Violence and prejudice against LGBTQIAPN+ people in the Medicine courseABSTRACT
Introduction: Gender and sexuality are rarely addressed during medical graduation. The curriculum is inadequate in ensuring the depathologization of diverse sex and gender conditions and in providing training for specific care for LGBTQIAPN+ individuals. LGBTQIAPN+ students experience several types of prejudice, and the literature on these perceptions is still scarce.
Objective: To describe situations of violence and prejudice in the medical course through reports from LGBTQIAPN+ students.
Methods: This is a qualitative, exploratory study that evaluated reports collected through an open, semi-structured online questionnaire made available to medical students in 2023. The questions addressed LGBTQIAPN+phobia, the educational program’s approach to sexual diversity, motivations for choosing the course, and the students’ future professional expectations. The reports were analyzed according to Bardin’s content analysis.
Results: Sixteen reports from participants with an average age of 22.9±3.8 years were evaluated. Twelve reported experiencing at least one episode of LGBTQIAPN+phobia within the university, with transphobia being the most frequently cited issue. The hierarchical environment and the perception of impunity towards preceptors and some faculty members were identified as perpetuating factors for prejudice and violence. Regarding the curriculum, the approach to the topic was reported as minimal and stigmatizing. Choosing medicine was described as an attempt to improve family acceptance and ensure future socioeconomic stability, with a positive expectation of employability, although accompanied by concerns about prejudice and the need to hide their sexuality.
Conclusion: LGBTQIAPN+ students report experiencing numerous situations of violence, particularly transphobia, during their medical training and identify gaps in education and support for the needs of this population. Impunity and hierarchical structures were pointed out as reinforcing prejudice.
Keywords:
Medicine; Sexuality; Gender Identity; Prejudice; Violence
RESUMO
Introdução: Gênero e sexualidade são pouco abordados durante a formação médica. O currículo é falho em garantir a despatologização das condições diversas de sexo e gênero e em capacitar os cuidados específicos para as pessoas LGBTQIAPN+. Os alunos LGBTQIAPN+ sofrem diversos tipos de preconceitos, sendo a literatura ainda escassa com relação a essas percepções.
Objetivo: Este estudo descreve situações de violência e preconceito no curso de Medicina por meio de relatos de alunos LGBTQIAPN+.
Método: Trata-se de um estudo qualitativo de natureza exploratória que avaliou relatos coletados por meio de um questionário online aberto semiestruturado disponibilizado para alunos do curso de Medicina no ano de 2023. As questões abordaram a LGBTQIAPN+fobia, o programa didático em relação ao tema diversidade sexual, as motivações em relação à escolha do curso e a expectativa profissional futura desses alunos. Os relatos foram avaliados segundo a análise de conteúdo de Bardin.
Resultado: Dezesseis relatos de participantes com idade média de 22,9±3,8 anos foram avaliados. Doze relataram vivência de pelo menos um episódio de LGBTQIAPN+fobia dentro da universidade, sendo a transfobia o aspecto mais citado. O ambiente hierárquico e a percepção da impunidade contra preceptores e alguns docentes foram apontados como perpetuadores das situações de preconceito e violência. Com relação ao currículo, a abordagem sobre o tema foi relatada como mínima e estigmatizante. A escolha da medicina foi referida como tentativa de melhorar a aceitação familiar e garantir estabilidade socioeconômica no futuro, havendo uma expectativa positiva de empregabilidade, embora acompanhada de receio quanto ao preconceito e à necessidade de ocultar a sua sexualidade.
Conclusão: Os alunos LGBTQIAPN+ relatam vivências de inúmeras situações de violência, sobretudo transfobia, no curso de Medicina e apontam lacunas no ensino e acolhimento das demandas dessa população. A impunidade e as estruturas hierárquicas foram apontadas como elementos reforçadores do preconceito.
Palavras-chave:
Medicina; Sexualidade; Identidade de Gênero; Preconceito; Violência
INTRODUCTION
LGBTQIAPN+ people (lesbian women, gay men, bisexual, transgender, queer, intersex, asexual, poly/pansexual and non-binary people and other terminologies that identify themselves as belonging to sexual and gender diversity) face various situations of violence and prejudice throughout their lives. University and access to education, which could encourage discussion of human rights, in some cases perpetuates violence and prejudice against this population1. The imposition of cisgender and heterosexual behaviour as something natural and preconceived is one of the main motivations for prejudice and violence against these groups, and educational institutions are among the places with the highest risk of violence2.
