Abstracts

Introduction

In 2011, Brazil instituted the National Policy for Comprehensive LGBT Health (PNSI-LGBT) ¹1. Ministério da Saúde. Portaria nº 2.836, de 1º de dezembro de 2011. Institui, no âmbito do Sistema Único de Saúde (SUS), a Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais, Travestis e Transexuais (Política Nacional de Saúde Integral LGBT). Diário Oficial da União 2011; 2 dec.. According to the policy, there is a need for a further guarantee of health access, vigilance, and adequate training of health professionals to offer the appropriate services to the lesbian, gay, bisexual, transgender, and related identities (LGBT+) population. However, homophobic practices ²2. Reis T. Manual de comunicação LGBTI+. Curitiba: Aliança Nacional LGBTI/GayLatino; 2018. are still present among health professionals in various contexts, including the use of the derogatory terms toward members of this group and the disrespect of the social name ³3. Rocon PC, Sodré F, Zamboni J, Rodrigues A, Roseiro MCFB. O que esperam pessoas trans do Sistema Único de Saúde? Interface (Botucatu) 2018; 22:42-53..

The health needs of the LGBT+ population differ from those of heterosexual individuals due to particular characteristics of its members, as well as due to considerable levels of stress experienced by LGBT+ individuals for constituting a minority (minority stress). They are subject to face normlessness and lack of social control since the dominant culture, social structures, and norms do not typically reflect those of the minority group ⁴4. Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull 2003; 129:674-97.^,55. Flentje A, Heck NC, Brennan JM, Meyer IH. The relationship between minority stress and biological outcomes: a systematic review. J Behav Med 2020; 43:673-94.. A meta-analysis showed that the LGBT+ population has a higher probability of suicide ⁶6. Haas AP, Lane A. Collecting sexual orientation and gender identity data in suicide and other violent deaths: a step towards identifying and addressing LGBT mortality disparities. LGBT Health 2015; 2:84-7. and worse health-related behaviors ⁷7. Jackson CL, Agénor M, Johnson DA, Austin SB, Kawachi I. Sexual orientation identity disparities in health behaviors, outcomes, and services use among men and women in the United States: a cross-sectional study. BMC Public Health 2016; 16:807. than heterosexual individuals. Social interaction is crucial for the development of a sense of well-being, such as receiving formal and informal social support from a primary health care provider and relatives ⁸8. Albuquerque MRCT, Botelho MN, Rodrigues C. Atenção integral à saúde da população LGBT: experiência de educação em saúde com agentes comunitários na atenção básica. Rev Bras Med Fam Comunidade 2019; 14:1758.^,99. Loria GB, Canesin GMF, Silva GM, Amorim GHO, Melo JM, Santos LR, et al. Saúde da população LGBT+ no contexto da atenção primária em saúde: relato de oficina realizada no internato integrado de Medicina de Família e Comunidade/Saúde Mental em uma universidade pública. Rev Bras Med Fam Comunidade 2019; 14:1807.^,1010. Lima AM, Nascimento RT, Cazelli C. Atributos da atenção primária à saúde e ferramentas de medicina de família no atendimento às diversidades sexual e de gênero: relato de caso. Rev Bras Med Fam Comunidade 2019; 14:1785.^,1111. Nichols TR. Social connectivity in those 24 months or less postsurgery. J Wound Ostomy Continence Nurs 2011; 38:63-8.. In the case of the LGBT+ population, formal support is improved by properly training the health team regarding LGBT+ topics ¹²12. Ross MH, Setchell J. People who identify as LGBTIQ+ can experience assumptions, discomfort, some discrimination, and a lack of knowledge while attending physiotherapy: a survey. J Physiother 2019; 65:99-105.^,1313. Lampalzer U, Behrendt P, Dekker A, Briken P, Nieder TO. The needs of LGBTI people regarding health care structures, prevention measures and diagnostic and treatment procedures: a qualitative study in a German metropolis. Int J Environ Res Public Health 2019; 16:3547..

