Promoting transgender healthcare competency: simulation scenario for medical students

Abstract

Background

Medical professionals, from trainees to practicing clinicians, often lack adequate preparation to provide care and understand the health needs of transgender and gender diverse (TGD) people, as documented worldwide. As a result, many medical trainees feel unprepared to deliver competent and affirming care to TGD patients. To address this educational gap, this study implemented a simulation-based learning activity as an initial exposure to TGD healthcare. We aimed to assess medical students’ attitudes and performance in a transgender healthcare simulation scenario.

Methods

We designed and evaluated a simulated scenario for the care of a transgender man with delayed menstruation, with the aim of training Obstetrics and Gynecology (OB/GYN) clerkship students in caring for TGD patients. The simulation and cross-sectional data collection took place in a university hospital located in the northeast of Brazil. From January to June 2023, the OB/GYN clerkship medical students were invited to run a simulated scenario and completed a brief quantitative, survey-based evaluation using a simplified “Scale of Satisfaction with Simulated Clinical Experiences”.

Results

Overall, many students reported limited prior experience in caring for transgender and gender diverse patients. For instance, only a small proportion had received formal instruction or had curricular content addressing the distinction between gender identity and sex assigned at birth during their undergraduate program. Similarly, many students acknowledged that sexual orientation may influence the care patients receive. The scenario simulated a consultation for a trans man with secondary amenorrhea, with two trans men participating as standardized patients. Of the 25 undergraduate students taking part, most students demonstrated behavior free from biases or assumptions about patients’ identities, although 44% reported difficulty using the patient’s chosen name and pronouns due to lack of training, and 60% found it challenging to provide counseling on health promotion and prevention. During debriefing, students expressed discomfort discussing sexual practices and limited knowledge about referral pathways for TGD care services. In general, students found certain aspects of the simulation challenging primarily due to limited prior training, with specific examples described above. Students generally responded positively to the simulation, indicating engagement and willingness to learn.

Conclusions

Simulation-based learning on transgender healthcare is an effective educational tool for medical students with limited prior exposure to TGD topics. Although students faced challenges, particularly in using correct pronouns, discussing sexual practices, and providing preventive counseling, they demonstrated engagement and receptivity to the scenario. These findings suggest that realistic simulation scenarios can enhance cultural competence and prepare students to provide affirming care to TGD individuals, regardless of prior experience learning about and working with this community.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-025-08235-y.

Background

Transgender and nonbinary individuals report frequent negative health care experiences, including misgendering (using incorrect gender pronouns), invalidation (dismissal or denial of their gender identity), and pathologization (treating their identity as a medical disorder). Health care avoidance, identity concealment and seeking out providers that are matched in terms of gender minority status are some strategies they use to cope with negative experiences [1].

In Brazil, it is estimated that 0.69% of the population identifies as transgender and 1.19% as non-binary, although this figure may be underestimated worldwide [2]. Transgender individuals have unique health needs; however, a majority of the members in the medical community are not adequately trained to address those needs [3–5].

Health professional attitudes and knowledge gaps contribute to and exacerbate these health disparities. In Brazil, the curricular guidelines for medical programs make no mention of teaching about sexual and gender diversity, despite emphasizing the importance of developing cultural competence and recognizing social markers of difference. This gap limits preparation for providing affirming care to transgender and gender diverse (TGD) individuals [6]. In Brazil, access to transgender healthcare is structured through a national health policy for LGBTQIA+ within the public health system. This framework provides a variety of gender-affirming care, including hormonal therapy, surgical procedures (such as genital and chest surgeries), and multidisciplinary support from a team of health professionals, in compliance with established clinical protocols. Awareness of this policy highlights the local relevance of preparing medical students to deliver competent care within the Brazilian healthcare system.

In Brazil, the curricular guidelines for medical programs make no mention of teaching about sexual and gender diversity. Still, they explicitly state the importance of developing cultural competence and recognizing social markers of difference during undergraduate studies, so that future professionals display an ethical and respectful attitude towards people from diverse social and cultural backgrounds. This regional context is reflected in a study from Chile, which revealed that most of the medical schools surveyed reported curricular spaces dedicated to teaching health issues of LGBTIQ+ individuals, primarily during the pre-internship training period [7]. However, the time allocated is insufficient, and attention to topics beyond sexual history or sexual orientation is limited, highlighting a regional need for more comprehensive education.