Currently in Brazil, more than 10% of the population identifies as LGBTQIAPN+3. Nonetheless, only a fraction of these people complete higher education. This is due to the challenges related to access and permanence in educational environments resulting from the prejudice and stigmatisation of these conditions. The deprivation of financial resources, resulting from family exclusion and social marginalisation, and the manifestation of explicit violence within the school environment are also issues that discourage these from remaining in educational institutions3.
In addition to prejudice and overt violence, institutional neglect of these situations favours students leaving the educational environment. Upon entering higher education minority groups find themselves having to adapt to the new reality, facing prejudice and discrimination from many teachers and students4. In some situations, subtle behaviours, such as hiding one’s sexuality, emerge as a defence mechanism in this setting5)-(8.
The curriculum and ill-prepared staff to welcome LGBTQIAPN+ people are other aggravating factors. The subject is usually covered for six hours during medical training in gynaecology, urology and psychiatry, with the majority of classes focusing on sexually transmitted infections (STIs) and HIV/AIDS9),(10.
Identifying situations of LGBTQIAPN+phobia in the academic and social environment can be an important process in reducing harm and designing strategies that can be implemented within the university environment for greater inclusion and permanence of these students. Therefore, the aim of this article is to describe situations of violence and prejudice on the medical course through the stories of LGBTQIAPN+ students.
METHODS
This is a qualitative study of an exploratory nature, based on the application of a semi-structured questionnaire conducted online, during the year 2023, with LGBTQIAPN+ people within the university environment.
FMRP-USP is responsible for undergraduate programmes in Medicine, Biomedical Sciences, Physiotherapy, Speech Therapy, Biomedical Information Technology, Nutrition and Metabolism and Occupational Therapy. In undergraduate teaching, the institution has implemented active teaching methodologies in simulation practices, video classes on online platforms, and face-to-face teaching in real-life scenarios, with practical activities in laboratories, family health centres, outpatient clinics, wards and diagnostic and treatment centres. Recently, the subject “Care for Sexual Diversity” has been incorporated into the Women’s Health module, with the objective of consolidating minimum strategies for general practitioners to be able to provide care for LGBTQIAPN+ people. The school also has specific committees created to include the discussion of inclusion and design strategies for implementation and training of the institution’s staff and students.
All undergraduate medical students at FMRP-USP were invited to take part in this research. The invitation was sent via e-mail and Whatsapp groups of the classes with a link to the REDCap® (Research Electronic Data Capture) form. Those who accepted the Free and Informed Consent Form (FICF) and declared themselves to be LGBTQIAPN+ were included. Participants under the age of 18 were excluded.
All responses were captured and stored in REDCap on the system of the Ribeirão Preto School of Medicine of the University of São Paulo (FMRP-USP). The questionnaire and data analysis were developed and conducted by the Gender, Health and Sexuality Academic League (LAGSSex). The questionnaire was split into two parts. Firstly, information was collected on the characterisation of the sample and, secondly, six questions with open answers were asked to assess the experiences within the university environment: 1) What is your impression of the intersection of academia and sexual and gender diversity? 2) Have you witnessed any bad experiences at university involving LGBTQIA+phobia? 3) Have you been the victim of any bad experiences at university involving LGBTQIA+phobia? 4) Do you have difficulties in having sexual or affective relationships? What are they and why do you think that this happens? 5) What do you expect from your professional life? 6) What were your expectations when you chose medicine? Participants were identified sequentially with the letter Q (questionnaire), followed by the letter ED (diversity student) and a number for each individual (QED01 to QED17).
The answers to the questionnaires were analysed using a qualitative and deductive approach according to Bardin’s content analysis11. The stages of coding the answers and completing the output matrix were developed independently by pairs of LAGSSEX members. All the answers were assessed by just one pair of assessors, with each pair assessing two questions in the questionnaire. Each pair of analysts completed an output matrix for each question, discrepancies between the pairs were resolved by consensus or intervention by a third party.
The output matrices were integrated and discussed according to each theme, seeking to identify patterns, sub-themes and representative speeches for each theme identified. Based on this discussion, a narrative summary of the conclusions of each theme was produced. The narrative synthesis of each theme was reviewed by the group of analysts and speeches illustrating these conclusions were selected by consensus. The sample was defined by convenience and includes all eligible interviews conducted in 2023.