Several authors highlight the challenge for health professionals in providing health care to the LGBT+ population due to transversal health practices instead of longitudinal ones ¹⁴14. Mello L, Avelar RB, Maroja D. Por onde andam as políticas públicas para a população LGBT no Brasil. Sociedade e Estado 2012; 27:289-312.. For example, in Brazil, all community health workers from one area of Rio de Janeiro reported that they had provided services to at least one LGBT+ person. However, 19.2% of them had identified prejudice and delays in services as barriers to adequate health services ¹⁵15. Souza M, Pinho A, Graever L, Pereira AR, Santana AMS, Pesqueno Junior CJP, et al. Access of the LGBTQI+ population from the perspective of community health agents, Brazil. Eur J Public Health 2020; 30 Suppl 5:ckaa166.770., demonstrating a lack of continuity of care ³3. Rocon PC, Sodré F, Zamboni J, Rodrigues A, Roseiro MCFB. O que esperam pessoas trans do Sistema Único de Saúde? Interface (Botucatu) 2018; 22:42-53.. This absence of continuity has increased the interest in identifying the broader sociocultural determinants related to vulnerabilities, stressful events, needs, and care management of the LGBT+ population, as well as the role of social networks in coping with the issues previously mentioned ¹⁶16. Valentine SE, Shipherd JC. A systematic review of social stress and mental health among transgender and gender non-conforming people in the United States. Clin Psychol Rev 2018. 66:24-38.. In this context, three aspects should be considered to achieve comprehensiveness in health care: the health professionals’ practice, the organization of health services, and policymaking ¹⁷17. Costa AM. Integralidade na atenção e no cuidado a saúde. Saúde Soc 2004; 13:5-15..

During the COVID-19 pandemic, stay-at-home practices have been increasingly encouraged. In Brazil, in March 20, 2020, the Ministry of Health officially announced the modes of transmission of the virus throughout the community and implemented initial social distancing strategies ¹⁸18. Ministério da Saúde. Portaria nº 454, de 20 de Março de 2020. Declara, em todo o território nacional, o estado de transmissão comunitária do coronavírus (covid-19). Diário Oficial da União 2020; 20 mar.. Since then, several historic and structural vulnerabilities related to social inequalities in Brazil ¹⁹19. Rocha R, Atun R, Massuda A, Rache B, Spinola P, Nunes L, et al. Effect of socioeconomic inequalities and vulnerabilities on health-system preparedness and response to COVID-19 in Brazil: a comprehensive analysis. Lancet Glob Health 2021; 9:E782-92. have emerged. Consequently, it is important to emphasize the significance of identifying the health issues and needs of the LGBT+, especially during this period, where numerous individuals have been struggling to cope with the crisis financially, mentally, or physically ²⁰20. Sears B, Conron KJ, Flores AR. The impact of the fall 2020 COVID-19 surge on LGBT adults in the US. https://williamsinstitute.law.ucla.edu/publications/covid-surge-lgbt/ (accessed on 30/Apr/2021).
https://williamsinstitute.law.ucla.edu/p... . The domestic violence rate is rising rapidly ²¹21. Xue J, Chen J, Chen C, Hu R, Zhu T. The hidden pandemic of family violence during COVID-19: unsupervised learning of tweets. J Med Internet Res 2020; 22:e24361., along with difficulties in adhering to social distancing measures ²⁰20. Sears B, Conron KJ, Flores AR. The impact of the fall 2020 COVID-19 surge on LGBT adults in the US. https://williamsinstitute.law.ucla.edu/publications/covid-surge-lgbt/ (accessed on 30/Apr/2021).
https://williamsinstitute.law.ucla.edu/p... ^,2222. Gibb JK, DuBois LZ, Williams S, McKerracher L, Juster RP, Fields J. Sexual and gender minority health vulnerabilities during the COVID-19 health crisis. Am J Hum Biol 2020; 32:e23499., as well as adverse psychological distress ²³23. Salerno JP, Devadas J, Pease M, Nketia B, Fish JN. Sexual and gender minority stress amid the COVID-19 pandemic: implications for LGBTQ young persons' mental health and well-being. Public Health Rep 2020; 135:721-7.^,2424. Gonzales G, Loret de Mola E, Gavulic KA, McKay T, Purcell C. Mental health needs among lesbian, gay, bisexual, and transgender college students during the COVID-19 pandemic. J Adolesc Health 2020; 65:645-8., including increased loneliness, social isolation, and reduced social support ²⁵25. Moore SE, Wierenga KL, Prince DM, Gillani B, Mintz LJ. Disproportionate impact of the COVID-19 pandemic on perceived social support, mental health and somatic symptoms in sexual and gender minority populations. J Homosex 2021; 68:577-91.^,2626. Kneale D, Bécares L. The mental health and experiences of discrimination of LGBTQ+ people during the COVID-19 pandemic: initial findings from the Queerantine Study. medRxiv 2020; 4 aug. https://www.medrxiv.org/content/10.1101/2020.08.03.20167403v1.full. 27.
https://www.medrxiv.org/content/10.1101/... . Although similar outcomes were also seen in Brazil ²⁷27. #VoteLGBT. Diagnóstico LGBT+ na pandemia. Desafios da comunidade LGBT+ no contexto de isolamento social em enfrentamento à pandemia de coronavírus. https://static1.squarespace.com/static/5b310b91af2096e89a5bc1f5/t/5ef78351fb8ae15cc0e0b5a3/1593279420604/%5Bvote+lgbt+%2B+box1824%5D+diagnóstico+LGBT%2B+na+pandemia_completo.pdf (accessed on 20/Feb/2021).
https://static1.squarespace.com/static/5... ^,2828. Torres T, Hoagland B, Bezerra D, Garner A, Jalil E, Coelho L, et al. Impact of COVID-19 pandemic on sexual minority populations in Brazil: an analysis of social/racial disparities in maintaining social distancing and a description of sexual behavior. AIDS Behav 2020; [Epub ahead of print]., previous studies did not specifically focus on extensive health characteristics during the pandemic, such as sexuality, discrimination, and internal homophobia. Torres et al. ²⁸28. Torres T, Hoagland B, Bezerra D, Garner A, Jalil E, Coelho L, et al. Impact of COVID-19 pandemic on sexual minority populations in Brazil: an analysis of social/racial disparities in maintaining social distancing and a description of sexual behavior. AIDS Behav 2020; [Epub ahead of print]. focused on HIV testing, oral pre-exposure prophylaxis access, and sexual behavior, whereas #VoteLGBT study (2020) ²⁷27. #VoteLGBT. Diagnóstico LGBT+ na pandemia. Desafios da comunidade LGBT+ no contexto de isolamento social em enfrentamento à pandemia de coronavírus. https://static1.squarespace.com/static/5b310b91af2096e89a5bc1f5/t/5ef78351fb8ae15cc0e0b5a3/1593279420604/%5Bvote+lgbt+%2B+box1824%5D+diagnóstico+LGBT%2B+na+pandemia_completo.pdf (accessed on 20/Feb/2021).
https://static1.squarespace.com/static/5... focused on mental health impacts and family social networks without any valid instruments. Both studies were conducted during the initial months of the pandemic ²⁷27. #VoteLGBT. Diagnóstico LGBT+ na pandemia. Desafios da comunidade LGBT+ no contexto de isolamento social em enfrentamento à pandemia de coronavírus. https://static1.squarespace.com/static/5b310b91af2096e89a5bc1f5/t/5ef78351fb8ae15cc0e0b5a3/1593279420604/%5Bvote+lgbt+%2B+box1824%5D+diagnóstico+LGBT%2B+na+pandemia_completo.pdf (accessed on 20/Feb/2021).
https://static1.squarespace.com/static/5... ^,2828. Torres T, Hoagland B, Bezerra D, Garner A, Jalil E, Coelho L, et al. Impact of COVID-19 pandemic on sexual minority populations in Brazil: an analysis of social/racial disparities in maintaining social distancing and a description of sexual behavior. AIDS Behav 2020; [Epub ahead of print].. To the best of our knowledge, this is the first study conducted among LGBT+ Brazilians adopting a wider health conceptual framework (i.e., validated tools and measures), common to other epidemiological studies, allowing comparisons with other published research.

