Participation of social movements in gay and lesbian health

Since the beginning of the 20th century, social movements have developed isolated or aligned actions to promote the right of gays and lesbians to health. This article explores the participation of social movements in gay and lesbian health from the framing perspective on social movements. A literature search was performed and a frame analysis was conducted of the discussions found in the selected articles. This article therefore constitutes a bibliographic essay. With respect to outcomes, the literature reveals alignment between social rights and Aids activism, resonating in improved access to healthcare for gays and lesbians. We conclude that, although the participation of social movements in the struggle for the right of gays and lesbians to health started at the beginning of the last century, it cannot be said, now at the end of the second decade of the 21st century, that the outcomes were entirely solid. In short, we highlight that: (1) in some societies, the claims of social movements have been transformed into political agendas, while in others precarious concessions have been made in relation to gay and lesbian rights; and (2) non-acceptance of the right of gays and lesbians to sexuality still exists.


Introduction
Social movements are understood as sociopolitical actions constructed by collective actors from different social classes and strata (p.251) 1 . Anchored in, but not confined to, associations, they aim to promote widescale mobilization 2 . As such, by transferring a problem from the personal to collective level, "associativism" can play an important role in triggering social movements 2 .
Goffman's concept of frame as used in the analysis of social experience has served as a source for various studies of social mobilization. Goffman defines frames as principles of organization which govern events -at least social ones -and our subjective involvement in them…(p. 34) 3 . Berger 4 observes that frame is a metaphor for what other sociologists have tried to invoke by words like "background", "setting", or a phrase like "in terms of " (p. 18). Via frame analysis, Goffman contributes to the expansion of intelligibility of processes of interaction, signification, and action on the part of individual or collective actors in given settings (p. 146) 5 .
Snow and Benford made a major contribution to the application of Goffman's theory to the analysis of social movements by diverting the attention of frames away from a purely cognitive perspective towards a political and cultural perspective of understanding social mobilization process (p. 89) 1 .
Benford and Snow developed the concept of master frames when analyzing the symbolic phenomenon that enables a diverse range of organizations to mobilize themselves momentarily around a given shared interpretation (p. 152) 5 .
Various theoretical formulations permeate Benford and Snow's works besides this concept, two of which are highlighted for the purposes of this study: frame alignment and resonance. The former is directed towards understanding collective action frame formation processes, while the latter relates to the outcomes of interpretative framing. Snow et al. 6 deem that frame alignment is necessary for the participation of social movement organizations. According to these authors, this alignment consists of the linkage of interpretative orientations to make individual interests, values, and beliefs and the ideologies of these organizations congruent and complementary. Hence, the engagement of potential adherents and maintenance of militants by social movements takes place through the convergence of individual interpretive frames and those developed and conveyed by social movement organizations (p. 150) 5 .
Snow identified four related, but by no means identical, basic alignment processes: frame bridging (involving the linkage of the interpretations of the movement and similar socially established interpretations); frame amplification (emphasis on a given socially available category that is favorable to the movement); frame extension (extension of the interests of social movements to include other important socially established issues and concerns); and frame transformation (replacing given social meanings with new understandings) 5 . In one of their other works, Snow and Benford 7 emphasize that social movements use frames that assign meaning to relevant events and conditions to garner bystander support and demobilize antagonists.
Benford and Snow 8 suggest that the concept of resonance is relevant to the effectiveness or mobilizing potency of framings. Silva et al. 5 observe that the outcomes of interpretive processes are directly related to three factors: (1) the characteristic features of the creators and voices of the movement (credibility, charisma, strategic orientation, and institutional role); (2) similarity between contested framing and extant culture (which could generate dilemmas by having greater acceptance and less contestation potential or tend towards transformation, which could receive less sympathy from interlocutors); and (3) balance between resonant and contested elements (contextualization of framing in a field of conflict to provide answers that neutralize rival interpretations). This third factor is an alternative to minimize the need for social movements to have characteristics that are the same as the extant culture 5 .
Although there are criticisms of Benford and Snow's theoretical formulations -one of which is the emphasis on the cognitive dimension for interpreting collective action -Silva et al. 5 stress the importance of these authors, given that they investigated the variables that affect the acceptance of interpretive collective action frames by the target audience of organizations, thereby analyzing the mobilizing potency of a range of interpretive frames (p. 151).
The actions of social movements can contribute to the development and transformation of civil and political society (p. 251) 1 both at a general level, as in the case of civil rights, and in specific areas such as health and education.
