Abstract

We conducted a socio-historical study covering the period 1979-2014 to explore the genesis of LGBT health policy in Bahia, Brazil, drawing on Pinell’s theoretical framework for the sociological analysis of public policy. To analyze the social space, we investigated the trajectories of the agents involved in policy formulation and the relations between these agents and the national social space and field of State power. The agents were predominantly from the scientific, human rights, sexual rights, feminism and AIDS fields, and had a high level of bureaucratic and militant capital, meaning they were well-versed in LGBT health issues. The historical conditions of possibility underlying the formulation of LGBT health policy included the formalization of the State Technical Committee on LGBT Health in 2014, in an effort to improve access to comprehensive health care for vulnerable groups; and the Bahia without Homophobia plan, which helped expand dialogue around with civil society and social movements and address the main criticisms of policy making.

Key words:
Sociogenesis; LGBT Movement; Comprehensive Health Policy; Medical Sociology; Equity in Health

Introduction

The genesis of LGBT health policy appears to be associated with the participation of social movements seeking to get this issue onto the government¹1 Green JN. Além do Carnaval: A homossexualidade masculina no Brasil do século XX. 3ª ed. São Paulo: Ed UNESP; 2022.^,22 Bezerra MVR, Moreno CA, Prado NMBL, Santos AM. Política de saúde LGBT e sua invisibilidade nas publicações em saúde coletiva. Saude Debate 2019; 43:8. and global agenda³3 Hawkes S, Buse K. Gender and global health: evidence, policy, and inconvenient truths. Lancet 2013; 381:1783-1787..

In Brazil, the LGBT movement emerged in the 1970s along with the student movement, feminist movements and counter-hegemonic and counterculture movements. Imbued with an anti-establishment and anti-authoritarian spirit, this movement sought to affirm multiple sexual orientations, engendering a discourse of cultural transformation and struggle for equality and democracy⁴4 Freitas CAM, Jesus NN, Carvalho VN, Kochergin CN, Santos AM, Prado NMBL. Os movimentos sociais e a gênese de uma política de saúde para a população LGBT+ no Brasil: reflexões à luz da análise sociológica em saúde. In: Santos AM, Carmo EM, Magno L, Prado NMBL, organizadores. População LGBT+: demandas e necessidades para a produção do cuidado: Salvador: EDUFBA; 2021. p. 137-177.^,55 Macrae E. A construção da igualdade - política e identidade homossexual no Brasil da "abertura". Salvador: EDUFBA; 2018.. Yet it was only in the 1980s that the trajectories of agents involved in the fight against violence, discrimination and the pathologization of homosexuals favored a convergence between the struggles of the LGBT community and the fight against HIV/AIDS⁶6 Brasil. Ministério da Saúde (MS). Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais, Travestis e Transexuais. Brasília: MS; 2013.. Although the efforts to control the HIV epidemic created greater visibility to the discussion of LGBT health, reservations have been aired about the stigmatizing nature of the association between AIDS and the social and health needs of LGBT people⁷7 Farah MFS. Gênero e políticas públicas. Rev Estud Fem 2004; 1(12):47-71..

The beginning of the 1990s saw a shift in the concentration of groups from the Southeast to the Northeast and a marked presence of activists who adopted a more pragmatic approach aimed at guaranteeing civil rights and fighting discrimination and violence against homosexuals⁸8 Facchini R. "Sopa de Letrinhas"? - Movimento homossexual e produção de identidades coletivas nos anos 90. Rio de Janeiro: Garamond; 2005.. These developments were important as they delineated the involvement of social movements in the state of Bahia; however, we were unable to find studies discussing the organization of the LGBT movement by groups of activists and NGOs and its participation in policy-making arenas. Existing research provides perspectives on the consolidation of the movement and the push for the recognition of citizenship. Studies by Camarotti⁹9 Camarotti R. A trajetória do movimento LGBT: a luta por reconhecimento e cidadania no contexto brasileiro e baiano [dissertação]. Salvador: Universidade Federal da Bahia; 2009. and Bezerra¹⁰10 Bezerra MVR. Barreiras estruturais e interdições dos corpos: desafios para implantação da política nacional de saúde integral LGBT na Bahia [dissertação]. Vitória da Conquista: Universidade Federal da Bahia; 2019., for example, address the trajectory of the LGBT movement in Bahia and its struggle for citizenship and social rights.

