Looking to Lgbt ’ s Health : a Literature ’ s Integrative Review

Introduction: Approach the questions about sex, sexuality, sexual orientation, gender identity and the free expression of them, opens a range of many possibilities that may guide us trough different paths. In this study, will be approached the questions related to the scientific publications after the National Integral Health Policy on Lesbians, Gays, Bisexuals, Transgender and Transsexuals (NIHP-LGBT).


Introduction
For years the LGBT (Lesbian, Gay, Bisexual, Transsexual and Transgender) has been struggling and reaching a growing presence in organs and regulatory councils of organized civil society in quest for their rights and duties recognition as Brazilian citizens.This fight also affects the health scope, as soon as regards the access to health services and obtain an equitable and comprehensive care offered by the Health Unic System (HUS).
Regarding access of LGBT people to health services based on the principles of universality, comprehensiveness and equity, gender identity and sexual orientation cannot and should not be differentiating attributes, as routinely intertwine in various ways to other, for example age, race/ color, social class, being a woman, a man, being a child, being old and being LGBT, may have health needs different, implying various demands [Mello et al 2011].
The performance of the Brazilian LGBT social movements, over the last decade, it was very important to give visibility, same as shy, the political and social field for These People.This event led to the conquest of space in the public sphere, allowing the creation of demands related to the government and society, being strengthened with the creation and implementation of public policies, focused on health, focusing on achievement and expansion of their rights [Facchini;Simões, 2009].
In December 2011, the Health Ministry (HM) launched Nº2.836 Ordinance establishing the National Integrative Health Policy of Lesbian, Gay, Bisexual, and Transgender (LGBT-NIHP).Its main objective is to promote the health of the population by eliminating discrimination and institutional prejudice and contribute to the reduction of inequalities and the consolidation of HUS as a universal, comprehensive and equitable system [Brazil, 2013].
According to (Mello et al, 2011) to be considered a population vulnerability and especially social risk, address issues related to the evolution of the health of the LGBT population, as driving the health care practices, lead us to complex reflections and dilemmatic such as sexual rights, reproductive and inalienable human rights of men and women.In addition, emphasizes the break of paradigms, discrimination, and the formation of stigmata, the different types of violence and prejudices that routinely happen to lesbians, gays, bisexuals, transvestites, transsexuals and transgender [Lionço, 2008].Therefore, it is pertinent to develop studies involving this issue, try to minimally reduce these types of injuries LGBT health.
Considered a landmark of Brazilian health LGBT health actions, the National Comprehensive LGBT Results: there are few advances in the fight for the LGBT people rights, a lot of barriers to this population health assistance even after the National Policy foundation.

Conclusion:
Was cleat, till the moment, poor effective the Brazilian legislation regarding the rights and duties of LGBT people on the social sphere and health sphere.There is a necessity of higher knowledge from the health professionals regarding this thematic and a higher quality, resoluteness and integrality at the assistance actions to this population health.
Health Policy directs and regulates the health care in the three spheres of government [Brazil, 2013].This policy reinforces the research objective, which is to analyze the publications that deal with the health of LGBT people after the implementation of your policy and see which aspects are being addressed on the health care of this population.