Considering these aspects, the aims of this study were: (1) to characterize the LGBT+ population in Brazil, their health care demands and behaviors, and possible barriers to health care access during the COVID-19 pandemic; and (2) to specify the characteristics of the COVID-19 pandemic in the context of the LGBT+ population in Brazil, including preventive behavior patterns and health consequences.

Methods

Study design

The Brazilian LGBT+ Health Survey is a population-based cross-sectional online study of LGBT+ individuals, aged 18 years or older, living in one of the five geographical regions of Brazil, namely Southeast, South, North, Northeast, and Central-West. The study was conducted between August 19 and November 30, 2020.

Sample

The study sample comprised all individuals who met the inclusion criteria and agreed to participate. No individual identification, such as name or date of birth, was collected to protect the identity of the respondents and achieve a higher rate of participation.

Considering that the LGBT+ individuals represent 3% of the total population in another country ¹²12. Ross MH, Setchell J. People who identify as LGBTIQ+ can experience assumptions, discomfort, some discrimination, and a lack of knowledge while attending physiotherapy: a survey. J Physiother 2019; 65:99-105., we expect to have a target LGBT+ population of nearly 4.7 million in Brazil. Considering the conservative prevalence of the main outcomes (50%, sample error = 5%), at a level of significance of 99%, we needed at least 664 respondents.

Initially, the survey link was shared on social media (i.e., Facebook, Instagram, and WhatsApp), the webpages of the researchers, and their students and friends using hashtags related to scientific research and LGBT+ topics, several webpages related to LGBT+ issues, and the webpage of a famous person in Brazil. The study was also advertised on the official websites of the participating universities, through face-to-face contact with students, and via radio and online press. Finally, we also contacted LGBT+ groups and associations and promulgated the study in some primary health care units ²⁹29. Justo LG, Severo AKS, Félix-Silva AV, Soares LS, Silva-Júnior FL, Pedrosa JIS. A territorialização na atenção básica: um relato de experiência na formação médica. Interface (Botucatu) 2017; 21:1345-54.. All individuals who accessed the questionnaire and agreed to participate were included, representing a convenience sample.