More specifically, social movements linked to social rights, AIDS, feminism, etc. have made a significant contribution to the homosexual movement. This movement -which emerged in some countries towards the end of the 1960shas four decades of existence in Brazil 9 . The homosexual movement in the U.S. is considered to be groundbreaking and the Brazilian movement emerged practically piggybacking on international precedents (p. 49) 10 . Major advances were made throughout this period and enormous challenges were faced against a backdrop of setbacks and offensives against the rights of gays, lesbians, bisexuals, transvestites, and transsexuals. According to Trevisan 10 , when the Brazilian government began to fund gay rights and AIDS programs, the discourse of gay activists was confused with the official discourse of the government. However, the Brazilian homosexual movement expanded, eventually including a host of different political subjects and becoming known as the LBGT (lesbians, bisexuals, transvestites, and transsexuals) movement. By the end of the 1990s, the movement had articulated a wide set of arrangements as concerns organization and internal dynamics and its relationship with other social actors 11 . In 2008, it was already evident that the participation of the LGBT community could help homosexuals transform the art of accepting differences into a political objective (p. 59) 10 . However, now, at the end of the 2010s, much remains to be constructed and discussed when it comes to the social and health rights of homosexuals.
In the face of the relatively long history of the homosexual movement, it is worth reflecting on the participation of social movements to date in issues linked to gay and lesbian health.
Based on these initial considerations, this article examines the participation of social movements in gay and lesbian health from the framing perspective. This analysis focuses on groups and associations that are anchored in the interrelations directly established between their members. It is understood that this does not deviate from social movement dimension, given that these movements inspire or serve as a point of reference for these groups.

methodology
This study is part of a wider investigation into the health agendas of gay and lesbian groups. It was supported by the CNPq (National Council for Scientific and Technological Development) and approved by the Ethics Committee of the Fernandes Figueira National Institute of Women's, Children's, and Adolescents' Health/Oswaldo Cruz Foundation.
This work consists of a qualitative literature review of relevant articles. Literature reviews enable the collection of a wide range of information and data dispersed throughout various publications and help to define the conceptual framework involving the object of study 12 .
However, the study was not limited to article extraction and synthesis. The discussions found in these articles were analyzed from a framing perspective of the participation of social movements in gay and lesbian health. This article therefore constitutes a bibliographic essay.
The article search was conducted using Elsevier's Scopus, one of the world's largest databases of peer-reviewed literature (https://www.elsevier. com). Combined searches were performed using the following keywords and Boolean operators: (Title-Abs-Key (group* or communit* or organization ) and key ( homosexual*) or key (gays) or key (lesbian*)) and key (health*) and Title-Abs-Key ( movement or activism* or activist* or mobilization)). This search yielded 130 abstracts. Thirty-two articles were selected after reading the abstracts because they mentioned the participation of movements, associations, or homosexual, gay, and lesbian groups. It was not possible to obtain the full text of two of the 32 articles. After reading the 30 articles in their entirety, ten articles were excluded because they did not specifically address the participation of social movements in health actions directed at gay and lesbians, resulting in a final sample of 20 articles.
The articles were categorized by year of publication, country/region, journal, audiences targeted by the social movements/associations, theme, and method.
The following guiding questions were used for the analysis: (1) How is the participation of social movements in gay and lesbian health framed? (2) What were the processes and outcomes of this participation?

Characterization of the articles
Over three-thirds of the selected articles were published in the first two decades of this century and the remaining one-quarter were published it the last decade of the last century. The oldest article was published in 1995 and the most recent article was published in 2018 (Chart 1). Although the sample included studies from all continents, over half the studies were conducted in North America.
One-quarter of the articles were published in specialized journals dedicated to different aspects of homosexuality, while the remaining articles were published in journals focusing on different areas of health. The predominant theme was HIV/AIDS, accounting for two-fifths of the studies. However, the articles explore a diverse range of issues related to homosexuality, including political mobilization, healthy aging, sexual rights, and cancer. The predominant methods used were document analysis and essays, showing that the discussions were anchored primarily in secondary sources. Not all the studies described the methods used. For classification purposes, those studies that failed to describe the method and comprised a free discussion of issues were considered essays.
In some of the articles, the discussions go beyond the gay and lesbian frame, encompassing the LGBT context, particularly in those published more recently 13,21,22,27,31 . These discussions do not delve into issues concerning all the actors that make up the LGBT context. This is to be expected, given that the search focused on gay and lesbian health.

