Obstacles and potentialities in the teaching process about transsexuality: perspectives of nursing teachers

Rayssa Maria da Silva1, Francisca Andreza Passos Silva2, Anna Kalyne César Grangeiro Adriano3, Sabrynna Lustosa de Lira4, Lumena Hellen da Silva5, Mariah Kemily Silva Barros6, Rayrla Cristina de Abreu Temoteo7, Marcelo Costa Fernandes8

1,2,3,4,5,6,7,8Federal University of Campina Grande. Cajazeiras (PB), Brazil.

Introduction

Brazil has led the ranking of countries with the highest rates of transphobic crimes, accounting for 40% of murders recorded worldwide and surpassing, in terms of violence, even some African countries that impose the death penalty on LGBTQIAPN+ people. Within Brazil, the Northeast has stood out as the most violent region for this group, accounting for 36% of transphobic crimes in the country.1

Educational institutions are not exempt from LGBTphobic practices, especially against the transgender, transsexual, or transvestite population, who face extreme social vulnerability. Transsexuality is understood as an identity that challenges the traditional correspondence between the sex assigned at birth and socially constructed gender. Although it presents unique characteristics, it refers to individuals who do not identify with the biological sex assigned at birth.2

The "Dossier on Murders and Violence against Brazilian Transvestites and Transsexuals"3 highlights that, although data on violence against this population is underreported, there is an increase in violence against trans people.

When considering this issue in the Brazilian context, it is urgent to rethink educational practices that perpetuate gender stereotypes. It is essential to promote an education that values the diversity of experiences and perspectives, as well as to understand moral and social issues, to build a more just and inclusive society.4

Traditional biomedical understanding conceives of transvestite and transsexual people as those whose gender identity does not diverge from their "biological sex," generally restricted to the genital configuration of vagina or penis. This approach is based on a cisgender perspective and the cisheteronormative paradigm, which establishes the correspondence between genetics, genitalia, and gender as the standard. In this sense, gender is assigned at birth by a medical-legal authority, based on the expectation of conformity between body, genitalia, and gender identity.5

Previously, transsexualism was classified in the tenth edition of the International Classification of Diseases (ICD-10) as a mental disorder related to gender dysphoria. However, after the revision of the ICD-10 and the publication of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), this classification was changed to gender incongruence, becoming recognized as a variation of normality, and no longer as a sexual disorder, as was stated in previous manuals.6

By removing the disorder label, this reformulation directly impacted the way trans people are viewed and treated in society and in health services, recognizing transsexuality as a legitimate expression of human diversity. Given the challenges trans people face in accessing healthcare services, it is important to understand how the nursing faculty understands transsexuality to explore how their perceptions influence the training of future healthcare professionals.

Given the challenges that persist in nursing education regarding the approach to transsexuality, especially in a context where gender diversity demands ethical, pedagogical, and care-related reflections, it is necessary to understand how this topic has been addressed in the academic environment. Therefore, the following research question is formulated: What are the obstacles and potentials faced in nursing education regarding transsexuality, based on the discourses of nursing faculty?

From this perspective, this study seeks to investigate the obstacles and potentials encountered in nursing education regarding transsexuality.

Method

This is a descriptive study with a qualitative approach conducted at a federal public Higher Education Institution (HEI) located in the Alto Sertão region of Paraíba, Brazil. This HEI was chosen as the research site because its undergraduate nursing program is the only public one in the region, giving the institution a crucial role in training healthcare professionals to meet the specific and significant demands of the field.

The study involved nursing faculty from the Nursing Academic Unit (UAENF), totaling 12 participating faculty members. At the time of the study, the UAENF had 24 faculty members, 16 of whom were nurses. However, two were on leave, one was acting as a substitute professor, and another was a thesis advisor, all of which were criteria used for exclusion. Data collection was conducted between May and June 2022. The inclusion criteria included tenured nursing faculty members assigned to the UAENF, while the exclusion criteria applied to faculty members on leave from teaching due to training, medical leave, vacation, or other reasons. A limitation of this study is that the sample was restricted to nursing faculty members affiliated with a federal public higher education institution (HEI) in the interior of Paraíba state. This limitation, although methodologically justified by the research focus, may have limited the diversity of perceptions and experiences analyzed.