Inclusion criteria for potential respondents were as follows: identifying themselves as LGBT+, being 18 years old or above, living in Brazil, having Internet access to answer the questionnaire, and being able to understand the questions.

Measurements

The researchers and a consultant team, composed of students, primary health professionals, and LGBT+ individuals, constructed the questionnaire. Measurements included sociodemographic characteristics, health-related measures (i.e., diseases, behaviors, health care access, and experiences with health care ³⁰30. Oliveira M, Harzheim E, Riboldi J, Duncan B. PCATool-ADULT-BRAZIL: a reduced version. Rev Bras Med Fam Comunidade 2013; 8:256-63.); sexuality; 19-item Internalized Homophobia Scale³¹31. Lira AN, Morais NA. Validity evidences of the Internalized Homophobia Scale for Brazilian gays and lesbians. Psico USF 2019; 24:361-72., including the perception of internal stigma and social oppression; violence; 6-item Perceived Everyday Discrimination Questionnaire³²32. Smith J, Ryan L, Sonnega A, Weir D. Psychosocial and lifestyle questionnaire 2006-2016. https://hrs.isr.umich.edu/sites/default/files/biblio/HRS%202006-2016%20SAQ%20Documentation_07.06.17_0.pdf (accessed on 03/May/2021).
https://hrs.isr.umich.edu/sites/default/... , including being treated with less courtesy or respect, receiving poorer service at restaurants or stores, receiving poorer service from doctors or hospitals, people acting as if you were not clever, people acting as if they were afraid of you, and being threatened or harassed; 3-item UCLA Loneliness Scale³³33. Hughes ME, Waite LJ, Hawkley LC, Cacioppo JT. A short scale for measuring loneliness in large surveys: results from two population-based studies. Res Aging 2004; 26:655-72.; and social network.

Quality assurance and control

A small pilot study with three respondents of different ages (21, 35, and 54 years old) and genders (transgender male, cisgender male, and cisgender woman) was conducted to identify potential problems with the instruments and procedures. Based on their feedback, some terms were modified for better adequacy and understanding. For example, regarding gender-related questions, the item “I don’t know” was removed from the gender identity question and replaced with the word “Other”. We also added terms such as “sexual and romantic experiences” and “sex reassignment surgery” and included a brief definition of the gender identities included in the questionnaire (cisgender, transgender, transvestite, and non-binary). Moreover, the questions option “I do not agree” were changed to “I disagree”.

Two versions of the questionnaire were constructed using MEDQuest (http://medquest.medicina.ufmg.br) and Google Forms (https://docs.google.com/forms). Respondents from the pilot study voted on the most suitable version (i.e., in terms of layout, font size, and usability). Therefore, an online link to Google Forms was used to collect data (http://bit.ly/inqueritosaudeLGBT+). These respondents were invited to access the final version of the questionnaire and participate.

Study management

Two federal universities conducted the Brazilian LGBT+ Health Survey. The study’s steering committee included researchers from these institutions and other consultants in Rio de Janeiro, health professionals working in primary care units, and LGBT+ individuals.

Ethical approval

This study followed all ethical aspects required by scientific studies involving human beings. Since it was anonymous, informed consent was not taken. However, the researchers included a brief explanation of the research objectives and design, provided contact information of the researchers, and informed respondents about the risks and benefits of participating. Individuals who agreed to participate were included in the study. This study was approved by the Research Ethics Committee of the Minas Gerais Federal University (protocol CAAE 34123920.9.0000.5149).

Data comparability

We used data from the recent Brazilian National Health Survey (PNS, in Portuguese), conducted in 2019, to compare the health-selected indicators of our LGBT+ health survey respondents with those of participants from the national survey. PNS data and descriptive results are publically available at (https://www.ibge.gov.br/estatisticas/sociais/saude/9160-pesquisa-nacional-de-saude.html). However, some 2019 microdata was not available at the time, precluding us from an individual-level PNS analysis. The PNS is a nationally representative study of the general Brazilian population aged 18 years and above, conducted in a probabilistic private household sample from urban and rural areas. The sample size was calculated according to 53% of the primary unit sample of Brazil, totaling 17,261 participants. Additional information can be found in the pertinent literature ³⁴34. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde 2019. Conceitos e métodos. https://metadados.ibge.gov.br/consulta/estatisticos/operacoes-estatisticas/XN (accessed on 12/Jan/2021).
https://metadados.ibge.gov.br/consulta/e... .

