Sexual diversity: a perspective on the impact of stigma and discrimination on adolescence

The objective of this article is to analyze the impact of stigma and discrimination against the LGBT adolescents’ psychic suffering. Qualitative study conducted in a specialized outpatient service of Child and Adolescent Mental Health Secondary Care of the Federal District’s Health Secretariat. Nine adolescents participated. Indepth interviews facilitated data collection, and data were analyzed with Iramuteq software and Bardin’s Content Analysis. Gender identity and sexual orientation intolerance based on heteronormativity violate human rights and are relevant social determinants in health, and overcoming the psychological distress problems identified, combined with respect for human rights of the LGBT community, is an essential vector for facing adolescent health inequalities. Discrimination against LGBT adolescents is a social determinant that health services must address since its leads to harmful consequences, such as school dropouts, lack of opportunities, family bond losses, and suicidal behavior.


introduction
This study analyzes adolescent psychological distress related to discrimination and stigmatization vis-à-vis sexual orientation and gender identity.The social norms that regulate right and wrong underpin the set of behaviors and presentations shaping the character and identity of a community.Thus oppression, intolerance, stigmatization, and exclusion reveal the vulnerability to which specific individuals and groups are subjected for not being accepted.The different expressions of their sexuality and gender identity are considered abnormal.
The concept of abnormality refers to that which deviates from standards, and these are constantly variable 1 .The author believes that economic deprivation, and above all, visibility, civility, respect, and dignity seem to be the identifying mark of these subjects.
Goffman 2 argues that when normal and stigmatized meet face to face, they will objectively and directly address the causes and effects of a certain stigma, evidencing the individual's inability to fully accept it, inhibiting completeness in the face of the typical intersubjective relationships of community life.Stigma is then conceptualized from a profoundly disparaging attribute and can refer to body abominations and individual, tribal, racial, national, and religious guilt.
The attempt to neutralize such differencesin the media, scientific statements, or public initiatives -is constant insofar a movement requires individuals to take a stand and define their place in society.This is because discrimination and stigma are related concepts, in which stigma provides all the elements to reinforce discrimination and deriving segregating policies 3 .
The essence of these statements is marked by heteronormativity -the biopolitical mechanism of bodies, which establishes the heterosexual pattern of societies, especially western ones -, and the individuals not fitting in it will suffer marginalization and violence 4 .
In this context, several forms of prejudice and discrimination that minimize and discipline the life opportunities of the LGBT people are identified, highlighting this group's stigmatization.Therefore, the Ministry of Health established the National Comprehensive Health Policy for Lesbians, Gays, Bisexuals, Transvestites, and Transsexuals (PNSILGBT) 4 to eliminate prejudice, discrimination, and institutional intolerance and promoting full access to health by this population within the Unified Health System (SUS).
The acronym referring to sexual diversity currently includes more letters and expressions of sexuality and gender identity.However, we chose to standardize its presentation as presented by the policy, considering sexual diversity and gender identity in all nuances and specificities.Although this paper does not aim to discuss queer theory, the term "LGBT condition" is understood from the perspective of this theory, which suggests that sexual diversity and gender expressions should not be categorized motionlessly and pre-established in the male-female binarism rationale since they are fluid in a broad spectrum of possibilities, constructed, deconstructed, and socially and culturally reconstructed in the historical process 5 .Thus, the term "LGBT condition" refers to this perception of fluidity and movement, of being within a particular construction of sexuality and gender.
Currently, initiatives in the Legislative and Judiciary powers aim to ensure greater inclusion of sexual diversities in the legal sphere by regularizing the civil union or the criminalization of discriminatory practices, demanding from the State responses to ensure human dignity and fundamental freedoms 6 .
The protection of this minority group historically excluded from State policies is also corroborated by international regulations, such as the Universal Declaration on Bioethics and Human Rights (UDBHR), by UNESCO, published in 2005.The UDBHR proposes ethical reflection as a tool for governments to establish adequate laws and standards, consolidating and guiding health protection policies, stating that "no individual or group should be discriminated against or stigmatized on any grounds, in violation of human dignity, human rights and fundamental freedoms" 7 (p.8).
The World Health Organization defines adolescence as the period of life between 10 and 19 years of age, marked by an intense biological and psychological transformation, a phase of identity construction and adoption of values and behaviors 8 .Amid so many social pressures, adolescents become more susceptible to emotional conflicts and psychological distress, especially when they perceive themselves in non-conformity with heteronormative discourses 9 .In this context, many adolescents exhibit certain risk behaviors, including the thought of death and attempted suicide 9 .
Veale et al. 10 compared the condition of psychic illness among the LGBT population and "heterocisnormative" young people, highlighting the higher rate of depression, suicide, anxiety, eating disorders, and substance abuse in the first group, and fewer opportunities for work and education due to the suffering related to the experience of stigma and discrimination 11 .In this sense, "psychological distress is not reserved for those with a specific diagnosis but something found in everyone's life, which will acquire particular manifestations of each individual" 12 (p.14).
Therefore, the protection of this population is a unique feature to ensure human dignity, a condition inherent to human beings.Human dignity presupposes respect for the other through moral plurality and human diversity 13 .

