ABSTRACT

The aim of this article is to investigate the intersections between the LGBTI+ agenda and bioethics as a disciplinary field. This research is based on a qualitative analysis and bibliographic review that encompasses topics related to bioethics, post-colonial studies, queer theory, human rights, and international relations. Through reflections on the political and social context that preceded the emergence of bioethics, focusing on the interpretation of sexuality and gender identity during colonial and imperial periods, we seek to understand how historical perspectives influenced the evolution of bioethics. Additionally, we aim to examine the consolidation of bioethics as a disciplinary field and area of scientific knowledge, highlighting the predominance of principlism in the second half of the 20th century. In this sense, we will analyze the potential of a feminist approach in bioethics to address the inequalities and oppressions present within its own structure, with a critical and reflexive view. Finally, we intend to present how the epistemological contributions of queer theory can support the development of a queer bioethics, from the Global South. These discussions aim to broaden the reflection on the inequalities and oppressions faced by the LGBTI+ community as a social group within the context of bioethics.

KEYWORDS
Bioethics; Queer theory; LGBT Person; Human rights; Global South

Introduction

This article aims to present some reflections on the relationships between sexual and gender diversity and bioethics based on the contextualization of bioethics as a disciplinary field. Therefore, the article is divided into three sections that are based on a bibliographical review of the themes that are intended to be related. In the first part, the aim is to present some reflections on the political and social context that precedes the emergence of bioethics as a discipline, highlighting the way in which sexual orientation and gender identity were interpreted in colonial, imperialist and Nazi-fascist contexts. Further on, we intend to analyze the intersection between bioethics, human rights and international relations, from where we locate the emergence of tensions and the epistemological redirections suggested from the perspective of post-colonial studies.

In the second section, we propose to analyze the emergence of bioethics as a disciplinary field, in which the hegemonization of principlism stands out in the second half of the 20th century. In this scenario, we intend to discuss – from the perspective of critical bioethics – how feminist-inspired bioethics can contribute with theoretical contributions regarding the consideration of inequalities and oppressions for the very foundation of bioethics.

In the third and final section, we seek to discuss, present and defend how the epistemological contributions of queer theory can support, from a critical bioethics perspective, a queer bioethics from a post-colonial perspective, as a first possibility of expansion of reflections on inequalities and oppressions related to the sex-gender diverse population in the disciplinary field of bioethics.

Structural LGBTIphobia and its bioethical consequences

In this first section, we intend to analyze how LGBTIphobia becomes a (bio)ethical problem and that it was present at different times, suggesting here that they need to be analyzed as continuities, such as the forms of European imperialism on the African continent and the Holocaust on the context of the Second World War. Thus, the Berlin Conference, held between 1884 and 1885, marked a crucial historical point in which the artificial division of the African continent between European powers began an intense period of colonization and domination over peoples and cultures considered ‘uncivilized’. This framing reflected a lack of correspondence to Western and European standards of intelligibility, recognizing only one model of civilization, language and culture. The conference mainly addressed economic issues, as industrialized European nations needed the raw materials available in Africa, such as gold, diamonds, rubber, cocoa, among others¹1 Coker A. Film as Historical Method in Black Studies: Documenting the African Experience. In: Kete MA, Karenga M. Handbook of Black Studies. California: SAGE Publications, Inc.; 2006 [acesso em 2023 nov 16]. p. 352-366. Disponível em: http://dx.doi. org/10.4135/9781412982696.n25.
http://dx.doi. org/10.4135/9781412982696... .

This period of European imperialist domination in Africa, characterized by systematized violence, resulted in an estimate of at least 10 million deaths²2 Milani MC. Estado Livre do Congo: imperialismo, a roedura geopolítica (1885-1908). [dissertação]. São Paulo: Universidade de São Paulo, Faculdade de Filosofia, Letras e Ciências Humanas; 2011. [acesso em 2023 nov 16]. Disponível em: http://dx.doi. org/10.11606/d.8.2011.tde-26042013-095008.
http://dx.doi. org/10.11606/d.8.2011.tde... , a genocide that is still neglected in the historiography of Africa, human rights and international relations. Colonialism not only imposed cultural practices and violence as so-called civilizational processes, but also introduced a legal regime completely different from the practices and worldviews of the different African ethnicities and social groups. This included the imposition of values and definitions of humanity through civil and criminal legislation, such as the anti-sodomy laws of the Victorian period in the United Kingdom, Germany and other countries, which were transplanted to Africa in processes of domination. This historical-colonial and imperialist context contributed to the structural LGBTIphobia still present today in some African States, reflected in legislation that criminalizes the existence of Lesbian, Gay, Bisexual, Transvestite and Transsexual, Intersex and other (LGBTI+) people.

It can be said that homophobia was structured as part of segregationist projects that have their origins in Western Europe, remaining even after the Holocaust, in which segments of the LGBTI+ population were subjected to violence and clinical experiments based on sexual orientation and/or gender identity. Values and perceptions, including the definition of humanity, were reflected in legal systems through the codification of permitted and prohibited behaviors and actions, based on moral values consolidated as law. It is understood that this structural LGBTIphobia must be contextualized in this historical-colonial and imperialist perspective of criminalization and reproduction of legal provisions that sought normalization based on heterosexuality and whiteness as a unique model of existence and recognition of rights.

