Abstract

This study analyzes the stigmatizing potential of studies on the LGBTQIA+ population indexed on the PubMED database. By a broad and systematic bibliographic search, 821 publications were found and 334 (40.68%) were included in this study. From these, 1838 keywords were extracted. Data analysis showed that the keywords “men who have sex with man” (192 repetitions) and “HIV” (98 repetitions) had the highest prevalence. Thus, according to the analysis, the LGBTQIA+ population is essentially described as “men who have sex with other men” and “HIV positive.” This study unveils the presence of stigmatizing characteristics in studies on the LGBTQIA+ population. However, such findings can help strengthen the critical perspective of a more humanized scientific practice, actually concerned with the specificities and needs of the LGBTQIA+ population.

Keywords:
Sexual and Gender Minorities; Prejudice; Social Stigma; Scientific Publication Indicators; Subject Headings

Introduction

In 2013, the World Health Organization (WHO) and the Pan American Health Organization (PAHO) developed the Addressing the Causes of Disparities in Health Service Access and Utilization for Lesbian, Gay, Bisexual and Trans (LGBT) Persons document (WHO, 2013WHO - WORLD HEALTH ORGANIZATION. Addressing the causes of disparities in health service access and utilization for lesbian, gay, bisexual and trans (LGBT) persons. Washington, DC: World Health Organization, 2013.). It highlights the important work of the Americas in providing public policies aimed at the health needs of the vulnerable LGBTQIA+ population (Lesbian, Gay, Bisexual, Transvestite/Transsexual/Transgender, Queer/Non-binary, Intersex, Asexual people, +/Other gender and/or sexual orientations), showing that optimizing access to health care and improving the general indicators of these individuals is essential (WHO, 2013WHO - WORLD HEALTH ORGANIZATION. Addressing the causes of disparities in health service access and utilization for lesbian, gay, bisexual and trans (LGBT) persons. Washington, DC: World Health Organization, 2013.).

In Brazil, after intense struggles based on the fundamental principles of the Federal Constitution of 1988, the National Policy on Comprehensive Health of Lesbians, Gays, Bisexuals and Transsexuals (PNSI-LGBT) was implemented by Ordinance No. 2,836, of December 1, 2011 (Brasil, 2013BRASIL. Ministério da Saúde. Secretaria de Gestão Estratégica e Participativa. Departamento de Apoio à Gestão Participativa. Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais, Travestis e Transexuais. Brasília, DF: Ministério da Saúde, 2013.).

In general, among its guidelines and objectives, the PNSI-LGBT presents the topic of sexual and gender diversity in the daily work processes of the Brazilian National Health System (SUS) (Brasil, 2013BRASIL. Ministério da Saúde. Secretaria de Gestão Estratégica e Participativa. Departamento de Apoio à Gestão Participativa. Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais, Travestis e Transexuais. Brasília, DF: Ministério da Saúde, 2013.). It stands out the implementation of some advances, such as the inclusion of the fields “social name,” “sexual orientation,” and “gender identity” in the e-SUS individual registration form, as well as in the violence reporting form in the Notifiable Diseases Information System (SINAN) (Brasil, 2013BRASIL. Ministério da Saúde. Secretaria de Gestão Estratégica e Participativa. Departamento de Apoio à Gestão Participativa. Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais, Travestis e Transexuais. Brasília, DF: Ministério da Saúde, 2013.).

However, in order not to transform it into an instrument of weak effectiveness, assuring its application along with human resources in health that believe in, implement, and consolidate this policy by practices directed to the multiple realities of individuals is as or more important than the policy itself (Brasil, 2013BRASIL. Ministério da Saúde. Secretaria de Gestão Estratégica e Participativa. Departamento de Apoio à Gestão Participativa. Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais, Travestis e Transexuais. Brasília, DF: Ministério da Saúde, 2013.). A virtuous circle is the result of professionals properly trained and able to fully meet the LGBTQIA+ health demands (Brasil, 2013BRASIL. Ministério da Saúde. Secretaria de Gestão Estratégica e Participativa. Departamento de Apoio à Gestão Participativa. Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais, Travestis e Transexuais. Brasília, DF: Ministério da Saúde, 2013.). The PNSI-LGBT suggests some paths:

Thus, sensitizing and training health professionals aligned to comprehensive care is essential, after all

However, the health educational process is fundamentally related to the role of scientific production in biomedical sciences, which are essentially guided-even if this influence is denied by utopic hygienist and “apolitical” discourses- by the interests and dictates of the hegemonic sociopolitical and economic context in which they are inserted (Canguilhem, 2020CANGUILHEM, G. O normal e o patológico. Rio de Janeiro: Forense, 2020.; Ciasca et al., 2021CIASCA, S. V.; HERCOWITZ, A.; LOPES-JUNIOR, A. Saúde LGBTQIA+: Práticas de cuidado transdisciplinar. Santana de Parnaíba: Manole, 2021.; Rosa, 2020ROSA, E. B. P. R. Cisheteronormatividade como instituição total. Petfilo, Florianópolis, v. 18, n. 3, p. 59-103, 2020. DOI: 10.5380/petfilo.v18i2.68171).