Methods
As this study part of the research project, Social Representations About Sexualities and Gender: dynamics, dimensions and inter subjectivity, it was decided to develop an Integrative Literature Review (ILR), which enables the composition study findings using different methodologies, allowing synthesize results without hurting the epistemological findings of the empirical studies included.For this process to flow free of epistemic follies the ILR requires reviewers to undertake the analysis and synthesis of all data in a systematic and rigorous manner [Soares;et al, 2014].
Therefore, and in view of these criteria it was necessary to follow steps to answer the main question of this study: which the profile of publications that deal with the health of LGBT people after the establishment of its policy and what aspects are being addressed on the health care of this population?
The following steps were followed: theme identification and selection of the research question; establishment of inclusion and exclusion criteria; identification of pre-screened and selected studies, conducting a careful reading of the titles, abstracts and keywords of all full publications to determine whether they were as the inclusion criteria of the study; categorization of the selected studies; analysis and interpretation of the results and, finally, presentation of review / knowledge synthesis for the preparation of the article [Mendes;Silveira;Galvão 2008].
The bibliographic setIt happened in the months from September to December 2015, through the HVL (Health Virtual Library) on the data basis MEDLINE (Medical Literature Analysisand Retrieval System on-line); LACSSH (Latin American and Caribbean Social Sciences and Health); SCIELO (Scientific Eletronic Library Online).The search for articles in the databases occurred through the following keywords indexed in Health Sciences Descriptors (HSD): Health; sexuality and LGBT.We used the Boolean AND operator with the combined descriptors as follows: health and LGBT and sexuality and LGBT population.Soon after the research found 40 articles published between the years 2012 and 2015, then was read abstracts and full texts, therefore, the studies did not mention the LGBT public were excluded, repeated and those whose data collection had happened before the establishment of the National Integrative Health Policy LGBT people.
After this reading, six papers fall into the following inclusion criteria: articles, theses, dissertations and monographs publications in full; in the Portuguese language, because it is a Brazilian politics, published between the years 2012 and 2015, for the purpose of this research is to analyze the publications that deal with the health of the LGBT population after the implementation of its policy, and examine which aspects they are being approached about the health care of this public.
The result of the material occurred by analyzing the articles through the construction of summary tables, which addressed the following aspects: title search, author and scientific mode, periodicals and number of publications, type of research and main results.After reading these articles sought to similar results by dividing them into the following thematic categories: barriers to assistance to LGBT health and the fight for direct LGBT person.

Study characterization
Regarding the year of publication of scientific works selected, on 01, it is clear that the four-year period 2012-2015, there was emphasis on the years 2013 and 2014, which presented two publications each year, on the topic in question.For the years 2012 and 2015 was found only one publication in both.However, it is remarkable that the scientific paper mode is predominant, since four publications not fit this style, being characterized as Course Conclusion Work (CCW) and one as master's dissertation.

(Table 1)
With regard to the academic the main author of the analyzed material, it can be observed that the study was developed for 1 occupational therapist; the study pointed como 2 by Nurse, studies 3, 4:05 by psychologists and study 6 by Lawyer.These data indicate the need for more health professionals awakening, with regard to health care and sexuality of LGBT people, since, in various fields of society, this population is considered invisible because it dictates different or abnormal because of their sexual orientation, becoming target of prejudice, stigma and violence.
You can see that the aspects that address sexual issues of people who do not fit the heteronormative model with cultural and social influence, imposed over the years, are produced and replicated, and therefore are changeable causes sexualities different tend to be made invisible, demoralized and excluded without realizing it.
LGBT people are vulnerable or are in vulnerable situations, in that break with this heteronormative model of sexual orientation and gender identity, suffering prejudice, discrimination and intolerance, concretized in homophobia, lesbophobia, biphobia and transphobia, which ends up hindering the health care of this public [Gross, 2015].
In health care to the LGBT population, it is necessary that the constituent normative principles of HUS, universality, comprehensiveness and equity are focused on public policies that actually promote coping exclusionary issues of homophobia and heterosexual normative, which produce and reproduce in health professionals, behaviors and biases to meet all users of public or private bodies as if they were heterosexual.These fixation situation gender norms generate serious situations of discrimination and prejudice against lesbian, gay, bisexual and transsexuals [Calderaro;Fernandes;Mello, 2008].
Elucidating the LGBT people and health professionals focusing on legislation, law and access obligations to the Health Unic System and on specific public policies existing in Brazil is a path to greater awareness, decreased prejudice and barriers to access to health services.
As for the characterization of the sample, in in scientific journals and in a multidisciplinary virtual library, which facilitates access to health professionals, strengthens and promotes the search for scientific knowledge and deepening study in the area and may thus result in the improvement of the working process and provided assistance to LGBT person.
As the theme is still little discussed, but is gaining impact, it can be observed that there is heterogeneity in the fields and areas of publications.It is notorious a predominance of studies on sexuality, health and LGBT population in the field of social sciences and the field of social psychology, as the results of the study in question.It is worth mentioning that the area of Health Sciences has been focusing on targeted studies to this, which can contribute directly in reducing vulnerability to this population, mainly because it is considered a population of social disease process.This can be proven as numbers of publications of the years 2013 and 2014.
Regarding the methodological design, Table 3 shows the dominance of the analysis of empirical The study shows that there are multiple causes in determining the illness of LGBT people: the attention of health professionals across the chain reactions involves the vulnerability process and lead to illness in this population, such as prejudice, violence and ignorance of support and policy networks aimed at this population.