Participants selected for the research were invited and accepted the invitation. The interviews were conducted by an undergraduate nursing student, previously trained to conduct them, in accordance with the methodological procedures defined in the research project. The interviewer, who identified as female and heterosexual, was not a faculty member at the unit. Semi-structured interviews were conducted using a questionnaire that addressed sociodemographic data and subjective questions related to the topic. Data collection occurred both in-person, with interviews scheduled according to the faculty's availability, in classrooms or offices, and remotely, via the Google Meet platform. Each questionnaire was administered individually, and the interviews were recorded in MP3 format for later transcription. The average length of each interview was approximately nine minutes.

In this study, the initial transcription of the data was performed by the lead researcher. Subsequently, the material was reviewed and validated by another member of the research team, who carefully listened to it, comparing the original audio recordings with the transcribed files, to ensure the content’s accuracy and quality to achieve the study's objective.

For data analysis and processing, the Collective Subject Discourse (CSD) method, based on the Theory of Social Representations (TSR), was adopted. This approach, commonly used in qualitative research, allows us to understand the thoughts, beliefs, values, and perceptions shared by a social group about a given phenomenon through systematized scientific procedures.

The results of the interviews with the teachers were analyzed using the CSD methodology, which enabled the synthesis and organization of the statements obtained in the interviews, resulting in the production of the final data. This methodology groups individual opinions or expressions with similar meanings into their respective Central Ideas (CI). This technique’s unique feature brings together, in each category, opinion content with similar meanings found in various statements, forming a synthesis discourse written in the first person singular. This procedure creates the impression that a collective expresses itself through a single individual.7

This technique is essentially based on analyzing the content of the interviews to identify the CIs and extract their Key Expressions (KE), which correspond to the essential excerpts of the discourse being analyzed.8

To develop the CSD, the CIs and KEs are synthesized, representing the thoughts of a specific group on the topic under investigation. It should be noted that this does not mean that all participants present identical expressions, but rather that, collectively, such discourses represent a shared vision. This approach facilitates the analysis of the interview content and contributes to the development and structuring of the work.9

The study began after approval by the Research Ethics Committee (REC) of the Universidade Federal Campina Grande (UFCG), Cajazeiras campus, receiving a positive opinion under number 5,258,839, in accordance with Resolution No. 466 of December 12, 2012, of the National Health Council (NHC). This resolution establishes guidelines and standards for research involving human subjects. The study was conducted in full compliance with ethical standards to ensure the protection and respect of participants. Furthermore, because the interviews were conducted virtually, the recommendations established in Circular Letter No. 01/2021 of the National Research Ethics Commission (CONEP) were followed regarding the protection of participants' privacy, data security, and the digital obtaining of the Free and Informed Consent Form (FICF). During the reading of the FICF, faculty members were informed about the study, its objectives, potential benefits, and risks.10

To comply with ethical principles, faculty members were identified by numerical acronyms, according to the chronological sequence of the interviews, ranging from NUR1 to NUR12. This measure was adopted to guarantee the participants' privacy during the study.

The research adopted the Consolidated Criteria for Reporting Qualitative Research (COREQ) as a methodological tool, ensuring transparency and rigor in the reporting of qualitative data. The use of COREQ enabled a detailed description of the data collection, analysis, and interpretation processes, ensuring the reliability of the results and favoring the study's replicability. Furthermore, this approach provided greater structure and criteria for the presentation of faculty members' statements, ensuring scientific quality and clarity in communicating the analyzed perceptions.11

Results

The first CI was developed based on the testimonies of six participants (NUR4, NUR5, NUR6, NUR9, NUR11, and NUR12) and addresses teachers' inexperience and lack of knowledge about transgender people, which allowed the construction of the following DSC.

CI01: Inexperience and lack of knowledge about trans people

CSD01: I don't have much experience with it. I think it's so difficult, you know why? There's so much new information on the subject, I think people know little about it. I think the scientific aspect itself lacks research. Many people are unable to discuss the topic openly, and often, professionals themselves, such as teachers, also feel uncomfortable. From my training, you realize that this isn't a discussed topic; it's a very new topic. It's not so new as an existence, but the way it's discussed, the way it appears in society today, and how society engages in this process of discussion and acceptance is something new. The little I know is what's reported on television, in the media, and in a very general way; I need to delve deeper. During my research, I've never researched it; it's not my focus, at least not yet. It's not my research focus, nor is it in my healthcare practice; I've barely done anything directly focused on it. In general, I've never worked with this topic [...].

The second CSD addresses institutional openness and interest in the topic of transsexuality, which made it possible to construct IC02 based on data from five participants (NUR2, NUR5, NUR6, NUR7, NUR11).