More recent studies-integrative and systematic reviews-showed the emergence of a medical and scientific discourse that endorses and reinforces the segmentation of the LGBTQIA+ population (Bueno et al., 2020BUENO, N. S.; GOMES, A. J. R.; CARVALHO, C. S.; TANIMITSU, L. Y. R.; GRACIANO, M. V. V.; OLIVEIRA, S. R. R.; ZANI, H. P. Os desafios no acesso à saúde da comunidade de Lésbicas, Gays, Bissexuais, Travestis e Transsexuais no Brasil: uma revisão integrativa. Brazilian Journal of Health Review, Curitiba, v. 3, n. 4, p. 8524-8538, 2020. DOI: 10.34119/bjhrv3n4-104
https://doi.org/10.34119/bjhrv3n4-104... ; Bezerra et al., 2019BEZERRA, M. V. R.; MORENO, C. A.; PRADO, N. M. B. L.; SANTOS, A. M. Política de saúde LGBT e sua invisibilidade nas publicações em saúde coletiva. Saúde em Debate, Rio de Janeiro, v. 43, n. 8, p. 305-323, 2019. DOI: 10.1590/0103-11042019S822
https://doi.org/10.1590/0103-11042019S82... ; Morris et al., 2019MORRIS, M.; COOPER, R. L.; RAMESH, A.; TABATABAI, M.; ARCURY, T. A.; SHINN, M.; IM, W.; JUAREZ, P.; MATTHEWS-JUAREZ, P. Training to reduce LGBTQ-related bias among medical, nursing, and dental students and providers: a systematic review. BMC Medical Education, Londres, v. 19, n. 1, p. 1-13, 2019. DOI: 10.1186/s12909-019-1727-3
https://doi.org/10.1186/s12909-019-1727-... ).

By a predominantly positivist and, therefore, “biologicist,” “a-historical,” and “asocial” perspective, essentially pathologizing measurements and/or interventions were developed in the face of any conditions of sex, gender, and sexuality that are not in line with the cis-heteronormative hegemony (Bueno et al., 2020BUENO, N. S.; GOMES, A. J. R.; CARVALHO, C. S.; TANIMITSU, L. Y. R.; GRACIANO, M. V. V.; OLIVEIRA, S. R. R.; ZANI, H. P. Os desafios no acesso à saúde da comunidade de Lésbicas, Gays, Bissexuais, Travestis e Transsexuais no Brasil: uma revisão integrativa. Brazilian Journal of Health Review, Curitiba, v. 3, n. 4, p. 8524-8538, 2020. DOI: 10.34119/bjhrv3n4-104
https://doi.org/10.34119/bjhrv3n4-104... ; Ciasca et al., 2021CIASCA, S. V.; HERCOWITZ, A.; LOPES-JUNIOR, A. Saúde LGBTQIA+: Práticas de cuidado transdisciplinar. Santana de Parnaíba: Manole, 2021.; Bezerra et al., 2019BEZERRA, M. V. R.; MORENO, C. A.; PRADO, N. M. B. L.; SANTOS, A. M. Política de saúde LGBT e sua invisibilidade nas publicações em saúde coletiva. Saúde em Debate, Rio de Janeiro, v. 43, n. 8, p. 305-323, 2019. DOI: 10.1590/0103-11042019S822
https://doi.org/10.1590/0103-11042019S82... ; Canguilhem, 2020CANGUILHEM, G. O normal e o patológico. Rio de Janeiro: Forense, 2020.; Morris et al., 2019MORRIS, M.; COOPER, R. L.; RAMESH, A.; TABATABAI, M.; ARCURY, T. A.; SHINN, M.; IM, W.; JUAREZ, P.; MATTHEWS-JUAREZ, P. Training to reduce LGBTQ-related bias among medical, nursing, and dental students and providers: a systematic review. BMC Medical Education, Londres, v. 19, n. 1, p. 1-13, 2019. DOI: 10.1186/s12909-019-1727-3
https://doi.org/10.1186/s12909-019-1727-... ; Rosa, 2020ROSA, E. B. P. R. Cisheteronormatividade como instituição total. Petfilo, Florianópolis, v. 18, n. 3, p. 59-103, 2020. DOI: 10.5380/petfilo.v18i2.68171).

According to Abade et al. (2020ABADE, E. A. F.; CHAVES, S. C. L.; SILVA, G. C. O. Saúde da população LGBT: uma análise dos agentes, dos objetos de interesse e das disputas de um espaço de produção científica emergente. Physis: Revista de Saúde Coletiva, Rio de Janeiro, v. 30, n. 4, p. 1-31, 2020. DOI: 10.1590/S0103-73312020300418
https://doi.org/10.1590/S0103-7331202030... ) and Bezerra et al. (2019BEZERRA, M. V. R.; MORENO, C. A.; PRADO, N. M. B. L.; SANTOS, A. M. Política de saúde LGBT e sua invisibilidade nas publicações em saúde coletiva. Saúde em Debate, Rio de Janeiro, v. 43, n. 8, p. 305-323, 2019. DOI: 10.1590/0103-11042019S822
https://doi.org/10.1590/0103-11042019S82... ), the result of this logic fundamentally based on hypothetical inferences about the LGBTQIA+ population materialized into a scientific production of insufficient quality and quantity.

This fragility is in line with a systematic review by Abade et al. (2020ABADE, E. A. F.; CHAVES, S. C. L.; SILVA, G. C. O. Saúde da população LGBT: uma análise dos agentes, dos objetos de interesse e das disputas de um espaço de produção científica emergente. Physis: Revista de Saúde Coletiva, Rio de Janeiro, v. 30, n. 4, p. 1-31, 2020. DOI: 10.1590/S0103-73312020300418
https://doi.org/10.1590/S0103-7331202030... ). According to the authors, although a recent trend of increasing scientific production on LGBTQIA+ health arose-higher in the international scenario in comparison with Brazil and Latin America-the verticalization of its content is seen by the “existence of three phases: that of studies on homosexuality as a disease until 1972; the phase of homophobia studies and its individual consequences; and from the 1990s on, a focus on school, health, and military institutions” (Abade et al., 2020ABADE, E. A. F.; CHAVES, S. C. L.; SILVA, G. C. O. Saúde da população LGBT: uma análise dos agentes, dos objetos de interesse e das disputas de um espaço de produção científica emergente. Physis: Revista de Saúde Coletiva, Rio de Janeiro, v. 30, n. 4, p. 1-31, 2020. DOI: 10.1590/S0103-73312020300418
https://doi.org/10.1590/S0103-7331202030... , p. 2).