This article therefore describes the genesis of policies in the state of Bahia focusing on the health of lesbians, gays, bisexuals, transvestites and transsexuals (LGBT) as a social problem that requires a specific government response¹¹11 Vieira-da-Silva LM. Gênese Sócio-Histórica da Saúde Coletiva. In: Lima NT, Santana JP, Paiva CHA. Saúde coletiva: a Abrasco em 35 anos de história. Rio de Janeiro: Ed. Fiocruz; 2015. p. 25-48.^,1212 Vieira-da-Silva LM, Pinell P. The genesis of collective health in Brazil. Sociol Health Illness 2014; 36(3):432-446.. It does so to gain insight into realized and exclude possibilities, considering that initial disputes and potential alternatives tend to be forgotten during the policy institutionalization process¹¹11 Vieira-da-Silva LM. Gênese Sócio-Histórica da Saúde Coletiva. In: Lima NT, Santana JP, Paiva CHA. Saúde coletiva: a Abrasco em 35 anos de história. Rio de Janeiro: Ed. Fiocruz; 2015. p. 25-48.^,1313 Bourdieu P. Sur l'État - cours de collège de france: 1989-1992. Paris: Raisons D'agir: Seuil; 2012..

Methodology

Study design

We conducted a study of the genesis of LGBT health policy in the state of Bahia focusing on the period 1979-2014. This period encompasses key events in the configuration of LGBT health policy in Bahia, beginning in 1980 with the foundation of the Group Gay da Bahia (GGB) and culminating in the creation of the State Technical Committee on LGBT Health in 2014.

This study is part of a larger study titled “Implementation of the National Policy on Comprehensive Health Care for Lesbians, Gays, Bisexuals, Transvestites and Transsexuals (PNSI-LGBT) in the state of Bahia”, approved by the Research Ethics Committee of the Multidisciplinary Health Institute, Federal University of Bahia on 13 December 2018. The study was conducted in accordance with the ethical norms and standards for research involving human subjects set out in national health council Resolutions 466 and 510, and all participants signed an informed consent form.

Study location

The study was undertaken in six municipalities in Bahia: Feira de Santana, Ilhéus, Itabuna, Jequié, Salvador, and Vitória da Conquista. These municipalities were chosen based on the following criteria: 1. Municipalities that have groups who promote prominent discussions to influence the formulation of health policy; and 2. Municipalities located in different regions of Bahia, with the aim of obtaining a representative sample of the state.

Attempts were made to conduct interviews with other agents involved in LGBT movements in other municipalities; however, this was not possible due to lack of availability and/or interest in the study.

Study participants

Interviewees consisted of militants from LGBT groups and officials from the Bahia State Department of Health, categorized as policy-makers, key informants, LGBT activists/militants and bureaucrats, based on a preliminary analysis of the main normative and technical documents that make up the LGBT policy framework.

Data collection

We analyzed normative and technical documents related to LGBT health policies, documents provided by the interviewees that could help provide an understanding of the policy making process, and publications critically reflecting on the history of the policy-making process in the state of Bahia.

Semi-structured interviews were conducted with a total of 25 agents, comprising individuals who were currently working/had worked in state or municipal health departments, state government managers and coordinators, groups of agents from the bureaucratic field and agents from the militant field, such as representatives of LGBT movements in Bahia.

All interviews were administered by the lead researcher with the support of previously trained researchers from the Bahia Health Care Networks Observatory (OBRAS - CNPq). The interview guide was divided into the following sections: genesis of state policy; interviewees’ perceptions of the needs and demands of LGBT people; involvement/participation of professional bodies in the genesis/emergence of policy; and the interviewee’s life trajectory. Sample size was determined using the data saturation technique.

All interviews were recorded using a digital voice recorder and all participants signed an informed consent form.

Data analysis

For document analysis purposes, excerpts from the documents were synthesized in an electronic spreadsheet under the following categories: a) document identification code; b) full bibliographical citation; c) document source (name of the bibliographic database, site, etc.); d) type of document (article, book chapter, technical document, position paper, media news); e) summary of main results; and f) preliminary assessment of the relevance of the document to the study objectives. All duplicate documents were excluded before completing the spreadsheet.

The interviews were transcribed in full and the collected empirical material was read systematically and organized into a summary table.

The document analysis and interviews were triangulated to gain insights into the timeline of events that culminated in the formulation of policy. The triangulation of the data sources allowed us to collate the data, ensuring the consistency of the collected evidence. The content of the interviews was also used to create a network of relations between the agents involved in the genesis of the policy.

