Transgender Population under the Bioethics Perspective: a Panorama of the Curricula and Bioethics Courses of Medical Schools of the State of São Paulo

Abstract:

Introduction:

Transgender people are subject to discrimination and illness due to social marginalization and lack of access to basic rights, especially health care. They suffer from the inadequacy of care directed to basic health demands, high incidence of diseases and non-fulfillment of specific demands. The vulnerability of these people reaches a disturbing level due to disrespectful attitudes that lead trans people to avoid seeking help. Understanding that medical education geared to the needs of marginalized populations is the basis for universal access and adequate care, it is essential that medical schools define contents and pedagogical strategies for vulnerable groups. The aim of this study was to investigate and discuss how (and if) the topic of transgender people healthcare is contemplated in the undergraduate curriculum of medical schools in the state of São Paulo.

Method:

Exploratory, descriptive-analytical study based on data collected from medical schools in São Paulo, conducted in two stages: 1^st, documentary research on the inclusion of the topic of trans people health in the undergraduate curricula; 2^nd, research with teachers of the Bioethics courses, where a questionnaire was applied to evaluate how and if the topic is approached as a programmatic content. The data obtained in the 1^st stage were analyzed quantitatively and are presented as relative frequencies of the evaluated characteristics, while those of the 2^nd stage were analyzed through the descriptive statistical method (closed questions) and content analysis (open questions).

Results:

We identified references to the trans topic in the formal curricula of only 2 of the 32 surveyed medical schools, with a total of 5 citations on the topic. Analyzing the questionnaires applied to teachers in the area of bioethics, we found reports of discussions on this topic in 5/12 (42%) schools. Although all participants consider the topic to be important, only 7/12 (58%) consider themselves prepared to address it.

Conclusion:

It is postulated that the evident lack of content aimed at trans health in medical schools can make it difficult to reduce transphobia and develop more dignified services within the healthcare network for these people. Based on the subsidies found in the Bioethics of Protection theoretical framework, we believe the medical curricula and Bioethics courses should create spaces to address this issue, using different and effectively transformative pedagogical practices, and respecting gender identity in all environments.

Keywords:
Transgender Persons; Education Medical; Bioethics

Resumo:

Introdução:

Pessoas transgênero constituem um grupo sujeito a situações de discriminação e adoecimento por causa da marginalização social e da falta de acesso a direitos básicos, em especial a saúde. Sofrem com a inadequação do atendimento voltado a demandas básicas de saúde, com a alta incidência de doenças e com o não atendimento de demandas específicas. A vulnerabilidade dessas pessoas atinge um nível preocupante em razão das atitudes desrespeitosas que as levam a não buscar ajuda. Como uma educação médica voltada às necessidades das populações marginalizadas constitui a base para a melhoria do acesso e para uma assistência adequada, é essencial que as escolas médicas definam conteúdos e estratégias pedagógicas destinados a grupos vulnerados. Com base nisso, este estudo se propôs a investigar e discutir como (e se) a temática da assistência à população trans está inserida no currículo de graduação das escolas médicas do estado de São Paulo.

Método:

Trata-se de um estudo exploratório, de natureza descritiva-analítico, realizado com base em dados coletados de escolas médicas paulistas. O estudo foi conduzido em duas etapas: 1. fez-se uma análise documental sobre a inserção da temática trans nos currículos de graduação e 2. adotou-se um questionário destinado aos professores dos cursos de Bioética com o objetivo de avaliar como e se o tema é abordado como conteúdo programático. Os dados obtidos na primeira etapa foram analisados quantitativamente e são apresentados por meio das frequências relativas das características avaliadas. Na segunda fase, examinaram-se os dados por meio do método estatístico descritivo (perguntas fechadas) e da análise de conteúdo (perguntas abertas).

Resultados:

Identificamos menções à temática trans nos currículos formais de apenas duas das 32 escolas médicas pesquisadas, com um total de cinco citações referentes ao tema. Na análise dos questionários aplicados aos docentes da área de bioética, encontramos relatos de discussões sobre esse tema em 5/12 (42%) das escolas. Apesar de todos os participantes afirmarem que a temática é importante, somente 7/12 (58%) se consideram preparados para abordá-la.

