Profile of notification of violence against Lesbian, Gay, Bisexual, Transvestite and Transsexual people recorded in the National Information System on Notifiable Diseases, Brazil, 2015-2017

REV BRAS EPIDEMIOL 2020; 23: E200006.SUPL.1 ABSTRACT: Objective: This study aimed to describe the profile of notifications of violence against LGBT people in Brazil, from 2015 to 2017. Methods: This is a cross-sectional descriptive study with secondary data on records of violence against LGBT people. The study population included individuals aged 10 and older with homosexual or bisexual orientation as well as transvestites or transgender identities. Results: Throughout the study period, 24,564 reports of violence were recorded. Regarding the victim’s profile, 69.1% were 20 to 59 years old, 50.0% were black, 46.6% were transsexual or transvestites and 57.6% were homosexual, of which 32.6% were lesbian and 25.0%, gay. In all age groups, the most frequent nature of violence was physical violence (75.0%). The probable author was male in 66.2% of the cases, being intimate partners the most frequent aggressors (27.2%), followed by strangers (16.5%). Conclusion: This study expands knowledge of violence against LGBT people in Brazil, reinforces the need to report these events and improve quality of information on individual’s sexual orientation and gender identity in order to produce evidence to support actions to tackle this problem.


INTRODUCTION
Violence is a global public health problem 1 . In addition, non-fatal violence affects tens of thousands of individuals daily. In Brazil, data from the 2013 National Health Survey showed that 3.1% of adults (≥18 years old) suffered some violence or aggression by an unknown person in the last 12 months prior to the interview, which corresponds to 4,604,000 Brazilians. The proportion of adults who were assaulted by an acquaintance was 2.5%, or 3,704,000 individuals 2 .
According to the data from Dial 100 (Disque 100), a service that receives, analyzes and forwards reports of human rights violations, a total of 12,477 complaints involving 22,899 violations committed against lesbians, gays, bisexuals, transvestites and transsexuals (LGBT) were received in Brazil between 2011 and 2017 3 . The data refer to reported violations, which do not correspond to the total number of daily violence against LGBT people. It is noteworthy that this scenario is worrying due to the underreporting of data related to LGBTphobic violence.
Violence is a complex, polysemic and multifactorial phenomenon, which can result in a myriad of consequences for the victim's physical and mental health. In order to monitor and give visibility to the problem, the Brazilian Ministry of Health implemented the Violence and Accident Surveillance System (Sistema de Vigilância de Violências e Acidentes-VIVA) and, in 2011, notification of violence became mandatory for all health services in the country 4,5 .

Palavras-chave:
Violência. Vulnerabilidade em saúde. Equidade em saúde. Minorias sexuais e de gênero. social conditions and representations associated to them, the National Comprehensive Health Policy for LGBT people (PNSILGBT) was instituted. This initiative is in line with the need for public policies focused on equity and defined through processes of social participation in the Unified Health System (Sistema Único de Saúde-SUS), such as LGBT health conferences 6,7 .
Considering the deliberations from the 13 th National Health Conference (2007), the Ministry of Health was responsible for including the questions of sexual orientation and gender identity in SUS information systems. Thus, in October 2014, new fields were included in the individual notification form of interpersonal/self-inflicted violence, such as social name, sexual orientation, gender identity and motivation of violence, making it possible to identify cases of violence towards the LGBT population 8 .
Sexual orientation is understood as the ability to have, feel, or develop emotional, affective or sexual attraction for another person(s). The sexual orientations presented in the notification form are 8 : heterosexual, person who is attracted or has relationships with people of the opposite sex/gender; homosexual (gay/lesbian), person who is attracted or has relationships with people of the same sex/gender; bisexual, person who is attracted to or has relationships with people of both sexes/genders.
Gender identity is the expression of an identity constructed based on how persons recognize themselves or presents themselves in relation to their own gender, and which may or may not correspond to their biological body. Gender identity, in its different expressions, may or may not involve changes in appearance or body. The gender identities presented in the notification form and self-declared by the users of the services are 8 : transvestites and transsexual women, who were born in a body designated as male and, because they do not identify with the male socio-cultural attributions, identify themselves with the female gender, according to their biopsychosocial well-being; transsexual men, who were born in a body designated as female and, because they do not identify with the female socio-cultural attributions, identify with the male gender, according to their biopsychosocial well-being; and cisgender, a person whose gender identity identifies with the gender they were born, based on genital sex.