Integrative Literature Review
In this research to LGBT health is seen as fragile even after the publication of important documents that ensure access and inclusion of LGBT people in health.The vulnerability of the recommended proposals will meet the discriminatory and hetero normative assistance by health professionals.Therefore, necessary to train human resources for health in relation to the specifics of LGBT health.
3 Qualitative grounded in the Social Representation Theory The results of this article focus on the apprehension in meeting the health of lesbian woman is marked by the fear of discriminatory reaction, if you choose to revise their sexual orientation.Hetero normative and biased standards are established by health professionals who proliferates wrong ideas on the health of lesbian woman.This reinforces the lack of information and knowledge of health professionals about the policies and rights to health geared to that audience.

Qualitative field and observational
This study shows that hetero normative legitimizes the production and maintenance of various situations of violence within the family, often culminating in the expulsion / origin home outlet or submission to systematic family violence.
5 Qualitative grounded in field diary It was addressed in this research the existence of transphobia in health services, marked by situations of prejudice and discrimination.It shows that health actions to transvestites and transsexuals occur in specialized outpatient services and showing the fragility of assistance at the level of primary care.Finally focuses on the need to train health professionals to that assistance be given warm and humane way.
data, these, surveys 1, 2:06 not fit in the literature review for reflection of subjective data, research 5 is based on the daily style field the 4 in the observational model and research 6 is grounded in the Social Representation Theory.
As for the synthesis of the results of the study revealed that there are few publications that involve or are related to health and sexuality of LGBT people, since the establishment of its National Policy in 2011.However, these outstanding publications were identified several factors that appear associated with health, sexuality and rights of the people of Lesbian, Gay, Bisexual, Transsexual and Transgender, and to better address these factors, discussions were grouped into two thematic categories: the first shows the "Barriers to Care for LGBT Health" and the second the "Fight by Direct LGBT person".

Barriers to Care for LGBT Health
It was observed that most of the research was discussed issues related to sexuality and health care to the LGBT user at different levels of attention.There is a focus mainly of the obstacles existing to the scope of public healthcare service, especially the prejudice, stigma, exclusion and the different types of violence.There are pre-established concepts in society with respect to gender, sexual orientation, sexuality, the disease process and vulnerability of LGBT people, which implies an exaggerated deficit in quality health care provided to these users.
Just from these concepts is that the professionals involved in the health care process, create, build and negotiate social and cultural provisions by representations that are built daily and this experience, go unnoticed health needs differently designed and represented [Oliveira;Santos, 2011].
Even before facing social prejudices, is the inner conflict before the rejection that LGBT people face, is therefore a major issue, since it is for health professionals to contribute to the construction and representation of identity of being, helping individuals to understand and solve their internal conflicts among which we can mention the discovery of the sexual orientation of that individual [Silva, Lima, Correia, 2013].
To Lionço (2008) sexual orientation, sexual and gender identity are characteristics that can be undefined concepts and, consequently, generates the lack of health professionals, leading deficit of health demands geared specifically the reality of sexual life, sexuality and health of LGBT people.The no real knowledge of these concepts, support networks, public policy and the generalization of this problem, configure in a major obstacle to access to health services that meets in full.
Even before the establishment of the National Comprehensive Health Policy Lesbian, Gay, Bisexual, Transsexual and Transgender (LGBT-NIHP), the Health Ministry (HM) already looking for that user and warned that violence and discrimination should be considered as driving forces in the development of diseases and mental suffering injuries.Linked to homophobia, other social exclusion factors should be scored as triggers of this population disease process, such as, unemployment, racism and lack of access to housing and food [Brazil, 2008].

