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Study evaluates effects of intervention program in order to change health professionals’ attitude towards the LGBTs population

The research was based on a social movement request, which proposed to raise awareness and improve the skills of these professionals to ameliorate the health quality of the LGBT population and to protect them from discrimination
Study evaluates effects of intervention program in order to change health professionals’ attitude towards the LGBTs population

Online course aims to increase awareness of specific needs of the LGBT population – Picture by Gustavo Diehl

Author: Amanda Hamermüller

An ideal society would be one that respects every single person. A society in which affection and love can be freely expressed, regardless of sexual orientation and/or gender identity. However, this is still far from reality. Brazil, for example, does not have a law that punishes discrimination against lesbians, gays, bisexuals, transvestites, transsexuals and transgender people (LGBT). Conversely, in Porto Alegre, a legislation implemented in 1996 provides administrative sanctions in such cases (Article 150, Amendment to Organic Law nº. 08/1994). This law was the result of pressure from an important LGBT movement that promotes LGBT pride parades since 1996. Additionally, Rio Grande do Sul has similar legislation since 2002 (Law nº. 11,872) as well as a decree (nº. 48,118), which requires that transgender people be treated by their social name, the name chosen by them. This decree provides a state identification document, since the federal government does not yet allow document rectification.

Nevertheless, according to official data of the Brazilian Secretariat for Human Rights of the Presidency of the Republic, in 2012 in Rio Grande do Sul around 202 accusations of discrimination and 396 notifications of LGBT rights violations were registered. These accusations include psychological abuse (166), discrimination in general (145), violation of physical integrity (58), sexual violence (10), institutional violence (3), and financial abuse (1). It is worth mentioning that Brazil has one of the highest homicide rates of transsexuals, with 689 cases registered in 2015, according to the Trans Murder Monitoring Project. At national level, there is the National Policy for Comprehensive Health of Lesbians, Gays, Bisexuals, Transvestites and Transgender (Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais, Travestis e Transexuais). This 2011 document reaffirms the Federal Constitution statement that "health is a basic right without discrimination of race, color or gender"; it also establishes guidelines for this right to be put into practice. Nowadays, there is also the assurance of sex reassignment surgery by the Brazilian Public Health System (SUS). According to the Ministry of Health, since its inclusion into the system in 2008, the number of procedures has jumped from 101 to 3,157 in 2014, with around 9,867 surgeries performed. The funding for these procedures grew 832.5% in the period, reaching R$ 154,8 million. Nowadays, the procedures are performed at Rio de Janeiro State University Hospital Pedro Ernesto and at Hospital de Clínicas in Goiânia, Recife, São Paulo, and Porto Alegre. These hospitals have the Gender Identity Program (Protig), which aims to provide transgender people and his/her family with medical assistance, psychological support, family counseling and sexual reassignment surgery, along with hormonal therapy, all of which are offered by  SUS.

According to Professor Angelo Brandelli: "these people say that it is very difficult to access the health service and when they  do, they suffer discrimination of all kinds". Brandelli published, in partnership with UFRGS and the State Health Department, an article which evaluates the effectiveness of a multidimensional intervention (educational, affective and behavioral) to change health professionals’ attitude towards the LGBT population. "I was invited to be the coordinator of the process of creating the Health Policy for the LGBT community. I have been researching this guideline since my Master’s degree and I thought about how I could apply my knowledge, a more theoretical knowledge,  in practice,"  he concludes. According to Brandelli, a decisive factor for conducting the research was the social movement demand to raise awareness and improve the skills of professionals to ameliorate the health quality of the LGBT population. Consequently, protecting them from violations and discrimination, besides  raising awareness of this group’s specific needs. Brandelli also adds that "We pretend that Brazil is a very easy place to live, but in fact it is a very violent country towards minorities. We must fight against this prejudice, especially in the health area, which is where these people are received". The topic was also a subject in the July issue of the University Journal, which brings a story on discrimination in the area of health.

Available at the site of the State Health Department, which invited health professionals to first respond to a questionnaire, this study was conducted in a four week distance learning course through  UFRGS VLE (Moodle) . Brandelli points out that "this study is part of people's daily practice. I was happy with those who wanted to participate". These participants could work in any area of health - students could not take part and they should also work in Rio Grande do Sul, both in public and private institutions.

The Study

The study had three segments: educational, behavioral and affective. In the first segment, a self-taught course was held, with content developed by gender and sexuality experts, health professionals, and members of the LGBT community. Therefore, in the first week, there was an introduction of the Brazilian legal framework on LGBT health protection and assurance, as well as an introduction to the topic of discrimination and its relation to health. In the second week, basic concepts of gender and sexuality were  presented.  In the third week, the course illustrated the best health care practices for the LGBT community, as well as promoted a discussion on popular misconceptions and  deconstructed myths and stereotypes.

In the first week of the behavioral segment, the participants were asked to report some experience with LGBTs. In case of any experience, the participants were encouraged to take the perspective of an LGBT and imagine how the contact could happen. In the following week, they created an evaluation plan for the needs of a LGBT health service user based on the content of the educational course. During the third week, they were invited to organize an action to improve the health of LGBT people in their services. Finally, they were asked to evaluate the activity proposed in the previous week and, in case they were not able to implement the action, there were discussions about institutional barriers, fears, and anxieties.

