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Cadernos de Saúde Pública

ISSN 1678-4464

37 nº.9

Rio de Janeiro, Setembro 2021


QUESTÕES METODOLÓGICAS

O Inquérito Nacional de Saúde LGBT+: metodologia e resultados descritivos

Juliana Lustosa Torres, Gabriela Persio Gonçalves, Adriana de Araújo Pinho, Maria Helena do Nascimento Souza

http://dx.doi.org/10.1590/0102-311X00069521


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RESUMO
A compreensão das demandas de cuidados de saúde e das possíveis barreiras ao acesso pode apoiar a formulação de políticas e as melhores práticas voltadas para a população de lésbicas, gays, bissexuais, transgêneros e identidades relacionadas (LGBT+). O Inquérito Nacional de Saúde LGBT+ teve como objetivos caracterizar a população LGBT+ durante a pandemia da COVID-19 e especificar as características da pandemia da COVID-19 nessa população. Este é um estudo transversal online com uma amostra de conveniência de 976 indivíduos identificados como LGBT+ com idade 18 anos ou mais, no Brasil. O inquérito permite a investigação da sexualidade, discriminação, homofobia interna, comportamentos relacionados à saúde e acesso a cuidados de saúde. O inquérito adota um arcabouço conceitual (p.ex.: ferramentas e medidas validadas) comum a outros estudos epidemiológicos, o que permite comparações. O artigo descreve a metodologia do inquérito, alguns resultados descritivos e indicadores de saúde selecionados, em comparação com a Pesquisa Nacional de Saúde. A maioria dos participantes era do Sudeste (80,2%), com média de idade de 31,3 (± 11,5 anos). Com relação à COVID-19, 4,8% testaram positivos. As taxas de episódios semanais de discriminação (36%) e de prevalência de depressão (24,8%) eram altas na população LGBT+ brasileira, o que destaca a saúde mental e a homofobia como preocupações no contexto LGBT+ durante a pandemia. Embora tenha transcorrido uma década desde a implementação da Política Nacional de Saúde Integral LGBT, ainda é necessário treinamento de profissionais de saúde para oferecer serviços adequados. O conhecimento das demandas específicas de saúde nesse grupo pode orientar melhores práticas centradas na pessoa, promover ambientes de acolhimento de minorias sexuais e contribuir para maior equidade durante a pandemia.

Saúde Mental; Política Pública; Estudo Observacional; Sexismo; Minorias Sexuais e de Gênero


 

Introduction

In 2011, Brazil instituted the National Policy for Comprehensive LGBT Health (PNSI-LGBT) 1. According to the policy, there is a need for a further guarantee of health access, vigilance, and adequate training of health professionals to offer the appropriate services to the lesbian, gay, bisexual, transgender, and related identities (LGBT+) population. However, homophobic practices 2 are still present among health professionals in various contexts, including the use of the derogatory terms toward members of this group and the disrespect of the social name 3.

The health needs of the LGBT+ population differ from those of heterosexual individuals due to particular characteristics of its members, as well as due to considerable levels of stress experienced by LGBT+ individuals for constituting a minority (minority stress). They are subject to face normlessness and lack of social control since the dominant culture, social structures, and norms do not typically reflect those of the minority group 4,5. A meta-analysis showed that the LGBT+ population has a higher probability of suicide 6 and worse health-related behaviors 7 than heterosexual individuals. Social interaction is crucial for the development of a sense of well-being, such as receiving formal and informal social support from a primary health care provider and relatives 8,9,10,11. In the case of the LGBT+ population, formal support is improved by properly training the health team regarding LGBT+ topics 12,13.

Several authors highlight the challenge for health professionals in providing health care to the LGBT+ population due to transversal health practices instead of longitudinal ones 14. For example, in Brazil, all community health workers from one area of Rio de Janeiro reported that they had provided services to at least one LGBT+ person. However, 19.2% of them had identified prejudice and delays in services as barriers to adequate health services 15, demonstrating a lack of continuity of care 3. This absence of continuity has increased the interest in identifying the broader sociocultural determinants related to vulnerabilities, stressful events, needs, and care management of the LGBT+ population, as well as the role of social networks in coping with the issues previously mentioned 16. In this context, three aspects should be considered to achieve comprehensiveness in health care: the health professionals' practice, the organization of health services, and policymaking 17.