These forms of segregation of the sex-gender diverse population were amplified during the Holocaust in the context of the Second World War, resulting in the deaths of approximately 6 million people, highlighting a State policy of segregation and elimination of unwanted population segments. In the Holocaust, we observe a combination of racism and homophobia that enhanced and sophisticated this machine of war and extermination organized by the State against groups that should be removed from that moral, political and social community, since they were understood as unwanted, but also as a threat.

Alongside Lindqvist³3 Lindqvist S. “Exterminate all the brutes”: One man’s odyssey into the heart of darkness and the origins of European genocide. New York: The New Press; 2021., we propose that the process of domination and extermination initiated on the African continent, from the Berlin Conference and the Holocaust in the context of the Second World War, be understood as an imperialist war machine that organizes itself and becomes more sophisticated over the decades. Under the aegis of racism and the election-rejection of unwanted bodies, and which has the sex-gender diverse population as one of its main targets, our hypothesis is that this machine still remains active.

This war machine is organized from a perspective that is mostly racist, LGBTIphobic and with necropolitical nuances⁴4 Mbembe A. Necropolítica. São Paulo: N-1 Edições; 2021.; and is actively involved in a series of practices that deserve our critical analysis. In this context, it is important to highlight that the pathologization of LGBTI+ people is a worrying manifestation of this reality. A notorious example of these pathologizing practices is the persistence of the so called ‘conversion therapies’⁵5 Golightley S. ‘I’m Gay! I’m Gay! I’m Gay! I’m a Homosexual!’: overt and covert conversion therapy practices in therapeutic boarding schools. Br. J. Soc. Work. 2023; 53(3):1426-1244.,⁶6 Tillewein H, Kruse-Diehr AJ. The impact of sexual orientation conversion therapies on transgender individuals. Psychol. Sex. 2023; 14(4):676-688. that seek to change sexual orientation. These therapies are widely condemned by health and human rights organizations, but are still practiced in many places, reflecting the persistence of deep-rooted prejudices.

The Nazi-fascist practices of exterminating unwanted populations and imprisoning enemies – or, in some way, of those people who threatened an ideal of family and morality that supported these same exceptional regimes – resulted in imprisonment and extermination in concentration camps, mostly of jewish people, as well as significant contingents of political dissidents, gypsies, people with some degree of physical disability, as well as sex-gender diverse people. According to the ‘Law for the protection of hereditary health’ that established eugenics as a practice in Nazi Germany, people who were schizophrenic, deaf and had some type and degree of disability should be sterilized⁷7 Adelson BM. The Lives of Dwarfs: Their Journey from Public Curiosity Toward Social Liberation. New Jersey: Rutgers University Press; 2005.. It was under this law that the Nazi doctor Joseph Mengele carried out his experiments on human beings belonging to these populational groups⁸8 Vansuch B. Mengele’s ethics: an analytical approach to understanding Josef Mengele’s motives. [tese]. Washington, DC: Georgetown University; 2011.. In particular, homosexual people were subjected to experiments to ‘cure’ homosexuality and the development of immunization for typhoid fever in the Buchenwald concentration camp⁹9 Röll W. Homosexual inmates in the buchenwald concentration camp. J. Homosex. 1996; 31(4):1-28..

Often, there is a silence regarding the violence committed against the LGBTI+ population during this period, as well as the lack of historical reparation from a bioethics and human rights perspective regarding this social group. It is this last portion of the indicated population that this article intends to focus on. In this context, a historical contextualization is necessary so that we can expose the homophobic and rejection practices that have been perpetrated historically and which, even today, result in criminalization and pathologization that have persisted throughout the 20th century, expanding into the 21st century. For this reason, it is worth highlighting that, at the end of the Second World War, the Nuremberg Code was approved, as a recognition that the instrumentalization of medicine and clinical research could happen through the action of social, political and economic organizations, making it necessary to establish guidelines to avoid situations such as those that occurred in the context of the Holocaust¹⁰10 Annas G, Grodin M. The nuremberg code. In: Emanuel EJ, Grady CC, Crouch RA, et al., editores. The Oxford textbook of clinical research ethics. New York: Oxford University Press; 2008. p. 136-140. However, the Nuremberg Code makes no mention of homosexual people.

The imprisonment of people identified as belonging to a sex-gender diverse population, mostly homosexuals, was established in Germany based on the interpretation of § 175 of the Imperial German Penal Code of 1871, which criminalized consensual relations between people of the same sex. Despite the fall of the Third Reich (1933-1945), the persecution of homosexuals continued. Homosexuality as an immoral conduct was confirmed by the German Constitutional Court in 1957, which declared that § 175 was not just a legacy of the Nazi regime to the extent that, according to the understanding of the German Constitutional Court, it should be considered immoral behavior in times of democracy as well¹¹11 Euchner EM. Morality politics in a secular age: strategic parties and divided governments in Europe. New York: Springer; 2019..

Thus, even after the end of the Second World War, with the founding of the United Nations (UN) and the proclamation of the Universal Declaration of Human Rights, the criminalization provided for in the Imperial German Penal Code of 1871 remained in force until 1994. In England and in Wales, the criminalization of homosexuality was only repealed in 1967¹²12 Han E, O’Mahoney J. British colonialism and the criminalization of homosexuality. Camb. Rev. Int. Aff. 2014; 27(2):268-288.; in Scotland, in 1980; and in Northern Ireland, in 1982. However, it continues to be valid in countries of former English colonies, such as Jamaica and Uganda, as well as in other countries on the African continent that still criminalize consensual relationships between people of the same sex, as well as public expression of sexual orientation and gender identity, with penalties ranging from life imprisonment to the death penalty.