Studies show that assaults against the LGBT population are often lethal and preceded by symbolic violence 9,10 . However, one of the main challenges for the implementation of the PNSILGBT is the lack of official data on this population 11 and the consequent lack of knowledge of their reality, which makes public policy planning difficult.
Under this perspective, the present paper aims to describe the profile of notifications of violence against LGBT people in Brazil from 2015 to 2017. Thus, this analysis may contribute to raising awareness about the problem and to the implementation of public policies for its confrontation, in addition to supporting the prevention of violence and the promotion of a culture of peace.

METHODS
This is a descriptive study of epidemiological profile of notifications of interpersonal and self-inflicted violence in LGBT people. The data were extracted from the Information System for Notifiable Diseases (Sistema de Informação de Agravos de Notificação-SINAN) and comprised the notifications registered by health services in Brazil from 2015 to 2017. This time frame refers to the years when it was possible to record information on sexual orientation and gender identity 8 Brasil-DATASUS).
Two different and independent variables from the notification form were used to contemplate the diversity that encompasses the LGBT population: sexual orientation and gender identity. For the study population, we selected notifications with the variable sexual orientation filled out as homosexual (gay/lesbian) or bisexual, and notifications with the variable gender identity filled out as transvestites, transsexual women, or transsexual men. Considering the intersections of sexualities and gender performances, notifications against heterosexual individuals are present in this study, as long as their gender identity is transsexual or transvestite, as well as cisgender individuals, as long as their sexual orientation is gay/lesbian or bisexual.
The notifications were described according to the characteristics of people in situations of violence (age group, ethnicity/color, disability/disorder, education, sexual orientation and gender identity); the characteristics of violence and the probable perpetrators (place of occurrence, recurrent violence, if the injury was self-inflicted and types of violence, number of people involved, sex and link of the person served with the probable author), according to the age groups 10 to 14 , 15 to 19, 20 to 59 years and 60 years old or more. Information was obtained on the attempted suicide between reports of self-inflicted violence, based on the assessment of the type of violence variable 8 .
To assess the quality of the variables: sexual orientation and gender identity, completeness analysis was performed, considering the percentage of filling out valid data (which does not include ignored or unfilled cases).
Considering that the study used public domain information, with aggregated information and without the possibility of individual identification, consideration by the Research Ethics Committee (CEP) was not needed, as provided by Resolution No. 510, of April 7, 2016. Of the total reports of violence against LGBT people analyzed, 69.1% of the people served were adults and 24.4% were adolescents. Black ethnicity/color predominated in all age groups, reaching 57% among adolescents aged 10 to 14 years old. The presence of disability or disorder was higher among the elderly (13.7%). There was a higher proportion of individuals with the lowest level of education (up to elementary school) in the elderly (45.8%), and only 9.1% of adults with notification of violence attended higher education. The proportion of schooling ignored during the filling out increased with age, reaching 45.2% of cases among the elderly ( Table 1).

RESULTS
As to sexual orientation, notifications among lesbians were predominant among the age groups of 10 to 14, 15 to 19 and 20 to 59, with 33.5, 31.9 and 33.9% of cases, respectively. Notifications among gays were higher among the elderly, accounting for 31% of cases. Regarding gender identity, most notifications, in all age groups, were for transsexual and transvestite people (46.6%), followed by those among cisgender people (option not applicable) (31.2%) and ignored (22.3%). With regard to transgenders, notifications among transsexual women were more frequent for all age groups, with adolescents aged 10 to 14 at 37%, elderly at 36.3%, adults at 31.8% and adolescents aged 15 to 19 at 28.2% (Table 1).
In all age groups, the main place of occurrence of the reported violence was the home, ranging from 54.6% among adolescents aged 15 to 19, to 78.9% among the elderly. Public spaces were the second most frequent ones, representing 26.7% of the notifications against adolescents aged 15 to 19. In the case of adolescents aged 10 to 14, school stands out as the third most important place (6.1%). The reported violence was repeated in more than a third of cases, in all age groups (Table 2).