Conclusões:

Postula-se que a evidente falta de conteúdo formativo voltado à temática trans nas escolas médicas pode dificultar a busca por um atendimento mais digno dentro da rede de atenção à saúde e o combate à transfobia. A partir de subsídios encontrados no referencial teórico da bioética de proteção, acreditamos que os currículos médicos e os cursos de Bioética deveriam criar espaços para abordar essa temática, empregando diferentes práticas pedagógicas efetivamente transformadoras e respeitando a diversidade de gênero em todos os ambientes.

Palavras-chave:
Pessoas Transgênero; Educação Médica; Bioética

INTRODUCTION

The term “gender” is defined in the Portuguese language as “a set of properties socially and culturally attributed to the sex of individuals”¹ and in the English language as “the physical and/or social condition of being male or female”². Although both definitions are coherent with each other, neither covers the complexity of the involved social phenomenon. Therefore, the concept of gender has been intensely discussed and reconstructed according to the historical period experienced, with important protagonism by the feminist movements, motivated by inequality in social and political relations between men and women³.

Jaqueline de Jesus defines gender as a form of personal and social classification of people who self-declare as men or women, consisting in a set of dynamically constructed gender roles and expressions regardless of the sex of birth⁴. In recent years, new issues related to gender have emerged, questioning the very binary concept of properties inherent to sex, and started to conceive a female-male spectrum to which people may or may not belong and in which they can move freely⁵.

In this context, transgender people, more often called trans people, are individuals who have varying degrees of gender non-conformity, that is, their gender identity differs from the sex-gender compulsory nature assigned at birth. However, how each person claims his or her identity varies, giving rise to several possible identity conditions. Trans activists in Brazil claim their identities and name them socially and politically as trans men, transsexual women and transvestites, as well as non-binary and queer people. The recognition of these subjectivities is essential to offer an effective line of care in trans health as recommended by the National Policy for the Integral Health of Lesbians, Gays, Bisexuals, Transvestites and Transsexuals⁶.

Due to the similarities in the guidelines of their representative movements, the result of prejudice and oppression, such people are often included in the collective designation LGBTQIA (Lesbians, Gays, Bisexuals, Transvestites, Transsexuals, Queer, Intersex and Asexuals). However, this grouping can result in misunderstandings, since two independent concepts are superimposed, that of gender variability and non-conformity to the gender assigned to birth and that of variations in sexual orientation, the latter referring to the gender to which the individual is sexually attracted.

In addition to suffering just like the entire population with inadequate care aimed at basic health demands, trans people suffer from high incidences of drug abuse, sexually transmitted infections (STIs), mental disorders and violence^7)-(9, and from unmet general and specific demands^10),(11, such as comprehensive monitoring of mental health, hormonal therapy and surgeries for body alterations^12),(13 considering the limitations of the expansion, reformulation and effective implementation of the Brazilian Unified Health System (SUS, Sistema Único de Saúde) “Transsexualizing Process” ⁽¹⁴. Unprepared health professionals often contribute to increase the trans population’s vulnerability, particularly when they adopt prejudiced attitudes that tend to make health care access even more painful, very often leading patients not to seek help^10),(15.

From a bioethical point of view, when thinking about interventions that are necessary for the well-being of these people, it is important to see them not only as vulnerable, that is, susceptible to being affected by unfavorable conditions, ultimately - all human beings, but as “vulnerated”, because they are effectively affected and often incapable, by their own means, of defending themselves against these conditions¹⁶.

Thus, based on the understanding that medical education aimed at the needs of marginalized populations is essential and constitutes the basis for increasing the interest in the issue and improving access and adequate assistance¹⁷, it is essential that medical schools define the contents and pedagogical strategies aimed at these groups, providing subsidies so that the trans population can have more efficient and respectful health care.

Based on preliminary data from the international literature and prompted by the scarcity of Brazilian data¹⁸, we propose to investigate whether the curricula of medical schools in the state of São Paulo offer formal spaces for both the contents related to the technical aspects of assistance to the trans population, as well as the discussion of ethical aspects related to the embracing of this part of the population. As we see bioethics as a tool for the promotion of skills related to this matter, we believe it is important to investigate in more details how and if Bioethics subjects in undergraduate medical courses include assistance to trans people.