CI02: Openness and Interest in the Topic at the Institutional Level

CSD02: I think that, in terms of ease, we currently live in a much more open environment for discussing this topic, much more feasible for addressing the topic of sexuality, gender, and sexual development in the classroom than it was in the past. We could say that this situation wouldn't have been the same a few years ago, but today, with this openness, with the media spreading it on social media, we feel more comfortable talking. I don't see any obstacles or resistance in the university environment; although I haven't experienced this, I believe that because it's a university environment, the ease lies in the lack of resistance to addressing the topic. I believe that if a professor is willing to address the topic, it's an easy topic to address in this academic environment. We have professors who work with the topic, and I think that makes it easier. I think the main advantage is interest and a willingness to establish a dialogue. If I find a topic interesting, it's a completely different thing to be free from prejudice. Today, everything is so interconnected that you can introduce a debate, a discussion and bring in very pertinent elements related to any topic.

The CSD of the third CI pointed out gaps in the Nursing degree curriculum as a challenge for professionals in providing care to transgender people, supported by contributions from three participants (NUR8, NUR10, NUR11).

CI03: Gaps in the curriculum related to the topic of trans people

DSC03: I think another very difficult issue would be bringing it to the management. The curriculum would need to be more open to this topic. It addresses sexual and gender diversity, addressing, for example, literature. Also, administrators and teachers don't have training or training courses in this area. Only those who are the most interested in this top attempt to pursue it, but it's not something that reaches some of them; it requires working groups to discuss this topic. At least in the Nursing DPP, we see very little on this, because we work in the classroom, but at the DPP level, in the subjects, we don't see it [...]. I believe that the difficulty would be for the teachers to feel the need to work on this subject, for the teachers, together with the center coordinators, to envision a change in the DPP, and based on the institution's needs.

Discussion

Transsexuality and healthcare in Brazil are discussed by authors who explore how gender binarism influences the perception and care of transgender people's needs. According to the aforementioned authors, transsexuality is an identity characterized by its fluid nature, involving people who do not identify with the biological sex they were assigned at birth. This disconnect between biological sex and gender identity represents a perspective that challenges traditional ideas about what it means to be male or female, questioning the social connection between gender and biological sex. This demonstrates the multiple ways in which identity can be experienced and expressed.12

An analysis of CI01, which formed CSD01, reveals gaps in faculty members' experience in discussing transsexuality. Faculty members expressed a clear limitation in their experience with transsexuality, indicating a lack of training or opportunities to delve deeper into the topic. They stated that they had not worked directly with the topic in their practice or training, which may suggest that they do not feel prepared to integrate transsexuality into their pedagogical and care approaches, due to their own learning process.

In Brazil, despite the existence of the National Policy for Comprehensive Health for Lesbian, Gay, Bisexual, Transvestite, and Transgender People, which establishes guidelines aimed at recognizing the social and health needs of this population, as well as promoting educational practices that foster knowledge, attitudes, and affirmative care with a view to equity, it is observed that the inclusion of content on the social and health issues of these individuals is still insufficient or even non-existent in most nursing schools and colleges. This gap contributes to limited professional training regarding experience with the topic of transsexuality.13

This gap is not limited to students but extends to faculty themselves, as revealed by the CI01 analysis. The discourses highlighted inexperience and insecurity when addressing the topic of transsexuality, which is related to the lack of specific training during their academic careers.

Nursing education is undergoing transformations, in which the construction of knowledge adapts to the demands of restructuring educational policies. Within this movement, clinical simulation is gaining prominence as an important methodological strategy, using technologies to recreate scenarios that reflect professional practice in a controlled and realistic environment.14

Therefore, there are potentialities in this scenario, such as expanding teaching methods, discussing inclusion, and raising awareness among future nurses about more assertive practices. Therefore, curricular adaptation, although marked by obstacles, represents an opportunity to promote paradigmatic shifts in healthcare education.

Thus, the inclusion of the topic of transsexuality in teaching can be strengthened by active methodologies that recreate scenarios, bringing students closer to the reality experienced by transgender people in healthcare services. The literature highlights the inadequacy of healthcare professionals' training to address the specific needs of transgender and transvestite people in the Brazilian Unified Health System (SUS), highlighting neglected care, a lack of adequate support, and a scarcity of discussions about their particularities.15

Health Sciences education is still predominantly structured around the transmission of normative representations of the body, with an emphasis on its biological functioning and pathological deviations, through disciplines such as anatomy, physiology, pathology, and other biomedical fields. This approach, often fragmented and guided by specializations, prioritizes the application of standardized clinical protocols aimed at the biological normalization of bodies, to the detriment of a more comprehensive and contextualized understanding of health.16

Concurrently, this teaching model, still heavily based on biomedical and normative approaches, contributes to the exclusion of topics such as transsexuality from curricula. By prioritizing technical and biological knowledge to the detriment of social, cultural, and gender issues, curricula end up disregarding the specificities of historically marginalized populations.