An example of how the articulation between criminalization and pathologization of sexual orientations and gender identities was operationalized is the case of Alan Turing, known as the founder of computational science and artificial intelligence, and who was fundamental during the Second World War, contributing to the decoding of Nazi-fascist codes and messages, in addition to his impact on the development of the global computer network¹³13 Bowen JP. Alan Turing: Founder of Computer Science. In: Bowen J, Liu Z, Zhang Z, editores. Engineering Trustworthy Software Systems. Cham: Springer International Publishing; 2017 [acesso em 2023 nov 16]. p. 1-15. Disponível em: http://dx.doi.org/10.1007/9783-319-56841-6_1.
http://dx.doi.org/10.1007/9783-319-56841... . However, in 1952, Turing was arrested on charges of indecency due to his homosexuality, and was subjected to chemical castration instead of prison¹⁴14 Doan L. Queer history queer memory: the case of Alan Turing. GLQ. 2017; 23(1):113-136., which led to his suicide.

Turing’s case also highlights the need to integrate sexual orientation and gender identity in the field of human rights, but, above all, in the theoretical bases of bioethics as a discipline. Even in the context of the existence of the UN and the Nuremberg Code, Turing and others were subjected to experimental treatments to reverse sexual orientation. It is crucial to question why these aspects were not considered in the Nuremberg code and how they were treated at a domestic and international level. Such factors show that the universality of human rights still does not fully cover sexual orientation and gender identity, remaining criminalized and pathologized in some states, a reflection of persistent colonial and imperialist logics.

This scenario exposes the constant need to think about human rights not only as a point of arrival, but, particularly, as a starting point¹⁵15 Herrera Flores J. A (re) invenção dos direitos humanos. Florianópolis: Fundação Boiteux; 2009.. Likewise, thinking about how some globalized localisms become universal and, therefore, deserve reflection for historical adequacy and geopolitical contextualization¹⁶16 Santos BS. A globalização e as ciências sociais. São Paulo: Cortez; 2005.. Here we claim the need to highlight how this projection impacts categories such as gender, class, sexuality and race, in an intersectional perspective when analyzing systems of subordination and discrimination, as well as policies that induce oppression, which result in situations of disadvantage and discrimination against black women, for example¹⁷17 Crenshaw K. Documento para o encontro de especialistas em aspectos da discriminação racial relativos ao gênero. Rev. Estud. Fem. 2002; 10(1):171-188.. Intersectionality and interdisciplinarity therefore become fundamental for understanding and contextualizing the categories of gender and sexuality as geopolitically located¹⁸18 Puar JK. Terrorist assemblages: homonationalism in queer times. London: Duke University Press; 2017.,¹⁹19 Puar J. Rethinking Homonationalism. Int. J. Middle East Stud. 2013; 45(2):336-339., especially when analyzed necessarily in conjunction with other categories such as race and religion, among other markers that affect the bodies of ‘other’ subjects; of ‘queer’ subjects.

The post-colonial approach highlights the hegemony of heteronormativity, imposed by the colonial and imperialist system, which influences social and institutional standards. This can be seen, especially on the African continent, when analyzing the role of European colonial actors and moral rhetoric to describe homosexual acts as unnatural or sinful in the context of Judeo-Christian codes¹²12 Han E, O’Mahoney J. British colonialism and the criminalization of homosexuality. Camb. Rev. Int. Aff. 2014; 27(2):268-288.. On the African continent, homosexual practices were present before the colonization processes, which does not mean that they were fully accepted, in the way that the processes of recognition of rights from the liberal perspective of rights in the West are organized. What must be highlighted is the impact of European colonialism on how local communities began to consider homosexuality¹²12 Han E, O’Mahoney J. British colonialism and the criminalization of homosexuality. Camb. Rev. Int. Aff. 2014; 27(2):268-288..

From this perspective, it is observed how heteronormativity shapes acceptance patterns, not only in imperialist countries, but especially in countries subjugated by imperialism, even after the recognition of sexual and gender diversity in dominant countries. This raises questions about how bioethics tends to predominantly reflect hegemonic perspectives and ignore other subaltern epistemologies.

Therefore, it becomes relevant to promote dialogues between human rights, bioethics, gender and sexuality in the context of international relations, especially in societies marked by colonial wounds.

The development of bioethics after the Second World War: the invisibility of sexual orientation and gender identity

By starting from these perspectives and this context, we seek to address gender, sexuality and bioethics considering the gaps in historical and (geo)political contextualization in many bioethical studies, which often neglect inequalities of race, gender, class and sexual orientation. Bioethics emerged as a relatively recent discipline, highlighted by the work ‘Bioethics: a Bridge to the Future’, by Van Rensselaer Potter, published in 1971. Although there is debate about its emergence in Madison or Washington, in the United States of America (USA), it is important to show that its origins are linked to clinical research and scientific development, responding to moral dilemmas in biomedical practice²⁰20 Diniz D, Guilhem D. O que é bioética. São Paulo: Brasiliense; 2002.. This period coincides with the intense activity of several social movements in the USA, such as the feminist, black and LGBTI+ rights movements.