MATERIALS AND METHODS

This is an exploratory, descriptive-analytical study, focused on medical schools in the state of São Paulo. We employed a mixed qualitative/quantitative two-stage approach.

In the first stage, a documentary analysis was carried out. We carried out a virtual search, using the transparency portal of each institution and through contact via e-mail with coordinators and principals of medical courses, on the political-pedagogical projects, curricular grids and school program content. Our inclusion criteria were the following: medical courses accredited by Brazilian Ministry of Education and Culture (MEC) and those located in the state of São Paulo. We excluded courses that did not have students attending each of the six years of graduation in 2017.

After the initial collection, we asked the coordinators or principals of the analyzed institutions to send the missing documents and complement the obtained information. With the course documents in hand, we used the following keywords related to the trans topic to search the text: “trans”, “transsexual(s)”, “transgender(s)”, “transvestite(s)”, “intersex”, “intersexual(s)”, “LGBT”, “gender”, “sex”, “sexual”, “sexuality” - aiming to verify whether there was an effective approach to this issue in the undergraduate medical curricula.

In the second phase, we sent teachers of Bioethics courses from different colleges an invitation e-mail accompanied by an Informed Consent Form and an online questionnaire containing 5 closed questions and 8 open questions. The obtained data were analyzed quantitatively using descriptive statistics and qualitatively through content analysis^19),(20.

RESULTS

Through a search carried out in the main databases (PubMed, SciELO and LILACS) using the term “education” together with “transgender(s)”, “trans”, “transsexual(s)” or “LGBT”, we were able to show that there is scarce data in the literature on the current situation of medical education aimed at the trans population, as well as its impact on their health care. No Brazilian studies were found, with most of the relevant data extrapolated from international studies (mostly North American) and aimed at the LGBT population as a whole and only rarely at the trans population.

Stage 1: Documentary analysis of the pedagogical projects of medical courses

Through the official portal of MEC (http://emec.mec.gov.br/), we identified 46 active medical courses in the state of São Paulo. Of these, 32 courses were included in the research, in which the six years of undergraduate medical education were already active in 2017. Based on this search, we were able to list 29 curricular grids containing the names of the disciplines, years in which they are offered and workload; 13 course programs or syllabi with a description of the content to be taught in each discipline and; 9 political-pedagogical projects containing the overall goal of the course, teaching methods, desired competences and skills. In total, we obtained such documents from 29 of the 32 surveyed institutions. We found 114 references of the keywords, but in only five of them it was possible to infer a direct association with the transgender topic. This is due to the fact that in some references, for instance “Sexualidade, concepção e integração social em saúde” (Sexuality, social conception and integration in Health); “Discutir o conceito gênero e sua aplicação aos estudos da área de saúde reprodutiva” (Discussing the concept of gender and its application to reproductive health studies); “Atendimento a vítimas de abuso sexual” (Assistance to victims of sexual abuse), although the trans topic could be included in the discussions, the activities did not show they had this specific purpose. The five references clearly related to professional training to deal with trans issues were found in only two of the medical schools.

In a private medical school in the countryside, we found 3 references: a mandatory online course “Saúde LGBT da UNA-SUS” (UNA-SUS LGBT Health) , an extension course “Educação LGBT e como abordar uma consulta médica” (LGBT education and how to perform a medical consultation), and an activity of the “Liga Acadêmica de Neuropsiquiatria” (Academic League of Neuropsychiatry) with the lecture “Gêneros e transsexualidade na conjuntura atual”. (Genders and transsexuality in the current scenario).

In a public medical school, also located in the countryside, we found two references, both on the syllabi of the Bioethics and Medical Ethics discipline: “Identidade de gênero e diversidade sexual” (Gender identity and sexual diversity) appears as a subject for discussion of the discipline, as well as “Transexualismo” (Transsexualism).

Stage 2: Analysis of questionnaires for Bioethics teachers

In the second stage of this study, we sent invitations to Bioethics teachers from medical schools located in the state of São Paulo, this time without excluding those in which not all six years of undergraduate medical education were active. The contacts were obtained through the Regional Medical Council of the state of São Paulo (Cremesp, Conselho Regional de Medicina do Estado de São Paulo) Bioethics Center, from the Brazilian Association of Medical Education (ABEM, Associação Brasileira de Educação Médica), directly from the coordinators of these medical schools or even from the Bioethics teachers themselves.