The faculty mentioned that the discussion about transsexuality is "new," reflecting a perception that, despite being an existing issue, its approach in educational and healthcare settings is recent. This may indicate a delay in updating Nursing curricula on issues of diversity.

Although the discussion about transsexuality is considered "new," it is important to emphasize that healthcare professionals have a responsibility to create a welcoming environment free from prejudice and discrimination.

The faculty stated that "people know little" about the topic, suggesting a significant knowledge gap that can impact the quality of teaching and the preparation of future professionals.

The statement about the need for more scientific studies indicates that the faculty recognizes a gap in academic and professional knowledge that needs to be addressed for more comprehensive training.

The faculty's criticism of the superficiality of available information, especially that disseminated by the media, reveals a legitimate concern about how transsexuality is presented. This perception highlights the urgent need for alternatives that transcend conventional media discourse, proposing more qualified, ethical, and contextualized approaches. In this scenario, the development of educational technologies emerges as a strategic and necessary response.

In the academic environment, clinical simulation has gained increasing importance, considered a methodological strategy that employs technologies to reproduce scenarios that simulate practice in a controlled and realistic environment. Various tools are used to experience a clinical situation, such as simulators (mannequins), simulated patients (people playing the role of a patient or performing a role-play), virtual learning objects (such as educational game software, videos, audio, and web technologies), and mixed methods (which combine more than one type of simulator).14

Some studies have shown that the adoption, or even the combination, of educational strategies that favor the active participation of those involved in the educational process has a high potential for promoting deeper and more lasting impacts on learning. These methodologies, due to their dialogic and experiential nature, encourage critical reflection, empathy, and engagement among professionals in training.13

Thus, the use of technologies for teaching offers benefits for both teachers and students. By adopting them, the faculty can provide a safe environment for experimentation, including trial and error among students, encouraging collaboration, and expanding clinical experience by exposing students to multiple care settings.

The reports that comprise CSD02 present an optimistic view of how transsexuality and issues related to sexuality are treated in the academic context.

The implementation of the transsexualization process policy in the SUS represents a historic milestone in the debate on healthcare for trans people in Brazil. This progress comes with the State's recognition of its responsibility to ensure comprehensive, universal, and, above all, equitable care for this population.17

Faculty members mention that, currently, there is greater openness to discussing topics of sexuality and gender compared to previous years. This suggests an evolution in social and academic dynamics, indicating that these topics are becoming more recognized and accepted in the university environment.

In recent years, political initiatives have emerged aimed at training healthcare professionals, seeking to improve care for the transgender population. A relevant example is the creation of the LGBTQIAPN+ Health Policy course, offered by the Open University of the Unified Health System (UNA-SUS) in the distance learning format, aimed at healthcare professionals but accessible to anyone who is interested.16 The course seeks to guarantee the LGBTQIAPN+ population access to comprehensive healthcare, promoting an egalitarian and quality approach.

This movement emphasizes the training and qualification of workers, aiming to acquire skills and competencies related to gender, sexuality, and transgenderism.

Health care for transgender people in Brazil is still under construction. Although there is a Decree regulating this policy, it cannot be effective without the creation of specialized facilities capable of receiving and addressing the demands and stories of these individuals.18

The statements of the faculty members who formed this CSD demonstrated that some professionals express comfort in approaching the topic, where discussion is not only permitted but encouraged. This reflects the importance of individual faculty motivation to address topics related to transsexuality in their classes.

Although these faculty members' statements about the lack of resistance in the university environment suggest that institutions are becoming more inclusive, health sciences education still focuses primarily on imparting knowledge about the human body, its biological functions, and pathological deviations. These disciplines, often presented in a fragmented manner, seek to teach universal clinical protocols for treating diseases and restoring the body to biological norms.

The emphasis in health sciences education on biological functions and pathologies, without considering gender diversity, leaves future professionals unprepared to care for transgender people. This lack of sensitivity and understanding can result in uninformed care, hindering the creation of a more welcoming healthcare environment for this population. The expressed idea of being free from prejudice suggests that the professor sees progress in the acceptance of diversity within the academic environment. The statement that "you can insert a debate into every topic" highlights the importance being given to issues related to sexuality and gender, indicating that these topics can be interconnected with various areas of knowledge, enriching the curriculum and student education.