RESULTS
Written reports from 16 participants between 8 August 2023 and 29 December 2023 were analysed. The participants had an average age of 22.9 ± 3.8 years. Nine (53.6%) identified themselves as of white race/colour, thirteen (81.3%) as cisgender and nine (53.6%) as bisexual (Table 1). Nine (53.6 per cent) reported that they lived alone and did not face any financial difficulties in attending medical school. Family was reported as a source of financial support by 15 participants (93.8 per cent).
LGBTQIAPN+phobia in medical school:
Twelve participants reported experiencing or suffering at least one episode of LGBTQIAPN+phobia, with transphobia being the most frequently cited aspect in their responses. Transphobia and the invalidation of the existence of trans people were reported in situations of staff and teachers using inappropriate pronouns or deadnaming (using the transgender person’s former name). Violence against LGBTQIAPN+ people was also reported to occur through comments and opinions expressed on employees’ social networks, with ignorance on the subject being the justification for the occurrence. In some situations it has been reported that the phobic behaviour is protected by an impression of impunity due to the hierarchy.
“There have been times when I’ve seen patients and they’ve addressed me correctly with female pronouns, but have then started addressing me in masculine terms after witnessing the boss addressing me in masculine terms (...) More recently, a teacher and prominent figure at the college was making jokes about men and told me that I’m ‘still a man even though I switched teams’, and repeatedly addressed me in the masculine, sometimes correcting herself and saying that she gets it wrong because ‘it’s hard to get it right’.” (QED10)
The hierarchisation of power in teaching environments is another factor reported by participants as fostering prejudice. The discussion of issues related to sexual diversity was reported in a jocular or derogatory manner. Some participants even reported situations of provocation associated with these speeches.
“LGBTQIA+phobic speech is recurrent among teachers and contractors on my course, without any shame whatsoever. Often in a provocative tone, they make a point of inserting intolerant speech without being questioned in any way about their position. This, in front of students and other professionals in inferior positions, knowing that there will be no response or reprimand due to their position of power.” (QED06)
Reports of transphobia also included situations outside the classroom. One participant reported that she had received a complaint from hospital staff for using the women’s toilet. As quoted by QED10: “When I get changed in the changing room I notice that several of the women look at me uncomfortably, and I’ve been confronted with a complaint for using the women’s changing room, so I only change inside the cubicle.” Another cisgender participant also reported witnessing similar situations. Some participants even considered using disabled toilets or individual cubicles as strategies for these people to avoid further confrontations.
LGBTQIAPN+phobia was also identified among the students. Situations of omission of help, physical aggression, stereotyping and prejudice within the university environment were reported. The situations reported involved psychological, moral and even physical violence.
“I was hit really hard in the face by a senior, who I later found out was homophobic. At the time I reported him and instead of being welcomed I was beaten even more because they tried to silence me and painted me as the villain of the story.” (QED04)
Academia and sexual diversity:
Perceptions about the interaction between academia and sexual and gender diversity were divided between social and academic issues. Most of the answers associated socialising in the academic environment with a negative connotation, since this environment was described as problematic and a breeding ground for violence, perpetuated by the hierarchy. In addition, such speech reinforces the need to improve institutional relations with the sex and gender diverse population, given that the issue is little discussed within the university. This gap was pointed out as a justification for feelings of fear and avoidance on the part of students, potentially causing harm and discomfort to these students. Despite this, a small proportion of the participants felt that the university environment was still more receptive when compared to environments outside the university.
“(...) the university is a very receptive environment to sexual diversity, especially in comparison with most of the environments outside it. (...) the issue of gender diversity, although it is still better than in the outside environment, I still have a lot of fear about coming out as trans here (...)” (QED03)
The lack of safe spaces for the LGBTQIAPN+ community leads to the repression of expressiveness, and the academic environment, according to some reports, replicates these barriers. Fear of external reactions, such as showing affection in public places, and concern about family acceptance were also highlighted. The following passages best describe these events: “... I feel that my life to date has been repressed, partly by myself. I feel afraid to express myself in my entirety. Sometimes it’s like my adolescence has just begun,” as described by (QED13) and “... I’m still afraid to show affection for my girlfriend in public environments when we don’t have a circle of friends/protection around us,” as reported by (QED05).
Despite the lack of focus on academic aspects, there was a strong impression that the inclusion of sexual diversity in medical training is rarely addressed. When discussed, it is restricted to a small group of subjects and teachers. Disregard and lack of interest were reported as reflections of the lack of preparation and updating of the teaching staff in relation to the subject. The teaching material was criticised by some participants. According to some reports, the approach to the subject of sexual and gender diversity reinforces the stigmatised view of LGBTQIAPN+ people, especially trans people.
