ensuring that more effective dialogues take place. It is common to hear health professionals say that transvestites are loud, they speak loudly and draw a lot of attention to themselves in public, making the professional feel uncomfortable and embarrassed. Addressing this type of stigma, Carolina suggested a more respectful attitude towards the professionals.

Finally, the third resource highlighted during the group discussion concerns fostering healthy professional–user relationships. It was raised by Tiê, who pointed to the need for professionals to treat STDs more naturally. Tiê’s discourse is aligned to what was suggested by Terto-Junior (2002), and describes professionals overly concerned and focussed solely on STD symptoms when talking to LGBT service users:

The problem is that we already carry a social burden, that if you have contracted a STD you must have had inappropriate sex. Even more because you had sex with another man, or even a homosexual, bisexual, trans, lesbian, and so on. (Tiê)

Final considerations

The aim of this study was to understand the meaning of possible resources to improve care in health services for the LGBT population. The resources discussed by the group concerned (a) the need to encourage contact between LGBT service users and health professionals and to value the potential for learning that it brings, particularly when not concerning the treatment of STDs; (b) a shift from health professionals being seen as omniscient experts to exercising their ability to ask questions and learn from service users; (c) the need go beyond fixed notions of sexual identity that do not embrace the plasticity of the history and life experiences of service users; (d) a change in the focus of treating STDs, which assumes an unequivocal association between STDs and the care provided to LGBT service users, overestimating the importance of addressing symptoms with no regards for their wellbeing; and (e) a move towards a more mindful care delivered to LGBT service users admitted into hospital, specifically transvestites, considering the risk of causing institutional exclusion, as commonly experienced in society.

It was also possible to identify some of the care deficiencies that health professionals display when focussing the health needs of LGBT service users, to which the aforementioned resources might be able to address. Professionals had questions about the language that should be used when addressing LGBT service users, and about the conduct that should be adopted when transgenders are admitted into hospital. They reported fears of insulting service users by asking questions or causing embarrassment when enquiring about their sexuality. We understand that these challenges are mostly anchored in the reproduction of heteronormative reasoning, which defines homosexuality as strange, inferior and embarrassing, as well as in the reproduction of the biomedical model of health care, which perpetuates the idealistic image of the omniscient expert health professional.

In an attempt to develop effective training strategies to improve the care provided for the LGBT population, the dialogue facilitation methodology was employed in this study so as to challenge traditional forms of professional training by valuing (a) polysemy and the collective construction of meanings, (b) the exercise of doubt and inquisitiveness and (c) the knowledge held by the users of health services as a resource to enable professional capacitation. This strategy allowed the group to experience in loco the resources that emerged from the discussion, as described by Julio when reflecting on his learning regarding asking more questions. The results suggest that this methodology has the potential to contribute for promoting professional training initiatives in health care that are centred on building professional–user relationships.

Finally, we highlight the political aspect involved in adopting the dialogue model proposed here. The proposal inverts the traditional power struggle instituted in the relationships among workers and users in the health services, especially with users who have suffered historical process of exclusion in society, such as the LGBT population. By creating a context in which service users are able to express how they would like to be treated by health professionals, we produce the possibility for building care practices that are aligned to political and philosophical ideals that have been fundamental to the Brazilian Unified Health System from the start: radical social inclusion, sensitivity to diversity and specificities, as well as a commitment to confront social inequalities. Considering the increase in the number of psychologists operating within the public health system in the last few decades in Brazil, and their professional qualifications, which value group work, conversational tools and political engagement, we believe that the methodology described here offers a valuable tool for use in multidisciplinary groups.