A significant aspect observed during the evolution of the COVID-19 pandemic is the relationship between social vulnerability and higher prevalence and lethality of the virus ¹1. Fundação Oswaldo Cruz. Análise da frequência, incidência, mortalidade e letalidade por COVID-19 em favelas cariocas. Boletim Socioepidemiológio da COVID-19 nas Favelas 2020; (1). https://portal.fiocruz.br/sites/portal.fiocruz.br/files/documentos/boletim_socioepidemiologicos_covid_nas_favelas_1.pdf.
https://portal.fiocruz.br/sites/portal.f... . The contrasts of this mortality between the poorest and richest show how social inequalities directly affect the Brazilian population’s health and make certain social groups more vulnerable ¹1. Fundação Oswaldo Cruz. Análise da frequência, incidência, mortalidade e letalidade por COVID-19 em favelas cariocas. Boletim Socioepidemiológio da COVID-19 nas Favelas 2020; (1). https://portal.fiocruz.br/sites/portal.fiocruz.br/files/documentos/boletim_socioepidemiologicos_covid_nas_favelas_1.pdf.
https://portal.fiocruz.br/sites/portal.f... .

In addition to the damages to health already known, the pandemic can be considered a traumatic event and thus generate serious consequences for the mental health of the population as a whole, namely: insomnia, depression, fear and anger reactions, substance abuse, acute reactions to stress, and posttraumatic stress disorder ²2. Shigemura J, Ursano RJ, Morganstein JC, Kurosawa M, Benedek DM. Public responses to the novel 2019 coronavirus (2019-nCoV) in Japan: mental health consequences and target populations. Psychiatry Clin Neurosci 2020; 74:281-2.. Thus, the pandemic can be understood as a catalyst for mental illness, especially for the most vulnerable populations.

Sexual and gender minorities, i.e., lesbian, gay, bisexual, transvestite, transsexual and transgender, queers, intersex, asexual, and other (LGBTQIA+) have suffered, and still suffer, a serious process of social exclusion throughout the history of contemporary societies ³3. Oliveira FAG, Carvalho HR, Jesus JG. LGBTI+ em tempos de pandemia da Covid-19. Diversitates International Journal 2020; 12:60-94.. One of the consequences of this fact is the worsening of the mental health status of these groups.

Aspects such as low schooling level, low socioeconomic status, violence, and difficulties in accessing health services are closely related to social minorities and, at the same time, they have been considered risk factors for common mental disorders in the general population ⁴4. Patel V, Kleinman A. Poverty and common mental disorders in developing countries. Bull World Health Organ 2003; 81:609-15.^,55. Fundação Oswaldo Cruz. Saúde mental e atenção psicossocial na pandemia COVID-19: recomendações gerais. Rio de Janeiro: Fundação Oswaldo Cruz; 2020.. Furthermore, other risk factors for mental health are specific to these marginalized groups: prejudice (or LGBTQIA+phobia) ⁶6. King M, Semlyen J, Tai SS, Killaspy H, Osborn D, Popelyuk D, et al. A systematic review of mental disorder, suicide, and deliberate self harm in lesbian, gay and bisexual people. BMC Psychiatry 2008; 8:70., lack of institutionalized protection, family rejection, and bullying ⁷7. Shah R, Eshel N, McGlynn L. Lesbian, gay, bisexual, trasngender, and queer/questioning students. In: Roberts LW, editor. Student mental health: a guide for psychiatrists, psychologists, and leaders serving in higher education. Washington DC: American Psychiatric Association Publishing; 2018. p. 416-9.. This whole social conjuncture cooperates for the fragility and vulnerability of these minorities.