Methods
This is an exploratory, descriptive, and qualitative study with adolescents serviced at a specialized outpatient mental health service for children and adolescents from the Secondary Care of the Health Secretariat of the Federal District (DF).This service was chosen because it is considered a reference center in the Federal District in adolescent health care and has a multidisciplinary team with specific LGBT adolescent care from comprehensive care, with individual and group servicing.Such practice aims to strengthen autonomy, belonging, and empowerment in the face of social exclusion resulting from non-normative gender identity and sexual orientation.
The convenience sample was selected by inclusion criteria: self-declared adolescent LBGT; receiving care at the service for at least six months; age 12-18 years; with the consent of those responsible.A sample group of nine adolescents was obtained, seven in the 14-17 years age group (77.8%) and two aged 18 (23.2%).Among them, five attended were from seventh to ninth graders (55.6%), three from first to thirdyear high school (33.3%), and one had completed high school (11.1%).
Data were collected through in-depth interviews with a semi-structured roadmap containing questions about the recognition of sexual orientation and non-normative gender identity, family perception and attitude, the experience of violence resulting from sexual orientation, and the role of health services.The researchers conducted the interviews at the health service premises from April to August 2019 and were recorded and transcribed in full.The excerpts of the participants' statements were identified with the letter A followed by the number of the interview.
Lexical analysis of the data was applied using the Iramuteq software (Interface de R pour les Analyses Multidimensionnelles de Textes et Ques-tionnaires), which allows classic textual statistical analyses, descending hierarchical classification, of similarities, word cloud, and group specificity research 14 .The software is not a method of analyzing data but a tool for processing them; that is, the data must be interpreted under the researcher's responsibility.Thus, Bardin's Content Analysis, a thematic modality 15 , was used to analyze the categories generated by the Iramuteq software.
This work was carried out with the School of Health Sciences (ESCS) support and followed the guidelines proposed by Resolution N° 466/2012 of the National Health Council and approved by the Research Ethics Committee of the Health Science Education and Research Foundation.

results
In the textual corpus analyzed using the Iramuteq software, using the Descending Hierarchical Classification (DHC) method, five classes emerged with the following percentage distribution in the presented results: class 1, 14.8%; class 2, 23.6%; class 3, 14.6%; class 4, 22.5%; and class 5, 24.6%.Figure 1 shows the dendrogram and the respective class names, together with the lexical analysis, that is, the words that were considered most significant.
Class 1 corresponds to family relationships, emphasizing the participation of the family in the context of violence; Class 2 refers to situations of psychological distress experienced by young people; Class 3 exemplifies discriminatory situations that highlight violent behavior and the mechanisms for coping with exclusionary attitudes; Class 4 corresponds to the importance of professional support to mitigate suffering; and Class 5 refers to the adolescents' individual, family and social perceptions of sexual diversity.
The results of the classes are presented below according to the reasoning that facilitates the theme, deviating from the order established by the Iramuteq software, to allow the reader a better understanding of the context presented by the adolescents in the thematic analysis of their statements.