For the purposes of this article, we adopt the concept of public policy as a course of action or omission of the state in response to a given health problem¹⁴14 Paim JS. Políticas de saúde no Brasil: epidemiologia e saúde. In: Roquayrol MZ, Almeida Filho N. Epidemiologia & Saúde. Rio de Janeiro: MEDSI; 2003. p. 587-603. and the perspective presented by Pinell¹⁵15 Pinell P. Análise sociológica das políticas de saúde. Rio de Janeiro: Ed. Fiocruz; 2010. for the sociological analysis of public policies based on theoretical elements of Bourdieu’s reflective sociology¹³13 Bourdieu P. Sur l'État - cours de collège de france: 1989-1992. Paris: Raisons D'agir: Seuil; 2012. (Chart 1).

The classification of agents into fields and social spaces was based on the composition of the different species of capital, drawing on studies by Vieira-da-Silva and Pinell¹²12 Vieira-da-Silva LM, Pinell P. The genesis of collective health in Brazil. Sociol Health Illness 2014; 36(3):432-446., Souza²⁴24 Souza JC. A gênese do programa de incentivo fiscal à alimentação do trabalhador (PIFAT/PAT) [tese]. Salvador: Instituto de Saúde Coletiva, Universidade Federal da Bahia; 2013. and Barros²⁵25 Barros SG. A política nacional de luta contra a aids e o espaço aids no Brasil [tese] Salvador: Universidade Federal da Bahia; 2013., and inspired by Bourdieu’s objectifications²⁶26 Bourdieu P. Espace social et genèse des classes. Actes Rech Sci Soci 1984; 52(1):52-53. in Homo academicus (Chart 2). We considered the following indicators: indicators of scientific capital - titles and publications in the area; indicators of symbolic capital - awards and recognition (notoriety) in the area; indicators of bureaucratic capital - positions occupied in the bureaucratic field and mobilized resources (here we draw on Bourdieu’s concept of field, which entails the identification of dispositions common to agents that constitute a habitus. These dispositions are acquired over the course of a trajectory, corresponding to successive positions occupied in the social space by the interviewee under specific historical conditions of possibility); indicators of political capital - political appointments and/or participation in political parties; indicators of militant capital - participation in unions and/or professional bodies, social movements and health movements; indicators of social capital - membership of one or more groups within the space, determined by relations between agents and other individuals and how these relations affect their choices and the positions they take. Symbolic capital was assessed only for group founders, referred to by the majority of interviewees as the leaders responsible for creating the social space in each location.

Based on the results of the interviews, we delineated the positions taken up by the agents and create a network of relations between the agents involved in the genesis of the PNSI-LGBT in the state. We created a sociogram representing the channels of influence between agents, common goals and affinities, as well as the groups and/or subgroups present in the space in which the emergence and genesis of the PNSI-LGBT took place. The sociogram was created using Gephi 0.9.2 (GNU General Public License v3) and the ForceAtlas2 layout (Figure 1).

Results and discussion

The identification of the historical conditions of possibility underlying the emergence of LGBT health policy in the state of Bahia permitted the, albeit partial, reconfiguration of the dynamics of the space, provided insights into the participation of agents from the bureaucratic and political fields and militant (associative) space and their relations, and allowed us to create a timeline of events culminating in the formalization of LGBT health policy. The analysis is structured around categories selected based on the assumptions of the sociological analysis of health policies proposed by Pinell¹⁵15 Pinell P. Análise sociológica das políticas de saúde. Rio de Janeiro: Ed. Fiocruz; 2010., considering the following contextual periods: 1) 1979-1999 - Need for problem-solving; 2) 2000-2008 - Social construction of the problem; 3) 2009-2011 - Social construction of proposals; 4) 2011-2014 - Recognition of the problem and formulation of actions and propositions.