Up to 5 attempts at contacting were made and responses were obtained from 13 teachers from 12 different institutions. Of these 12 institutions, 5 are public and 7 private. Everyone who started the questionnaire answered it in full. For the school with more than one participant, we combined the data, and where the numbers were in conflict, we presented the ones with the greatest trans subject representation. We observed that most Bioethics classes are concentrated at the beginning of the undergraduate course, with 9/12 (75%) of the institutions teaching classes only between the first and sixth semesters and only 1 (8.3%) teaching classes in the last two years of the course. The average workload throughout the course was 102.3 hours, with a median of 66 hours.

Of those who answered the questionnaire, 10/12 (83%) confirmed the existence of content aimed at vulnerable populations, with an average workload of 15.5 hours and a median of 9 hours. Among those who teach some content aimed at vulnerable populations, 9/10 use lectures and/or dialogued expositions, 7/10 use case discussions, 3/10 use seminars presented by students and 5/10 use artistic works.

Table 1
Indicators of workload and program content in the bioethics courses.

Characteristic and Indicator	Medical schools or colleges N (%)
Workload in Bioethics
Up to 60 hours	6/12 (50%)
Between 61 and 120 hours	3/12 (25%)
More than 120 hours	3/12 (25%)
Programmatic content for ‘vulnerated’ populations	10/12 (83%)
Workload with content aimed at ‘vulnerated’ populations
Up to 6 hours	4/10 (40%)
Between 7 and 12 hours	4/10 (40%)
More than 12 hours	2/10 (20%)
Content aimed at the Trans population	5/12 (42%)

• Distribution of the results obtained from the questionnaires answered by the teachers responsible for the Bioethics course in the medical schools of the state of São Paulo.

As for the presence of contents specifically aimed at the transgender population, 5/12 (42%) confirmed the presence of this content, and of these, only three reported the workload, with an average of 4.7 hours among those who answered. Only 2/12 (17%) colleges have content aimed at the transgender population in other disciplines, with mentions being made of psychiatry, endocrinology and gynecology.

Among the institutions of which the bioethics courses do not have any content aimed at the transgender population (7/12, 58%), only 2/7 reported proposals to include the topic in the course. One participant reported that the Medical Students’ Academic Directory had been leading discussions on the issue.

All participants (12/12) considered it important to address the issue of “medical care for the transgender population”; however, 5/12 (42%) considered that they were not prepared for it, needed further studies or assistance from other professionals, and most of teachers have been working as such for less than 10 years, showing a trend towards younger teachers in this discipline.

There were several reasons why bioethics teachers consider the inclusion of the trans topic to be important. One reported that discussions in non-formal spaces were taking place due to the presence of trans students in the course, another reported that the importance stems from vulnerability and discrimination, and that students lack information. Another three commented on the importance of demystifying and eliminating prejudices. One raised the need to understand specific health needs and another said it was important to consider sexuality as a social construct, in addition to biological factors.

The most frequently suggested pedagogical proposal, mentioned by 5/12 (42%) of the interviewees, consists of holding debates, seminars or health practices with the direct involvement of trans people in the classroom.

DISCUSSION

Based on what was observed in our study, the medical education scenario in the state of São Paulo, regarding the health of trans people, proved to be a matter of concern, with only 42% of the assessed schools teaching classes on the topic, dedicating only 4.7 hours on average for the academic discussion of the topic. Although the speech of the educators involved in the ethical training of new medical professionals is aligned with the idea of reinforcing the importance of these discussions (100% of those who answered the questionnaire), we observe that some of these teachers (42%) do not consider themselves sufficiently prepared to safely address the trans topic.

Unfortunately, the lack of teaching space offered in medical courses to promote skills aimed at improving the care of a group as vulnerable as the trans population, resembles what is observed in the international literature. In a Canadian study, the interviewed professionals recognized flaws in their training and agreed there was a need for a better approach to the subject in teaching spaces²¹. In another study, carried out in 176 American and Canadian medical schools, less than a third of them addressed the subject, with an average workload of 5 hours²².