During the COVID-19 pandemic, stay-at-home practices have been increasingly encouraged. In Brazil, in March 20, 2020, the Ministry of Health officially announced the modes of transmission of the virus throughout the community and implemented initial social distancing strategies 18. Since then, several historic and structural vulnerabilities related to social inequalities in Brazil 19 have emerged. Consequently, it is important to emphasize the significance of identifying the health issues and needs of the LGBT+, especially during this period, where numerous individuals have been struggling to cope with the crisis financially, mentally, or physically 20. The domestic violence rate is rising rapidly 21, along with difficulties in adhering to social distancing measures 20,22, as well as adverse psychological distress 23,24, including increased loneliness, social isolation, and reduced social support 25,26. Although similar outcomes were also seen in Brazil 27,28, previous studies did not specifically focus on extensive health characteristics during the pandemic, such as sexuality, discrimination, and internal homophobia. Torres et al. 28 focused on HIV testing, oral pre-exposure prophylaxis access, and sexual behavior, whereas #VoteLGBT study (2020) 27 focused on mental health impacts and family social networks without any valid instruments. Both studies were conducted during the initial months of the pandemic 27,28. To the best of our knowledge, this is the first study conducted among LGBT+ Brazilians adopting a wider health conceptual framework (i.e., validated tools and measures), common to other epidemiological studies, allowing comparisons with other published research.

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

Methods

Study design

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

Sample

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

Considering that the LGBT+ individuals represent 3% of the total population in another country 12, we expect to have a target LGBT+ population of nearly 4.7 million in Brazil. Considering the conservative prevalence of the main outcomes (50%, sample error = 5%), at a level of significance of 99%, we needed at least 664 respondents.

Initially, the survey link was shared on social media (i.e., Facebook, Instagram, and WhatsApp), the webpages of the researchers, and their students and friends using hashtags related to scientific research and LGBT+ topics, several webpages related to LGBT+ issues, and the webpage of a famous person in Brazil. The study was also advertised on the official websites of the participating universities, through face-to-face contact with students, and via radio and online press. Finally, we also contacted LGBT+ groups and associations and promulgated the study in some primary health care units 29. All individuals who accessed the questionnaire and agreed to participate were included, representing a convenience sample.

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

Measurements

The researchers and a consultant team, composed of students, primary health professionals, and LGBT+ individuals, constructed the questionnaire. Measurements included sociodemographic characteristics, health-related measures (i.e., diseases, behaviors, health care access, and experiences with health care 30; sexuality; 19-item Internalized Homophobia Scale31, including the perception of internal stigma and social oppression; violence; 6-item Perceived Everyday Discrimination Questionnaire32, including being treated with less courtesy or respect, receiving poorer service at restaurants or stores, receiving poorer service from doctors or hospitals, people acting as if you were not clever, people acting as if they were afraid of you, and being threatened or harassed; 3-item UCLA Loneliness Scale33; and social network.

Quality assurance and control

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

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

Study management

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

Ethical approval

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

Data comparability

We used data from the recent Brazilian National Health Survey (PNS, in Portuguese), conducted in 2019, to compare the health-selected indicators of our LGBT+ health survey respondents with those of participants from the national survey. PNS data and descriptive results are publically available at (https://www.ibge.gov.br/estatisticas/sociais/saude/9160-pesquisa-nacional-de-saude.html). However, some 2019 microdata was not available at the time, precluding us from an individual-level PNS analysis. The PNS is a nationally representative study of the general Brazilian population aged 18 years and above, conducted in a probabilistic private household sample from urban and rural areas. The sample size was calculated according to 53% of the primary unit sample of Brazil, totaling 17,261 participants. Additional information can be found in the pertinent literature 34.

Statistical analyses

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

Results

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

 

 

Tab.: 1
Table 1 Characteristics of the Brazilian LGBT+ population. The Brazilian LGBT+ Health Survey, August-November 2020 (N = 976).

 

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

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

 

 

Tab.: 2
Table 2 Selected health indicators of the participants in the Brazilian LGBT+ Health Survey (August-November 2020, N = 976) and participants from the Brazilian National Health Survey (PNS; 2019, N = 17,261).

 

Discussion

The Brazilian LGBT+ Health Survey in this study provides data from a population that is neglected in most of the nationally representative studies in Brazil. The covered topics included an array of characteristics. Despite the concentration of respondents in the Southeast region and the significant number of highly educated individuals compared to a previous published national study 35, we demonstrate that both weekly episodes of discrimination and depression prevalence among the LGBT+ population were high in Brazil. Regarding the perception of homophobia, a higher proportional score for social oppression was found compared to the internal stigma component score.