Despite the Holocaust and human rights violations under the Nazi-fascist regimes, with emphasis on the genocide of millions of Jews, including LGBTI+ Jews, compulsory research with human beings and the subsequent establishment of an international human rights regime, structural inequalities and categories such as class, race, gender and sexuality have not yet been fully considered in bioethics as a disciplinary field. In the USA, after events of bad practice in research with human beings, the need to establish ethical principles for scientific research arose²⁰20 Diniz D, Guilhem D. O que é bioética. São Paulo: Brasiliense; 2002..

The Belmont report, originated in 1978 at the initiative of the US government and congress, aims to universalize ethical principles to address moral dilemmas in scientific research, especially after irregularities related to clinical experiments that have occurred since the Second World War. The principles of respect for human beings, beneficence and justice are fundamental, integrating Western moral traditions. The publication of this report marked the integration of bioethics as a disciplinary field in the academic sphere²⁰20 Diniz D, Guilhem D. O que é bioética. São Paulo: Brasiliense; 2002..

Based on the Belmont report, Beauchamp and Childress proposed that moral conflicts could be analyzed and resolved via ethical principles. In this sense, in the work ‘Principles of biomedical ethics’²¹21 Beauchamp TL, Childress JF. Principles of biomedical ethics. New York: Oxford University Press; 2001., published in 1979, the authors defend the principles of autonomy, beneficence, justice and nonmaleficence to structure their theory based on these four ethical vectors. This theory was dominant in the field of bioethics for almost two decades, even causing some confusion with the discipline itself. In other words, often, saying bioethics would imply referencing and defending the principlism elaborated by Beauchamp and Childress²⁰20 Diniz D, Guilhem D. O que é bioética. São Paulo: Brasiliense; 2002..

As mentioned, the role of principlism bioethics (or principlism) has become a hegemonic aspect of bioethics, even confusing itself with the discipline itself²²22 Rego S, Palácios M, Siqueira-Batista R. Bioética para profissionais da saúde. Rio de Janeiro: Editora Fiocruz; 2009.. In general, the principlism defended by Beauchamp and Childress has as its scope of analysis mainly clinical research with human beings, as well as human labor activity itself in the provision of health services, which involves several professions linked to the health area. Inevitably, as has been developing in recent years, bioethics presents itself as an area of interdisciplinary studies, in which the perspectives of applied ethics are linked, seeking reflections on human behavior in specific situations, as well as collective health – particularly when considering the impact of certain practical and political decisions within society.

In general terms, the American perspective on bioethics, which has become hegemonic, especially through principlism theory, does not significantly highlight variables such as social and economic inequality between social groups, as well as the different levels of perception and protection of human rights and their impact on decision-making processes. In this way, it becomes evident that the universality that does not announce its origin and limits can hide the so-called globalized localisms¹⁶16 Santos BS. A globalização e as ciências sociais. São Paulo: Cortez; 2005., including categories such as gender, class, race and sexual orientation that are interconnected in a complex way.

In this way, interdisciplinarity as a founding characteristic of bioethics must be expanded and enriched based on the adoption and perception of new categories and subordinate perspectives in historical, political and social processes, based on the analysis of hegemonic epistemologies in dialogue and/or confrontation with subaltern epistemologies. It is in this way that the geopolitical location of knowledge and the perspective that starts from an initial division between the Global North and the Global South become relevant to think about a more democratic bioethics and that considers in its foundations this complexity of elements and categories that, in this article, add to feminist-inspired bioethics and post-colonial studies.

The aim is to differentiate this approach from that of American inspiration and which characterizes principlism bioethics, which is: a concern focused on the way of acting. We understand that reflection on the foundation is decisive so that, in fact, bioethics considers other sociopolitical variables in its definition, as well as other categories of analysis that are important for the expansion and democratization of this discipline. The debate about the basis for acting and the way of acting will certainly guide the differentiation between multiple perceptions of bioethics, among which stand out the principlism based on an American perspective and other theories that consider inequalities in structuring its own foundations.

Garrafa, Martorell and Nascimento²³23 Garrafa V, Martorell LB, Nascimento WF. Críticas ao principialismo em bioética: perspectivas desde o norte e desde o sul. Saúde Soc. 2016; 25(2):442-451. address criticisms of principlism in bioethics, highlighting the confusion between principlism and bioethics itself. The authors highlight the overvaluation of the principle of autonomy, leading to an individualism that disregards issues of collectivity and social justice. An illustrative example is the informed consent industry, in which autonomy becomes more of a formality than a true clarification in the decision-making process in clinical research²³23 Garrafa V, Martorell LB, Nascimento WF. Críticas ao principialismo em bioética: perspectivas desde o norte e desde o sul. Saúde Soc. 2016; 25(2):442-451.. Furthermore, the ‘universalism’ present in principlism bioethics is discussed, in which the aim is to universalize a morality, ignoring cultural particularities and differences between social groups. Criticisms from the South seek to contextualize autonomy within different cultural contexts and emphasize the need for bioethics to address not only individual biomedical conflicts, but also global and collective issues²³23 Garrafa V, Martorell LB, Nascimento WF. Críticas ao principialismo em bioética: perspectivas desde o norte e desde o sul. Saúde Soc. 2016; 25(2):442-451..

The debate about the foundation of bioethics and the hegemony of principlism theory over bioethics begins to receive contributions, especially in Latin America, where it seeks to consider other variables that affect the foundation of bioethics, as well as the limits of principlism bioethics. In this scenario, among other theories, protection bioethics, intervention bioethics and feminist-inspired bioethics stand out, promoting epistemological tension regarding other relevant variables that must be considered by bioethics.