In the last segment, affective, the professionals participated in groups of approximately 20 people, led by a tutor (which could be health professionals, LGBT activists and postgraduate students in the field of LGBT health and issues). According to Brandelli, all participants presented signs of distress at the beginning of the  intervention. For this reason, the tutors were instructed to talk about individual doubts and to mediate group discussions in the forums. In the first week, the participants had a discussion about the two videos that presented accounts of discrimination in health service settings. In the next three weeks, they were instructed to debate about other's activities in the forums. During this period, the tutors encouraged discussions focusing on the cases of preconceived beliefs.

Before carrying out the study, the following aspects were considered:

  • Health professionals’ attitude towards LGBTs before the program in relation to their sociodemographic characteristics;
  • The predominance of cases of discrimination in health services, as reported by participants;
  • The effect of the program on groups notoriously associated with higher levels of prejudice (men, religious people, small town dwellers, and people who had no previous education on the subject).

At the beginning and end of the program the participants were invited to respond to a questionnaire. The questions related to the sociodemographic topic involved questions on gender, age, education level, population density of the place of residence (less than 100,000 inhabitants, between 100,000 and 500,000 inhabitants, more than 500,000 inhabitants) and religiosity. Additionally, the participants were asked about their occupation (nursing, psychology, medicine, etc.); the nature of their activity (assistance, education, management, etc.); their activity area (municipal, state, federal, private services or NGO); and the level of care of this activity (primary – community clinics; secondary – specialized clinics; tertiary – large hospitals, or other – schools, penitentiaries, NGOs, etc.). The participants were also asked about past experiences in courses or activities related to sexual and gender diversity. Finally, they were asked  whether they had ever witnessed or known of any humiliation, physical abuse or maltreatment of any LGBT in their health service setting.

Around 457 participants were enrolled in the program, 307 of whom agreed to participate and complete the pre-evaluation and post-evaluation study. The average age of these participants was 34 years old, ranging between 18 and 62 years old. Almost 70% of them had already participated in educational activities on sexual and gender diversity. However, considering people from smaller towns with less than 100,000 inhabitants, this percentage dropped to 65.2%.


In general, the level of prejudice of health professionals before the intervention was high- only 11% of participants fit the minimum level of prejudice. However, by the end of the program, this number increased to 19.87%. In a nutshell, almost 70% of participants had no knowledge about the topic; 24% had already heard about it; and almost 7% witnessed discrimination in health service settings. At the beginning of the course, the levels of prejudice among men, although higher, did not present statistical difference when compared to those among women.  However, the intervention had almost twice the effect among  women. On the other hand, in terms of level of prejudice by population density of the place of residence, it remained unchanged. Cities with more than 500,000 inhabitants had lower levels of prejudice, followed by cities between 100,000 and 500,000; and finally, cities with less than 100,000 inhabitants, which presented higher levels of prejudice. Additionally, those who had some type of religiosity did not present significant difference in the level of discrimination at the beginning and end of the intervention, differently from non religious people.

Researchers noted that prejudice follows a certain line. According to them, prejudice was higher among those with lower educational level, inhabitants of smaller cities, without prior knowledge on the subject, and religious people. Despite of high levels of prejudice, 68.74% of the professionals were not aware of cases of discrimination in their  settings. This percentage dropped to 44% when only those with the lowest degree of prejudice were taken into account. According to Brandelli, this result can be due to the fact that other professionals do not possess the necessary knowledge to identify discrimination, including the one coming from them.

According to Brandelli, although prejudice is in decline, the program did not eliminate it completely. "We are in a context that reinforces prejudice, so it is very difficult to reduce it with just one action, but we are happy that it shows some decline," he emphasizes.

Brandelli also points out that research and interventions in this context are recent and scarce in Brazil. "The area of prejudice is very new, we lived in a dictatorship until recently; we could not have studied this subject then," he says. He adds that the courses in the area of health collaborate to spread prejudice. "Not mentioning diversity is to permit prejudice to arise, because we live in a very conservative society, and if the university does not assume the lead to fight  it, professionals will naturally reproduce it," he notes. In another research carried out by his group, the professor defined the level of prejudice among UFRGS students. The result of this research shows that health courses present a high level of prejudice.

He also emphasizes that a set of strategies is needed to change this scenario, such as specific legislation that punishes discriminatory practices, pedagogical actions in health courses and, directed at professionals who are already in the labor market,  training that enables these people to be in contact with the LGBT community.

Brandelli has a positive view on the impact of his work. "This study shows how psychology has also a practical utility in the field of collective health, since we  usually see only its clinical side," he concludes.


Scientific Papers

COSTA, A. B. et al. Effectiveness of a multidimensional web-based intervention program to change Brazilian health practitioners attitudes toward the lesbian, gay, bisexual and transgender population. Journal of Health Psychology, [s.l.], v. 21, n. 3, p.356-368, 1 mar. 2016. SAGE Publications.

COSTA, Angelo Brandelli et al. Prejudice Toward Gender and Sexual Diversity in a Brazilian Public University: Prevalence, Awareness, and the Effects of Education. Sex Res Soc Policy, [s.l.], v. 12, n. 4, p.261-272, 6 maio 2015. Springer Science + Business Media.


Translated by Rafaela S. Silva under the supervision of Professor Márcia Moura da Silva (UFRGS)

Text in Portuguese available at:

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