“(...) In a way, I see a lack of preparation on the part of teachers in various areas related to gender diversity, and there is no clear desire on the part of the teaching staff to train themselves to learn about diversity-related issues.” (QED12)
Motivations for choosing the course and future professional prospects:
With regard to professional expectations, points such as the expression of sexuality and gender touched on subjects such as employability, gender equality and professional performance. The possibility of expressing one’s sexuality was identified as something that could be negative in professional work due to the prejudice and stigma associated with the LGBTQIAPN+ population. The concealment of sexual orientation in cis people, especially males, has been identified as a protective factor, although it limits the expression of sexuality. According to (QED15): “I believe that as cis-gender and non-apparent (of non-heterosexual sexual orientation), many patients who would cause problems will just ignore it or not even imagine it (...) usually it is fine.”
Among the tools to avoid the need to hide their sexuality, they emphasised the need to work in areas with less contact with patients or in places that cater for the diverse population.
“(...) unless I work in an area of medicine with a special focus on the LGBT population, (...) it would be difficult for me to succeed professionally, regardless of my competence, because the transphobia prevalent among the medical profession would be an obstructive factor.” (QED10)
As regards choosing medicine as a profession, employability and financial security stood out as motivators for the career choice. Some reports associate “being a doctor” with professional prominence, which can positively influence employability and social, family and personal acceptance. This can be seen in QED01’s account: “My expectation was to be accepted at home, not to be a monster to my parents,” and
“(...) the main reason I chose Medicine over Literature was because I knew I’d be less likely to be unemployed as a doctor than as a teacher. (...) In any case, stigma towards trans people exists in almost all professions, and if I’m going to suffer it, suffering it as a doctor isn’t the worst option (...).” (QED03)
The expectation that the university environment would be welcoming and inclusive was reported by the majority of participants. The hope of studying medicine at an institution of excellence in research and public health, the existence of a more progressive and inclusive environment in which there would be mutual respect between teaching staff and students and the freedom to explore one’s sexuality were points that reinforced this expectation. Nonetheless, three participants reported that the university environment is a sexist, LGBTQIAPN+phobic and conservative place and pointed to the need to improve the reception of LGBTQIAPN+ people.
“I expected an academic environment of mutual respect between teachers and students, as well as a more progressive and inclusive mentality, because it is expected that in an environment of science and so much excellence in public health, conservative and ignorant values would not be compatible. But the conservatism of the medical profession, composed mainly of men from the economic elite, who remain systematically and structurally in positions of power, overrides any progressivism.” (QED06)
DISCUSSION
The aim of this article was to describe the experiences of sex- and gender-diverse students enrolled on the medical course at a public university. In general, the reports described the university as an LGBTQIAPN+phobic environment characterised by a rigid teaching structure that imposes barriers to the inclusion of different sexes and genders. In addition, the accounts reported often reinforce the idea that, for some students and teachers, sexual and gender diversity is something unnatural and therefore pathological; as well as presenting content that touches on situations of violence, reinforced by conservatism, machismo and power hierarchies.
The participants exposed countless situations involving LGBTQIAPN+phobia, from embarrassment to reports of physical violence. Similarly, a study of students at Spanish universities showed that 61.2% of participants reported experiencing violence against LGBTQIAPN+ people. There were reports of people hiding their sexual orientation or gender identity, witnessing or suffering discrimination and humiliating comments, as well as psychological attacks. However, few students (1.2%) said that victims reported cases of violence to the relevant authorities12.
On several occasions, speech involving situations of violence and prejudice was uttered or validated by teachers and preceptors, which reinforces the conservative and discriminatory view that still exists within the medical course. This hierarchical position of power is responsible for the invisibilisation and silencing of these students or even the sex and gender diverse patients under their care13. Some reports also question the impunity of some professionals, which is seen as a further aggravating factor when it comes to LGBTQIAPN+phobia issues in medical school.
Ignorance of the subject also reinforces the lack of attention given to this issue in medical training. According to the accounts given, this neglect of the issue, combined with the free expression of prejudiced ideas by some teachers and senior students, naturalises and validates LGBTQIAPN+phobia within the university setting14)-(17.
Faced with these challenges, as a strategy to remain in the university environment and mitigate situations of prejudice, some students reported resorting to concealing their identity, known as ‘masking’. This concept is characterised as the attempt by trans or homosexual people to hide their real gender identity or sexual orientation in order to fit in with pre-established norms18. A study that also assessed the experience of trans students within the university environment identified that strategies such as masking are capable of reducing conflicts and promoting less risk of attacks on the LGBTQIAPN+ community19),(20. However, it is important to emphasise that this alternative also reinforces sexism and does not promote progress in the discussion of the inclusion of these people in the university environment.