Framing the participation of social movements in gay and lesbian health
At least two master frames stand out in the selected literature: social rights and AIDS activism. These master frames help to understand the articulation between different social movements and state and civil organizations to defend the demands, struggles, and claims of homosexual movements in relation to gay and lesbian health.
According to Nunes 33 , social rights may be considered an example of a master frame within the protests of social movements in general. Homosexual movements in particular anchor their claims and struggles in the frame of rights linked to sexuality, citizenship, and health. Despite advances at an international level in the policy field, these rights have yet to become reality in a number of countries and homophobia remains common in some societies where they are legally recognized. This behavior is better understood within the cultural frame in which it is embedded. In the Republic of Cameroon, for example, same-sex relationships between men are ingrained in the collective psyche of Cameroonians as part of colonial practices, representing symbols of shameful behavior, as national leaders were forced by colonial masters to have sex to determine who was the "headman" 21 .
Historically, lesbians have not always attained the same rights as gays. In Ireland, in 1985, al-though it was recognized that the lesbian community was known for its activism, scholars, political analysts, and the media tended to focus more on gays 25 . Despite this, the selected articles included an extensive study of the demographic, health, mental health, and community life experiences of 1,925 lesbians from all 50 U.S. states and several territories conducted in 1984 29 . The study gave lesbian movements access to a frame that encompassed lesbians' concepts of health, how they interacted with the dominant society, and social connection and support within the lesbian community 29 . Not all their claims resonated in the guarantee of rights. Early drafts of the report of the Fourth World Conference on Women held in Beijing in 1995 implied acceptance of lesbian options. However, despite a petition signed by thousands of people from 60 different countries, the U.S. delegation was intimidated by religious politics to silence this type of affirmative statement 31 .
In some situations, within the homosexual movement or in its relationship with other social movements, there are cases in which lesbians feel doubly excluded: in movements in which there are sexist gay men and in feminist movements in which there are homophobic women 23 . Besides exclusion, lesbians may feel strange in both the gay movement, because they are women, and women's movement, because of their sexual orientation, and have to develop resistance in the face of the insistence on having to choose between their sexuality and their gender 30 .
Non-white gay men may have to face structural homophobia more than white gay men 22 . With respect to racial issues, one of the articles demonstrated that black and white homosexual communities in Memphis were unable to resolve their differences and work together to educate Memphisians about the potential dangers of AIDS 16 . With regard to racial inequality, in 2007, the National Black Gay Men's Advocacy Coalition was recognized as an important advocacy force on black gay and bisexual men's health and wellness issues in the U.S. Socioeconomic status also influences the protection of gay and lesbian rights and access to health services, since these rights often depend on financial capital 30 . In this respect, given the diverse range of factors that influence the gay and lesbian rights frame, it is necessary to explore intersections of identities, such as sexuality, ethnicity, gender, rural/urban and indigenous identities 24 , and socioeconomic classes 0 .
Apparently going against the defense of gay rights, Berner 14  Federation of Gay and Lesbian Rights, created in 1950. In 1983, when there were only two known cases of AIDS in the country, the Federation publicly recommended that homosexual men refrain from donating blood. According to the author, this was a unique initiative and the first by a gay organization in Europe. The initiative led to tensions both inside and outside Sweden: internally, some members of the organization believed that the recommendation would stigmatize homosexual and bisexual people, making it look as though gay people were responsible for spreading AIDS, rather than victims; externally, the Swedish health authorities believed that the recommendation was creating hysteria. However, amidst uncertainty about AIDS, the Federation had privileged information about the risk of blood transfusion from the U.S. obtained via an extensive network of movements. For the authors, this was one of the most important HIV preventive measures ever taken in the country. Does the case in question alter the human rights frame that governs the action of social movements? No. The frame was resignified. The right of homosexuals to donate blood was reconsidered, undermining a highly symbolic act in the country because it was understood that the blood of certain people could pose a mortal risk. Thus, for the Federation, the right to receive uncontaminated blood was equal for all, while the right to donate blood was not equal for all 14 .
International AIDS activism is another master frame that can be used to understand the participation of the homosexual movement in the area of health. The U.S. AIDS movement encompasses lobbying groups, service providers, and community-based organizations, representing the diverse interests of people of various races, ethnicities, genders, sexual preferences, and HIV "risk behaviors" 17 . Activism in this country was therefore built on the foundation of the gay and lesbian movement and borrowed from its particular strengths and inclinations 17 .