Thus, following the hypothesis of the existence of a stigmatizing content in the scientific literature on LGBTQIA+ health, this study aimed to critically analyze a possible ideologically “LGBTQIA+phobic” bias in the most recent health-related studies available in “one of the most important and well-known bibliographic databases in the world:” PubMed/Medline (Honório and Santiago-Júnior, 2021HONÓRIO, H. M., SANTIAGO-JÚNIOR, J. F. Fundamentos das Revisões Sistemáticas em Saúde. São Paulo: Santos Publicações, 2021., p. 49). We based our study under this presupposition, on both the capability of the bias to come from cis-heteronormativity and the absence of contents in the scientific literature that addressed the topic studied.

Methodology

An active search was performed in PubMed, a database developed by the National Center for Biotechnology Information (NCBI), by the advanced method. This database was chosen because it is one of the main sources of health scientific production in English and has a wide indexing and high quality control (Honório and Santiago-Júnior, 2021HONÓRIO, H. M., SANTIAGO-JÚNIOR, J. F. Fundamentos das Revisões Sistemáticas em Saúde. São Paulo: Santos Publicações, 2021.).

For the search strategy, the keywords “Sexual and Gender Minorities” and its “Alternative Terms/Entry Terms,” “Previous Indexing,” and “See Also,” which were interconnected by the Boolean operator “OR” (Appendix I), were used (VHL, 2009BVS - BIBLIOTECA VIRTUAL EM SAÚDE Biblioteca Virtual em Saúde - Tutorial de Pesquisa Bibliográfica. São Paulo: Bireme, 2009.).

For the search strategy, which was understood as a programming language, a “notepad” (Notepad/Windows^®) was used, since some characters, when coming from other word processors, may not be correctly interpreted in the search platforms, impairing the process of identification and data collection (VHL, 2009BVS - BIBLIOTECA VIRTUAL EM SAÚDE Biblioteca Virtual em Saúde - Tutorial de Pesquisa Bibliográfica. São Paulo: Bireme, 2009.).

Thus, on September 12, 2021, the search was performed in the PubMed database. Initially, 25,984 studies were found. Using the most frequent and efficient search strategy, which prioritizes the search for fully available studies of greater scientific rigor, the filters “Text Availability (Free full text)” and “Article Type (Clinical Trial; Meta-Analysis; Randomized Controlled Trial; Review; Systematic Review)” were applied (Honório and Santiago-Júnior, 2021HONÓRIO, H. M., SANTIAGO-JÚNIOR, J. F. Fundamentos das Revisões Sistemáticas em Saúde. São Paulo: Santos Publicações, 2021.). In total, 821 studies were exported under the “PubMed” format (Honório and Santiago-Júnior, 2021HONÓRIO, H. M., SANTIAGO-JÚNIOR, J. F. Fundamentos das Revisões Sistemáticas em Saúde. São Paulo: Santos Publicações, 2021.).

Later, the previously exported files were selected by the Rayyan selection platform (Rayyan^®/QCRI/web app) (Ouzzani et al., 2016OUZZANI, M.; HAMMADY, H.; FEDOROWICZ, Z.; ELMAGARMID, A. Rayyan - a web and mobile app for systematic reviews. Systematic Reviews, Oxford, v. 5, p. 2-10, 2016. DOI: 10.1186/s13643-016-0384-4
https://doi.org/10.1186/s13643-016-0384-... ). Having a title, abstract, and/or keywords that referred to the LGBTQIA+ population and a time frame that proved the contemporaneity of the scientific content-more precisely, the last fifteen years of the 21st century (2006-2021)-were the inclusion criteria. Having not even one keyword in English and a format other than article (editorials, reviews, journalistic texts, technical notes, or other) were the exclusion criteria.

The eligibility process was developed independently by two of the authors of this study in two phases: reading titles and abstracts and extracting keywords (Honório and Santiago-Júnior, 2021HONÓRIO, H. M., SANTIAGO-JÚNIOR, J. F. Fundamentos das Revisões Sistemáticas em Saúde. São Paulo: Santos Publicações, 2021.). In case of discrepancy, reviewers could solve it by two consensus meetings, in which studies were read in full; the presence of a third evaluator was not necessary (Honório and Santiago-Júnior, 2021HONÓRIO, H. M., SANTIAGO-JÚNIOR, J. F. Fundamentos das Revisões Sistemáticas em Saúde. São Paulo: Santos Publicações, 2021.).

Besides these processes, data were collected from the 334 included studies (about 40.7% of all studies found). The established publication interval was from 2006 to 2021. Results were structured in a spreadsheet (Excel/Windows^®) under three aspects: title, year of publication, and keyword(s) used.

Then, the analytical process of this study started (Honório and Santiago-Júnior, 2021HONÓRIO, H. M., SANTIAGO-JÚNIOR, J. F. Fundamentos das Revisões Sistemáticas em Saúde. São Paulo: Santos Publicações, 2021.). Data were statistically treated in the IRAMUTEQ (Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires ^© ) software, in which the descriptive and inferential analyses were performed (Camargo and Justo, 2018CAMARGO, B. V.; JUSTO, A. M. Tutorial para uso do software Iramuteq (Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires). Santa Catarina: Laboratório de Psicologia Social da Comunicação e Cognição, 2018). In the descriptive analysis, the number of different keywords found was measured, as well as the frequency (absolute and relative) of their repetitions (Camargo and Justo, 2018CAMARGO, B. V.; JUSTO, A. M. Tutorial para uso do software Iramuteq (Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires). Santa Catarina: Laboratório de Psicologia Social da Comunicação e Cognição, 2018). In the inferential analysis, three tests (Zipf diagram, similitude analysis, and word cloud) were performed to measure the powers (behavior of the frequencies of words) and possible interconnections between keywords (Camargo and Justo, 2018CAMARGO, B. V.; JUSTO, A. M. Tutorial para uso do software Iramuteq (Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires). Santa Catarina: Laboratório de Psicologia Social da Comunicação e Cognição, 2018).