Another point of weakness was the fear associated with using physical spaces that are exclusive to certain genders, such as toilets. According to reports, these places are open to behaviours of harassment, aggression and invalidation, leading LGBTQIAPN+ people, especially trans people, to avoid them21)-(24. Recently, FMRP-USP started a process of literacy in the toilets through signs stating that people are “free to use the toilet according to the gender they identify with”, in line with the 1988 Brazilian Federal Constitution25. Another strategy adopted by the college was to abolish the gender distinction in single-use toilets, a strategy already established in universities abroad.
Despite the fact that the University of São Paulo allows the inclusion of the social name in its students’ records, some reports from this survey showed that there is still resistance and disrespect towards its use in the university environment. Although the use of social names has been compulsory in Brazilian educational institutions since 2015, as of 2017, 79 of the country’s 284 public universities had not yet signed up to the possibility of using them internally26. This invalidation is one of the barriers responsible for trans people not staying at university27. In addition to the use of the social name, the misuse of pronouns was mentioned by the participants. In some situations, demands for correct usage were treated in a jocular and disrespectful manner by the speakers.
Despite the negative experiences, there was an expectation of a welcoming and inclusive environment before entering university. However, the reality observed was that the elitism still present in medicine and the social pressure to consolidate cisheteronormativity in the course directly conflicted with this environment, which should favour critical and scientific thinking. On several occasions, violence, even in a tenuous manner, was present in speech, reinforcing social ills reflected in the world outside the university28)-(30. A study carried out at the Federal University of Southern Brazil also identified the perception of symbolic and distinct violence, despite the expectation that university would be different from previous experiences in the family and school setting31.
People from the LGBTQIAN+ community have their competence judged and based on their gender identity and sexual orientation, and not simply on their academic activities, curricular performance and attitudes2. The decision to study medicine was described as an attempt to prove their competence and refrain from stigmatised and aggressive experiences. Junqueira considers the process of invisibility and silent exclusion to be one of the most overwhelming forms of oppression, reflected in the limitation of spaces for medical practice after graduation for LGBTQIAPN+ students32.
The lack of topics related to the LGBTQIAPN+ community within the curricula of medical courses leads to the ill preparation of health professionals to deal with this population and promotes the maintenance of stigmatisation of these people in the university environment. On average, less than 5 hours of the medical course is devoted to the study of sexual medicine, and this discussion generally focuses on the prevention of sexually transmitted infections and the prevention of unplanned pregnancies9),(10. Students who learnt about this subject in extracurricular activities were better able to demonstrate comfort, knowledge and confidence in caring for this population, demonstrating the need to include this subject in the curriculum33.
In contrast to these reports, the Ribeirão Preto School of Medicine has been open to training and to including gender and sexual orientation issues in the medical curriculum. For example, the curriculum for classes prior to 2023 already offered an elective subject on Reproductive Health, Sexuality and Gender, with a workload of 30 hours. The topic has also been part of the discussion in the Women’s Health module since 2020, and in 2023 it was included in the Health and Community axis34. Furthermore, the presence of the Human Rights Commission (CDH), created in 2016, and the Centres for Inclusion and Belonging (CIP) and the Advisory Commission for Inclusion and Belonging (CAIP) play an important role in developing humanistic skills to improve the inclusion of members of the LGBTQIAPN+ academic community and provide literacy to professionals linked to the faculty. Such measures could indirectly result in a more welcoming future for students, as well as a better approach to LGBTQIAN+ groups in academia in the future35. Nonetheless, the changes, especially to the curriculum, affect the students more than the preceptors and teachers, and investing in the literacy and training of these professionals is a necessity that goes hand in hand with this change.
CONCLUSION
LGBTQIAPN+ students report experiencing countless situations of violence, especially transphobia, in the medical course and identify gaps in teaching and meeting the demands of this population. Impunity and hierarchical structures were identified as factors that reinforce such prejudice.
ACKNOWLEDGMENTS
We would like to thank former student and founder of Lagssex, Stella Guilhermina Branco Fontanetti, a trans doctor, for taking the initiative to address and question curricular structures and institutional prejudice, which were the pillars of this article, and the entire LGBTQIAPN+ community of students at the Ribeirão Preto School of Medicine of the University of São Paulo, who agreed to participate and expose their vulnerabilities during this process.
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Research data is available in the body of the document.