1979-1990 - Need for problem-solving

The main LGBT rights and health agendas in the state of Bahia arose from the participation of various LGBT groups operating in the state that organized themselves between the end of the 1970s and 1990s. Examples include: Grupo Lésbico da Bahia (GLB), Grupo Gay da Bahia (GGB), Quimbanda Dudu - Grupo Gay Negro da Bahia and Associação das Travestis de Salvador (ATRAS), from Salvador; Grupo de Ação e Integração Homossexual (GAIH), from Feira de Santana; Humanus, from Itabuna, and EROS, from Ilhéus. These groups initially fought against discrimination and stigma and to promote prevention/protection in response to the incipient HIV/AIDS epidemic⁴4 Freitas CAM, Jesus NN, Carvalho VN, Kochergin CN, Santos AM, Prado NMBL. Os movimentos sociais e a gênese de uma política de saúde para a população LGBT+ no Brasil: reflexões à luz da análise sociológica em saúde. In: Santos AM, Carmo EM, Magno L, Prado NMBL, organizadores. População LGBT+: demandas e necessidades para a produção do cuidado: Salvador: EDUFBA; 2021. p. 137-177.^,99 Camarotti R. A trajetória do movimento LGBT: a luta por reconhecimento e cidadania no contexto brasileiro e baiano [dissertação]. Salvador: Universidade Federal da Bahia; 2009..

During the 1993-1996 administration, the Salvador City Council Health Department established connections with entities and NGOs from the municipality to develop infection control plans. However, health promotion actions still remained scarce²⁷27 Reis T. O movimento homossexual. In: Figueiró MND, organizadora. Homossexualidade e educação sexual: construindo o respeito à diversidade. Londrina: EdUEL; 2007. p. 101-102..

A key agent was Luiz Mott, one of the founders of the GGB²⁸28 Brasil. Ministério da Saúde (MS). Manual do Multiplicador - Homossexual. Brasília: MS; 1996.^,2929 Mott L. O imprescindível GGB, Grupo Gay da Bahia. In: Green JN, Caetano M, Fernandes M, Quinalha R, organizadores. História do movimento LGBT no Brasil. São Paulo: Alameda; 2018. p. 211-225., who played an important role in developing the infection control plans and bringing this proposal to Bahia. Sociologist and professor at the Federal University of Bahia, with a high level of scientific and militant capital, Mott transited through several organizations that he helped to build, including lesbian groups, ATRAS, Grupo Vida Feliz, made up of people with HIV/AIDS, and the black homosexual group Quimbanda Dudu⁹9 Camarotti R. A trajetória do movimento LGBT: a luta por reconhecimento e cidadania no contexto brasileiro e baiano [dissertação]. Salvador: Universidade Federal da Bahia; 2009.. He made a significant contribution to the initial strengthening of LGBT leader training at a time when the movement in Bahia faced major difficulties in training leaders due to the timid and “limited presence of the movement, and especially the GGB, in the university environment”⁹9 Camarotti R. A trajetória do movimento LGBT: a luta por reconhecimento e cidadania no contexto brasileiro e baiano [dissertação]. Salvador: Universidade Federal da Bahia; 2009.(p.90).

Years later, some of the theoretical elements developed by Mott were included in the final state policy proposal. Many agents mentioned having incorporated his theories into the proposal because they admired his work and trajectory or because they had a direct relationship with the researcher within the scientific field:

Another key militant leader at this time was Keyla Sympson, a transvestite who founded ATRAS and gained the recognition of the transvestite movement, despite having only recently moved to Salvador:

The main militant agents within the space of relations between agents, an associative environment that emerged between the 1980s and 1990s, were gay men’s groups, propelled mainly by the GGB and the development of transvestite leaders. However, these groups were still largely limited to the state capital, Salvador, and municipalities in or closer to the metropolitan region. The expansion of the LGBT movement to smaller towns and cities took place only at the end of the 1990s and beginning of the 2000s. In municipalities like Vitória da Conquista, militancy was still in its infancy in the 1980s, mainly due to discrimination and homophobia:

In view of the above and according to Pinell¹⁵15 Pinell P. Análise sociológica das políticas de saúde. Rio de Janeiro: Ed. Fiocruz; 2010., the need to create a policy to control the HIV epidemic and recognize LGBT rights in Bahia stemmed from the government’s acknowledgement of the ineffectiveness and inadequacy of public prevention, testing and health promotion campaigns, “as well as the need to organize the “associative environment” that was emerging at the time”.

2000-2008 - Social construction of the problem

The social construction of the problem in Bahia was driven by a range of agents from the militant, bureaucratic and scientific fields, who brought together concerns about the health needs of LGBT people in a variety of social spaces¹⁵15 Pinell P. Análise sociológica das políticas de saúde. Rio de Janeiro: Ed. Fiocruz; 2010.. There key milestones marked the social construction of the problem: 1. The “NGOization” of LGBT groups and AIDS prevention support groups (GAPAs); 2. The development of the “Projeto SOMOS” by the GGB and impetus for the interiorization of the LGBT movement in Bahia; and 3. The launch of the Brazil without Homophobia program by the federal government and local and state conferences preceding the 1^st National LGBT Conference.