By the argumentative approach, during the period of discussion of this study, all carefully raised information was analyzed (Honório and Santiago-Júnior, 2021HONÓRIO, H. M., SANTIAGO-JÚNIOR, J. F. Fundamentos das Revisões Sistemáticas em Saúde. São Paulo: Santos Publicações, 2021.).

As this study did not involve human beings, its development was not subjected to approval by a human research ethics committee.

Results

In total, we extracted 1,838 keywords from the 334 included studies. However, before analyzing the collected data, we performed a textual standardization, since some words (Appendix II) had the same meaning, but were written in similar and/or abbreviated ways, which could compromise the quality of the analytical process (Camargo and Justo, 2018CAMARGO, B. V.; JUSTO, A. M. Tutorial para uso do software Iramuteq (Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires). Santa Catarina: Laboratório de Psicologia Social da Comunicação e Cognição, 2018).

In the descriptive analysis, of the 1,838 words found (“Number of occurrences”), 859 (46.74%) were different from each other (“Number of forms”) and 662 (36.02%) appeared once (“Number of hapax”). Each study had an average of 5.5 keywords (“Average occurrences per text”) (Camargo and Justo, 2018CAMARGO, B. V.; JUSTO, A. M. Tutorial para uso do software Iramuteq (Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires). Santa Catarina: Laboratório de Psicologia Social da Comunicação e Cognição, 2018) (Figure 1).

The most used forms (“Actives forms”) were “men having sex with men” (MSM) and “HIV” (human immunodeficiency virus), which appeared 192 and 98 times, respectively. The frequency of the third most prevalent keyword (“prep;” frequency of 38 times) was respectively and approximately 5.0 and 2.6 times higher in comparison with the aforementioned keywords (Figure 2).

The inferential analysis started with the Zipf diagram, a lexicographic analysis that presents the behavior of the frequencies of words in a graph that shows in its vertical axis (y) the position of the frequencies of words in descending order and in its horizontal axis (x) the frequencies of the forms (both in logarithmic scales) (Camargo and Justo, 2018CAMARGO, B. V.; JUSTO, A. M. Tutorial para uso do software Iramuteq (Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires). Santa Catarina: Laboratório de Psicologia Social da Comunicação e Cognição, 2018). Thus, this visual resource showed the power of some keywords along with the database (Figure 3).

In order to find the degree of potential of the most prevalent words, we performed the similitude analysis (Camargo and Justo, 2018CAMARGO, B. V.; JUSTO, A. M. Tutorial para uso do software Iramuteq (Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires). Santa Catarina: Laboratório de Psicologia Social da Comunicação e Cognição, 2018). The keywords “men having sex with men” and “HIV” created a strong interconnection of two critical nodes, which hierarchically led to other keywords (Figure 4).

The word cloud test showed that the keyword “men having sex with men” presented the highest latency of the critical node due to the greater complexity of its internal interconnections (Camargo and Justo, 2018CAMARGO, B. V.; JUSTO, A. M. Tutorial para uso do software Iramuteq (Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires). Santa Catarina: Laboratório de Psicologia Social da Comunicação e Cognição, 2018) (Figure 5).

Therefore, the analysis of the keywords used by the included studies showed that the LGBTQIA+ population is essentially described by the scientific literature as “men who have sex with other men” and “HIV-positive.”

Discussion

This study showed the existence of a stigmatizing bias in the scientific production on LGBTQIA+ health.

We used keywords in the analytical process of this study because they are the main indexing components for scientific publications (Brandau, Monteiro, and Braile, 2005BRANDAU, R.; MONTEIRO, R.; BRAILE, D. M. Importância do uso correto dos descritores nos artigos científicos. Brazil Journal of Cardiovascular Surgery, São Paulo, v. 20, n. 1, p. 7-9, 2005. DOI: 10.1590/S0102-76382005000100004
https://doi.org/10.1590/S0102-7638200500... ; Honório and Santiago-Júnior, 2021HONÓRIO, H. M., SANTIAGO-JÚNIOR, J. F. Fundamentos das Revisões Sistemáticas em Saúde. São Paulo: Santos Publicações, 2021.). Moreover, using a well-structured vocabulary increases the chances of finding quality scientific information (Brandau, Monteiro, and Braile, 2005BRANDAU, R.; MONTEIRO, R.; BRAILE, D. M. Importância do uso correto dos descritores nos artigos científicos. Brazil Journal of Cardiovascular Surgery, São Paulo, v. 20, n. 1, p. 7-9, 2005. DOI: 10.1590/S0102-76382005000100004
https://doi.org/10.1590/S0102-7638200500... ; Honório and Santiago-Júnior, 2021HONÓRIO, H. M., SANTIAGO-JÚNIOR, J. F. Fundamentos das Revisões Sistemáticas em Saúde. São Paulo: Santos Publicações, 2021.). Brandau, Monteiro, and Braile (2005BRANDAU, R.; MONTEIRO, R.; BRAILE, D. M. Importância do uso correto dos descritores nos artigos científicos. Brazil Journal of Cardiovascular Surgery, São Paulo, v. 20, n. 1, p. 7-9, 2005. DOI: 10.1590/S0102-76382005000100004
https://doi.org/10.1590/S0102-7638200500... , p. 9) also state that

Therefore, regarding the keyword used in our search for bibliographic content-“Sexual and Gender Minorities,” which was located in the category “Persons category” and subcategory “Persons”-some questions are worthy of discussion.

First, the emergence of the term “Sexual and Gender Minorities” was not spontaneous and/or unilateral; on the contrary, it was the result of the meeting of interests between science and the historical background of the LGBTQIA+ fight, which gained strength and prominence from the 1980s, in favor of civil rights, including the right to health-after all, the outbreak of the HIV/AIDS epidemic was part of the background of that time (Bezerra et al., 2019BEZERRA, M. V. R.; MORENO, C. A.; PRADO, N. M. B. L.; SANTOS, A. M. Política de saúde LGBT e sua invisibilidade nas publicações em saúde coletiva. Saúde em Debate, Rio de Janeiro, v. 43, n. 8, p. 305-323, 2019. DOI: 10.1590/0103-11042019S822
https://doi.org/10.1590/0103-11042019S82... ; Brasil, 2002BRASIL. Ministério da Saúde. Secretaria de Políticas de Saúde. Coordenação Nacional de DST e Aids. Guia de Prevenção das DST/Aids e Cidadania para Homossexuais. Brasília, DF: Ministério da Saúde, 2002.).