Family relationships
Class 1 addresses family relationships, including their position regarding the sexual orientation and gender identity of the adolescents interviewed.The family's discovery of the adolescent's sexual orientation or gender identity is evidenced, facilitated by the breach of friend's confidentiality or the adolescent's declaration.We observed that the difficulties regarding sexual orientation or gender identity were unrelated to the structure, family composition, social class, or kinship.
However, traditional moral values are seen as factors that hindered adolescents' acceptance of sexual orientation or gender identity and exposed them to various violent situations, especially those related to religious values.These aspects uphold rejection and denial and act as a mechanism that enhances the feeling of oppression in the participants: Yes, my parents, they were looking for ... they were trying to understand, so much so that they took me to church to understand.It was even when they tried to say that they were going to do an exorcism on me.(A6) My grandmother is a pastor, her husband is a pastor, and my uncles are pastors.There was a church on the side of our house in which they gathered, so I always grew up in this religious... and oppressive environment, right?(A8) However, while most participants pointed to religion as the trigger of oppression, a report opposes this statement and emphasizes the importance of religion as an aid mechanism before hardships.In this sense, the Spiritist Center was a place of support and understanding, providing comfort and accepting the suffering adolescent: It helps a lot [religion] because most of them are from my family, who are from this Spiritist Center.There were days when I cried there.Then,   The maternal figure stands out among the family members as necessary support and comfort, favoring the adolescents to develop a feeling of adequacy to their own body and motivation to fight for their rights -for example, social name and use of clothes compatible with gender identity.It can be seen in this report that the mother's loving acceptance and respect for diversity acted as a mechanism to protect destructive behaviors -self-mutilation and suicide: My mother didn't know much about these cases or things.I was showing videos of trans girls to my mother, explaining what it was like; what it is like to be a trans girl.Then my mother was the one who hooked on the most, you know?She became more protective; she wanted to know more about it and helped me a lot.I've thought a lot about wanting to give up, but I have a wonderful family that likes me, and I think about it.(A2)

Prejudice situations and ways of coping
Class 3 addresses the discriminatory experiences that can favor social exclusion, giving rise to a feeling of shame and school dropout.
Among the reports, the statement of an adolescent with a female appearance and pansexual orientation stands out, which portrays the intense suffering resulting from sexual violence suffered at school, resulting in school abandonment, fear of going out, and self-perceived vulnerability.The severe report points to the violation of human dignity and State powerlessness, represented by educational institutions, to ensure the protection of these adolescents: So, let's say that, at the time of that school, I looked much more feminine than I do now.So, the boys there thought I was kind of that experiment they talk about, right?I was battered at school.I suffered collective rape from colleagues at my school, and it was when I really wanted to stop studying for health reasons.I didn't feel well in the school environment.It was when I felt vulnerable the most.(A6) In some families, we can observe the construction of social roles since childhood, for men and women marked by standards that define what is suitable for each gender, such as hair size, clothes, behavior, and games.In this line, the statement of a transsexual adolescent portrays punishment for not adopting a normative and desired behavior by the family, violating her rights, with exposure to a situation that disqualified the expression of her gender identity and exposed her to humiliation on social networks: When I was a child, there were remnants there that I was not a cis or straight person, and they scolded me a lot: my uncles mostly.My hair was already long, and people already mistook me for a girl.That was something for them that went: "oh, my God!"In 2017, at the beginning of the year, they shaved my hair.They shaved my hair, recorded a live on Facebook.Everyone in the house was there: my grandma, my grandpa, and my uncles.(A8)