In CSD03, the gaps and challenges faced in integrating the topic of transsexuality and gender diversity into the Nursing program curriculum were highlighted.

The professors pointed out that one of the main difficulties is getting the administration, such as the Course Board and the institution's Core Faculty, to recognize and incorporate sexual and gender diversity into the curriculum. This suggests a disconnect between what is discussed in the classroom and official curricular guidelines.

The lives of transgender men and women, with their specificities and singularities, require the State and public health services to prepare for differentiated treatment. Specialized care that considers one’s body transformation needs as a health issue is essential. Likewise, these services must encompass the political, aesthetic, social, economic, and cultural implications that accompany gender transition processes, recognizing these factors as part of the health and illness process.

Discrimination is a phenomenon that has always been present in Brazilian society and, despite progress, continues to influence social relations. Furthermore, the State, in many situations, exerts its power over minorities, legitimizing the violation of their rights. Universities must offer courses that address diversity to ensure that nurses in training are adequately prepared to serve all populations, including minority groups such as transgender people.

Faculty members also mention that both administrators and professors lack specific training in this area, which limits their ability to effectively address sexual and gender diversity. This lack of training can result in resistance or insecurity when addressing these issues.

The statement that only those who are interested seek information indicates that the responsibility for training often falls on faculty members, without a proper structured institutional support.

The finding that the Nursing Degree Pedagogical Project (DPP) does not sufficiently address the topic of sexual and gender diversity highlights a significant gap in student education. This can impact professional training and the ability to address diversity in healthcare, resulting in insufficient pedagogical approaches.

It is imperative to reflect on how future healthcare professionals, especially nursing graduates, understand transsexuality and the specific healthcare needs of transgender people. Understanding these representations will enable reevaluation and improvement of professional training, aiming for more qualified, humane care that is tailored to the specific needs of this population. Furthermore, it will enable future nurses to develop a more sensitive approach, contributing to reducing stigma and improving access to and the quality of healthcare services for transgender people.

The discourse indicates that the faculty must recognize the need to update the DPP to include diversity, highlighting the lack of a strategic vision that integrates these topics into the curriculum.

A limitation of this study is the restricted sample size to nursing faculty members affiliated with a federal public higher education institution (HEI) located in the interior of Paraíba. This limitation, although methodologically justified by the research focus, may have limited the diversity of perceptions and experiences analyzed.

Conclusion

Based on the analysis of the participating faculty members' discourses, this study's objective was achieved by highlighting both the obstacles and potentialities present in the process of teaching transsexuality in nursing education. This research emphasizes the complexity of teaching transsexuality and gender diversity in nursing education, highlighting both the advantages and challenges faced by faculty members.

The discourse analysis revealed that the topic of transsexuality still faces significant obstacles in nursing education. There is a lack of systematized content in the DPPs, which limits a consistent approach to gender diversity in academic training. At the same time, the reports reveal an institutional environment more open to debate, with faculty members demonstrating interest and willingness to address the topic in their teaching practices, representing an improvement over previous educational contexts. However, many professionals still report inexperience and lack of knowledge on the topic, a consequence of initial training that did not include discussions on gender identity and sexual orientation, which creates uncertainty when approaching the topic with students.

These findings reveal a changing landscape where structural limitations and possibilities for transformation coexist. Based on this research’s results, institutional administrators can be encouraged to seek initiatives to train the faculty on the topic of transgender people.

Authors' contributions

Study design: Rayssa Maria da Silva. Data collection: Rayssa Maria da Silva. Data analysis and interpretation: Francisca Andreza Passos Silva. Manuscript writing: Francisca Andreza Passos Silva. Critical review of the manuscript: Anna Kalyne César Grangeiro Adriano; Sabrynna Lustosa de Lira; Lumena Hellen da Silva; Mariah Kemily Silva Barros; Rayrla Cristina de Abreu Temoteo and Marcelo Costa Fernandes. Approval of the final version of the text: Rayrla Cristina de Abreu Temoteo and Marcelo Costa Fernandes.

Conflict of Interest

The authors have declared no conflict of interest.

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Corresponding Author

Francisca Andreza Passos Silva

E-mail: franciscaandrezaps@gmail.com

© The Author(s) 2025. This work is licensed under Creative Commons Attribution 4.0 International. License text for use: https://creativecommons.org/licenses/by/4.0/