Ayres, Castellanos, and Baptista (2018AYRES, J. R.; CASTELLANOS, M. E. P.; BAPTISTA, T. W. F. Entrevista com José Ricardo Ayres. Saúde e Sociedade, São Paulo, v. 27, n. 1, p. 51-60, 2018. DOI: 10.1590/S0104-12902018000002
https://doi.org/10.1590/S0104-1290201800... , p. 52) corroborate this idea:

Thus, the aforementioned keyword, according to the “scope note of the Health Sciences Descriptors (DeCS/MeSH),” “was coined in the 1990s by some epidemiologists who studied the spread of sexually transmitted infections [STIs] in men who, regardless of their sexual identity, had sex with men” (VHL, 2017BVS - BIBLIOTECA VIRTUAL EM SAÚDE. Descritores em Ciências da Saúde (DeCS/MESH). Sexual and Gender Minorities. Bireme, 2017. Disponível em: <Disponível em: https://decs.bvsalud.org/ths/resource/?id=56859&filter=ths_termall&q=Sexual%20and%20Gender%20Minorities >. Acesso em: 1 set. 2021.
https://decs.bvsalud.org/ths/resource/?i... ).

However, the comparison with its historical background establishes the paradox of the term “Sexual and Gender Minorities.” Initially, an important achievement materialized in the leading role of a vast and important scientific production on the HIV/AIDS epidemic-which directly affected, and continues to affect, the provision of public health policies aimed to tackle and control this epidemic (Abade et al., 2020ABADE, E. A. F.; CHAVES, S. C. L.; SILVA, G. C. O. Saúde da população LGBT: uma análise dos agentes, dos objetos de interesse e das disputas de um espaço de produção científica emergente. Physis: Revista de Saúde Coletiva, Rio de Janeiro, v. 30, n. 4, p. 1-31, 2020. DOI: 10.1590/S0103-73312020300418
https://doi.org/10.1590/S0103-7331202030... ; Brasil, 2002BRASIL. Ministério da Saúde. Secretaria de Políticas de Saúde. Coordenação Nacional de DST e Aids. Guia de Prevenção das DST/Aids e Cidadania para Homossexuais. Brasília, DF: Ministério da Saúde, 2002.; Ciasca et al., 2021CIASCA, S. V.; HERCOWITZ, A.; LOPES-JUNIOR, A. Saúde LGBTQIA+: Práticas de cuidado transdisciplinar. Santana de Parnaíba: Manole, 2021.).

On the other hand, this term also carries, as well as instrumentalizes, a decontextualized view of health sciences on the LGBTQIA+ population, a reflection that becomes irrefutable with the scope of the keyword-which was revised in 2017, by the DeCS/MeSH platform.

This term is essentially guided by the normal-pathological dichotomy and points to a possible way to pathologize being LGBTQIA+, a reality weakened by Canguilhem (2020CANGUILHEM, G. O normal e o patológico. Rio de Janeiro: Forense, 2020.), after all, the frequent positivity adopted by health sciences of what is “normal” or “pathological” would be a minimalist analysis before the multitude of physiological and contextual possibilities of experiencing life. The author, under the precepts of Max Weber, states that establishing a standard to affirm the existence of health or disease only transforms these concepts into an ideal and, therefore, vague and unreachable type that is unrelated to the life process of people, besides statically contemplating the extremes of the health-disease process and, thus, disregarding the continuity of its numerous intermediate stages (Canguilhem, 2020CANGUILHEM, G. O normal e o patológico. Rio de Janeiro: Forense, 2020.).

Moreover, Louro (2001LOURO, G. L. Teoria queer: uma política pós-identitária para a educação. Revista Estudos Feministas, Florianópolis, v. 9, n. 2, p. 541-553, 2001. DOI: 10.1590/S0104-026X2001000200012
https://doi.org/10.1590/S0104-026X200100... ) and Sodré (2005SODRÉ, M. Por um conceito de minoria. In: Paiva R; Barbalho A. (Org.). Comunicação e cultura das minorias. São Paulo: Paulus, 2005.) state the need to replace the term “sexual minorities” by “silenced majorities.” According to them, this logic would strain the contradiction between the questionable numerical limitation and the necessary empowering of demands in the spectrum of political institutions, since the “minoritization” of LGBTQIA+ people is not related to its quantitative aspect, but to the qualitative aspect of the biopower of their existence in the social scenario (Louro, 2001LOURO, G. L. Teoria queer: uma política pós-identitária para a educação. Revista Estudos Feministas, Florianópolis, v. 9, n. 2, p. 541-553, 2001. DOI: 10.1590/S0104-026X2001000200012
https://doi.org/10.1590/S0104-026X200100... ; Sodré, 2005SODRÉ, M. Por um conceito de minoria. In: Paiva R; Barbalho A. (Org.). Comunicação e cultura das minorias. São Paulo: Paulus, 2005.).

Another limitation of the keyword “Sexual and Gender Minorities” is that it does not address the vulnerability of the LGBTQIA+ population, including in health (Ciasca et al., 2021CIASCA, S. V.; HERCOWITZ, A.; LOPES-JUNIOR, A. Saúde LGBTQIA+: Práticas de cuidado transdisciplinar. Santana de Parnaíba: Manole, 2021.; WHO, 2013WHO - WORLD HEALTH ORGANIZATION. Addressing the causes of disparities in health service access and utilization for lesbian, gay, bisexual and trans (LGBT) persons. Washington, DC: World Health Organization, 2013.; Brasil, 2013BRASIL. Ministério da Saúde. Secretaria de Gestão Estratégica e Participativa. Departamento de Apoio à Gestão Participativa. Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais, Travestis e Transexuais. Brasília, DF: Ministério da Saúde, 2013.).