Feminist-inspired bioethics: theoretical contributions for an emancipatory bioethics

From the 1990s onwards, feminist-inspired bioethics, in the context of the third wave of feminism, established its roots in bioethical debates through publications that sought to add other categories to the canons of bioethics, such as gender perspectives and inequalities within the social context²⁴24 Diniz D, Guilhem D. Feminismo, bioética e vulnerabilidade. Est. Fem. 2000; 8(1):237-244.. These reflections were anchored in works on feminine and feminist ethics produced since the 1960s. It is necessary to highlight that, since its origins, feminist-inspired bioethics aimed to highlight social inequalities with emphasis on gender asymmetries and, as pointed out the authors, act as a potential agent of provocation of the universalist and abstract assumptions of principlism bioethics²⁴24 Diniz D, Guilhem D. Feminismo, bioética e vulnerabilidade. Est. Fem. 2000; 8(1):237-244..

The importance of contextualizing bioethics is highlighted considering categories such as sexual orientation, gender, identity, race and social class, as the lack of foundation based on these assumptions increases the invisibility and vulnerability of certain groups, perpetuating inequalities. Discriminations resulting from the intersection of oppressions indicate that moral conflicts cannot be resolved solely based on principles such as autonomy and freedom. Therefore, it is crucial to place these principles in the context of inequalities as structuring and inseparable variables of individuals and their decision-making power.

The contextualization of individual characteristics reveals reasons for social inequality and limitations to the exercise of autonomy and freedom, especially in Latin American societies with high levels of inequality. This is reflected in the disparity in income, access to basic sanitation, health, education and quality food. Structural LGBTIphobia also contributes to the non-recognition of LGBTI+ people as subjects of rights, placing them at a social disadvantage in the face of a cis-heteronormative perspective on the organization of society and its institutions.

We therefore recognize the need to develop a critical bioethics that incorporates into its foundations reflection on inequalities and situations of oppression and vulnerability that affect non-hegemonic and racialized sex-gender diverse bodies, with the aim of verify the degree of autonomy and freedom in decision-making processes, which intersect not only the field of clinical bioethics, but, above all, collective health and human rights in general. This incorporation is fundamental to make bioethics effectively emancipatory.

We highlight that, in the work ‘Feminism and bioethics: beyond reproduction’, Susan Wolf²⁵25 Wolf SM. Feminism & bioethics: beyond reproduction. New York: Oxford University Press; 1996. indicates that feminist bioethics is not limited to the discussion about human reproduction and procreation and its effects on women’s health from a medical ethics or bioethics perspective²⁵25 Wolf SM. Feminism & bioethics: beyond reproduction. New York: Oxford University Press; 1996.. Furthermore, Wolf’s proposal, in addition to other authors who make up the work in question, seeks to emphasize the relationships between feminism and bioethics based on the concern regarding the incorporation of feminist perspectives in relation to various issues established in the field of bioethics. In this way, these perspectives problematize the different bioethical approaches that are based on principlism, as well as utilitarianism or Kantian-inspired theories that do not confront, from a political and social perspective, racism, sexism and class relations, which present themselves as structural²⁵25 Wolf SM. Feminism & bioethics: beyond reproduction. New York: Oxford University Press; 1996..

This approach becomes extremely relevant as medical and bioethical practices are also inserted in these contexts, affecting the lives and the exercise of autonomy of people in situations of oppression and vulnerability. In the work organized by Wolf²⁵25 Wolf SM. Feminism & bioethics: beyond reproduction. New York: Oxford University Press; 1996., the intersection of oppression becomes evident when taking into account the impacts on low-income black women regarding access to the health system, decision-making processes and autonomy over the body, especially in situations of pregnancy and access to abortion options, as well as the practice of cesarean sections in women who want a natural birth²⁵25 Wolf SM. Feminism & bioethics: beyond reproduction. New York: Oxford University Press; 1996..

Based on these propositions, it is necessary to reflect not only on the need to incorporate, through bioethics, into its foundations, categories such as gender, social class and, specifically, sexual orientation and gender identity, but, particularly, to problematize which principles and values inform bioethics. In other words, on what basis is bioethics understood? Who determines bioethics? Here we highlight once again how the context in which the definition of bioethics is inserted can be not only important, but decisive to effectively face problems related to social inequalities that still present themselves as issues on the contemporary bioethics agenda.

The hegemonic context, especially in an increasingly exclusionary neoliberal scenario – in which public health is organized worldwide in the form of large conglomerates and clinical research has been guided mainly by decision-making processes involving business groups and big pharma – makes it is necessary to think about critical bioethics and what its orientation is in relation to the chosen foundation.

In this article, we intend to reflect on the influences and scope of feminist-inspired bioethics, especially to think about inequalities from a diversity perspective, which is directly linked to gender identity and sexual orientation. The criticisms addressed to principlism from a North/South division, and which take into account the center-periphery relationship and the processes of coloniality, converge with the criticisms and findings presented by feminist-inspired bioethics, further highlighting a process to be built to pave new directions for bioethics. In this sense, it is important to articulate the contributions of queer theory regarding criticisms of binaries and heteronormativity as standards for recognizing rights.

Confluences between bioethics and queer theory: paths to overcoming binarism

The theoretical inputs offered by feminist-inspired bioethics contribute to the discussion about the need to denaturalize binarism. The need to understand that binarism is a cultural and historical construction marked by the contributions of Western Judeo-Christian civilization becomes relevant for reflection on the processes of colonization and imperialism that also expand to the colonization of bodies and, as consequence, sexual orientations and gender identities, especially from the perspective of the State and social institutions.