In addition to integrating transgender-specific content into the medical curriculum, clinical exposure through simulated clinical scenarios with standardized transgender patients could significantly improve medical students' attitudes and perception of general preparedness to provide care to TGD patients. This study aimed to develop a clinical simulation scenario and assess the perception and performance of medical undergraduates to practice cultural competences in health care for the TGD population, situating the research in the Brazilian medical education context.

Methods

This was a quantitative cross-sectional observational study that took place from June 2023 to March 2024 in two steps: (1) Diagnostic assessment and (2) Scenario construction and evaluation.

Step 1

To identify the learning needs, an anonymous online questionnaire [8] entitled "Competency for the health care of lesbians, gays, bisexuals, and transgender people" was sent to undergraduate medical students in their internship period. The survey focused specifically on participants’ own educational experiences with sexual and gender diversity, assessing their prior exposure and perceived preparedness in LGBTQIA+ healthcare topics. Additionally, sociodemographic questions were included in the same survey form. Participants were recruited from Brazilian medical schools through institutional dissemination via email and Instagram, using a snowball sampling strategy. Any undergraduate medical student in Brazil during the internship period was eligible to participate. For a 95% confidence level, a sample size of n = 96 was calculated. All the participants filled in a consent form.

Step 2

Based on the information obtained in Step 1, a clinical simulation scenario was developed. Clerkship medical students in their final two years of the medical program were invited to take part in the simulation training at the Assis Chateaubriand Maternity School, part of the Federal University of Ceará Hospital Complex, located in Fortaleza, Ceará, Brazil.

The scenario development group was made up of two physicians (one physician who works in a non- academic clinical setting with training in sexual health and counseling, and a university professor with expertise in health professions education) and one physician assistant were the main architects behind the simulation encounter case, as well as three medical undergraduates, two of whom were in their medical clerkship. The steps established for creating the scenario consisted of setting learning objectives and competencies assessed, an inventory of human and material resources, instructions for facilitators and division of tasks, support material, scenario context (briefing) and script for the patient-actors, teaching support tools and theoretical reference and checklist of objectives to be completed by a faculty observer (Neves & Pazin-Filho, 2018, provides an example of best practices for simulation case creation) [9].

A realistic clinical simulation scenario was designed to be low-complexity and low-technology, involving only standard gynecological outpatient equipment and straightforward procedures, making it feasible to implement in the educational setting. It portrayed a trans man not undergoing hormone therapy, presenting with secondary amenorrhea. He was in a stable relationship with a trans woman and was not using any contraceptive method. The simulation environment consisted of a gynecological outpatient consultation setup with two mirrored examination rooms. Two trans men were hired as actors through self-selection sampling and participated in the simulations after signing a consent form. Prior to data collection, a pilot simulation was conducted with a reduced number of participants (n = 4) to identify and address potential biases or distractors in the scenario that could compromise the validity of the results.

Before applying the scenario, the undergraduates were given a consent form. After the experience, they were asked to answer two scales: The first, a simplified "Simulated Clinical Experiences Satisfaction Scale” [10], with 6 statements and Likert-type answers, ranging from 1 (lowest level of satisfaction) to 10 (highest level of satisfaction). Certain items were excluded because they were not applicable to the context of this specific scenario, which focused on a single gynecological consultation with standardized transgender patients. Next, the validated survey "Competency for the health care of lesbians, gays, bisexuals, and transgender people" was administered in its original Portuguese version. After that, the participants were allocated to a conference room with a table and circular seating arrangements for the debriefing.

The data obtained from the questionnaires was categorized and analyzed in the Microsoft Excel program. Fisher's exact test, Pearson's chi-square test, and Mann–Whitney test were applied to compare sociodemographic variables with survey responses. Non-parametric tests were chosen due to the categorical or non-normally distributed nature of the data. Fisher's exact test was used for small sample sizes, chi-square for categorical comparisons, and Mann–Whitney for ordinal or non-normally distributed continuous variables. We followed the recommendations of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) protocol for reporting cross-sectional studies [11].

Results

A total of 104 undergraduate medical students participated in Step 1. The mean age was 24.7 years. Half of the students identified as white (50%) and 49% as black, with the majority being cis women (60%), 28% identifying as LGBTQIA+, including a subset of non-cisgender students. Most participants (82%) were enrolled in public universities, and 59% were in their first year of clerkship (Table 1).

Table 1.