The understanding of the state of vulnerability of the LGBTQIA+ population-a socially created and/or imposed condition-is in accordance with Ayres, Castellanos, and Baptista (2018AYRES, J. R.; CASTELLANOS, M. E. P.; BAPTISTA, T. W. F. Entrevista com José Ricardo Ayres. Saúde e Sociedade, São Paulo, v. 27, n. 1, p. 51-60, 2018. DOI: 10.1590/S0104-12902018000002
https://doi.org/10.1590/S0104-1290201800... , p. 54):

Moreover, the use of this term generalizes LGBTQIA+ identities and, thus, disregards the dynamicity of their respective existential journeys. This idea is in line with Albernaz and Kauss (2015ALBERNAZ, R. O.; KAUSS, B. S. Reconhecimento, igualdade complexa e luta por direitos à população LGBT através das decisões dos tribunais superiores no Brasil. Revista Psicologia Política, Florianópolis, v. 15, n. 34, p. 547-561, 2015., p. 552):

This population currently includes several identities that can not be limited to a group, since after each dialogue, they reinvent and transform themselves and the very heterogeneity of their groups.

The historical and social background of this population is very different from others, since its members-essentially cisgender-focus much of its efforts on criminalizing prejudice and, mainly, legitimizing their family compositions, besides the recognition of homosexual relationships (marriage) and the conception and/or adoption of children (Ciasca et al., 2021CIASCA, S. V.; HERCOWITZ, A.; LOPES-JUNIOR, A. Saúde LGBTQIA+: Práticas de cuidado transdisciplinar. Santana de Parnaíba: Manole, 2021.). On the other hand, individuals in transition (TQI+) still fight for basic rights related to their existentiality, especially for the depathologization and collective acceptability of their identities (Ciasca et al., 2021CIASCA, S. V.; HERCOWITZ, A.; LOPES-JUNIOR, A. Saúde LGBTQIA+: Práticas de cuidado transdisciplinar. Santana de Parnaíba: Manole, 2021.).

Considering this, LGBTQIA+ health care must be in accordance with Cardoso and Ferro (2012CARDOSO, M. R.; FERRO, L. F. Saúde e população LGBT: demandas e especificidades em questão. Psicologia: ciência e profissão, Brasília, DF, v. 32, n. 3, p. 552-563, 2012. DOI: 10.1590/S1414-98932012000300003
https://doi.org/10.1590/S1414-9893201200... , p. 557): “the discussion on the disease process of the LGBT population also requires the specification of the concepts of sexual identity and gender identity. Although everyone goes through a disease process, the journey is different in each case.” Therefore, these same authors show “the imminent need for professional training of health agents for actions in view of the specificities of the LGBT population” (Cardoso and Ferro, 2012CARDOSO, M. R.; FERRO, L. F. Saúde e população LGBT: demandas e especificidades em questão. Psicologia: ciência e profissão, Brasília, DF, v. 32, n. 3, p. 552-563, 2012. DOI: 10.1590/S1414-98932012000300003
https://doi.org/10.1590/S1414-9893201200... , p. 554).

In the context of public health policies, Bezerra et al. (2019BEZERRA, M. V. R.; MORENO, C. A.; PRADO, N. M. B. L.; SANTOS, A. M. Política de saúde LGBT e sua invisibilidade nas publicações em saúde coletiva. Saúde em Debate, Rio de Janeiro, v. 43, n. 8, p. 305-323, 2019. DOI: 10.1590/0103-11042019S822
https://doi.org/10.1590/0103-11042019S82... , p. 306) address key points to transform them into effective instruments, highlighting:

Far from the conception of a possible ideal and/or final design of the term “Sexual and Gender Minorities,” studies show the potential of the “queer theory” to be an inducing and directing agent to reach it (Butler, 2019BUTLER, J. Problemas de gênero. Feminismo e subversão da identidade. Rio de Janeiro: Civilização Brasileira, 2019.; Louro, 2001LOURO, G. L. Teoria queer: uma política pós-identitária para a educação. Revista Estudos Feministas, Florianópolis, v. 9, n. 2, p. 541-553, 2001. DOI: 10.1590/S0104-026X2001000200012
https://doi.org/10.1590/S0104-026X200100... ). After all, the queer movement, based on the continuous organization of social and cultural life, includes in its dialectical approach the need to provide the passage (“passability”) of living practices that question the unisonance of cis-heteronormativity, consecutively considering the understanding and belonging of the diversity of resistant LGBTQIA+ identities and, thus, breaking with any perspectives of naturalness, normality, and pathologization (Butler, 2019BUTLER, J. Problemas de gênero. Feminismo e subversão da identidade. Rio de Janeiro: Civilização Brasileira, 2019.; Louro, 2001LOURO, G. L. Teoria queer: uma política pós-identitária para a educação. Revista Estudos Feministas, Florianópolis, v. 9, n. 2, p. 541-553, 2001. DOI: 10.1590/S0104-026X2001000200012
https://doi.org/10.1590/S0104-026X200100... ).