A large-scale study, which analyzed questionnaires completed by 4,262 Canadian and American medical students, suggests that greater exposure to LGBT content during undergraduate programs better prepares the students and increases their confidence to address specific topics. However, 67.2% of these students classified their curricula between “average” and “very bad” in this regard²³.

On the other hand, it is possible to find reports of significant improvement in students’ knowledge and attitude after educational interventions focused specifically on LGBT content, such as terminology, perception of personal biases, sexual health anamnesis and referral decisions^24),(25.

Considering this scenario, in which the trans topic has scarce teaching scenarios in medical schools, and the fact that Bioethics teachers, even though they consider the topic important, do not feel safe to approach it, it is urgent to discuss how Bioethics education could contribute to prepare doctors to be better trained to deal with transgender people, in addition to the nosological classification of transsexualism²⁶, which has been recently reclassified using a nonpathological category in the new International Classification of Diseases (ICD-11)²⁷.

Although the term “transsexualism” was not included in the searched keywords due to its mostly derogatory and pathology-related connotation, we chose to include it in the results, considering the clear association with the assessed topic. Furthermore, due to the method used, it was not possible to deepen the context of the employment of this term and we were unable to identify whether the suffix “-ism” was actually used as a disease or to instigate a discussion.

To improve this scenario of information conveyed by the medical schools, good practices in medical training are necessary, for which scientific evidence is required, updated and aimed at the addressed population, considering regional, ethnic, cultural and religious peculiarities that are interrelated with gender and sexual orientation issues. It is also crucial that medical professionals develop social and communicative skills in order to understand and evaluate the specific demands of each group and each person who seeks care, avoiding harmful situations that could contribute to the increase in physical and psychological suffering.

The acquisition of these skills, as well as the scientific production aimed at professional medical practice, occurs mainly in the university environments. According to the National Curriculum Guidelines for the Undergraduate Medical Course²⁸, the graduated professionals should be able to work in the Brazilian Unified Health System, offering qualified assistance to all the population segments found in the national territory.

Initially, it is important to note that we understand bioethics not only as an academic area focused on the discussion of ethical conflicts in biological sciences and in human health care, but also as a tool to provide ethical clarification and moral guidance for problem-solving. As biological sciences and health care are subjects of general interest and of evident complexity, we understand that bioethics could promote, through formal education, competences that would help not only academic coping with bioethical problems, but also the most widely experienced practical problems, whether they are of ethical, moral or political nature²⁹.

In order to analyze this scenario and aiming to best address the different ethical and moral problems faced by trans people, especially regarding their demand for adequate health care, this study takes as its main theoretical reference the analysis model known as Bioethics of protection, which elects two priority values: 1) the Rawlsian notion of justice as equity, by which unequal people are treated unequally; and 2) the principle of beneficence, through which we help others to consolidate their legitimate interests¹⁶.

There is abundant evidence^10),(15) that ignorance and prejudice are preponderant factors in limiting health care for the trans population. We understand that such a process of marginalization is a slow construct, supported by mechanisms of social control, such as the criminalization and ‘pathologicalization’ of diversity, practiced in our history in relation to color, religion, sexual orientation, as well as gender identity^30),(31.

We believe that the teaching of bioethics can empower individuals not only to make decisions and act according to their own values, but also guide them towards employing rationality to communicate, seeking, for instance, to understand diversity as a legitimate and desirable attribute of reality. Thus, by promoting skills associated to morality and democracy²⁹, bioethics can collaborate for the gradual change of the socio-cultural characteristics involved in the genesis of vulnerability and, as we postulate, of the vulnerating of trans individuals.

The performance of health professionals stands out as a tool to promote equity, as it represents the route of access to an invaluable asset and one that has multiple subjectivities. However, when the debate on access to health care for transgender people is neglected in the university environment, these professionals can act in the opposite direction, causing greater suffering, due to inappropriate attitudes^10),(15. Therefore, structuring institutional processes that move towards rethinking political-pedagogical projects and building new medical training in a more inclusive manner carry great transformation potential, as the access to health care determines the viability of other fights to be fought, such as the occupation of cultural, work and scientific production spaces.