Statistical analyses

We conducted descriptive analyses using proportions and the respective 95% confidence intervals (95%CI) and means and standard deviation (SD). Additionally, we used some health-selected aggregate data prevalence and the respective 95%CI to perform an initial comparison with the most recent representative data from Brazil, the PNS conducted in 2019. These analyses were conducted using Stata 14.0 SE (https://www.stata.com).

Results

Between August and November 2020, a total of 1,036 individuals agreed to participate. Of these, 60 respondents did not meet the inclusion criteria and were excluded: 44 cisgender females and 8 cisgender males who reported being heterosexual, and 8 individuals under the age of 18. The final sample comprised 976 respondents. Table 1 shows the selected characteristics of the respondents listed.

Most of the respondents were homosexual (72.1%), cisgender (41.5% female and 49.9% male), and white (60.1%). The mean age was 31.3 (± 11.5 years). Nearly 30% had post-graduate level education, and 27.1% were receiving government income support during the COVID-19 pandemic. Respondents were concentrated in the Southeast region (80.2%). Of these, 56.1% were from the State of Minas Gerais and 28.2% from the State of Rio de Janeiro. Regarding COVID-19 characteristics, 4.8% tested positive for COVID-19 and 61.5% reported full adherence to social distancing measures. Furthermore, 36% reported at least a weekly episode of discrimination, and the respondents’ mean internalized homophobia score were 22.3 (± 6.3), with higher proportional scores for the social oppression component than the internal stigma component.

Table 2 shows the comparison of health-selected indicators with those of the PNS. Overall, the LGBT+ population reported a higher prevalence of medical diagnosis of depression compared with the PNS participants (24.8% vs. 10.2%). Regarding lifestyle, most of the LGBT+ respondents reported weekly alcohol ingestion (82.7%), and 20.9% were smokers. Both alcohol ingestion and smoking behavior prevalence rates were higher among the LGBT+ respondents than PNS among participants (26.4% vs. 12.6%). Lastly, the LGBT+ respondents reported using reference health services less compared with the PNS participants (50.2% vs. 73.8%).

Discussion

The Brazilian LGBT+ Health Survey in this study provides data from a population that is neglected in most of the nationally representative studies in Brazil. The covered topics included an array of characteristics. Despite the concentration of respondents in the Southeast region and the significant number of highly educated individuals compared to a previous published national study ³⁵35. Kendall C, Kerr L, Mota RS, Guimarães MDC, Leal AF, Merchan-Hamann E, et al. The 12 city HIV surveillance survey among MSM in Brazil 2016 using respondent-driven sampling: a description of methods and RDS diagnostics. Rev Bras Epidemiol 2019; 22:e190004., we demonstrate that both weekly episodes of discrimination and depression prevalence among the LGBT+ population were high in Brazil. Regarding the perception of homophobia, a higher proportional score for social oppression was found compared to the internal stigma component score.