The 1990s represent a period of theoretical-epistemological crossovers for different areas of knowledge. In the feminist movement, one can identify, based on the work of some authors, the third wave; on the other hand, some anti-gender initiatives are beginning to be designed based on the actions of members of the Vatican and theologians²⁶26 Corrêa S. A “política do gênero”: um comentário genealógico. Cad. Pagu. 2018; (53):e185301.; in the field of bioethics, the development of feminist-inspired bioethics can be observed, in particular, based on contributions from Latin America²²22 Rego S, Palácios M, Siqueira-Batista R. Bioética para profissionais da saúde. Rio de Janeiro: Editora Fiocruz; 2009.,²³23 Garrafa V, Martorell LB, Nascimento WF. Críticas ao principialismo em bioética: perspectivas desde o norte e desde o sul. Saúde Soc. 2016; 25(2):442-451.; and in queer studies, it is worth highlighting the conference by Teresa de Lauretis at the University of California²⁷27 Lauretis, T. Queer theory: lesbian and gay sexualities an introduction. Differences. 1991 [acesso em 2023 nov 16]; 3(2):3-18. Disponível em: https://doi. org/10.1215/10407391-3-2-iii.
https://doi. org/10.1215/10407391-3-2-ii... , which represents a milestone in discussing sexualities perceived as pathological together with other categories such as gender and race, which, for this research, acquire fundamental importance.

Lauretis’ proposal can be summarized in the role that should be played by queer theory, specifically, of highlighting subordinated discourses in debates and works on gender and sexuality²⁷27 Lauretis, T. Queer theory: lesbian and gay sexualities an introduction. Differences. 1991 [acesso em 2023 nov 16]; 3(2):3-18. Disponível em: https://doi. org/10.1215/10407391-3-2-iii.
https://doi. org/10.1215/10407391-3-2-ii... . Furthermore, queer theory would have the function of dialoguing with other epistemologies and areas of knowledge at the same time that it would perform a political function and challenge the theoretical matrix in force until then and which organized gender and sexuality as analytical categories²⁷27 Lauretis, T. Queer theory: lesbian and gay sexualities an introduction. Differences. 1991 [acesso em 2023 nov 16]; 3(2):3-18. Disponível em: https://doi. org/10.1215/10407391-3-2-iii.
https://doi. org/10.1215/10407391-3-2-ii... . In this way, queer theory would, from its roots, have a destabilizing and contesting character regarding the experiences of gays and lesbians, as well as the perspectives that became hegemonized and that still reproduced and naturalized whiteness and heteronormativity.

Paul Preciado provokes a dialogue and intersections between queer theory and bioethics based on a tensioning of the perspectives that guide these theories. In ‘Testo Junkie’, published in 2008, Preciado autoethnographs his experiences when self-applying testosterone in the form of an ointment on his body for a period of 236 days, describing the different feelings and experiences that are perceived from this hormonal application, in addition to contextualizing them politically and socially²⁸28 Preciado P. Testo junkie: sexo, drogas e biopolítica na era farmacopornográfica. São Paulo: N-1 Edições; 2018..

Preciado’s contributions go beyond questioning gender and subjectivation processes in capitalist/neoliberal contexts. Preciado describes the post-Second World War period as the ‘pharmacopornographic era’, marked by changes in wealth accumulation and post-Fordist society²⁸28 Preciado P. Testo junkie: sexo, drogas e biopolítica na era farmacopornográfica. São Paulo: N-1 Edições; 2018.. Biotechnological advances stand out, including the development of medicines by the pharmaceutical industry, such as contraceptive pills and treatments for erectile dysfunction. The author also analyzes the state use of female hormones, such as progesterone and estrogen, as a form of biopolitical regulation, especially regarding female bodies²⁸28 Preciado P. Testo junkie: sexo, drogas e biopolítica na era farmacopornográfica. São Paulo: N-1 Edições; 2018..

These forms of management and production of bodies occur under what Preciado calls pharmacopornographic biocapitalism, a context in which the construction of subjectivities is observed through biotechnological expansion, which is fed back from digital forms of access to information, stimulating the related desire with the modeling of bodies through surgery, the use of hormones, the application of supplements and synthetic prostheses, and the use of anesthetizing and psychotropic substances and medications. This context organizes not only the construction of bodies, but also desires and forms of construction of affections²⁸28 Preciado P. Testo junkie: sexo, drogas e biopolítica na era farmacopornográfica. São Paulo: N-1 Edições; 2018.. Such perspectives that intertwine the foundations of queer theory, gender theories and bioethics propose, under other paradigms, reflection on the essentializations and biologizations that guide the fields of knowledge in the Western tradition.

Based on Preciado’s propositions, we can question the bioethical implications and, in this sense, the role of bioethics itself in the reiteration and affirmation of cis-heteronormativity or, in another way, in the construction of an emancipatory potential of cis-heterodissident bodies and identities. As can be seen historically, and in this context of binarity and neoliberalism, such as governmentality and management of bodies and desires especially based on Michel Foucault’s propositions, some situations highlight bioethical conflicts in the context of sexual orientation and gender identity.

