Forms of LGBTQIAPN+ vulnerability in Brazil

This integrative literature review identifies the forms of vulnerabilities experienced by lesbian, gay, bisexual, transgender individuals and as well as those of other identities in Brazil. The analysis of the five selected and classified articles revealed mental and physical vulnerabilities in contexts of violence, training environments, COVID-19, existence and deprivation of liberty. These vulnerabilities are historically associated with this community and have been accentuated over the years. Organization of social movements for this population and scientific production incentives are needed to afford greater visibility, reduce injustices and promote changes to the current scenario.


Forms of LGBTQIAPN+ vulnerability in Brazil
The political movement of lesbians, gays, bisexuals, transgender, and others (LGBTQIAPN+) emerged in Brazil following the establishment of similar political and social movements in North America and Europe.Originating in the 1980s, a period marked by the reopening of democratic processes after the military dictatorship, the movement gained significant momentum alongside endeavors aimed at enacting social reforms to mitigate inequalities 1 .
The LGBTQIAPN+ community frequently encounters instances of prejudice, violence, and societal marginalization, often perpetuated within institutional frameworks, including the realm of health care.This is primarily attributed to the prevailing binary, cisgender, and heteronormative societal framework, which marginalizes any deviations from its established norms 2 .
Given the context of vulnerability and inequality manifesting in both individual and collective contexts, this community has begun to advocate for improvements in quality of life, recognition of civil rights, and the pursuit of gender equality through political channels 3 .
Vulnerability can be characterized as the inability to safeguard one's interests 4 , with groups being deemed vulnerable based on intrinsic and extrinsic factors.According to Rogers and Ballantyne 5 , intrinsic factors center on the individual, while extrinsic factors encompass the socio-economic milieu and unjust societal conditions, calling for various measures to safeguard the concerned population.
Gradually, tailored programs and policies have been formulated for the community.For instance, the implementation of the National Policy for Comprehensive Health Care for Lesbians, Gays, Bisexuals, Travestis, and Transsexuals (PNSILGBT) in 2012 aimed to enhance equity in the services provided by the Brazilian Unified Health System (SUS) and eliminate institutional biases and discrimination 6 .Initiatives such as "Brazil Without Homophobia," the establishment of a General Coordination for the Advancement of LGBTQIAPN+ Rights, and the National Plan for the Advancement of Citizenship and LGBT Human Rights are some of the efforts to alleviate prevailing disparities 7 .
This study seeks to explore the primary manifestations of vulnerability affecting the LGBTQIAPN+ population within the Brazilian context.Given the outlined backdrop, a comprehensive assessment of key dimensions of vulnerability serves as a crucial instrument for spotlighting the issues at hand.This endeavor contributes to the broader endeavor of safeguarding the health, well-being, and overarching rights of this community.

Method
This study undertook an integrative review approach.Departing from the identification of the central issue and the guiding question, the process involved delving into the scientific literature, determined by predefined inclusion criteria.Subsequently, the collected data were structured, analyzed, and the resultant findings were deliberated upon.
The study was carried out from September to October 2022, with a specific focus on the guiding query: What are the primary manifestations of vulnerability prevalent within the LGBTQIAPN+ community in Brazil?To address the subject, health science terminologies (DeCS/MeSH) were employed in combination with Boolean operators across databases such as SciELO, LILACS, and PubMed.The search queries included terms like "social vulnerability or health vulnerability and sexual and gender minorities and Brazil." A succinct overview of the procedure for selecting and treating the chosen articles is outlined in Figure 1, employing a flowchart that aligns with the recommendations established by the Prisma group 8

Results
From the database search, a total of 35 texts were located.Out of these, two were closed-access articles, and eight were duplicates.Among the remaining 25, which were read in their entirety, 20 were rejected either for not addressing the guiding question or for presenting vulnerability dimensions similar to those found in another study analyzed during the pre-selection phase.As a result, five articles were chosen for the integrative review (Chart 1).Findings from studies in which the reported vulnerabilities resembled those of other works were incorporated into the discussion section.
Chart 1. Summary of articles selected for discussion, including title, authors, year, database, study approach, objective, and identified vulnerabilities

Discussion
As mentioned, studies yielding analogous outcomes to those chosen were harnessed to enrich the discussion.To encompass the multifaceted realms within which the LGBTQIAPN+ population is positioned and thoughtfully reflect upon them, a deliberate choice was made to categorize dimensions or contexts to reflect upon and classify the diverse forms of vulnerability.