Therefore, national and international studies ⁸8. Di Giacomo E, Krausz M, Colmegna F, Aspesi F, Clerici M. Estimating the risk of attempted suicide among sexual minority youths. JAMA Pediatr 2018; 172:1145-52.^,99. Teixeira-Filho FS, Rondini CA. Suicide thoughts and attempts of suicide in adolescents with hetero and homoerotic sexual practices. Saúde Soc 2012; 21:651-67.^,1010. Remy LS, Scherer J, Guimarães L, Surratt HL, Kurtz SP, Pechansky F, et al. Anxiety and depression symptoms in Brazilian sexual minority ecstasy and LSD users. Trends Psychiatry Psychother 2017; 39:239-46.^,1111. OutRight Action International. Vulnerability amplified: the impact of the COVID-19 pandemic on LGBTIQ people. New York: OutRight Action International; 2020.^,1212. Carman M, Bourne A, Fairchild J. COVID-19 impacts for LGBTIQ communities and implications for services: a research briefing paper by Rainbow Health Victoria. Melbourne: Rainbow Health Victoria; 2020.^,1313. #VOTELGBT. Diagnóstico LGBT+ na pandemia. https://www.votelgbt.org/pesquisas (acessado em Set/2020).
https://www.votelgbt.org/pesquisas... ^,1414. Francisco LCF, Barros AC, Pacheco M, Nardi AE, Alves V. Anxiety in sexual and gender minorities: an integrative review. J Bras Psiquiatr 2020; 69:48-56. reveal that sexual and gender minorities - when compared to the non-LGBTQIA+ population - present higher prevalence of depression and anxiety, higher risk for suicide and they make a more intense use of psychoactive substances.

Pandemic, mental health and LGBTQIA+ populations

In a recent national survey ¹³13. #VOTELGBT. Diagnóstico LGBT+ na pandemia. https://www.votelgbt.org/pesquisas (acessado em Set/2020).
https://www.votelgbt.org/pesquisas... , conducted with about 9,000 participants, which aimed to investigate the greatest effects of the pandemic for the LGBTQIA+ population, 42.72% of respondents indicated mental health as the main effect experienced during this period, followed by “new rules of conviviality”, “loneliness”, “family life”, and “lack of employment and money”.

Among the reasons that make LGBTQIA+ more vulnerable at times like the current one, we can mention the high rates of violence to which they are subjected daily. Despite the lack of data, figures collected by the Institute for Applied Economic Research (IPEA) in the Atlas of Violence¹⁵15. Cerqueira D, Bueno S, Lima RS, Neme C, Ferreira H, Alves PP, et al. Atlas de violência 2019. Brasília/Rio de Janeiro/São Paulo: Instituto de Pesquisa Econômica Aplicada/Fórum Brasileiro de Segurança Pública; 2019. show a 127% increase in reports of LGBTQIA+ homicide in 2018 in Brazil. Moreover, one of the most important health measures recommended by health agencies has been social distancing that, in the case of LGBTQIA+, may mean remaining confined to potential aggressors, often their own families or intimate partners ¹¹11. OutRight Action International. Vulnerability amplified: the impact of the COVID-19 pandemic on LGBTIQ people. New York: OutRight Action International; 2020.^,1212. Carman M, Bourne A, Fairchild J. COVID-19 impacts for LGBTIQ communities and implications for services: a research briefing paper by Rainbow Health Victoria. Melbourne: Rainbow Health Victoria; 2020.^,1313. #VOTELGBT. Diagnóstico LGBT+ na pandemia. https://www.votelgbt.org/pesquisas (acessado em Set/2020).
https://www.votelgbt.org/pesquisas... ^,1616. Pinto IV, Andrade SSA, Rodrigues LL, Santos MAS, Marinho MMA, Benício LA, et al. Perfil das notificações de violências em lésbicas, gays, bissexuais, travestis e transexuais registradas no Sistema de Informação de Agravos de Notificação, Brasil, 2015 a 2017. Rev Bras Epidemiol 2020; 23 Suppl 1:e200006.supl.1..

The increase in domestic violence due to social distancing has been brought to the discussions ¹⁷17. Vieira PR, Garcia LP, Maciel ELN. The increase in domestic violence during the social isolation: what does it reveals? Rev Bras Epidemiol 2020; 23:e200033., but generally with an exclusive focus on heterosexual cisgender women. However, it is noteworthy that among the homicides by LGBTQIA+phobia in Brazil, the victim’s residence is the second place of highest occurrence of murders ¹⁸18. Mendes WG, Silva CMFP. Homicide of lesbians, gays, bisexuals, travestis, transexuals, and transgender people (LGBT) in Brazil: a spatial analysis. Ciênc Saúde Colet 2020; 25:1709-22., with transsexual, transgender, and transvestite people being preferred targets of this type of violence, followed by lesbians and then gay men ¹⁶16. Pinto IV, Andrade SSA, Rodrigues LL, Santos MAS, Marinho MMA, Benício LA, et al. Perfil das notificações de violências em lésbicas, gays, bissexuais, travestis e transexuais registradas no Sistema de Informação de Agravos de Notificação, Brasil, 2015 a 2017. Rev Bras Epidemiol 2020; 23 Suppl 1:e200006.supl.1..