Our data emphasize mental health, discrimination, and social oppression as major concerns in the LGBT+ context 36,37,38 and during the COVID-19 pandemic 20,22,23,24,25,28. Even though the PNSI-LGBT was instituted in 2011 in Brazil, discrimination in health services is still a barrier to achieving better mental health 6 and health-related behaviors 7, and complete health care access 3 for LGBT+ individuals. The LGBT+ population is likely to suffer from minority stress 4, including both distal stressors (i.e., prejudice or discrimination events or conditions) and proximal stressors (i.e., concealment of sexual orientation, and internalization of societal stigma), generating allostatic overload (i.e., negative health consequences due to chronic stress exposure) 5. Countries with higher levels of aggregate LGBT+ acceptance show better individual self-rated health and well-being 39. In Brazil, higher social oppression related to homophobia explains the increased rate of both physical violence against the LGBT+ population 40 and suicidal ideation among its members 41. However, we cannot discard the possibility of overreporting discrimination in online surveys 42.

One mechanism related to heightened stress during the COVID-19 pandemic, coupled with social distancing, loss of social support, and increased social media use, is the higher alcohol 43 and tobacco misuse reported by respondents during this time. After three months of social distancing measures, LGBT+ women's social media postings related to alcohol use moved from only “associated with parties” to “socialization” and “dealing with COVID-19” 43. In an online survey of alcohol and tobacco use in Brazil, LGBT+ respondents who reported alcohol and tobacco use before the COVID-19 pandemic, showed an increase in the consumption of these substances during the pandemic (29.7% vs. 49.4%) 28, which partially explains the higher rate of their consumption in our sample, compared to that among the PNS participants.

Another mechanism to alleviate stress among LGBT+ individuals is the adequacy of interventions to protect the affected persons 16 and to generate more appropriate health care use 11. However, we demonstrated that fewer LGBT+ individuals have been using a reference health service, probably due to difficulties in health care access during the pandemic 28 or poor inclusivity approaches of health professionals 12,44. Therefore, knowledge of specific health demands of the LGBT+ population is the key 1,44,45 to strengthening patient professional connectedness and promoting high-acceptance settings for sexual minorities. Our results might guide person-centered best practices in primary health care, such as creating welcoming conditions inclusive of LGBT+ patients, fostering an environment that supports and nurtures all patients and families; facilitating the disclosure of sexual orientation and gender identity, advancing effective communication; and promoting community involvement and advocacy 45.

Regarding testing positive for COVID-19, we found a higher prevalence (4.8%) than previously reported by Torres et al. 28 in a Brazilian LGBT+ sample (1.7%). However, Torres et al. conducted an online survey from April to May 2020, whereas our study was conducted from August to November 2020; therefore, the increased infection rate in our study was expected. In November 2020, the COVID-19 prevalence among the general Brazilian population accounted for nearly 3% (https://www.worldometers.info/coronavirus/country/brazil/, accessed on 03/May/2021), close to the prevalence found in our sample. Data from the United States did not find any difference in testing positive for COVID-19 between LGBT+ and non-LGBT+ individuals (10.3% vs. 8.6%) 20. Nevertheless, the LGBT+ population in Brazil 28 and other countries 20,22 reported difficulties in adhering to social distancing measures, mainly due to socioeconomic vulnerability 28 and adverse psychological distress 20,22,23,24,25,28.

Our study has limitations that must be acknowledged. First, the LGBT+ health survey was conducted online, decreasing the response rate, which is inherent to online surveys. Second, only respondents with Internet access were included. In Brazil, Internet access has not yet reached the whole population (79.1% of Brazilians had Internet access in 2018 46 and it is not available among the most vulnerable groups. Third, comparing data from a non-representative online sample with those from a representative household sample might introduce both selection and information bias, precluding us from further interpretation. However, considering the unavailability of nationally representative datasets and the difficulty in developing a nationally representative study of the LGBT+ population, this study might contribute to the beginning of an understanding of the health needs of its members and the obstacles they face when using health care services. Further online studies should consider weighting in their surveys, considering all Brazilian regions to achieve national representativeness and avoiding overrepresentation of some states, as we found in the case of Rio de Janeiro and Minas Gerais, the states with the highest number of respondents and where the participating universities were placed. Additionally, we encourage a face-to-face recruitment in different vulnerable settings, providing the appropriate material to access the questionnaire. Further, the strengths of this study include anonymous recruitment, which is considered at more effective way of increasing adherence in this population. Moreover, this is the first study in Brazil with a broad coverage of respondents from the five geographical regions of the country and questions regarding a wide range of health dimensions.

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

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