Psychological distress
Class 2 shows the feelings of adolescents who experienced discriminatory situations causing intense psychological distress.Persistent situations of prejudice and violence promote negative feelings affecting the mental health of adolescents.Psychological distress can be recognized by the statements about isolation, fear, and sadness, limiting the social life of some adolescents, hindering an adequate and healthy routine.Thus, the fear of suffering new violence limits their involvement and inclusion in different social contexts, causing school dropout, withdrawal from friends, and loss of affective bonds: I attempted suicide four times already.I was hospitalized several times.I developed panic syndrome because of that.Moreover, it's because I was hospitalized, and it was bizarre.The mental and physical sequel is for the rest of your life, right?(A3) It's a trauma, a scar that stays there with you.

It's fear of going out or taking a bus. It's a trauma that remains, a huge scar that prevents you from living in the social environment. (A6)
In the context of discrimination, prejudice against gender identity can emerge significantly in the lives of adolescents who question themselves about their nature, body, and role.Prejudice then triggers an identity conflict and generates a constant need to reaffirm gender, as reported below by two transsexual adolescents: Then, I was always giving myself a trigger of who I was, who I am.So, I kept asking myself in the mirror, you know?Because I'm a little trans.So, I kept asking myself in the mirror: "Who am I? who am I really?"(A2) All the time, you're being questioned about yourself and your identity... What are you talking about?You have to reassert yourself, and then it's like a cornered animal, you know?(A3)

Perceptions of sexual orientation and gender identity
Class 5 concerns self-perception and social perception in the face of diversities.Social control over sexuality is portrayed in the experience of a gay adolescent who had a video recorded while having an affective relationship with his boyfriend.The video was released at school, and the adolescent became the subject of jokes.However, this experience also showed the emotional support of friends who, concerned with exposure to this violence, offered support and protection: I didn't confess anything.It was kind of discovered.I kissed a boy and then I started dating him.Then it all started in the school's interclass games.Then we hooked up and talked to some of our friends.These friends recorded us, and the whole school heard about the video.Then, a bunch of boys came and hassled me.Some girls came and gave me a ride, dropping me off at the corner of my home.(A1) The transsexual adolescent's invisibility is related to stigmatization and not belonging to the place.Thus, to ensure heterosexual hegemony, it is necessary to limit their experiences, even if violently.When facing this process, one of the participants described transsexual invisibility in the social context and the understanding of sexual organ identity: Some people say some meaningless things.I mean, for example, one thing that we listen to the most is: "Do you have a dick?Let me see!".

People say things like that [body expression of doubt], and I don't know what to talk about, as if everything is, as if a sexual organ defines everything, everything about who you are [pause], which is quite different, you know? It is not something like this that will define who you are. (A4)
In the family setting, the statement of a transsexual adolescent brings the father's behavior towards his gender identity, resulting in oppression and discomfort to stand up socially and assert himself as a subject of rights, preventing the development of an environment of listening and understanding: I didn't even come out, and my father simply suspected it and put me against the wall because of it.He was pressuring me [body expression of prison], and I was trapped, you know?Trapped, trapped, trapped.So, it was something that always hurt.I never had a space to be able to talk and to make them start understanding the situation.So, I always had to keep things to myself.(A4) Thus, self-perception of self and way of living and experiencing one's sexual and gender diver-sity can initially be conflictive and long: It was nervous, but in the end, everything worked out, I think.It is a very time-consuming process.However, it was easy to tell at the time.I think the most significant difficulty, above all, is with us, you know?I really can.Because the world is weighing a lot, and you have to keep your head up.So, this is the heaviest part.(A7)