Thinking about a queer, deviant, sissy, fag bioethics or even its unfolding of ‘queer’ into ‘cuir’ based on a terminological restructuring from the South/Latin America, in a post-colonial context, implies contesting the forms of hegemony, of universalization and standardization, which converges with Vidarte’s proposals²⁹29 Vidarte P. Ética Bixa: Proclamações libertárias para uma militância LGBTQ. São Paulo: N-1 Edições; 2020.. His propositions become fundamental for thinking about a queer (bio)ethics and, with this, expanding not only the spaces of application of bioethical thinking, but forging a bioethical foundation that already has, from its base, the moral consideration of the body, queer, deviant, fag, sex-gender diverse subject and subjectivity.

In this sense, it becomes necessary to think about a localized (bio)ethics, as the idea of universalism is inevitably related to LGBTIphobia and its structural oppressions. A fag/queer (bio)ethics must have as its foundation the reflection on the identities and subjectivities of the LGBTI+ population as structures, in order to oppose structural homophobia. It is in this sense that this queer (bio)ethics must intersect with an anti-racist, anti-fascist and anti-ableism perspective in its structure, in order to highlight the privileges that intersect different categories, such as race, gender and social class. Queer (bio)ethics must be anti-neoliberal par excellence²⁹29 Vidarte P. Ética Bixa: Proclamações libertárias para uma militância LGBTQ. São Paulo: N-1 Edições; 2020..

Vidarte’s²⁹29 Vidarte P. Ética Bixa: Proclamações libertárias para uma militância LGBTQ. São Paulo: N-1 Edições; 2020. proposal and his critique of universalism and the abstract subject are exemplified in what he calls ideal homophobia and real homophobia. In this sense, ideal homophobia is one that affects LGBTI+ people in an abstract way. Real homophobia can be understood as localized homophobia that must be contextualized territorially, economically and racially. This differentiation between ideal homophobia and real homophobia allows us to observe the forms of oppression that affect LGBTI+ subjects and that are not limited only to the issue of sexual orientation or gender identity, but are enhanced based on territory, social class and of the race.

From this perspective, it is also worth highlighting the criticism of neoconservatism among LGBTI+ people, particularly in a context of commodification in the light of neoliberalism of these sexual orientations and gender identities. The liberal and economic perspective on the promotion of LGBTI+ rights inevitably overlaps the idea of the individual with the idea of the collective. The breaking of oppressions²⁹29 Vidarte P. Ética Bixa: Proclamações libertárias para uma militância LGBTQ. São Paulo: N-1 Edições; 2020. is directed in the opposite way, as it must be established by reinforcing the idea of collectivity as a possibility for valuing the individual.

This perspective echoes the ideas of Jasbir Puar¹⁸18 Puar JK. Terrorist assemblages: homonationalism in queer times. London: Duke University Press; 2017.,¹⁹19 Puar J. Rethinking Homonationalism. Int. J. Middle East Stud. 2013; 45(2):336-339., specifically in the context of the incorporation of LGBTI+ people by the Nation-State and the neoliberalism that influences these processes. Homonationalism determines which bodies will be recognized by the Nation-State. Non-binary and non-white queer bodies often do not fit into this recognition due to standards of intelligibility and belonging. The intersections of gender, race and nationality, in this logic, are crucial in determining who will be recognized as part of the LGBTI+ community.

Although Puar focuses on the analysis of homonationalism in the USA¹⁸18 Puar JK. Terrorist assemblages: homonationalism in queer times. London: Duke University Press; 2017.,¹⁹19 Puar J. Rethinking Homonationalism. Int. J. Middle East Stud. 2013; 45(2):336-339., her contributions are relevant in this context, in which the hegemonic perspectives of bioethics and debates on queer theory are predominantly influenced by the Global North, especially the USA. The cultural and economic influence of the USA can also be seen in the dissemination of patterns of homonationalism beyond its borders, taking on forms of neo-imperialism.

Final considerations

In this article, our proposal is to contribute to an approachment between bioethics and queer theory from a post-colonial perspective. Secularism as a structuring principle of bioethics in opposition to a religious vision/ understanding of bioethics implies some reflections. Therefore, it is worth asking: to what extent can traditional bioethics that call themselves secular manage to deal with all the elements and categories that make up the bioethical proposal? In this sense, it becomes imperative to reflect on processes of historical reparation from a bioethical perspective in which binarism is identified as a key point to be overcome so that, effectively, a critical bioethics can be constructed that brings gender and sexual diversity to its foundations.

The persecution of LGBTI+ people under Nazi-fascist regimes exemplifies a eugenics macro-project that denied recognition of rights and protection of life to certain groups. Currently, the global criminalization of LGBTI+ people is still common, evidenced by restrictive laws in several countries. In the USA, bills aim to prevent advances in the rights of trans people³⁰30 Paiva P. População LGBTQIA+ Sob Ataque Nos Estados Unidos. Híbrida. 2023. [acesso em 2023 nov 16]. Disponível em: https://revistahibrida.com.br/mundo/eua-drag-queen-lei-anti-lgbtqia/.
https://revistahibrida.com.br/mundo/eua-... , reflecting social and institutional hostility. In Uganda, recent legislation imposes prison sentences, including the death penalty, for LGBTI+ people³¹31 Reuters D. Uganda promulga lei anti-LGBTQ que inclui pena de morte. CNN Brasil. 2023 maio 29. [acesso em 2023 nov 16]. Disponível em: https://www.cnnbrasil.com.br/internacional/uganda-promulga-lei-anti-lgbtq-que-inclui-pena-de-morte/.
https://www.cnnbrasil.com.br/internacion... , illustrating state repression based on sexual orientation and gender identity. The ban on LGBTI+ pride parades in Russia³²32 Thomas Kristen L. We’re Here, We’re Queer, Get Used to It: Freedom of Assembly and Gay Pride in Alekseyev v. Russia. Or. Rev. Int. Law. 2012; 14:473-508. and the threat of arrest for displaying the rainbow flag show how individual freedoms are under attack globally. In Brazil, the recent discussion about the ban on same-sex marriage³³33 Buss G. Comissão adia votação que pode proibir união civil homoafetiva [Internet]. Poder 360. 2023 set 5. [acesso em 2023 nov 16]. Disponível em: https://www.poder360.com.br/congresso/comissao-adia-votacao -que-pode-proibir-uniao-civil-homoafetiva.
https://www.poder360.com.br/congresso/co... reflects conservative opinions that deny fundamental rights based on sexual orientation. These examples highlight the urgent need for an analysis of these issues from a bioethical perspective, offering an ethical framework for examining policies and practices that affect the lives and dignity of LGBTI+ people.