The fact that AIDS activism brings together different social movements and organizations does not mean that there have not been tensions between the parties at times. For example, Johnson et al 20 observe that in the U.S., in 1985, public health officials and activists agreed that counseling should be provided both before and after testing to ensure that patients were tested voluntarily and understood the meaning of their results. However, in 2014, in the face of doubts about whether counseling worked and justified on the basis of cost, officials discontinued the approach, which carried important ethical and symbolic meanings for gay activists 20 .
With the advent of AIDS treatment, gay communities developed distinctive forms of engagement with science to appropriate scientific knowledge. Activism has also enabled a shift in focus over time from HIV/AIDS to the overall health and wellbeing of gay men, including older men 19 .
In the 1980s, led mainly by gay men, community activists organized themselves vehemently to respond to the AIDS epidemic. However, today, there is growing recognition that the health of gay men and bisexuals involves much more than HIV/AIDS prevention and treatment, given the existence of significant physical, behavioral, and mental health disparities, social stigma, and structural homophobia 22 .
A study conducted in 2007 28 with representatives from 17 cities and 14 countries (United States, Canada, Australia, New Zeeland, South Africa, and nine European countries), showed that gay communities are undergoing different structural changes and that these changes have important implications, both for AIDS-related discussions and social rights in general. The key findings of the study were as follows: (a) in all cities, the virtual gay community was larger than the offline physical community; (b) most cities identified that while the gay population in their cities appeared stable or growing, there was a decline in the gay community; (c) in some cities there was greater integration of heterosexuals into historically gay-identified neighborhoods and less attendance at gay events; and (d) there was less volunteerism in gay or AIDS organizations. The participants questioned, with societal acceptance, equal rights and effective HIV treatments, whether the gay community would exist, or exist as strongly, in the future. In light of the findings, the authors suggested that HIV prevention planning, interventions, treatment services, and policies should be reviewed to address men who have sex with men (MSM) 28 .
The two master frames addressed here are overlapping and may also include other frames of the experience of the participation of social movements in gay and lesbian health. An example of this overlapping is the document titled "Promotion of Sexual Health". Produced in 2000 and co-authored by the World Health Organization, the document proposes a central role for sexual rights 31 . The emergence of sexual rights may be linked to the women's and gay and lesbian rights movements of the 1970s, on the one hand, and the AIDS pandemic of the 1980s on the other 31 .
The overlapping of these two master frames may also constitute a set of frames. Paraphrasing Berger, it comprises frames with frames within frames within frames (p. 18) 4 .

Processes and outcomes of the participation of social movements
The literature points to social movement processes incorporating different frame alignments, focusing primarily on HIV/AIDS. This alignment principally involves strategic efforts by social movement organizations to link their interests to resources providers 6 . In this sense, alignments exist between both social movements and state organizations and social movements and other social movements.
One case stands out in the selected literature involving the British Sexological Society, which, at the beginning of the 20 th century promoted the alignment of different frames to defend homosexuality. The Society, which operated between 1914 and the end of the 1930s, worked to promote homosexual rights and was composed of well-known figures from the field of psychology (such as Ernest Jones), literature (such as Bernard Shaw), sexual and social reform (such as Stella Browne), and medicine 33 . Due to social pressures, society members adopted an expanded platform including all manner of sexual problems and concerns and had a "hidden" homosexual rights agenda 33 .
Homosexual communities in the Global North were the first to mobilize themselves around the AIDS crisis, impelling state health agencies to overcome inertia, even antipathy 13 .
In the Global South in Brazil in the 1980s, the AIDS movement brought together three important partners: the progressive Catholic Church, the sanitary reform movement; and the nascent gay liberation movement 26 . In the 1990s, this movement created links with the feminist and women's health movements and with various "users" of the Brazilian health system such as diabetes patients, drug users, and people with mental health disorders 26 .
In Australia, the alignment between gays, drugs users, sex professionals, doctors, people with AIDS, and the government enabled movements to develop actions across multiple social, structural, behavioral, and health service levels 15 .
The U.S. AIDS movement encompassed a wide range of grassroots activists, lobbying groups, service providers, and community-based organizations -representing the diverse interests of people of various races, ethnicities, genders, sexual preferences, and HIV "risk behaviors"and engaged in a variety of projects directed at various social institutions 17 .
In the U.S., many lesbians and heterosexual women engaged in AIDS activism because they were schooled in the feminist health movement of the 1970s 17 . Also in the U.S., at the beginning of the century, the frame amplification process led to the emergence of a new wave of activism anchored in a policy of identity organized by disease-specific groups 18 . Another example of frame amplification occurred in San Francisco in the 1990s, when lesbian health activism drew connections between breast cancer and HIV/AIDS 30 . Using the focus shift strategy, a segment of this activist group drew attention to the fact that lesbian concerns had been left out of the HIV/AIDS movement and raised awareness of the higher risk of breast cancer among lesbians. As a result, the disease became emblematic of wider lesbian health needs 30 .
