When discussing gender identity, it is important to emphasize that “gender” is related to traits/characteristics of socio-psycho-cultural origin, such as femininity and masculinity, and to the notion of social groups of what is considered feminine or masculine; it is also linked to stereotypes^4* and/or what society expects and attributes to what it is to be a man or to be a woman (11). This is different from “sex,” which relates purely to the biological aspects: reproductive anatomy, chromosomal formation of the genome, gonads/hormones, and sexual behavior, according to traits and characteristics of biological etiology (12).

Thus, we see a contradiction between what it is to be a man or a woman, going beyond biological discussions and entering the sociocultural sphere; the result of the construction of the environment in which a person lives, reaffirming the words of Simone de Beauvoir (13): “On ne naît pas femme, on devient femme”^5**, which reflects the meaning of the construction of being a woman and the social, cultural, and political impacts contained in this condition; aspects that should be considered in the identity process, moving away from the idea that associates all this dynamic of “being” with the characteristics merely of biological etiology (14).

It should be mentioned that gender identity^6*** is on the agenda of discussion in contemporary society when it comes to issues related to transsexuality or transvestility, or even non-binarity, in which both break with the culturally standardized cisgender concept from ancient times, with the biblical figures and based on the origins of humankind, according to Creationism^7****, as Scott (15) points out in his historical analysis of gender construction.

Medicine and other sciences interested in discovering the foundations of the human body needed to create definitions of sexual practices and identities(16). Thus, from the twentieth century, a process of biomedical deconstruction began to take place, seeking to understand the phenomenon of health/sickness as it relates to the transgender public, going beyond the term “transsexualism,” which refers to the pathology provided for in the International Classification of Diseases—ICD 10 (17,18), code F640, which defines transsexuals as individuals “affected by disease, capable of undergoing reparative surgical interventions, able to adapt their physical body to the sex they have in their mental representation” (19,20).

From this nomenclature and all the prejudiced analysis that surrounded and involved it, “transsexualism” configured as “gender identity disorder” was later replaced by “gender identity disorder” and the current Diagnostic and Statistical Manual of Mental Disorders – DSM-5 (21–23), it is called “gender dysphoria,” which, unlike the previous classifications, views transsexuality as a “psychological state of acute suffering that requires intervention, above all, medical” (16).

These milestones in the scientific literature on health and diagnosis involve the urgent need for professionals who act in the transsexualizing process, with the panorama and training demystified concerning the factors involved in perpetuating the prejudiced and pathological view of gender dysphoria, composing multidisciplinary and interdisciplinary teams that understand this process and in the specificities of the individual. However, the data shown in Table 3 demonstrate this unpreparedness, as 42 participants (57.53%) were unaware of basic concepts of gender identity (3.4).

In this discussion, it is important to question Brazilian religiosity, which influences the national scenario in various ways; it acts as a positioning (ideology) and as an instrument of social intervention, intervening in the day-to-day political decisions (repressing or releasing some practices) and in judicial policy and state decisions. Therefore, in the current social context, in which various religious leaders are also present in the legislative and executive spheres of the country, they influence their ideologies with regard to decision-making on issues of relevance to these citizens (24).

Since religion is important in social configurations, its convictions, its positions, and its actions in the field of sexuality influence the experiences and policies of sexuality and gender, being prioritized by religious leaders, especially from a Judeo-Christian perspective, as a matter of debate and negative regulation, gender themes, such as abortion and discussions about the LGBT+ population, go against the predictive concept of the Secular State^8*, to which Brazil belongs (24–26).

In Jewish-Christian religious traditions, the sexual behavior of LGBT+ people demonstrates spiritual weakness to resist “demonic temptations,” in violation of biblical beginnings, and moving away from the divine and His plan for families, idealized by the figures of Adam (a heterosexual cisgender man) and Eve (a heterosexual cisgender woman), created in the formation of humanity, according to Genesis (27,28).

Moreover, from the religious perspective, Fernandez (29) shows the influence of healthcare professionals’ religion on the care provided, with worrying reports that contradict the perspective desired by the SUS, with its policies of comprehensive, equitable, and universal health for every citizen, especially for LGBT+ users, corroborating Roncon (30) and Souza (31.32), who emphasize discriminatory practices, through religious discourses on transgender people, generating mental anguish due to ignorance or neglect of scientific foundations that break with the demonic idealization about these communities, and the social prejudice that surrounds this portion of the population^9*.

Psychological follow-up, guidance on the correct use of hormonal medications, regular consultations with the health team, evaluations for surgical interventions, performing surgeries, and the post-surgical rehabilitation process are some of the demands to be met, as many LGBT+ subjects have been on the waiting list for a long time (sometimes years). Therefore, the health team must ensure humanized and unprejudiced conduct (4).

These are characteristics that the health professional should demonstrate in the care of the LGBT+ public, specific people with gender dysphoria, since the data from this research indicates a lack of knowledge about gender identity and a lack of training on this theme (Table 3), which prompts two questions related to the educational processes: does academic education (initial education) fail to approach/address gender themes in the curricula of health professionals? How does the professional development of health professionals take place, or how should it take place, in relation to this subject and the public?