Participants' answers to questions related to training content in the questionnaire "Competency for the health care of lesbians, gays, bisexuals, and transgender people" (n = 104)

Question	N	%	N	%
“Did your graduation program give you the opportunity to …?”	Yes		No
Formative contents: Gender identity
Differentiate gender identity from sex assigned at birth?	70	67.3	34	32.6
Understand what it means to be "travesti"?	35	33.6	69	66.3
Understand the concept of being transgender?	60	57.6	44	42.3
Search for literature on the subject of gender?	22	21.1	82	78.8
Discuss the health needs of travestis and transgender people?	45	43.2	59	56.7
Listen to a travesti and/or transgender person talk about their health needs?	22	21.1	82	78.8
Listen to a health professional talk about their experience of receiving and caring for travestis and transgender people?	55	52.8	49	47.1
Formative contents: Healthcare
Understand the barriers faced by the travesti and transgender population when seeking the public health system?	37	35.5	67	64.4
Understand how to reduce the major barriers faced by the lesbian, gay, bisexual, travesti and transgender population when seeking health services?	23	22.1	81	77.8
Learn about the right of travestis and transgender people to use their social name in health services?	72	69.2	32	30.7
Use the social name in the care of travestis and transgender people?	84	80.7	20	19.2
Identify practices of prejudice and discrimination against lesbian, gay, bisexual, travesti and transgender people in health services	49	47.1	55	52.8
Tackle prejudice and discrimination against lesbian, gay, bisexual, travesti and transgender people in health services?	38	36.5	66	63.4
Understand how to proceed when receiving lesbian, gay, bisexual, travesti or transgender people who have suffered some kind of violence (physical, psychological, verbal, institutional, intra-family, moral, property, sexual, symbolic or other) at the health service?	27	25.9	77	74
Understand the transsexualisation process offered by the public health system?	15	14.4	89	85.5
Understand how to proceed when receiving travestis and transgender people seeking bodily changes in public health services?	17	16.3	87	83.6
Formative contents: Public policies
To learn about the National Policy for the Integral Health of Lesbians, Gays, Bisexuals, Travestis and Transgender people?	11	10.5	93	89.4
Participate in experiences that address the goals of the National Policy for the Integral Health of Lesbians, Gays, Bisexuals, Travestis and Transgender people?	15	14.4	89	85.5
Explore public policies and initiatives at state and municipal level to promote the health of the lesbian, gay, bisexual, travesti and transgender population?	13	12.5	91	87.5

Source: Research data

Regarding gender identity topics, 32.6% of the participants said they had not had the opportunity to differentiate between gender identity and sex assigned at birth during their undergraduate studies and 30.7% had not been introduced to Brazil’s legal policy allowing and recognizing the use of a social name. Only 16.3% reported knowing how to provide appropriate gender-affirming medical care in the public health system, including clinical, referral or administrative steps. When the questions were aimed at understanding diverse sexual orientations, 37.5% said that they had previous opportunities to discuss the health demands of people with diverse sexual orientations. Finally, 10.5% were aware of the national health policy for sexual and gender minorities within the public health system (Table 1).

In the context of this study, it is important to clarify the term “travesti,” as it holds specific cultural and political significance in Latin America. In this research, “travesti” refers to a politicized Latin American gender identity that resists binary frameworks and is marked by feminine expression, body modifications, and collective activism, a form of political organization and survival rooted in community building, mutual care networks in the face of state neglect, and a public struggle for visibility, citizenship, and human rights against pervasive social and institutional violence [12].

Eighty-two point six percent (82.6%) of respondents believe that information such as gender identity and sexual orientation should be included in health service protocols, while 95.1% recognize the need to include the topic of the Integral Health of sexual and gender minorities in health undergraduate studies (Table 2).

Table 2.

Participants' answers to questions related to conceptions, from the questionnaire "Competency for the health care of lesbians, gays, bisexuals, and transgender people" (n = 104)