Within this scope, we are driven to debate the role of the trans population regarding this initiative of establishing a dialogue between academia and society. In addition to the marginalization that they suffer, trans people rarely occupy institutional spaces such as university collegiates, in which important questions about the pedagogical project are decided. Therefore, we often find individuals who speak for trans people, without necessarily knowing about their experiences in depth.

As previously described, the exercise proposed by the bioethics of protection requires the consolidation of each individual’s legitimate interests. This intuitively implies in the need to approach vulnerated individuals to know their needs. This approaching, however, occurs invariably from the perspective of the protecting agent³². Thus, the concept of protection takes the risk of assuming a paternalistic bias, culminating in invasive practices that can ultimately deprive supposedly protected individuals from exercising their individual desires, while generating a false sense of justice in the academic community.

Hence, we face what Bauman³³ calls an “aporia of proximity”, defined by the paradox of not acting, assuming a position of indifference, or acting based on one’s personal interpretation of others’ suffering, eventually assuming a paternalistic attitude, hindering or preventing the autonomous manifestation of the protected individuals.

To deal with this impasse, we propose a critical use of the Bioethics of protection, using a collective construction of interventions, stimulating not only the participation, but also a leading role of vulnerable populations, so that we are not erroneously led to assess priorities and propose inadequate approaches. This proposal meets the demands of the national and international trans social movement with the motto “Nothing about us, without us”.

We know that the creation of pedagogical documents (curricula, syllabi, program content, political-pedagogical project) is seen as a painful bureaucracy on the part of teachers. This allows the presentation of incomplete, outdated or simply poorly prepared documents, which can make interpretation of the abovementioned data extremely difficult. It is possible that initiatives focused on the trans topic have simply not been made explicit in these documents. Even so, it seems evident that the subject is not approached proportionately and with the necessary care. Our study found that only 2/29 (7%) medical schools express some concern about preparing future doctors to care for trans patients.

As previously discussed in this work, some international data reinforce the importance of new studies and, especially, new educational interventions aimed at transgender health^21)-(25. Our study corroborates these findings with local data, and proposes the need to establish defined objectives, choose contents and propose pedagogical practices that ultimately lead to transformations within the scope of assistance.

However, this path must be followed with caution, in order to avoid the medicalization of gender diversity, since the focus on diagnosing and seeking clinical-surgical approaches in the “transsexualizing process” can be too simplistic, sometimes even contributing to the exclusion of these individuals. The provision of specialized services for the transition of gender expressions, as well as for general health care of the trans population is necessary but should not be considered sufficient for comprehensive care. In this sense, health education is essential, both concerning the training of health professionals and the enlightenment of the population. Therefore, we seek to ensure compliance with established rules (such as the use of a social name in health services), and to foster the respect and generosity that must permeate all contacts between doctors and patients¹².

CONCLUSION

We understand that it is up to medical schools to arouse interest in the trans issue, not only in the few students who may become specialists capable of examining, prescribing and performing procedures, but mainly in the group of students, in order to strip them of their prejudices and seek excellence in the most basic aspect of health care: human contact.

Contrary to what Brazilian society thinks, we are convinced that discussions about gender identity should be stimulated in medical courses. We believe that the inclusion of the trans community in this process is essential, participating in pedagogical activities through testimonies and debates, helping in the collective construction of future actions. As we observed in this study, this proposal frequently appears among teachers, but it still lacks a more systematic institutional implementation.

The courses on Bioethics are privileged spaces for these discussions. Although universally present, they have a reduced workload, which makes it difficult to include the trans issue amidst an arsenal of important issues addressed by Bioethics. In this sense, it is important to provide greater support for the training of teachers in this discipline, allowing them to approach the subject by effectively transforming pedagogical tools, from its proposition in the academic environment to everyday practice, respecting gender diversity in our work, education and leisure environments. Within this commitment, we would actually fulfill the role of the university both in inclusive and liberating professional training, as well as by providing a questioning environment at the service of dynamic social demands.

ACKNOWLEDGMENTS

The authors would like to thank Cremesp institutional and financial support for the development of the research.

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Publication Dates

• Publication in this collection
  03 Aug 2020
• Date of issue
  2020

History

• Received
  07 Oct 2019
• Accepted
  18 June 2020