Our data emphasize mental health, discrimination, and social oppression as major concerns in the LGBT+ context ³⁶36. Wang Y, Hu Z, Peng K, Xin Y, Yang Y, Drescher J, et al. Discrimination against LGBT populations in China. Lancet Public Health 2019; 4:e440-1.^,3737. DeSouza ER, Wesselmann ED, Ispas D. Workplace discrimination against sexual minorities: subtle and not-so-subtle. Canadian Journal of Administrative Sciences 2017; 34:121-32.^,3838. Rees S, Crowe M, Harris S. The lesbian, gay, bisexual and transgender communities' mental health care needs and experiences of mental health services: an integrative review of qualitative studies. J Psychiatr Ment Health Nurs 2020; 28:578-89. and during the COVID-19 pandemic ²⁰20. Sears B, Conron KJ, Flores AR. The impact of the fall 2020 COVID-19 surge on LGBT adults in the US. https://williamsinstitute.law.ucla.edu/publications/covid-surge-lgbt/ (accessed on 30/Apr/2021).
https://williamsinstitute.law.ucla.edu/p... ^,2222. Gibb JK, DuBois LZ, Williams S, McKerracher L, Juster RP, Fields J. Sexual and gender minority health vulnerabilities during the COVID-19 health crisis. Am J Hum Biol 2020; 32:e23499.^,2323. Salerno JP, Devadas J, Pease M, Nketia B, Fish JN. Sexual and gender minority stress amid the COVID-19 pandemic: implications for LGBTQ young persons' mental health and well-being. Public Health Rep 2020; 135:721-7.^,2424. Gonzales G, Loret de Mola E, Gavulic KA, McKay T, Purcell C. Mental health needs among lesbian, gay, bisexual, and transgender college students during the COVID-19 pandemic. J Adolesc Health 2020; 65:645-8.^,2525. Moore SE, Wierenga KL, Prince DM, Gillani B, Mintz LJ. Disproportionate impact of the COVID-19 pandemic on perceived social support, mental health and somatic symptoms in sexual and gender minority populations. J Homosex 2021; 68:577-91.^,2828. Torres T, Hoagland B, Bezerra D, Garner A, Jalil E, Coelho L, et al. Impact of COVID-19 pandemic on sexual minority populations in Brazil: an analysis of social/racial disparities in maintaining social distancing and a description of sexual behavior. AIDS Behav 2020; [Epub ahead of print].. Even though the PNSI-LGBT was instituted in 2011 in Brazil, discrimination in health services is still a barrier to achieving better mental health ⁶6. Haas AP, Lane A. Collecting sexual orientation and gender identity data in suicide and other violent deaths: a step towards identifying and addressing LGBT mortality disparities. LGBT Health 2015; 2:84-7. and health-related behaviors ⁷7. Jackson CL, Agénor M, Johnson DA, Austin SB, Kawachi I. Sexual orientation identity disparities in health behaviors, outcomes, and services use among men and women in the United States: a cross-sectional study. BMC Public Health 2016; 16:807., and complete health care access ³3. Rocon PC, Sodré F, Zamboni J, Rodrigues A, Roseiro MCFB. O que esperam pessoas trans do Sistema Único de Saúde? Interface (Botucatu) 2018; 22:42-53. for LGBT+ individuals. The LGBT+ population is likely to suffer from minority stress ⁴4. Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull 2003; 129:674-97., including both distal stressors (i.e., prejudice or discrimination events or conditions) and proximal stressors (i.e., concealment of sexual orientation, and internalization of societal stigma), generating allostatic overload (i.e., negative health consequences due to chronic stress exposure) ⁵5. Flentje A, Heck NC, Brennan JM, Meyer IH. The relationship between minority stress and biological outcomes: a systematic review. J Behav Med 2020; 43:673-94.. Countries with higher levels of aggregate LGBT+ acceptance show better individual self-rated health and well-being ³⁹39. van der Star A, Branstrom R. Acceptance of sexual minorities, discrimination, social capital and health and well-being: a cross-European study among members of same-sex and opposite-sex couples. BMC Public Health 2015; 15:812.. In Brazil, higher social oppression related to homophobia explains the increased rate of both physical violence against the LGBT+ population ⁴⁰40. Pinto IV, Andrade SSA, Rodrigues LL, Santos MAS, Marinho MMA, Benício LA, et al. Profile of notification of violence against lesbian, gay, bisexual, transvestite and transsexual people recorded in the National Information System on Notifiable Diseases, Brazil, 2015-2017. Rev Bras Epidemiol 2020; 23 Suppl 1:e200006.SUPL.1. and suicidal ideation among its members ⁴¹41. Ramírez EGL, Delgado YK, Volpato RJ, Claudio JCM, Pinho PH, Vargas D. Suicidal ideation in gender and sexual minority students in the largest Brazilian university. Arch Psychiatr Nurs 2020; 34:467-71.. However, we cannot discard the possibility of overreporting discrimination in online surveys ⁴²42. Hirsch O, Löltgen K, Becker A. Comparing health survey data from Internet- and paper-based convenience samples of lesbian women in Germany. Sex Health 2014; 11:351-8..

One mechanism related to heightened stress during the COVID-19 pandemic, coupled with social distancing, loss of social support, and increased social media use, is the higher alcohol ⁴³43. Cerezo A, Ramirez A, O'Shaughnessy T, Sanchez A, Mattis S, Ross A. Understanding the power of social media during COVID-19: forming social norms for drinking among sexual minority gender expansive college women. J Homosex 2021; 68:560-76. and tobacco misuse reported by respondents during this time. After three months of social distancing measures, LGBT+ women’s social media postings related to alcohol use moved from only “associated with parties” to “socialization” and “dealing with COVID-19” ⁴³43. Cerezo A, Ramirez A, O'Shaughnessy T, Sanchez A, Mattis S, Ross A. Understanding the power of social media during COVID-19: forming social norms for drinking among sexual minority gender expansive college women. J Homosex 2021; 68:560-76.. In an online survey of alcohol and tobacco use in Brazil, LGBT+ respondents who reported alcohol and tobacco use before the COVID-19 pandemic, showed an increase in the consumption of these substances during the pandemic (29.7% vs. 49.4%) ²⁸28. Torres T, Hoagland B, Bezerra D, Garner A, Jalil E, Coelho L, et al. Impact of COVID-19 pandemic on sexual minority populations in Brazil: an analysis of social/racial disparities in maintaining social distancing and a description of sexual behavior. AIDS Behav 2020; [Epub ahead of print]., which partially explains the higher rate of their consumption in our sample, compared to that among the PNS participants.