N Methodological design Summary of results
6 Literature Review The results of this paper was possible to observe social concept of sexuality, hetero normative and the rights that LGBT individuals plead, generating discussion of the social and cultural role.It focuses although the way society conceives of sexuality interfere and hinder the acceptance of LGBT people, which ends up generating the curtailment of rights of this user as a Brazilian citizen.
It is notorious the HM concern with complexity in the health field and weaknesses that address sexual issues of LGBT people.In the Policy launched in 2011 there is the focus on the fight against prejudice by showing that it can generate the worst form of exclusion and illness LGBT users.However, it is noticeable, as shown in the survey results analyzed in Table 3 that even after the emergence of politics, these barriers to care in health care still exist, is more broadly, as regards the assistance weakness in various levels of health care or more specifically, regarding the right of use of the social name adopted by this class in all society segments.
Corroborating to Duarte (2014), by pointing out that the situations of discrimination, invisibility and institutional prejudice and the lack of preparation, lack of knowledge on gender identity or expression, sexual orientation still exist and happen naturally, adds that the full neglect and ignorance form the heart of the matter and that much needs to be done minimally to reverse the effects of years of exclusion and invisibility.This assertion depicts the fragile execution of the National Policy for HUS their employees when it comes to this topic.
Health professionals should be alert to the occurrence of prejudice and discrimination to LGBT population also within the family, where these acts of violence committed by family members themselves, usually end in expulsion or abandonment of these people, putting in serious situation of vulnerability and social risk [Brazil, 2010].It is noted the need for constant search for this population, the rights and advances in all fields and areas that address or relate to inclusion and acceptance of full and equal form of LGBT people.
However, despite the said advances in the field of sexual rights LGBT health, with a view to building a public policy for this population, especially with regard to the recognition of the discriminatory effects of prejudice and exclusion in different social segments is Duarte ( 2014), claims to be a histori-cal phenomenon in the social determination of the health-illness care process, which prints on a larger scale, suffering and illness, setting in greater vulnerability to this population segment.
Because it is a slow and challenging social construction for both the population involved and for health professionals, the improvement of the care planning is required, the training of health professionals on the subject in question, scientific improvement, to occur activation new ideas, legal support and strengthening of care, based on the elucidation demystification of stigmas and eradication of various forms of violence and prejudice, explicit or subjective.

Fight for the Rights of LGBT People
By observing the syntheses of research results selected in this study, it is evident that, in addition to several barriers surrounding the LGBT population to health services, there is a constant struggle of this population parcel for their social and political rights in an attempt to reach achievements and recognition of their citizenship.
Thus, in a prejudice of coping context and discrimination arise social movements organized by this part of the population and the interconnected groups, now recognized as Brazilian LGBT Movement.In performing this movement is a set of claims, including the free expression of their sexual orientation, changing the name in identity documents, access to health policies and the protection of the State against violence motivated by prejudice [Carrara, 2010].
Brazilian Law is still truly silent with regard to the rights of these users of health services.These rights that mark the citizenship of LGBT group are, in fact, forgotten and left aside by the legislature, which evades the time of the formulation of laws to protect and defend these minorities, and this is often due to the nature of issues religious and moral, which reflect in electoral campaigns against conservative groups in society [Gross, 2015].
However, the way to express themselves freely, thoughts, attitudes and sexual behaviors oriented dwarf heterosexuality, are considered abnormal for most of the population, which can generate violent and exclusionary attitudes to the individual and family LGBT.And it is precisely guided in an attempt to reverse this situation, which in 2004, is launched by the Federal Government Brazil without Homophobia Program -Program to Combat Violence and Discrimination against LGBT and the Homosexual Citizenship Promotion, that the LGBT population is advancing slowly and conquering spaces.
For Mello Avelar; Maroja, (2012) this evolution continues with the completion, in 2008, the First National Conference of Gays, Lesbians, Bisexuals, Transvestites and Transsexuals, with the theme "Human Rights and Public Policy: the way to ensure the citizenship of gays, Lesbians, Bisexuals, Transvestites and Transsexuals (LGBT) ", launch of the" National Plan for the Promotion of Citizenship and Human Rights of Lesbian, Gay, Bisexual and Transgender" (NPPCHR-LGBT).The following year, in 2009 published the decree creating the "National Human Rights Program 3" (NHRP-3).From these initiatives, it was possible to reflect more broadly on the process of designing and implementing public policies for LGBT people in Brazil, so in 2011 instituted the National Policy for Integral Lesbian Health, Gay, Bisexual, transvestites, Transsexuals and Transgender (LGBT-NIHP) [Brazil, 2013].
Even with the advances of social rights achievements with inclusion in the political environment and the establishment of standards and legislation for the LGBT population, is unfortunately still factual aggression, torture, discrimination in public agencies and government authorities.Moreover, economic discrimination against free movement, privacy and work, family breakdown, educational, scientific and religious defamation and discrimination in the media, insulting and anti-gay prejudice, anti-lesbian and anti-transgender are common forms, and often they go unnoticed, violence.This type of violence against sexual orientation has multiple forms of expression, from jokes to stereotypical representations.Gross (2015) It states that such violence is a hostile reaction to the hetero normative misdemeanors.
How do I reverse this attitude and assuming LGBT citizenship rights, where several are raised discussions by the legitimate social movements of this class, which has been traced back as ethics in care, the influence of religion and moral values of Brazilian society that can expose, clearly, the contours of a historical process ongoing that reveals how effectively principles, policies and actions materialize or not in the everyday [Bittencourt;Fonseca;Segundo, 2015].
This embodiment can be proven from the observation of reality that slowly is being changed, and an example would be to guarantee the use of the social name of transvestites and transsexuals, which reveals the freedom of expression and citizenship and their identity genre.
It is noteworthy be necessary to monitor the guarantee of the rights of LGBT people, as well as the bodies that claim rights to this segment of the population must remain vigilant regarding the direction and attitude of care towards this population, because only then will it be possible get greater achievements and consequently respect, visibility, breaking religious and social paradigms.