The “NGOization” of LGBT groups and GAPAs

The end of the 1990s and beginning of the 2000s saw the “NGOization” of social movements. The most prominent LGBT organizations in Bahia were located in Itabuna, Ilhéus, Feira de Santana and Salvador³⁰30 Ramos S. O papel das ONGs na construção de políticas de saúde: a Aids, a saúde da mulher e a saúde mental. Cien Saude Colet 2004; 9(4):1067-1078.. It is important to underline that the legal constitution of LGBT NGOs and associations reinforced the positions occupied by these agencies (movements and institutions) with the aim of transforming power relations and the rules of the game in the interests of the groups¹³13 Bourdieu P. Sur l'État - cours de collège de france: 1989-1992. Paris: Raisons D'agir: Seuil; 2012.. In other words, through legally constituted NGOs, the movement was able to raise funds to develop their actions and participate in more wide-ranging spheres of discussion. Thus, NGOization was both a mode of political organization and way of getting funding:

This articulation brought the social movements and in vogue agendas closer together.

Development of the “Projeto SOMOS” by the GGB and impetus for the interiorization of the LGBT movement in Bahia

A second crucial moment for the social construction of the problem was the growing interiorization of the LGBT movement in Bahia, driven by the Projeto SOMOS led by the GGB. The project involved two phases. The first phase was implemented between 1999 and 2000 with the participation of groups such as ATRAS and GAIH. The second phase was undertaken between 2001 and 2002, with the participation of Humanus, EROS and, once again, ATRAS and GAIH, among others. The aim of the Project was to strengthen and promote the diffusion of LGBT groups in the areas where they operated⁴4 Freitas CAM, Jesus NN, Carvalho VN, Kochergin CN, Santos AM, Prado NMBL. Os movimentos sociais e a gênese de uma política de saúde para a população LGBT+ no Brasil: reflexões à luz da análise sociológica em saúde. In: Santos AM, Carmo EM, Magno L, Prado NMBL, organizadores. População LGBT+: demandas e necessidades para a produção do cuidado: Salvador: EDUFBA; 2021. p. 137-177.^,99 Camarotti R. A trajetória do movimento LGBT: a luta por reconhecimento e cidadania no contexto brasileiro e baiano [dissertação]. Salvador: Universidade Federal da Bahia; 2009.:

Actions were also proposed within bureaucratic and scientific spaces: by the Bahia State Department of Health (SESAB) - activities developed by the former regional health board (DIRES) focusing on the provision of broader and more comprehensive health care in inland areas of the state; and by universities and agents with high levels of scientific capital, including the promotion of educational events during the weeks leading up to the annual gay pride parade:

Publication of the Brazil without Homophobia program by the federal government and local and state conferences preceding the 1^st National LGBT Conference

The most prominent discussion for the formulation proposals for health actions began with the publication of the Brazil without Homophobia program in 2004, later reinforced by local and state LGBT conferences in 2008 in the run up to the 1^st National LGBT Conference³¹31 Conselho Nacional de Combate à Discriminação (CNCD). Brasil sem homofobia: programa de combate à violência e à discriminação contra GLBT e promoção da cidadania homossexual. Brasília: CNCD; 2004..

Brazil was the first country to hold a representative and institutional national conference addressing this theme³²32 Secretaria Especial dos Direitos Humanos (SEDH). Relatório da Conferência Nacional de Gays, Lésbicas, Bissexuais, Travestis e Transexuais - GLBT. Brasília: SEDH; 2008.. The federal government initiative drew the attention of a number of legislators, the Public Prosecutor’s Office and, particularly, LGBT activists. The conference was widely attended by the public and included activities to celebrate the 60th anniversary of the Universal Declaration of Human Rights³²32 Secretaria Especial dos Direitos Humanos (SEDH). Relatório da Conferência Nacional de Gays, Lésbicas, Bissexuais, Travestis e Transexuais - GLBT. Brasília: SEDH; 2008.^,3333 Freitas CAM, Carvalho VN, Jesus NN, Bezerra MVR, Santos AM, Kochergin CN, Prado NMBL. Health policies for the LGBT population, cultural competence, and the organization for access to services: A systematic review. Cad Genero Diversidade 2022; 8(2):127-164..