Another mechanism to alleviate stress among LGBT+ individuals is the adequacy of interventions to protect the affected persons ¹⁶16. Valentine SE, Shipherd JC. A systematic review of social stress and mental health among transgender and gender non-conforming people in the United States. Clin Psychol Rev 2018. 66:24-38. and to generate more appropriate health care use ¹¹11. Nichols TR. Social connectivity in those 24 months or less postsurgery. J Wound Ostomy Continence Nurs 2011; 38:63-8.. However, we demonstrated that fewer LGBT+ individuals have been using a reference health service, probably due to difficulties in health care access during the pandemic ²⁸28. Torres T, Hoagland B, Bezerra D, Garner A, Jalil E, Coelho L, et al. Impact of COVID-19 pandemic on sexual minority populations in Brazil: an analysis of social/racial disparities in maintaining social distancing and a description of sexual behavior. AIDS Behav 2020; [Epub ahead of print]. or poor inclusivity approaches of health professionals ¹²12. Ross MH, Setchell J. People who identify as LGBTIQ+ can experience assumptions, discomfort, some discrimination, and a lack of knowledge while attending physiotherapy: a survey. J Physiother 2019; 65:99-105.^,4444. Moscheta MS, Souza LV, Santos MA. Health care provision in Brazil: a dialogue between health professionals and lesbian, gay, bisexual and transgender service users. J Health Psychol 2016; 21:369-78.. Therefore, knowledge of specific health demands of the LGBT+ population is the key ¹1. Ministério da Saúde. Portaria nº 2.836, de 1º de dezembro de 2011. Institui, no âmbito do Sistema Único de Saúde (SUS), a Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais, Travestis e Transexuais (Política Nacional de Saúde Integral LGBT). Diário Oficial da União 2011; 2 dec.^,4444. Moscheta MS, Souza LV, Santos MA. Health care provision in Brazil: a dialogue between health professionals and lesbian, gay, bisexual and transgender service users. J Health Psychol 2016; 21:369-78.^,4545. Lim FA, Brown DV, Kim SMJ. Addressing health care disparities in the lesbian, gay, bisexual, and transgender population: a review of best practices. Am J Nurs 2014; 114:24-34. to strengthening patient professional connectedness and promoting high-acceptance settings for sexual minorities. Our results might guide person-centered best practices in primary health care, such as creating welcoming conditions inclusive of LGBT+ patients, fostering an environment that supports and nurtures all patients and families; facilitating the disclosure of sexual orientation and gender identity, advancing effective communication; and promoting community involvement and advocacy ⁴⁵45. Lim FA, Brown DV, Kim SMJ. Addressing health care disparities in the lesbian, gay, bisexual, and transgender population: a review of best practices. Am J Nurs 2014; 114:24-34..