Visgueira (33), analyzing the knowledge of medical students, for example, about gender identity (n=122), showed high percentages of inadequate responses regarding the differences between definitions and specific behaviors of the transsexual population; moreover, the approach to the subject during the undergraduate course was minimal or non-existent; data that corroborate the analysis in this study, which showed that 58 of the participants (79.45%) reported not having received any training on the theme of LGBT+ and gender identity.

This panorama also reflects the inefficiency of Higher Education Institutions (HEIs) with regard to gender discussions, how these relate to the health–disease process, and their approaches to the care of the LGBT+ population, with this being an important requirement for compliance with the National Curricular Guidelines (NCDs) for health professionals, which define, as part of the professional profile, an academic background with a generalist, humanist, critical, and reflexive basis in ethical principles and understanding of social, cultural, and economic reality, acting for the benefit of society, at all levels of healthcare, based on scientific and intellectual rigor (34,35).

Another finding of this study is that of the 37 participants aged between 21 and 30 years (50.67%), 34 had a service experience of 5 years or less (94.59%; n=37). Therefore, they were mostly new graduates, corroborating the concept that there is a lack of focus on LGBT+ health in the curricula. It should be noted, however, that although the principles recommended in the conduct of health professionals are established in these NCDs, which extend to any citizen who needs care and follow-up, the data and concerns of this study justify the criticisms made here, especially those related to access to health services for transsexual people (34,36,37).

It is understood that there is a need for more training, given that most of the participants (87.67%) said they hoped to achieve the characteristics and perceptions that professionals need to have to serve the LGBT+ population (38.39); understanding gender dysphoria and the specificities of care for this public, in compliance with the fundamental principles of the SUS: health as a right of all (universality), applying prevention, promotion and rehabilitation actions to health (integrality) and reducing inequalities by offering the necessary support to those who need it most (equity) (40– 42).

The lack of debate about the care of this portion of the population during academic training becomes critical to fulfilling the National Policy on Continuing Education of the Brazilian Ministry of Health (43) for the development of the professional in service, training him/her for necessary actions in the areas in which they work, finding solutions to the problems they face, articulating professional practice and learning, and effectively implement public health policies such as the PNSILGBT+ (44.45).

With these specificities in the care and treatment of the transgender public and members of the LGBT+ community, in 2007, during the 13^th National Health Conference (CNS), through the implementation of the PNSILGBT+, approved only in 2009 and instituted in the SUS in 2011, measures were taken to guarantee sexual and reproductive rights, professional development practices in health, and review of the academic curricular, encouraging the production of scientific research, technological innovation and the sharing of therapeutic advances, protocols to combat violence, non-discriminatory regulation of blood donations, the adaptation of forms and medical records and the health information system, to bring into its texts, for the first time, the distinction between gender identity and sexual orientation (46).

Another milestone was reached at the 1st National Conference of Lesbians, Gays, Transvestites, and Transsexuals, held in Brasília/DF, in 2008; based on the Federal Constitution of 1988, strategic guidelines were created aimed at promoting citizenship and human rights to meet the specificities of lesbian, gay, bisexual, transvestite, and transsexual scare in the health–disease process (2).

In that same year, GM Decree 1707, of August 18, 2008, which established the transsexualizing process under the SUS, and SAS Decree of August 19, 2008, which approved and regulated this process in the SUS, was forwarded to public consultation, in the period from June 26 to July 30, 2008, installed in the DATASUS consultation tool, and published in the DOU through Ordinance 1279, of July 25, 2008 (2.46).

The National Policy for Integral Healthcare for Men (Política Nacional de Atenção Integral à Saúde do Homem)(47), instituted in 2009 by the Ministry of Health within the SUS, through Decree 1,944 of August 27, 2009 (48), guarantees the specificities of gay, bisexual, transvestite, and transsexual men, with the publication of its version of the Basic Care Notebook no. 26, Sexual and Reproductive Health (Caderno da Atenção Básica n⁰ 26, Saúde Sexual e Reprodutiva), which deals with the themes of sexual orientation and gender identity, aimed at providing guidance and training for health professionals to care for the LGBT+ population (49).

The abovementioned policies initiated the transformation of the SUS as the main sector in the care and assistance provided to transgender people. This research, with its participants and its data, aims to reinforce the adaptations in care and assistance of this public, encouraging debates at the curricular level among future professionals, and as part of the professional development of professionals, among other aspects needed to expand the knowledge of working professionals, and break the cycle of institutional and professional prejudice that pose barriers to the inclusion and adaptation of transvestites and transsexuals when it comes to health services.

During this research, there were limitations in terms of the completion of questionnaires by the participants. The questionnaires were sent out online, at the recommendation of the Research Ethics Committee, due to the issues faced worldwide by the COVID-19 Pandemic; there were also difficulties in accessing the questionnaire, and a fear among the participants of getting the questions wrong, and these impressions may have led to them withdrawing their participation in the survey, or failing to complete the questionnaires.