Considering particularly the interconnection between the most prevalent and powerful keywords found in this study-“men having sex with men” and “HIV”-Lima et al. (2014LIMA, D. J. M.; PAULA, P. F.; AQUINO, P. S.; LESSA, P. R. A.; MORAES, M. L. C.; CUNHA, D. F. F.; PINHEIRO, A. K. B. Comportamentos e práticas sexuais de homens que fazem sexo com homens. Revista Brasileira de Enfermagem, Brasília, DF, v. 67, n. 6, p. 886-890, 2014. DOI: 10.1590/0034-7167.2014670604
https://doi.org/10.1590/0034-7167.201467... , p. 887) described a clear context for its application:

However, according to Knauth et al. (2020KNAUTH, D. R.; HENTGES, B.; MACEDO, J. L.; PILECCO, F. B.; TEIXEIRA, L. B.; LEAL, A. F. O diagnóstico do HIV/aids em homens heterossexuais: a surpresa permanece mesmo após mais de 30 anos de epidemia. Caderno de Saúde Pública, Rio de Janeiro, v. 36, n. 6, p. 1-11, 2020. DOI: 10.1590/0102-311X00170118
https://doi.org/10.1590/0102-311X0017011... ), who made inferences about the last 2018 HIV/AIDS Epidemiological Bulletin, this stigmatizing direction (still guided by the experience from the beginning of the HIV epidemic) lost its meaning. Regarding exposure categories, for example, heterosexual men are the majority (49% of cases), followed by homosexual (38%) and bisexual (9.1%) men (Knauth et al., 2020KNAUTH, D. R.; HENTGES, B.; MACEDO, J. L.; PILECCO, F. B.; TEIXEIRA, L. B.; LEAL, A. F. O diagnóstico do HIV/aids em homens heterossexuais: a surpresa permanece mesmo após mais de 30 anos de epidemia. Caderno de Saúde Pública, Rio de Janeiro, v. 36, n. 6, p. 1-11, 2020. DOI: 10.1590/0102-311X00170118
https://doi.org/10.1590/0102-311X0017011... ).

According to the authors, prejudice against some individuals and invisibility in favor of others may be the main explanation for the current scenario.

In practice, this almost symbiotic relationship between the terms “men having sex with men” and “HIV” can affect LGBTQIA+ health care. The needs, specificities, and demands of this population are predominantly predefined by research objects and, consequently, in their reproduction-otherwise, the critical reflection on the relationship between cause and consequence and the encounter between individual and health professional precede (Bezerra et al., 2019BEZERRA, M. V. R.; MORENO, C. A.; PRADO, N. M. B. L.; SANTOS, A. M. Política de saúde LGBT e sua invisibilidade nas publicações em saúde coletiva. Saúde em Debate, Rio de Janeiro, v. 43, n. 8, p. 305-323, 2019. DOI: 10.1590/0103-11042019S822
https://doi.org/10.1590/0103-11042019S82... ; Brasil, 2002BRASIL. Ministério da Saúde. Secretaria de Políticas de Saúde. Coordenação Nacional de DST e Aids. Guia de Prevenção das DST/Aids e Cidadania para Homossexuais. Brasília, DF: Ministério da Saúde, 2002.; Cardoso and Ferro, 2012CARDOSO, M. R.; FERRO, L. F. Saúde e população LGBT: demandas e especificidades em questão. Psicologia: ciência e profissão, Brasília, DF, v. 32, n. 3, p. 552-563, 2012. DOI: 10.1590/S1414-98932012000300003
https://doi.org/10.1590/S1414-9893201200... ; Ciasca et al., 2021CIASCA, S. V.; HERCOWITZ, A.; LOPES-JUNIOR, A. Saúde LGBTQIA+: Práticas de cuidado transdisciplinar. Santana de Parnaíba: Manole, 2021.; Luiz and Struchiner, 2002LUIZ, R. R.; STRUCHINER, C. J. Inferência causal em epidemiologia: o modelo de respostas potenciais. Rio de Janeiro: Fiocruz, 2002.).

Rios and Adrião (2022RIOS, L. F.; ADRIÃO, K. G. Sobre descrições, retificações e objetividade científica: reflexões metodológicas a partir de uma pesquisa sobre condutas sexuais e HIV/aids entre homens com práticas homossexuais. Saúde e Sociedade, São Paulo, v. 31, n. 1, p. 1-13, 2022. DOI: 10.1590/S0104-12902022210427
https://doi.org/10.1590/S0104-1290202221... , p. 4) define this perspective as “a priori,” breaking with the objective of scientific knowledge, which “comes from the action of analytically facing the obstacles that arise along the process of knowing.” The authors (Rios and Adrião, 2022RIOS, L. F.; ADRIÃO, K. G. Sobre descrições, retificações e objetividade científica: reflexões metodológicas a partir de uma pesquisa sobre condutas sexuais e HIV/aids entre homens com práticas homossexuais. Saúde e Sociedade, São Paulo, v. 31, n. 1, p. 1-13, 2022. DOI: 10.1590/S0104-12902022210427
https://doi.org/10.1590/S0104-1290202221... , p. 4) also describe the scientific experience “as an exercise of rectification of errors of the process itself, a reflection on the way, a properly methodological discussion, where the simple presentation of the research procedures is insufficient to ensure scientificity.”

Thus, undergoing a process of resignification and extension of the scientific production on LGBTQIA+ health beyond HIV/AIDS is essential-without dispensing this important public health problem, but considering other scientific demands (Bezerra et al., 2019BEZERRA, M. V. R.; MORENO, C. A.; PRADO, N. M. B. L.; SANTOS, A. M. Política de saúde LGBT e sua invisibilidade nas publicações em saúde coletiva. Saúde em Debate, Rio de Janeiro, v. 43, n. 8, p. 305-323, 2019. DOI: 10.1590/0103-11042019S822
https://doi.org/10.1590/0103-11042019S82... ; Brasil, 2002BRASIL. Ministério da Saúde. Secretaria de Políticas de Saúde. Coordenação Nacional de DST e Aids. Guia de Prevenção das DST/Aids e Cidadania para Homossexuais. Brasília, DF: Ministério da Saúde, 2002.; Ciasca et al., 2021CIASCA, S. V.; HERCOWITZ, A.; LOPES-JUNIOR, A. Saúde LGBTQIA+: Práticas de cuidado transdisciplinar. Santana de Parnaíba: Manole, 2021.).