The emergence of feminist bioethics highlights gaps in secular bioethical approaches, which do not adequately address issues of inequality and oppression. The simple claim of secularism is not enough to incorporate these complexities. It is essential that bioethics also declares itself feminist, anti-racist, anti-LGBTIphobic and anti-neoliberal to effectively address the challenges faced by people in vulnerable situations. The absence of a bioethical basis based on inequalities and oppression can perpetuate exclusion and social vulnerability.

Phenomena such as the rise of nazism, fascism and colonial domination in Africa highlight the importance of strengthening democratic institutions and the participation of historically excluded groups. Otherwise, these groups may be instrumentalized and have their lives belittled even in democratic settings. In the context of democratic regimes and the strengthening of human rights, it becomes increasingly necessary to discuss the basis of these rights and their universality.

Even after the emergence of the Universal Declaration of Human Rights, the binomial pathologization and criminalization still threatens non-normative sexual orientations and gender identities, demanding a bioethical approach committed to human rights and democracy. The confluence of these multiple knowledge points to the need to develop and strengthen interdisciplinarity and intersectionality between health/biomedical sciences and social and human sciences as a rich source of contributions that can theoretically constitute an important analytical framework from a bioethical perspective, in order to situate subjects, bodies and territories, historically and socially, without the sectoralization or cut-off that creates artificialities that become naturalized in scientific research and that perpetuate themselves over time as an immutable truth. The identification of inequalities and oppression is essential to contextualize society and individuals, considering their complexities and historical and social factors. A postcolonial bioethics must highlight historically subordinated categories, challenging hegemonic perspectives. In this sense, queer studies contribute to these reflections as they question the cultural and historically constructed binariness.

Some examples include the need to define the gender/sex of babies at birth, affecting the rights of intersex people; the pathologization of heterodiscordant orientations and identities; and the criminalization of doctors for carrying out pioneering genitalization surgeries in the 1970s in Brazil, accused of causing mutilations due to the lack of recognition of these surgeries at the time. How to promote an emancipatory bioethics in the face of heteronormativity and binarism in medical practices and the recognition of human rights? There is also the criminalization of sexual orientations and heterodiscordant gender identities in many countries, as well as the pathologization of transgenderism and the lack of recognition of the rights of LGBTI+ families. These issues highlight the need for specific public policies to protect this population, both domestically and internationally.

A clear example is the instrumentalization of the LGBTI+ agenda to create moral panic, such as the fake news broadcast during the presidential campaign in Brazil in 2018, about ‘cock baby bottles’ allegedly distributed by the Workers’ Party. Likewise, the creation of ‘gender ideology’ that opposes theories that question the naturalization of gender. The use of ‘gender ideology’, which can be understood as a discursive dispositif of a (bio)political and bioethical nature³⁴34 Carvalho HR, Oliveira FAG. A ideologia de gênero como dispositivo bioético político: políticas antigênero no Brasil, o crescimento da extrema direita e o papel contramajoritário do Supremo Tribunal Federal. Rev. Bras. Estud. Homocult. (no prelo) 2023., has influenced debates on sexual and reproductive rights, education on sexual orientation and gender identity, and adoption by LGBTI+ families. Such questions inevitably call upon bioethics as a disciplinary field, as they focus on the recognition of which people deserve legal protection and, as they do not have this legal, political and social recognition, they are unable to exercise the management of their own lives with autonomy and freedom. Furthermore, the impact on the mental health of children and adolescents includes LGBTIphobic bullying, disrespect for social names and the lack of discussion of gender and sexuality in schools. Therefore, it is essential to train not only education professionals, but also health professionals, integrating gender and sexuality into bioethics and collective health instead of treating them as isolated disciplines.

Thinking about a queer bioethics implies moving the debates and foundations of bioethics from the clinical-hospital-laboratory sphere and bringing it to the street level, of conflicts, disputes and forms of human segregation socially structured in complex historical-political processes. The contextualization of bioethics in a perspective of democracy, human rights and international relations in which the categories of sexual and gender diversity are highlighted allows us to design the scenarios that shape bioethics as a discipline, in contexts in which these elements are present and, on the other hand, when these rights/categories are restricted.

These reflections seek to point out the need to articulate bioethics with different categories and institutions and denaturalize the idea of an epistemological approach or distancing of bioethics from society. The isolation of this discipline from other categories, therefore, leads, albeit indirectly, to the reiteration of social inequalities and discrimination.

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