It is important to emphasize that the local conferences held before the national conference raised the specific concerns and identified the peculiarities of each municipality and each different segment of the LGBT community:

After the 1^st National LGBT Conference in 2008, the broader debate about LGBT health was further consolidated by criticism levelled by the movement at health actions. Groups adopted successive positions to press the government to include specific issues on the agenda of the health social space.

2009-2011 - Social construction of proposals

The findings show that the agents from the different fields (scientific, bureaucratic, and militant) put forward distinct yet often overlapping propositions (Chart 3). However, the creation of the LGBT Health Technical Area (ATS-LGBT) within SESAB in January 2013 led a convergence of proposals in tandem with the health equity movement, which encompasses different vulnerable populations, including LGBT people³⁴34 Santos A, Santana YV. Do texto ao contexto: por uma política de saúde para a população trans. In: Santos AM, Carmo EM, Magno L, Prado NMBL, organizadores. População LGBT+: demandas e necessidades para a produção do cuidado: Salvador: EDUFBA; 2021. p. 51-76..

The ATS-LGBT came into being because a SESAB staff member embraced the LGBT agenda. An agent from the bureaucratic field whose trajectory included working with sexual minorities, human rights, and LGBT health, she was willing to take on the debate about the health of this population in the social space of the SESAB:

As part of this movement, various agents from the state of Bahia got together to discuss the creation and implementation of LGBT policies, focusing on health. From their capital and trajectories, it is possible to observe which position each agent adopted and which place they occupied in the social space that was beginning to take shape. In this respect, the findings show that the strong presence of agents from the LGBT movement with a high level of militant and symbolic capital made a significant contribution to the consolidation of the network of relations and convergence of proposals.

Another important milestone was the creation of the State Committee for the Promotion of LGBT Citizenship and Human Rights in the Bahia State Department of Justice and Human Rights (SJDH), in 2010, in response to calls from the social movement.

These articulations can be seen in the sociogram in Figure 1, which shows the connections between agents and the groups and/or subgroups present in the space in which the emergence and genesis of the PNSI-LGBT took place. Figure 1 synthesizes the nodes and links overlaid on the territorial map of Bahia, showing the regional distribution of the groups, influenced by the agents and formation of social movements, particularly by the GGB and SOMOS project.

The GGB is represented by a single node in the center of the sociogram and has various lines linking it to groups in the municipalities included in this study. The primary articulation of the GBB and other groups gave rise to secondary articulations through other groups in their respective areas, strengthening the LGBT movement. The sociogram also highlights management institutions, including SESAB, municipal health departments, and municipal councils.

2011-2014 - Recognition of the problem and formulation of actions and propositions

The need for a comprehensive LGBT health policy in the state of Bahia was identified in the meetings promoted by the State Committee on LGBT Policy, made up of representatives of different state government departments: health, education, social development, promotion of equality, among others. The creation of the Committee resulted in the institutionalization of the demands of the LGBT population in Bahia³⁵35 Bezerra MVR, Magno L, Prado NMBL, Santos AM. Condições históricas para a emergência da Política Nacional de Saúde Integral LGBT no espaço social da saúde no estado da Bahia, Brasil. Cad Saude Publica 2021; 37(8):1-19.^,3636 Bezerra MVR, Magno L, Prado NMBL, Santos AM. Transposição de arquétipos morais ao espaço público e sua influência na implantação da PNSILGBT na Bahia. In: Santos AM, Carmo EM, Magno L, Prado NMBL, organizadores. População LGBT+: demandas e necessidades para a produção do cuidado: Salvador: EDUFBA; 2021. p. 207-228..

Committee meetings promoted by the SJDH were attended by agents from various segments of the LGBT community, health bureaucrats representing primary care and the STI and AIDS program, and the SESAB staff member who embraced the LGBT agenda. Despite the participation of agents from a range of fields with differing viewpoints, there were no objections to the proposal to create a technical area within SESAB. From this social space, a network of relations comprising agents from the militant, bureaucratic, and scientific fields was built that would culminate in the emergence of the LGBT health technical area social space:

The State Committee on LGBT Health was initially made up of representatives of SESAB’s Care Management Directorate and LGBT technical area (Antônio Purificação and Guida França), representatives of CUS, a LGBT student group from the Federal University of Bahia (for example Leandro Colling), a representative of gay members of the Fórum Baiano LGBT (Wesley Francisco), a representative of the transvestite community (Keyla Sympson), and representatives of the Superintendency for Health Surveillance and Protection (SUVISA) and Epidemiological Surveillance Directorate (DIVEP), among others.