Regarding testing positive for COVID-19, we found a higher prevalence (4.8%) than previously reported by Torres et al. ²⁸28. Torres T, Hoagland B, Bezerra D, Garner A, Jalil E, Coelho L, et al. Impact of COVID-19 pandemic on sexual minority populations in Brazil: an analysis of social/racial disparities in maintaining social distancing and a description of sexual behavior. AIDS Behav 2020; [Epub ahead of print]. in a Brazilian LGBT+ sample (1.7%). However, Torres et al. conducted an online survey from April to May 2020, whereas our study was conducted from August to November 2020; therefore, the increased infection rate in our study was expected. In November 2020, the COVID-19 prevalence among the general Brazilian population accounted for nearly 3% (https://www.worldometers.info/coronavirus/country/brazil/, accessed on 03/May/2021), close to the prevalence found in our sample. Data from the United States did not find any difference in testing positive for COVID-19 between LGBT+ and non-LGBT+ individuals (10.3% vs. 8.6%) ²⁰20. Sears B, Conron KJ, Flores AR. The impact of the fall 2020 COVID-19 surge on LGBT adults in the US. https://williamsinstitute.law.ucla.edu/publications/covid-surge-lgbt/ (accessed on 30/Apr/2021).
https://williamsinstitute.law.ucla.edu/p... . Nevertheless, the LGBT+ population in Brazil ²⁸28. Torres T, Hoagland B, Bezerra D, Garner A, Jalil E, Coelho L, et al. Impact of COVID-19 pandemic on sexual minority populations in Brazil: an analysis of social/racial disparities in maintaining social distancing and a description of sexual behavior. AIDS Behav 2020; [Epub ahead of print]. and other countries ²⁰20. Sears B, Conron KJ, Flores AR. The impact of the fall 2020 COVID-19 surge on LGBT adults in the US. https://williamsinstitute.law.ucla.edu/publications/covid-surge-lgbt/ (accessed on 30/Apr/2021).
https://williamsinstitute.law.ucla.edu/p... ^,2222. Gibb JK, DuBois LZ, Williams S, McKerracher L, Juster RP, Fields J. Sexual and gender minority health vulnerabilities during the COVID-19 health crisis. Am J Hum Biol 2020; 32:e23499. reported difficulties in adhering to social distancing measures, mainly due to socioeconomic vulnerability ²⁸28. Torres T, Hoagland B, Bezerra D, Garner A, Jalil E, Coelho L, et al. Impact of COVID-19 pandemic on sexual minority populations in Brazil: an analysis of social/racial disparities in maintaining social distancing and a description of sexual behavior. AIDS Behav 2020; [Epub ahead of print]. and adverse psychological distress ²⁰20. Sears B, Conron KJ, Flores AR. The impact of the fall 2020 COVID-19 surge on LGBT adults in the US. https://williamsinstitute.law.ucla.edu/publications/covid-surge-lgbt/ (accessed on 30/Apr/2021).
https://williamsinstitute.law.ucla.edu/p... ^,2222. Gibb JK, DuBois LZ, Williams S, McKerracher L, Juster RP, Fields J. Sexual and gender minority health vulnerabilities during the COVID-19 health crisis. Am J Hum Biol 2020; 32:e23499.^,2323. Salerno JP, Devadas J, Pease M, Nketia B, Fish JN. Sexual and gender minority stress amid the COVID-19 pandemic: implications for LGBTQ young persons' mental health and well-being. Public Health Rep 2020; 135:721-7.^,2424. Gonzales G, Loret de Mola E, Gavulic KA, McKay T, Purcell C. Mental health needs among lesbian, gay, bisexual, and transgender college students during the COVID-19 pandemic. J Adolesc Health 2020; 65:645-8.^,2525. Moore SE, Wierenga KL, Prince DM, Gillani B, Mintz LJ. Disproportionate impact of the COVID-19 pandemic on perceived social support, mental health and somatic symptoms in sexual and gender minority populations. J Homosex 2021; 68:577-91.^,2828. Torres T, Hoagland B, Bezerra D, Garner A, Jalil E, Coelho L, et al. Impact of COVID-19 pandemic on sexual minority populations in Brazil: an analysis of social/racial disparities in maintaining social distancing and a description of sexual behavior. AIDS Behav 2020; [Epub ahead of print]..

Our study has limitations that must be acknowledged. First, the LGBT+ health survey was conducted online, decreasing the response rate, which is inherent to online surveys. Second, only respondents with Internet access were included. In Brazil, Internet access has not yet reached the whole population (79.1% of Brazilians had Internet access in 2018 ⁴⁶46. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional por Amostra de Domicílios Contínua. Acesso à Internet e à televisão e posse de telefone móvel celular para uso pessoal. https://biblioteca.ibge.gov.br/visualizacao/livros/liv101705_informativo.pdf (accessed on 12/Jan/2021).
https://biblioteca.ibge.gov.br/visualiza... ) and it is not available among the most vulnerable groups. Third, comparing data from a non-representative online sample with those from a representative household sample might introduce both selection and information bias, precluding us from further interpretation. However, considering the unavailability of nationally representative datasets and the difficulty in developing a nationally representative study of the LGBT+ population, this study might contribute to the beginning of an understanding of the health needs of its members and the obstacles they face when using health care services. Further online studies should consider weighting in their surveys, considering all Brazilian regions to achieve national representativeness and avoiding overrepresentation of some states, as we found in the case of Rio de Janeiro and Minas Gerais, the states with the highest number of respondents and where the participating universities were placed. Additionally, we encourage a face-to-face recruitment in different vulnerable settings, providing the appropriate material to access the questionnaire. Further, the strengths of this study include anonymous recruitment, which is considered at more effective way of increasing adherence in this population. Moreover, this is the first study in Brazil with a broad coverage of respondents from the five geographical regions of the country and questions regarding a wide range of health dimensions.

In conclusion, our data emphasize that mental health, discrimination, and social oppression are major concerns in the LGBT+ context and during the COVID-19 pandemic. Although a decade has passed since the institution of the PNSI-LGBT in Brazil and appropriate training of health professionals to offer services to the LGBT+ population is still needed. Knowledge of the specific health demands of this group might guide person-centered best practices in primary health care and promote sexual minority high-acceptance settings.

References

Publication Dates

History