Conclusions
In order to analyze the publications that deal with the health of LGBT people after the establishment of the National Integrative HealthPolicy (NIHP-LGBT) and see which aspects are being addressed on the health care of this population can be observed initially the scarcity of publications on this theme, which is reflected in need of awakening of health professionals to research on this topic.
Regarding the findings of this research, it was seen that after the imposition of NIHPLGBT in 2011, there was a predominance of use of subjective data to achieve the objectives of the vast majority of studies showing that listening to this population and professionals health who deal with this population can serve as barriers capture tool and quality of the provided services.
The results showed that there are still barriers to assistance to LGBT health and these still continue to clutter the comprehensive care of Lesbian, Gay, Bisexual, Transsexual and Transgender, since the lack of reception of health services, fear of LGBT people to show their true sexual orientation or gender identity, prejudice and pre-set by society and health professionals concepts.In this context, the lack of knowledge of these professionals regarding the equitable assistance, comprehensive and specialized for that audience, combined with lack of support and confidence to free speech if their sexual orientation and gender identity LGBT users, plus the very exclusion of society by social and religious aspects and the various types of violence they are subjected to, interfere directly the health care of these people and wounds with what is recommended by the Laws and Regulations and the health System.
Regarding the struggle for the rights of LGBT people, it was observed that many achievements have been made, but at a slow pace and with little effectiveness of policies and objectives.It is known that only the fact that the theme is on the rise and the current focus already established itself as a positive point to be evaluated.However, it is still worrying to have that after the implementation of the National Policy, rather than it directs and regulates is deployed.Thereby, reflected in the grandeur of this struggle, the difficulties and challenges that LGBT person is subject only want to be assisted in full in all health areas.This paradox instigates reflection for the reason of non-fulfillment of the constitutional rights of Brazilian citizens, in addition to their sexual orientation or gender identity, which can be inferred that people are merely sexual beings and their sexuality or identity makes it less human rights and lower.
Finally, the need for measures aimed at implementing the objectives and strategies that are proposed in the Brazilian legislation to improve the quality of life was observed for increased search for the rights and obtaining assistance for humanized health, skilled, resolute and full of LGBT person as said the Brazilian Constitution and the Health Unic System.International Archives of Medicine is an open access journal publishing articles encompassing all aspects of medical science and clinical practice.IAM is considered a megajournal with independent sections on all areas of medicine.IAM is a really international journal with authors and board members from all around the world.The journal is widely indexed and classified Q1 in category Medicine.

Table 2 ,
it is observed that the research were published

Table 1 .
Relationship of scientific productions identified in the research: title scientific work, author and year of publication and scientific mode.

Table 2 .
Distribution Ratio of publications: journals in electronic library.

Table 3 .
Aspects of scientific productions identified in the survey: methodological design used and summary of results.