And this change, according to Bezerra et al. (2019BEZERRA, M. V. R.; MORENO, C. A.; PRADO, N. M. B. L.; SANTOS, A. M. Política de saúde LGBT e sua invisibilidade nas publicações em saúde coletiva. Saúde em Debate, Rio de Janeiro, v. 43, n. 8, p. 305-323, 2019. DOI: 10.1590/0103-11042019S822
https://doi.org/10.1590/0103-11042019S82... , p. 320), is related to the “urge to instigate the construction of a new paradigm in the teaching process in health courses, which contemplates an academic training capable of discussing gender diversity as a social issue related to the health care process.” For the conception of this movement, the authors raise intriguing questions:

Moreover, we must reinforce that the keywords found in this study were not chosen at random, since they are products of a science consciously or unconsciously guided by the interests and dictates of their sociopolitical and economic context (Canguilhem, 2020CANGUILHEM, G. O normal e o patológico. Rio de Janeiro: Forense, 2020.; Ciasca et al., 2021CIASCA, S. V.; HERCOWITZ, A.; LOPES-JUNIOR, A. Saúde LGBTQIA+: Práticas de cuidado transdisciplinar. Santana de Parnaíba: Manole, 2021.; Rosa, 2020ROSA, E. B. P. R. Cisheteronormatividade como instituição total. Petfilo, Florianópolis, v. 18, n. 3, p. 59-103, 2020. DOI: 10.5380/petfilo.v18i2.68171).

Keywords, according to Foucault (2016FOUCAULT, M. As palavras e as coisas. São Paulo: Martins Fontes, 2016.), not only designate, but also confer and even impose the ways how human beings may follow their own existence.

This study shows the need to discuss possible ways to curb the essentiality of the stigmas existing in the scientific literature on LGBTQIA+ health.

Obviously, no precise solution to overcome this obstacle exist, however, the starting point is promoting a necessary epistemological change: removing LGBTQIA+ individuals from the condition of “thing” and placing them as “citizens” in the study design (Turato, 2013TURATO, E. R. Tratado da metodologia da pesquisa clínico-qualitativa: construção teórico-epistemológica, discussão comparada e aplicação nas áreas da saúde e humanas. Petrópolis: Vozes, 2013.).

Moreover, along with this new process of constructing scientific knowledge, the idea of representativeness is another sine qua non point-after all, according to Rosa (2020ROSA, E. B. P. R. Cisheteronormatividade como instituição total. Petfilo, Florianópolis, v. 18, n. 3, p. 59-103, 2020. DOI: 10.5380/petfilo.v18i2.68171), cis-heteronormativity is present in all institutions. In her study, among a diversity of places, the author distinguished spaces of scientific research, which are fundamentally occupied by heterosexual, white, and cisgender researchers, a system that produces inherently discriminatory scientific contents. Its

Ciasca et al. (2021CIASCA, S. V.; HERCOWITZ, A.; LOPES-JUNIOR, A. Saúde LGBTQIA+: Práticas de cuidado transdisciplinar. Santana de Parnaíba: Manole, 2021., p. 509-510) confirm this fragility:

This study had limitations. First, we did not fully analyze the content of the studies found. However, as aforementioned, keywords present the essentiality of their scientific research, distinguishing fundamental points, such as population and outcomes (Brandau, Monteiro, and Braile, 2005BRANDAU, R.; MONTEIRO, R.; BRAILE, D. M. Importância do uso correto dos descritores nos artigos científicos. Brazil Journal of Cardiovascular Surgery, São Paulo, v. 20, n. 1, p. 7-9, 2005. DOI: 10.1590/S0102-76382005000100004
https://doi.org/10.1590/S0102-7638200500... ; Honório and Santiago-Júnior, 2021HONÓRIO, H. M., SANTIAGO-JÚNIOR, J. F. Fundamentos das Revisões Sistemáticas em Saúde. São Paulo: Santos Publicações, 2021.).

Secondly, regarding the process of selecting sources of information, we searched studies indexed on the PubMed database. Thus, as the selection process followed an analytical approach of studies that were performed in developed countries and/or regions, the phenomenology studied in interface with other cultural socioeconomic contexts was not contextualized.

However, despite their feasibility in future studies, the results found by simply accessing studies published on other databases and/or platforms, such as the Latin American and Caribbean Health Sciences Literature (LILACS), the Scientific Electronic Library Online (SciELO), and the Virtual Health Library (VHL), would not be other than those mentioned in this study, since, despite its increasing production, research in underdeveloped or developing countries is strongly influenced by the guidelines of the scientific production of centers of excellence, which are mostly located in more developed and rich regions (SciELO, 2014SCIELO - SCIENTIFIC ELECTRONIC LIBRARY ONLINE. A bibliometria do mundo em desenvolvimento - Publicado originalmente na newsletter da Elsevier “Research Trends Issue 35: Developing Research in Developing Countries”. SciELO em Perspectiva, 2014.).

Finally, the authors experienced a paradox regarding the study methodology. On the one hand, rejecting the complex and valued methodological design, which would probably reinforce the “LGBTQIA+phobic” bias of health studies. On the other hand, designing a study that seeks to honor the subjectivities related to the production of knowledge and, therefore, a more humanized study aimed at the real needs of LGBTQIA+ people. This conflict is in accordance with Turato (2013TURATO, E. R. Tratado da metodologia da pesquisa clínico-qualitativa: construção teórico-epistemológica, discussão comparada e aplicação nas áreas da saúde e humanas. Petrópolis: Vozes, 2013., p. 25):

Final Considerations

By comparing the objective of this study with the data collected and analyzed, we confirmed the existence of an ideologically “LGBTIA+phobic” bias in studies produced and indexed on the PubMed/Medline database.

This study does not aim to deny or renounce science; on the contrary, it yearns for quality and humanized research aimed at the specificities and needs of the LGBTQIA+ population, embodied in public policies that optimize access to care and improve the general health indicators of these individuals.

Acknowledgments

More than thanking, we dedicate this study to the resistant and/or resilient LGBTQIA+ lives.

References

Publication Dates

History