Self-inflicted injuries accounted for 29.9% of notifications among adolescents aged 15 to 19, 24.8% among adults, 18.4% in the 10-14-year age group, and 12.1% among the elderly (Table 2). Among the 6,043 notifications of self-inflicted violence, 29% were suicide attempts, which mainly occurred to adolescents aged 15 to 19 (22.7%) and adults (71%).  Regarding the type of violence, physical violence was the most frequent in all age groups, being thus distributed according to the life cycle: physical (45.9%) and sexual (40.7%) against adolescents aged 10 to 14; physical and psychological/ moral against people aged 15 to 19 (70.8 and 24.1%) and also against adults (79.1 and 30.6%); and physical (73.1%) and neglect/abandonment (27.7%) against the elderly ( Table 2).
The violence perpetrated by two or more authors represented 24.2% of the notifications, varying from 20.8% among adolescents aged 10 to 14 to 29.3% among the elderly. Most of the probable perpetrators of the violence were male, ranging from 59.1% among the elderly to 68.2% among adults (Table 2).
Family members were the most frequent authors of violence reported against adolescents aged 10 to 14 (29.4%) and the elderly (38.5%). Among adolescents aged 15 to 19, the aggressors of intrafamilial relationships (29.8%, considering family members and intimate partners) and strangers (19.5%) stand out. In adults, violence by intimate partners was more frequent (32.5%) (

DISCUSSION
There was a progressive increase in the number of notifications of violence against LGBT people registered in SINAN, which demonstrates the growing sensitivity of the health sector to situations of violence against this population. From 2015 to 2017, there were, on average, more than 22 notifications of interpersonal and self-inflicted violence per day, which means almost one notification per hour for LGBT people in Brazil. It is noteworthy that the highest number of notifications were found among lesbians and transsexual women. Such data reinforces the fact that, when the expressions of sexuality and gender break with the norms of society, this estrangement can be manifested in a violent way 12 .
However, this record refers only to the cases that requested assistance from the health services and in which the professionals proceeded with the notification. In other words, the data presented here constitute only a picture of the violence seen in health services against the LGBT population and are subject to the underreporting of events.
The high percentage of ignored cases in the variables sexual orientation and gender identity can be a consequence of prejudice and difficulties in the approach of these issues by health professionals. The report of discriminatory practices in establishments is recurrent, which negatively impacts the access of the LGBT population to health services, especially of transvestite and transgender people. Thus, it is stated the need for constant training of health teams for humanized care and guided by the PNSILGBT, as well as training for the proper filling out of the notification form.
A study carried out in the capital of Northeastern Brazil with analysis of the meanings attributed by 15 community health agents (CHA) to health care for the LGBT population showed that there is stigma and prejudice in health care and that the professionals interviewed bring traditional and heteronormative concepts to their job. In addition, little knowledge of the equity policy, low implementation of its guidelines in primary care and scarce provision of training for CHA were identified 13 .
In another study with 12 managers from a city in Paraíba State to assess their conceptions about the LGBT population, there was a lack of knowledge and some confusion about trans identity, limitations in understanding the affective-sexual experiences of lesbians, gays and bisexuals and blaming of the LGBT community for situations of violence and restrictions on access to health services 14 .
In most of the notifications analyzed, LGBT people identified themselves as black and were in the 20 to 59 age group. Divergent sexuality, which shifts from the normative cis heterosexual pattern, combined with structural racism, makes the LGBT black person even more vulnerable to situations of violence. However, it is believed that the experiences of violence and discrimination occur differently for lesbians, gays, bisexuals, transvestites and transsexuals, in which the social markers of ethnicity/color, class, generation, sexual orientation and gender operate intersectionally 15  The main places of occurrence of violence against LGBT people were the home and the street. In cases where there is violence in the private sphere, it is considered that the family or intimate unit does not function as a support and protection network, potentiating the damage caused by social discrimination experienced in public spaces. An ethnographic study with transvestites carried out in Santa Maria City (Rio Grande do Sul State) in 2012 exposed that the home is the place where violent attitudes of prejudice, discrimination and physical aggressions manifest early, culminating in the person being expulsed from home 16 .
Among adolescents, school was also a scenario for the occurrence of violence. The school environment is of fundamental importance in the life experience of adolescents and young people and, for people who demonstrate homo-affective behaviors, discriminatory practices and bullying are recurrent, reinforcing the social exclusion of students 17 . For the promotion of a plural and inclusive education, sexual and gender diversity must be debated in schools and continuing education on the topic are needed for teachers and professionals working in the education of children, adolescents, young people and adults 18 .