The Committee meetings gave rise to the creation of the Bahia without Homophobia plan in 2011, inspired by the Brazil without Homophobia program, which, according to one of the interviewees, was the embryo for the genesis of LGBT health policy in Bahia:

And that’s when the LGBT health policy started to be discussed, because it was only in 2009, I’m talking ten years ago, that we started ten years ago, that we started to think that we needed a specific policy across the three levels of management to think about comprehensiveness in this population, which was distant from the unified health system, because it really was distant (E-07).

While symbolically demarcated with someone who was prepared to take on the LGBT agenda, the LGBT health technical area had yet to be formalized. It was only in 2013, two years after the creation of the PNSI-LGBT, that the agent formally became responsible for the technical area:

There is no evidence suggesting that scientific capital alone was a decisive factor in assigning agents a prominent position in the bureaucratic field. However, the combination of scientific capital with other types of capital enabled agents to reach higher positions, as was the case with the coordinator of the Gender Identity Clinic, Ailton Santos. The proposal for the clinic was born from his PhD thesis in 2014 after returning from Rio de Janeiro.

However, despite the creation of networks of relations, the process of formulating state policy proposals made slow progress, since it was bound to the SJDH:

Despite the absence of a formal policy on SESAB’s website, various legal and institutional apparatus, including the State Committee on LGBT Health, the Gender Identity Clinic, and SESAB’s LGBT technical area, constituted potential spaces for promoting the inclusion of LGBT people’s right to health³⁴34 Santos A, Santana YV. Do texto ao contexto: por uma política de saúde para a população trans. In: Santos AM, Carmo EM, Magno L, Prado NMBL, organizadores. População LGBT+: demandas e necessidades para a produção do cuidado: Salvador: EDUFBA; 2021. p. 51-76.:

Finally, it was possible to gain important insights into alliances between social groups with common interests, negotiations of and adjustments to LGBT health policies, and the dynamics of the social game, characterized by the clashes between the groups of agents interested in implementing the policy.

It is worth highlighting that the elements presented here provide important insights into the recent emergence and genesis of LGBT health policy in Bahia, which is still in the early stages of implementation and development, and indicate some new directions for future research.

Final considerations

Based on the synthesized evidence, this analysis of the sociogenesis of LGBT health policy in Bahia shows how organized social movements and institutions/agents in the state came together and how their articulation led to the proposal of actions to promote comprehensive health care for this segment of the population, despite the policy not being available on a website in the public domain. The failure to provide a transparent explanation of the official document illustrates Bourdieu’s claim that as history moves forward, the space of possibilities closes as decisions and choices are forgotten by the agents through the process of objectification of proposals and counterproposals that circulate during the policy formulation process¹³13 Bourdieu P. Sur l'État - cours de collège de france: 1989-1992. Paris: Raisons D'agir: Seuil; 2012..

It is worth reiterating that the study of policy genesis has the potential to reveal a diverse range of propositions, including those that did not prevail until the end of the process. In addition, the theoretical framework allowed us to elucidate the motivations and historical conditions of possibility underlying the creation of the LGBT Health Technical Area, representing the state government’s response to the need to enhance actions geared towards LGBT health.

Possible study limitations include the fact that it was not possible to conduct some interviews with suggested agents, which may have resulted in the absence of some details of the historical facts analyzed by the study. However, the fact we collated the data with information from other sources minimized potential information gaps.

Acknowledgements

We are grateful to the Ministério da Saúde, DIAHV, Secretaria de Vigilância em Saúde, and Conselho Nacional de Desenvolvimento Científico e Tecnológico for the funding awarded via the joint call for proposals CNPq/MS-DIAHV Nº 11/2018 - Core area 3 - Service Management Analysis (grant reference number 404011/2018-7). This study was also conducted with the support of the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) - Funding code 001. AM Santos is grateful to the CNPq for awarding a research output grant and senior postdoctoral fellowship (grant Nº 102139/2022-9). Finally, we would like to thank the study participants for their willingness to take part in the study and extreme helpfulness, and the members of the Bahia Health Care Networks Observatory (OBRAS) for their support in executing the study.

References

Publication Dates

History