Question “Mark how you would answer the statements below using the options on the side.”	Agree		Don’t agree		NFO
	N	%	N	%	N	%
Concepts dimension: Individual
Travestis and transgender people are welcomed in the health service in the same manner as people who are not travestis or transgender people	8	7.6	87	83.6	9	8.6
An individual's sexual orientation has no influence on the care they receive in the health service	19	18.2	77	74	8	7.6
Concepts dimension: Community
The public health service must offer comprehensive and specialised care for body modifications in travestis and transgender people	89	85.5	7	6.7	8	7.6
Gender identity and sexual orientation must be included in the protocols for healthcare services	86	82.6	5	4.8	13	12.5
Gender identity and sexual orientation should not be taken into account when notifying violence and mortality among the population	6	5.7	93	89.4	5	4.8
Health services should promote events focussing on the health of lesbians, gays, bisexuals, travestis and transgender people	96	92.3	2	1.9	6	5.7
Concepts dimension: Systemic
The existence of a specific public health policy for lesbians, gays, bisexuals, travestis and transgender people is not important	6	5.7	91	87.5	7	6.7
Men's health policy should also address transgender men, as well as gay and bisexual men	94	90.3	5	4.8	5	4.8
Women's health policy should also include transgender women, travestis, lesbians and bisexuals	92	88	6	5.7	6	5.7
It is not necessary to include the topic of the Integral Health of Lesbians, Gays, Bisexuals, Travestis and Transgender people in undergraduate health programmes	4	3.8	99	95.1	1	0.9

NFO No formed opinion

Source: Research data

To guide the development of the simulation, the research team, including the three physicians and the medical students, analyzed the results of the Step 1 survey to identify common gaps in students’ educational experiences and areas of difficulty. These findings directly informed the learning objectives, case content, and focus areas of the clinical simulation scenario.

Students were invited to participate in the simulation at two distinct time points to ensure a smaller group size for the debriefing, allowing all participants to actively engage in the discussion. In December 2023, 21 undergraduate medical students were invited, 9 of whom agreed and took part in the first simulation. In January 2024, a second invitation targeted a different cohort of 25 students, 17 attended, and 16 participated. Overall, a total of 25 students took part in the proposed simulation.

The majority (92%) did not exhibit behavior reflecting value judgments, such as expressing disapproval verbally or through body language, or making stereotypical assumptions. 60% of the participants also found it difficult to provide advice on health promotion and prevention. This included uncertainty about how to address topics such as contraception options for trans men or routine screenings in gender-affirming care. They also reported difficulty conducting a sexual history (48%), and 80% were unable to correctly advise the patient on access routes and areas of assistance promoted by the public health system for TGD people (Table 3).

Table 3.

Results of the assessment of medical students' performance in the simulation, for each item on the checklist (n = 25)

Competence assessed	Achieved as expected		Partially achieved		Did not fulfil the objective
	N	%	N	%	N	%
Use the patient's social name and only their social name to refer to them (including corresponding pronouns)	14	56	11	44	0	0
Avoid prejudgment (don't show signs of surprise when realizing that the patient is trans and don't ask prejudiced questions)	23	92	2	8	0	0
Ask about sexual partnerships and practices	13	52	8	32	4	16
Make the interview sequential and concise	10	40	14	56	1	4
Suspect that the patient may be pregnant and request a pregnancy test	15	60	6	24	4	16
Understand and explain the hormonal therapy and surgeries offered by the public health system	5	20	13	52	7	28
Be welcoming, listen to the patient's complaints and provide guidance on health promotion and prevention	10	40	14	56	1	4

Source: Research data

The Simulated Clinical Experiences Satisfaction Scale used in this study is a validated instrument originally comprising 17 items. For the purposes of this study, it was simplified to 6 Likert-type items ranging from 1 (lowest satisfaction) to 10 (highest satisfaction) to better reflect the context of the simulation. This scale has been previously used to assess satisfaction with clinical simulation experiences, providing relevant feedback for educational interventions. The participants were satisfied with the proposed activity, especially with the realism and credibility of the scenario (Table 4).

Table 4.

Participants' satisfaction based on the simplified Simulated Clinical Experiences Satisfaction Scale (n = 25)

Question	Scale Mean (0–10)
Learning achieved	8.76
Satisfaction with scenarios’ level of difficulty	8.84
Satisfaction with debriefing	9.24
Link between scenarios and theory	9.08
Realism of the scenarios developed	9.52
Credibility during the scenario	9.44

Source: Research data

Complementing these quantitative findings, excerpts from the debriefing sessions highlighted critical educational gaps and opportunities. One student admitted, “everything I know so far was from social interaction, not from the medical school itself”, reflecting a lack of structured curricular content. Others emphasized the importance of respectful and inclusive communication, such as asking patients how they prefer to be addressed and what they expect from the consultation. The relevance of multidisciplinary care and understanding the technical nuances of transgender health was also raised: “I felt a lack of understanding of the technical aspects, like physiologic differences and specific protocols in care”. Moreover, students acknowledged structural barriers within the institution, stating that “we need to train our faculty to prevent homophobic and transphobic attitudes during medical training”. These reflections demonstrate a critical need for the integration of comprehensive, practical, and affirming transgender health content into medical education.