Socioeconomic vulnerability is also a relevant aspect, permeating income and labor bonds. It is known that the pandemic has caused job losses and precarious employment ties - that were already fragile - which may aggravate the socioeconomic situation of these populations ¹¹11. OutRight Action International. Vulnerability amplified: the impact of the COVID-19 pandemic on LGBTIQ people. New York: OutRight Action International; 2020.^,1212. Carman M, Bourne A, Fairchild J. COVID-19 impacts for LGBTIQ communities and implications for services: a research briefing paper by Rainbow Health Victoria. Melbourne: Rainbow Health Victoria; 2020.. An North American study indicates that the largest portion of this population in the country is part of the informal market and also has occupations potentially more exposed to SARS-CoV-2, such as work in bars and restaurants, in addition to having lower income and lower conditions of access to health ¹⁹19. Whittington C, Hadfield K, Calderón C. The lives and livelihoods of many in the LGBTQ community are at risk amidst COVID-19 crisis. Washington DC: Human Right Campaign Foundation; 2020.. In Brazil, when considering only the populations of transgender, transsexual and transvestite, vulnerability is even greater given the specificities of these groups ¹²12. Carman M, Bourne A, Fairchild J. COVID-19 impacts for LGBTIQ communities and implications for services: a research briefing paper by Rainbow Health Victoria. Melbourne: Rainbow Health Victoria; 2020.. A study conducted with 672 transsexuals in the State of São Paulo revealed that, from 2014 to 2015, only 16.7% were in the formal market ²⁰20. Silva MA, Carla GL, Veras MASM. Work and health issues of the transgender population: factors associated with entering the labor market in the state of São Paulo, Brazil. Ciênc Saúde Colet 2020; 25:1723-34. and, still, many worked as sex workers ²¹21. Reidel M. A pedagogia do salto alto: histórias de professoras transexuais e travestis na educação brasileira [Dissertação de Mestrado]. Porto Alegre: Universidade Federal do Rio Grande do Sul; 2013.. Regarding the homosexual and bisexual population, an international systematic review ²²22. Ozeren E. Sexual orientation discrimination in the workplace: a systematic review of literature. Procedia Soc Behav Sci 2014; 109:1203-15. indicates that gay and bisexual men receive less than their heterosexual colleagues. Furthermore, the unemployment rate in this population, found by a survey ¹³13. #VOTELGBT. Diagnóstico LGBT+ na pandemia. https://www.votelgbt.org/pesquisas (acessado em Set/2020).
https://www.votelgbt.org/pesquisas... , is 21.6% in Brazil and, during the pandemic, 44.3% suffered a total shutdown of their activities.

Social life is another significant aspect placed on frailty for LGBTQIA+ during the pandemic. As they are sometimes rejected in the family nucleus, a significant mechanism of resistance and survival of these groups lies in the bond they establish with their communities, so that, considering the social distancing measures, these individuals experience a serious impact because of the impossibility of a more active and face-to-face contact with their affections and familiar places, which leads to an experience of isolation and loneliness ¹¹11. OutRight Action International. Vulnerability amplified: the impact of the COVID-19 pandemic on LGBTIQ people. New York: OutRight Action International; 2020.^,1212. Carman M, Bourne A, Fairchild J. COVID-19 impacts for LGBTIQ communities and implications for services: a research briefing paper by Rainbow Health Victoria. Melbourne: Rainbow Health Victoria; 2020.^,1313. #VOTELGBT. Diagnóstico LGBT+ na pandemia. https://www.votelgbt.org/pesquisas (acessado em Set/2020).
https://www.votelgbt.org/pesquisas... .

Considering so many aspects that compromise LGBTQIA+ individuals’ mental health, it is indispensable that the authorities define care strategies for this moment.