Repeated violence was observed in more than a third of the analyzed notifications. Health professionals must be trained to act in a humanized and efficient way in health care, promoting comprehensive care for people in situations of violence and articulating the network of protection and guarantee of rights to prevent new cases of aggression. In view of the complexity of the events, which take place both in private spaces, with people of intimate and affectionate relationships, as well as in public environments, the integrated performance of various sectors of the State and civil society is essential to tackle gender inequities and investment in actions to prevent and promote a culture of diversity 19,20 .
Physical violence was the most common type of aggression in all life cycles. However, in adolescents, sexual violence was the second most reported type. A survey conducted in three cities in the countryside of São Paulo State in 2009 showed a prevalence of victimization for sexual violence approximately twice as high among non-heterosexual adolescents compared to heterosexuals 21 .
Psychological/moral violence was the second most recorded type of notifications of violence against LGBT people in adolescents aged 15 to 19 and adults. Quite prevalent in the family and in the collective sphere, psychological violence is characterized by situations of humiliation, verbal aggressions and threats motivated by a prejudiced and heteronormative discourse that disqualifies LGBT people 22,23 . Neglect, identified in a higher percentage among the elderly, involves a multiplicity of motivations and varies from abandonment, the removal of family members due to the lack of appreciation for aging, to the cut-off by partners and discrimination by society 24 .
The most frequent perpetrator of the violence against adolescents and the elderly reported were family members. In adults, the most frequent perpetrators were intimate partners. The family's difficulty in accepting the sexual orientation and gender identity of adolescents has repercussions on psychological suffering throughout their lives. Thus, the family environment can present itself as the first space for discrimination and experiencing violence for LGBT adolescents. In the case of homo-affective and non-binary experiences, members can be considered deviant from the hegemonic rule and the family now has violent mechanisms for reprehending and complying with the norm.
It is observed the use of coercive, corrective, punitive practices and the violation of rights in the intrafamily environment, which can lead to death 25,26 . In this sense, the escape from the family context appears as a common way to maintain the mental and physical health of LGBT people. In addition, the practice of self-inflicted violence can be related to the rejection of sexual orientation and gender identity of individuals in the context of family relationships.
The presence of the sexual orientation and gender identity fields in the SUS violence notification form is an advance, serving as a reference for other similar initiatives in health information systems. The act of notifying triggers the process of inserting the person in a situation of violence into the care line and the safety net. The adequate record of violence against gays, lesbians, transsexuals, and transvestites in health services is articulated with the principles of universality and equity of SUS. It also has the role of generating evidence to support the development of guidelines and actions aimed at reducing inequities in an intersectional manner, closer to respect for human rights and the achievement of social justice [27][28][29] .
This study represented an important step towards expanding knowledge of violence against the LGBT population in the country. From 2015 to 2017, notifications of violence against lesbians and transgender women stood out, most of them carried out at home and perpetrated by people from family, intimate or affectionate relationships.
Health services are strategic places for the reception of people in situations of violence. In the case of the LGBT population, it is essential that health teams provide humanized care, considering the markers of gender, ethnicity/color, and sexual orientation to overcome inequities. Thus, constant training on the PNSILGBT in health services and a better understanding of the notification form and its role in the network to confront violence are of utmost importance.
As a limitation of this study, the data presented must be highlighted for representing a picture of the violence attended and reported in health services. Therefore, it is assumed that there is underreporting of cases and that the data presented does not reveal the prevalence of violence experienced by the LGBT population. Studies are suggested to assess the factors associated with interpersonal and self-inflicted violence in this group to identify risk factors and prevention strategies. It is also recommended to study the lethal violence against LGBT people, as well as the economic impact of this problem.
Finally, it is believed that it is the duty and role of the State to foster a culture of recognition of differences, and social and economic redistribution in the face of social injustices arising from intolerances to sexual diversity and gender expressions. In this way, the fields of health and education can contribute greatly to overcoming LGBTphobia, guided by strategies that promote a culture of peace, plural and inclusive education and prevention of violence, in guaranteeing respect for individual freedom and human dignity.