Professional support
Class 4 represents the professional assistance offered by the health service and the ways of coping.The complexity of psychological distress in the face of prejudice due to the LGBT condition highlights the need for acceptance and care spaces as a fundamental support for their development, representing an environment of listening and speaking for sharing experiences and building support and solidarity networks: For this service, I went to a thing at the Ministry of Health called DiverSUS, and it was about empowering LGBT adolescents.I think that if it weren't for this service, I wouldn't have had contact with so many things, so many courses, which opened so many doors, you know?(A3) I liked it a lot because here I can have a place to speak, you know?So, I think it is essential for all those coming here.They will have a place to speak, where they will be able to talk about their life, when you feel difficulties, or when you are happy.It is a place where people talk.(A6) Given these aspects, the group service modality called "Sexual and gender diversity group" is a tool that allows developing more protective relationships between peers and bonds with the professionals responsible for conducting the group and other adolescents who experience similar situations.This modality enables the expanded support network and enhances the ways of coping with daily hardships: They talk a lot and help us a lot with this psychological issue.They are great people who cheer you up and help you.They know how to talk to you, and you kind of open up to them, you know?It's so much history that you end up meeting new people, and they start to help you.We help each other.(A2)

Discussion
The plural and diverse cultural contexts of adolescents and their families offer different perspectives for development, especially concerning sexual orientation and gender identity issues.Stigma or denying the LBGT condition of children can exacerbate suffering due to the difficulty of those responsible in offering adequate support to cope with the countless adversities in other social contexts, favoring continuous violent cycles 16,17 .
In this context of exclusions, the results of this study indicate that most of the participants' families highlight the strict, religious, moral values as an aspect that compromises the family bond and reinforces control, surveillance, persecution, and punishment behaviors.However, opposing this statement, religious activities are pointed out by one of the participants as a protective factor, strengthening the family bond and improving psychological distress.This aspect is also described by Ribeiro and Scorsolini-Comin 18 , who revealed that, despite accepting only heterosexual relationships, some religious communities accept and provide the construction of a support network for young people.
The results suggest that prejudice suffered by adolescents stems from the misunderstanding of gender and sexual orientation differences.Denying homosexual orientation is so deeply rooted socially, with repercussions on self-acceptance, due to the rejection imposed on them 19 .However, the lack of self-acceptance is associated with psychological distress and evidenced by fear and insecurity 20,21 .
Zanatta et al. 22 emphasize that self-acceptance is a fundamental factor in allowing the adolescent's affirmation in the face of normative thinking and can promote comfort and act as a fundamental element for the development, empowerment, and struggle for the respect for their rights and otherness.The authors conclude that self-acceptance and respect, and affection in the family environment are crucial support for the adolescent, strengthening the care spaces and allowing the construction of life projects.
However, the chronic stress generated by the need to hide gender identity and sexual orientation and experience a context of appearances, associated with guilt for not meeting parents' expectations and shame in family environments, can cause suffering even after individuals declare their LGBT status.This is due to the marks left by years of exclusion and violence, resulting in an increased risk of suicide than heterosexual adolescents 9,23,24 .
Accordingly, epidemiological data reveal the growing number of deaths by suicide in recent decades.The Pan American Health Organization points out that approximately 800 thousand people die by suicide globally each year 25 .In the U.S., a survey highlighted the 20% probability of suicide among non-heterosexual youth and 4% among heterosexual young people 26 , while another reported a suicide attempt rate of 41% among transgender people and 1.6% among cisgender people 27 .
According to the Pan American Health Organization 28 , the suicide rate increased 10.14% from 2000 to 2012 in Brazil, registering suicide rates of 5.8 per 100 thousand in 2012.A study with young high school students in São Paulo, with a mean age of 17 years, revealed that 20.7% of heterosexual young people declared that they had already had suicidal thoughts, while the percentage was 38.6% among LGBT young people 9 .
Denial or stigma regarding the LGBT condition of adolescents, identified by labels, stereotypes, and discrimination, cause pain and suffering, influencing a growing suicidal behavior and limiting the resources and opportunities of this group 16 .
Therefore, discrimination and stigmatization are violations of human dignity, considering the process of individual identity construction, which must respect the individual and not deny his development.Stigma diminishes people and induces them to break with their human dignity, decreasing their chances of life while increasing the vulnerability of individuals and groups, which directly affects their health conditions 13 .
The results point to severe school violence episodes related to stigma and discrimination regarding sexual orientation and gender identity.Thus, the school should become responsible for increasing the adolescent's social belonging, ensuring respect for cultural and moral diversities, so that students have in that environment the appropriate support for their protection 29,30 when they are victims of stigma and discrimination.
Zmyj and Wehlig 31 stress the importance of anti-homophobic intervention strategies that provide a reasonable number of interventions given to the same group of adolescents -instead of isolated activities.In the health context, it is crucial to have spaces accommodating the demands of adolescents in psychological distress and working on empowerment and coping strategies.
In this sense, the health service assumes a vital role in carrying out intersectoral actions for the comprehensive health of the LGBT population, proposing responses to address the vulnerabilities of this population 17,22 , strengthening bonds between the subjects and the services for the deconstruction of heteronormative postures and seeking to realize the rights of adolescents in psychological distress, according to the objectives established by public policy, affects this population (PNSILGBT).This policy aims to implement strategies that guarantee the confrontation of inequities and inequalities while ensuring the consolidation of a universal, comprehensive, and equitable SUS 4 .However, while having existed for a decade, with autonomy to act at all levels of complexity of health care, this policy faces barriers that adversely affect the quality of reception and assistance to the LGBT population, which are mainly related to local political resistance, influenced by moral positions and resulting in discriminatory and stigmatizing behaviors 32 .
Andorno 33 emphasizes the importance of recognizing individual rights and freedoms to ensure human dignity, regardless of any condition.However, violence related to the LGBT condition breaks with these aspects, which can be enhanced by the abandonment and devaluation of affirmative policies at certain political moments, resulting in greater exposure of people to stigma and discrimination that cause social exclusion and decreased opportunities in life 34 .
After analyzing the data, in summary, gender identity and sexual orientation intolerance based on heteronormativity violates human rights and is a significant social determinant in health.The adolescents' statements showed that cultural and religious factors converge at the core of clinical conditions and their therapeutic approaches 35 .Overcoming the psychological distress and respecting the human rights of the LGBT community is an essential vector for tackling health inequalities in adolescence.