Mental and physical vulnerability within the context of violence
The first study, signed by Pinto and collaborators 11 , works on a comprehensive examination of violence against lesbian, gay, bisexual, transgender, and queer individuals in Brazil.The authors underscore the most salient dimension of vulnerability afflicting this community-violence.By delving into the Notifiable Disease Information System, the authors ascertain a staggering 24,564 documented instances of violence against LGBTQIAPN+ individuals from 2015 to 2017.This encompasses cisgender homosexuals and bisexuals, alongside transgenders and travestis.
Notably, cases involving persons of Black ethnicity were prevalent across all assessed http://dx.doi.org/10.1590/1983-803420233470EN Forms of LGBTQIAPN+ vulnerability in Brazil age groups.Another pivotal revelation pertains to the venues in which these incidents predominantly occur: the domicile, trailed by public spaces and educational institutions 11 .
Following physical harm, psychological or mental violence emerges as the foremost category in reported notifications 11 .Instances of mental violence, characterized predominantly by humiliation, verbal derogation, prejudiced speeches, as well as threats, bear considerable potential for long-term issues.These may lead to traumas or enduring "triggers" persisting throughout an individual's life.Moreover, such aggressions give rise to barriers and patterns that extend into other physical and psychological consequences, thus engendering a pernicious cycle of harm 12,16 .
While violence directed at the LGBTQIAPN+ community, or LGBTphobia, is the most conspicuous manifestation of vulnerability to which this minority is exposed, it is essential to recognize that this community still lacks access to full security and rights 17 .Notably, in June 2019, the Brazilian Supreme Federal Court deemed LGBTphobia a criminal offense through Law 7,716/1989 18 , which addresses discrimination based on race or color, until more exclusive legislation is formulated.However, the pressing need for protective strategies and measures remains.
It is vital to underscore that the data analyzed by the authors pertain solely to reported cases within the system.Therefore, acknowledging that the underreporting of incidents conceals the true reality is of paramount importance.In the backdrop of apprehension regarding prejudice and other forms of mistreatment 19 , healthcare practitioners must assist victims of violence and meticulously document such incidents, aligning with the tenets of the PNSILGBT 6 .

Vulnerability within the context of formative environments
Matta and collaborators 12 undertook a qualitative analysis study examining the perceptions of high school students concerning sexual diversity.Drawing from a sample of 132 students from both public and private schools, the study noted a level of acceptance and visibility toward sexual minorities.Additionally, a notable share of students identified themselves as non-heterosexual.
The school milieu carries substantial potential for engaging with this theme and plays a pivotal role during formative years, particularly high school, in fostering understanding and broadening perspectives.Although contexts that involve increased interaction with LGBTQIAPN+ individuals tend to mitigate instances of LGBTphobia 20 , the prevalence of vulnerability factors since early schooling is still noteworthy.Despite the gradual acceptance of the notion of sexual diversity, educational environments still serve as a breeding ground for prejudiced viewpoints and initial encounters with LGBTphobia 21 .
This assertion is bolstered by the findings of Pinto and collaborators 11 , which identified schools as the third most prevalent setting for instances of violence.Matta and collaborators 12 also highlight that instances of intolerance are chiefly directed at students who deviate from cis-heteronormative expectations.Students interviewed express discomfort with gestures, clothing, and comments from peers that express attributes incongruent with their biological sex.
In response, educational institutions should formulate strategies to counter and eradicate prejudiced perspectives, introducing initiatives or educational programs focused on sexual diversity and tackling bullying 22,23 .This includes combating the selective discrimination that is present even within the LGBTQIAPN+ community, where individuals who identify as gay, travesti, or transgender with strong feminine behaviors encounter higher degrees of prejudice than those conforming to conventional masculine standards 24 .

Vulnerability within the context of the COVID-19 pandemic
The emergence of the COVID-19 pandemic in late 2019 and early 2020 reverberated across various aspects of people's lives, posing novel challenges within the realm of health.Moreover, this health crisis exacerbated existing vulnerabilities, magnifying the disparities for those already struggling with precarious situations 25 .
Sousa and collaborators 13 expound upon the repercussions of the pandemic on the lives of LGBTQIAPN+ persons.Given the plethora of vulnerabilities inherent in the day-to-day experiences of these individuals, the pandemic has triggered adverse effects, accentuating disparities http://dx.doi.org/10.1590/1983-803420233470EN Forms of LGBTQIAPN+ vulnerability in Brazil across various domains, including personal relationships and the healthcare milieu.
One fragility underscored in a study 13 pertains to domestic vulnerability, which was exacerbated by the pandemic situation.The strategy of social isolation implemented to curb the spread of the SARS-CoV-2 virus led to extended periods of confinement at home.LGBTphobia present within familial contexts manifests through a lack of acceptance and acknowledgment of sexual orientation and/or gender identity, resulting in verbal altercations, physical confrontations, and emotional distress 26 .
The prolonged social isolation during the pandemic also led to the constriction of access to secure spaces and a sense of belonging.In cases where familial support systems are fragile, seeking refuge becomes even more challenging 27 , rendering individuals more susceptible to abuse and violence within their own homes.This reality is further illuminated by a Pinto and collaborators' study 11 , which revealed that even before the pandemic, the primary site for occurrences of violence was inside the familial space.
Another aspect highlighted by Sousa and collaborators 13 is social vulnerability, evident in the precariousness of employment opportunities, which are largely informal and were further compromised during the pandemic.This economic hardship has driven individuals to resort to extreme measures, including engaging in sex work.However, this choice introduces additional vulnerabilities, including a heightened susceptibility to sexually transmitted infections (STI)-such as HIV/AIDS or even COVID-19 itself 28 .
Within the health domain, the landscape shaped by the rapid transmission of the novel coronavirus, coupled with delayed governmental interventions and the backdrop of stigma against the LGBTQIAPN+ population, has engendered additional obstacles in accessing healthcare.This is particularly pertinent for those who rely on SUS for treatment of STI, leading to the marginalization of specific needs 29 .
Pre-existing frailties are evident in health promotion and disease prevention strategies targeting the LGBTQIAPN+ community, and the COVID-19 situation has further exacerbated this state of affairs.It becomes clear that instituting awareness and information dissemination strategies is pivotal in furnishing the necessary support for novel coping mechanisms.