Key take-home messages identified during debriefing included recognition of the educational gap, appreciation of the opportunity to practice skills before real-life encounters, the importance of using the social name and corresponding pronouns, and understanding the access pathways within the public health system for TGD patients.

Discussion

The study demonstrates that realistic clinical simulation is an effective introductory educational activity for medical students with limited prior exposure to transgender and gender-diverse (TGD) healthcare.

A feasible, low-complexity, low-tech scenario was devised in this study, consisting of the situation of a trans man reporting secondary amenorrhea. Two actors who were trans men were hired to take part, to optimize the veracity of the scenario. The participants were satisfied with the proposed activity, especially with the realism and credibility of the scenario. The aspect worst evaluated by the students was their performance in the activity.

Most of the students achieved the assessed competences as expected and avoided prejudgment during the consultation. However, some had difficulty using their social name and corresponding pronouns when referring to the simulated patient. There was a worse performance in the assessment regarding the explanation of hormone therapy and the surgeries offered by the public health system. Students reflected that much of their knowledge came from social interaction rather than structured medical training and emphasized the importance of inclusive communication, multidisciplinary care, and understanding technical aspects of TGD health. The simulation scenario was well received by participants, who highlighted the realism and credibility of the case, despite facing challenges due to limited prior education.

In our study, students were able to identify specific gaps in their own training, particularly regarding communication skills, assumptions, and knowledge about gender identity and gender-affirming care. This self-awareness is critical, as a lack of formal education on LGBTQIA+ health is a widespread issue. For instance, Arthur (2021) [13] observed that 69% of medical undergraduates did not receive specific training aimed at LGBTQIA+ health demands, and a 2015 survey showed that only a few US faculty had comprehensive LGBT-competency training, despite their interest in addressing these issues [14]. This phenomenon of inadequate training can negatively influence the care provided to this population. Thus, recognizing their own knowledge deficits can make students more receptive to seeking and/or receiving education related to the matter, considering that the contents that permeate the study of human sexuality still carry taboos and have a tenuous mention in the curricula of undergraduate medical courses. It is noteworthy that current transgender medical education is largely composed of one-time, awareness-based interventions. While these show significant short-term improvements, they often suffer methodologically from a lack of long-term assessment, emphasis on clinical skills, or evaluation of patient outcomes [15].

These findings align with prior studies reporting limited curricular coverage of TGD health in medical training, reinforcing the need for structured educational interventions. White et al. (2015) [6] found that a median of 5 h was dedicated to teaching content related to LGBT health and 33% of medical schools reported 0 h of LGBT-related content being taught during clinical years of medical schools. In addition, fewer than 35% provided content related to hormone therapy and gender-confirming surgery. Within the scope of medical residency, the perception of OB/GYN residents regarding their training experiences in caring for TGD is no different, with lack of clinical and surgical training, despite their interest in further learning in this field [16].

The study highlights critical gaps in communication skills, clinical preparedness, and knowledge about gender-affirming care among students. Many TGD do not seek needed health care as a result of experiences with discrimination. Gaps regarding TGD’s health and health care needs include contraceptive method preferences, the influence of gender-affirming hormone use on fertility, desires for and experiences with pregnancy, and a range of other sexual and reproductive health outcomes [17–19].

This study demonstrates that structured clinical simulations using TGD actors can improve students’ comfort, skills, and awareness of healthcare gaps. Evidence suggests that clinical exposure to transgender medicine during clinical years can improve access to care for TGD individuals [20].

In this study, students repeatedly reported feelings of confusion and a delay in clinical reasoning when they realized that they were dealing with a trans patient. Similar reports were made by White (2015) [6], where participants admitted to feeling uncomfortable due to their lack of knowledge of specific terminology. At the same time as the students recognized being transgender as a marker of vulnerability, they highlighted the importance of health promotion measures aimed at the specificities of TGD people.

As well as being aware of the existence of specialized services for TGD people, the participants showed a humble attitude during the simulation by admitting their lack of knowledge about referral routes in the public health service. At the end of the debriefing, the participants emphasized the need to train teaching staff and incorporate the subject into the curriculum focusing on the development of skills and attitudes. In a previous pilot study, most undergraduate medical students felt that they had not received adequate training in TGD care topics, despite 9 out of 10 believing that they would care for TGD patients in the future [11].