Final considerations
The development of this study allowed analyzing the discriminatory situations to which the LGBT population is subjected daily, identifying family and social violence in the face of adolescents' sexual diversities, reducing opportunities, school dropout, repressed sexuality, loss of family bond, and suicidal ideas and behaviors.
This study shows that stigmatization and social exclusion experienced by the LGBT population causes severe damage to mental health during adolescence, such as depression, ideation, suicide attempt, and suicide.Family support and self-acceptance are fundamental mechanisms for coping and empowering adolescents.Therefore, the adolescents participating in this study developed strategies within specialized mental health services for children and adolescents, a space of care and listening that was an essential source of support and strengthened bonds to deconstruct heteronormative postures, assuring fundamental human rights.
Therefore, care for LGBT adolescents in health devices is an important space that promotes empowerment, including critical discussion of discriminatory and stigmatizing experiences produced in different social and political contexts, based on the appropriation of the inviolable right to human dignity in coping and resistance.It is noteworthy that, in order to be successful, actions must take place in an articulated, inter-sectoral network, bearing in mind the role of different societal segments, including work qualification, job opportunities, and access to education, leisure, and culture.The need to realize and implement PNSILGBT actions is highlighted and a perspective to understand the reality and vulnerabilities experienced by these adolescents.collaborations JCP Silva and RR Cardoso contributed substantially to the design, work planning, data collection, preparation of the manuscript, and approval of its final version.ÂMR Cardoso contributed fundamentally to the design, work planning, data analysis and interpretation, critical review of the content, and approval of the final version of the manuscript.RS Gonçalves contributed significantly to the analysis, critical review of the content, and approval of the final version of the manuscript.