Social vulnerability within the context of existence
Gomes and collaborators 14 delve into the construction of gender identity expression and its significance in acknowledging and accommodating the needs and distinctiveness of individuals who do not conform to the cisgender heteronormative paradigm.However, socio-cultural constructs still deem identities that do not conform to cis bodies and/or a binary system of sex as pathological and, therefore, outside the norm 30 .
Throughout history, the LGBTQIAPN+ movement has been defined by the endeavor to secure recognition for the existence of these individuals.The notion of the "non-subject," as explored by Butler 31 , originates from deviating from the enforced pattern of heteronormativity.This socially constructed regulatory mechanism is built upon predetermined behavioral norms, where any deviations or traits that deviate (biological sex, sexuality, gender identity) are deemed abhorrent, unseen, and dehumanizing 32 .
Consequently, individuals outside this imposed framework are marginalized and vulnerable across all domains, with their rights denied due to their lack of acknowledgment.Those straying from the cisgender heteronormative paradigm are even more susceptible to instances of violence and vulnerability compared to LGBTQIAPN+ individuals who conform to this construct.
Additional exacerbating factors, such as structural racism, disproportionately target black LGBTQIAPN+ individuals 33 .According to the study by Matta and collaborators 12 , these characteristics manifest within educational institutions through the intolerance faced by homosexuals who do not align with the heteronormative standard.This hostility compels these individuals to conceal or mask their sexual orientation and/or gender identity.
The operation of the cis-heteronormative and binary model is evident within the realm of public health, where gender identity serves as a significant determinant of health.The healthcare system cannot still educate professionals and formulate tailored strategies to enhance the wellbeing of this demographic 34 .

Vulnerability in the context of imprisonment
Souza and collaborators 15 explore the challenges of providing healthcare assistance to LGBTQIAPN+ individuals within the Brazilian prison system through a comprehensive review of literature and documents.Their analysis paints a somber picture of the reality faced by the community, often relegated to the fringes of society and occasionally forced into prostitution and criminality.
Within the context of incarceration, conditions mirror those experienced in the broader daily life of the LGBTQIAPN+ community.However, these difficulties are compounded by individual, societal, and systemic vulnerabilities specific to the prison environment.This includes disregard for fundamental rights guaranteed by the Constitution, such as access to healthcare 15 .
Similar to the public healthcare system, the prison environment also aligns with the cis-heteronormative model, leading to elevated rates of violence, bias, and isolation.This strips individuals who diverge from the norm of their basic rights 35 .Consequently, aside from being rendered invisible, this population becomes more susceptible to complications arising from illnesses, particularly HIV/AIDS 36 .

Final considerations
Despite Brazil's rich demographic diversity, persistent inequality prevails due to a negative outlook toward minority communities.The LGBTQIAPN+ population in the country, while sizable, continues to grapple with challenges related to the assertion of their rights and fundamental conditions for their existence, including access to healthcare, equitable job opportunities, safety, and respect.
Embedded within Brazil's historical social norms, the oppression propagated by the cisheteronormative system is evident.This system humanizes solely those bodies that align with the anticipated norm of sexual orientation and gender identity.Such an oppressive mechanism views sexual and gender diversities as deviations from the prescribed norm, relegating individuals to invisibility and undermining their social rights.This process engenders vulnerabilities that jeopardize both an individual's physical well-being and societal integration.
Violence targeting LGBTQIAPN+ individuals, manifesting as the most conspicuous manifestation of these vulnerabilities, initiates within educational environments and intensifies within contexts that restrict avenues of escape.It becomes even more pronounced in settings where already fragile fundamental rights fail to extend protection to these individuals.National policies like the PNSILGBT endeavor to mitigate inequalities in healthcare but call for further enforcement.Moreover, continual training and education for healthcare professionals are imperative, focusing on enhancing their aptitude for providing an inclusive and attentive environment for specific groups.This is pivotal for fostering comprehension and guiding these socially vulnerable populations.
The uncovered studies hold immense value in comprehending and delving into the realm of vulnerabilities experienced by the LGBTQIAPN+ community, as well as the nuances associated with delivering care within social and healthcare networks.Presently, there is a discernible momentum and significance attached to this agenda, underscoring the demand for more research and propositions addressing this subject matter.Such studies should aspire to decrease disparities and usher in transformative changes within the current landscape.

Érica
Quinaglia Silva is a research productivity fellow of the National Council for Scientific and Technological Development of Brazil.
Flowchart illustrating the systematic procedure for article selection, following Prisma guidelines.