Undergraduates who have received instruction on the health of TGD people as part of the curriculum seem to feel more comfortable and confident caring for this population [14]. Likewise, the use of clinical simulation with scenarios involving specific health issues of people with sexual and gender diversity allows students to get in touch with demands and realities that are seldom explored in undergraduate courses, fostering critical thinking and driving the search for new knowledge [7]. Hiring TGD actors to play the role of the patient also seems to be an asset, since their perception can be enriching in the student's feedback [21, 22].

Some authors have identified best practices to make gender-affirming care the norm for patients of all genders. They offered comprehensive clinical guidance for managing clinical encounters with patients of all genders, such as recommending the use of the same intake form for all patients, systematically allowing patients to indicate how they wish to be approached, presenting the topic of pregnancy and family formation in a neutral way and collecting the sexual history of all patients [17, 23]. Finally, almost all of the participants recognize the need to include topics about gender minorities health care in health graduation courses. Developing a competent workforce of healthcare providers equipped to care for TGD patients requires specific curricula on transgender health.

The study team included members of the LGBTQIA+ community, which we recognize as essential in research addressing the health of marginalized populations. One of the authors identifies as a lesbian, and one of the undergraduate medical students involved in the project design identifies as a gay man. Although no team members identified as transgender, we made efforts to include trans perspectives through literature review, consultation of community-informed materials, and the participation of trans men actors in the simulation. We acknowledge that the absence of trans individuals in the research team may have limited certain dimensions of the study and emphasize the importance of including trans voices and leadership in future research. Other limitations include the fact that the population surveyed in Step 1 was not the same as the cohort that participated in the simulated scenario in Step 2. The Step 2 cohort was a smaller group of OB/GYN clerkship students, which limits the direct comparability of the findings between steps. Additionally, although data on participant LGBTQ+ identity were collected, this factor remains a potential confounder in the analysis of activity performance, as individuals from the community may have different baseline competencies. These limitations highlight the importance of including trans voices and leadership in future research, as well as conducting similar studies across diverse settings to assess reproducibility and generalizability.

Overall, the study confirms that integrating TGD-specific simulation into undergraduate medical curricula can foster skill development, inclusive attitudes, and awareness of systemic barriers, representing an effective strategy for preparing future healthcare providers.

Conclusions

Given the crucial role of medical schools in shaping the knowledge, attitudes, and professional competencies of future physicians, they must adopt both local and national strategies to enrich training focused on the care of LGBTIQ + patients. This study demonstrates that TGD-specific clinical simulations can effectively expose students to common educational gaps, foster inclusive attitudes, improve practical skills, and raise awareness of systemic barriers. Educational interventions with emphasis on clinical skills to meet the needs of sexual minorities will create a curriculum that addresses not only knowledge, but also attitudes and skills, thus reducing the health inequalities faced by the transgender community. Medical educators have a responsibility to ensure trainees master the clinical competencies required to provide high-quality, affirming care, and future research should explore the long-term impact of such interventions.

Abbreviations

LGBTQIA₊

Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual and Other Identities

OB/GYN

Obstetrics/gynecology

SP

Standardized patients

STROBE

Strengthening the Reporting of Observational Studies in Epidemiology

TGD

Transgender and gender diverse

Authors’ contributions

L.N.E.S and R.A.C.P. were responsible for creating the project, writing the main manuscript and acquiring funding. L.N.E.S and A.M.S. were responsible for the conception; R.A.C.P revised the work. R.A.C.P and D.F.B. designed the research methods and were responsible for the analysis; L.F.M. and J.P.V.L. were in charge of interpretation of data; A.M.S. drafted the work; All authors approved the submitted version (and any substantially modified version that involves the author's contribution to the study) and agreed to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.

Funding

This study received funding from the Brazilian Association of Medical Education (ABEM). ABEM's financial support was fundamental to the execution of this project, enabling data collection and dissemination of the results. ABEM had no influence on the design of the study, the collection, analysis and interpretation of the data, or the writing of the manuscript.

Data availability

The datasets generated and or analysed during the current study are not publicly available due to containing personal and sensitive information related to the participants' gender identity and sexual orientation but are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study was approved by Assis Chateaubriand Maternity School Research Ethics Committee under CAAE 69064723.1.0000.5050. All procedures involving human participants were conducted in accordance with the ethical standards of the institutional Research Committee and with the principles of the Declaration of Helsinki (1964) and its subsequent amendments. Written informed consent was obtained from all participants prior to their inclusion in the study.

Consent for publication

Not applicabe.

Competing interests

The authors declare no competing interests.