The Brazilian Ministry of Health - in its booklet on suicide in the COVID-19 pandemic ²³23. Fundação Oswaldo Cruz. Saúde mental e atenção psicossocial na pandemia de COVID-19: suicídio na pandemia de COVID-19. Rio de Janeiro: Fundação Oswaldo Cruz; 2020. - lists some warning factors that deserve special attention, among them: preexisting mental health disorders, with emphasis on depression and anxiety; use of alcohol and/or other drugs; lack of social support; existence of hostility in the family environment; and suffering and concerns about one’s own sexuality. In another booklet ²⁴24. Fundação Oswaldo Cruz. Saúde mental e atenção psicossocial na pandemia de COVID-19: recomendações para gestores. Rio de Janeiro: Fundação Oswaldo Cruz; 2020. that deals with recommendations for public administrators, the Brazilian Ministry of Health indicates that one of the points that should receive attention is the identification of vulnerable groups from the psychosocial point of view, and it highlights several recommendations that can be put in force by public administrators during the pandemic to ensure access to mental health in this population. However, it is clear that despite its significance, the existence of legal instruments, guidelines and regulations, it is not enough to assure the population’s access to their rights.

Often these groups are exposed to prejudice even in health services, which can lead to decreased demand and adherence to treatments ²⁵25. Baptiste-Roberts K, Oranuba E, Werts N, Edwards LV. Addressing health care disparities among sexual minorities. Obstet Gynecol Clin North Am 2017; 44:71-80.^,2626. Dahlhamer JM, Galinsky AM, Joestl SS, Ward BW. Barriers to health care among adults identifying as sexual minorities: a US national study. Am J Public Health 2016; 106:1116-22.. Thus, it is observed that the heteronormativity present in several care fields produces a devaluation or non-recognition of these identities, contributing to the perpetuation of violence and discrimination that affect the conditions of access and quality of health care ²⁷27. Ferreira BO, Bonan C. Opening the closets of access and quality: an integrative review on the health of lgbtt populations. Ciênc Saúde Colet 2020; 25:1765-78.. A study ²⁷27. Ferreira BO, Bonan C. Opening the closets of access and quality: an integrative review on the health of lgbtt populations. Ciênc Saúde Colet 2020; 25:1765-78. reports that the main difficulties in accessing health services for this public are related to the fear of suffering prejudices and the fear of revealing sexual orientation, thus, this information is often omitted in care.

In the Brazilian Unified National Health System (SUS), specialized mental health care is provided by the Psychosocial Care Network (RAPS), which is one of the main services provided in psychosocial care centers (CAPS). However, it must be emphasized that the RAPS faces significant obstacles, such as insufficient equipment in some Brazilian regions and municipalities ²⁹29. Gama CAP, Guimarães DA, Coelho VAA, Carvalho RC, Campos CG, Fraga AMS. A implantação da rede de atenção psicossocial na Região Ampliada de Saúde Oeste de Minas Gerais - BR. Cad Saúde Colet (Rio J.) 2020; 28:278-87., which leads to long waiting lines, and reference and counter-reference problems ³⁰30. Quinderé PHD, Jorge MSB, Franco TB. Rede de atenção psicossocial: qual o lugar da saúde mental? Physis (Rio J.) 2014; 24:253-71.. It is also noteworthy, considering the great percentage of discrimination suffered in health services, demonstrated in studies ³¹31. McClain Z, Thomas R, Yehia BR. Sociocultural and systemic barriers to health for gender and sexual minority populations. In: Smalley KB, Warren JC, Barefoot, Nikki K, editors. LGBT health: meeting the needs of gender and sexual minorities. New York: Springer; 2018. p. 16-8., the lack of qualification of health professionals to deal with the sufferings related to sexuality.

Considering these data, it is possible to say that the mental health of sexual and gender minorities lacks, not only specific attention in terms of emergency public health policies during the pandemic, but, above all, mobilization and concrete actions. However, this data attest a profound invisibility of the issue by the State and sometimes also by academia ³²32. Bezerra MV, Moreno CA, Prado NM, Santos AM. Política de saúde LGBT e sua invisibilidade nas publicações em saúde coletiva. Saúde Debate 2019; 43(n.spe 8):305-23., even during a time of extreme need. Moreover, it is urgent that such discussion reach social spaces and that the LGBTQIA+ population achieve more visibility. Also, that the current situation be a lesson for future moments.

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