In India, urban middle class lesbians engaged in AIDS activism, developing a strategy to criticize the patriarchy and promote the struggle for sexual rights within a wider structure based around women's sexual rights 27 .
The alignment between gay communities and lesbians has not always been so effective however. In Chile, for example, the gay-feminist alliance was more rhetorical than real 18 , while in New Zeeland, feeling strange due to the sexism of some conservative gay movement members and homophobia of certain feminist heterosexuals, lesbians formed independent lesbian feminist groups 23 .
Another type of alignment observed in the literature was that between social movements and the biomedical model. In the U.S., AIDS activism aligned itself to the biomedical model using four key tactics: the acquisition of cultural competence, political representation, the bringing together of epistemological and ethical claims making, and the taking of sides in pre-existing methodological disputes 17 . AIDS treatment activism suggests that the so-called "new social movements" have distinctive forms of engagement with science and that this engagement shapes these movements in quite distinctive ways. The authors suggest that an extended study of the relation between biomedicine and social movements could provide for a deeper and more comprehensive analysis of the construction of medical knowledge and the transformation of medical practice 17 .
The participation of AIDS activists illustrates what sociologists such as Berg and Casper assert: that medical therapeutics cannot be understood separately from questions of knowledge construction and that our conception of scientific practice can be furthered by careful attention to the local details of medical work 18 . According Adam, by aligning themselves to social movement success stories, the social sciences can promote a robust agenda that examines: the ways that people are socially organized and networked; popular strategies developed in the face of HIV risk; the socio-historical movement of sexual and drug cultures; the dynamics of popular mobilization to advance health; institutional sources of HIV discourses; and popular understandings of HIV technologies and messages 13 .
In terms of health policy, the experience of the response to HIV provides lessons that are applicable across health promotion, including the need to: harness community mobilization and action; sustain participation and leadership across partnerships; commit to social, political and structural approaches; and build and use evidence from various sources to continuously adapt and evolve 15 .
Framing theory shows us that alignments towards gay and lesbian health, specifically, and rights, in general, should be complemented with constraints or incentives from the interactions between activists and those who hold power, from the social and historical context, and from the political regime (p. 168) 33 .
The literature shows that the actions directed at gay and lesbian health developed by social movements had resonance. This may be considered a positive outcome, despite the fact that resonance was limited by various factors.
The resonance of the U.S. AIDS movement in the 1970s enabled it become the first social movement to convert disease "victims" into "activist-experts", due to its mobilizing potency, making a significant contribution to disease prevention 13 . In the following decades, the movements assured that gays and lesbians were assigned a unique social status, going against the hegemony that considered homosexuality to be a disease or immoral, and reconstituting themselves as legitimate "interest groups" fighting for civil rights 13 . Within these movements, there were doctors, scientists, educators, nurses, and various other types of professionals. On the one hand, this enabled the AIDS movement to create an unusual capacity to contest mainstream experts on their own ground. On the other, it facilitated the creation of bridges between "experts" and "the public" 17 .
Also in the U.S., lesbian movements provided the point of departure for funding to support research into the risk of breast cancer risk among lesbians, an area of research that still existed in 2018 30 .
In Ireland at the end of the 1970s, the AIDS crisis was used by the gay community to criticize the criminalization of homosexual acts, absence of sex education in schools, and limited access to condoms and sexual health services, showing that the Irish State was ill-prepared to respond to the challenges posed by AIDS 25 .
In India, the HIV/AIDS epidemic brought a number of challenges for both the state and society, raising questions about, among other things, heteronormative patriarchy and the participation of people of alternative sexualities, who launched the struggle to reform the anti-sodomy law 27 . Years after the 1994 International Conference on Population and Development in Cairo, international donor agencies acting in the fields of demography and health and the demonstration effect of homosexual rights movements in western countries pressured India to include MSM in its HIV/AIDS control programs to defend their rights and address their role as "bridge populations " in infecting women 27 .
In the Republic of Cameroon, while laws deny full citizenship to homosexuals and imprisonment for homosexual relations continues, due to mobilization by social movements and support from international agencies the rights of LGBT groups are recognized and the country provides universal access to antiretroviral therapy, thereby creating "therapeutic citizenship" 21 . It is questioned, however, whether, against the homophobic backdrop, this initiative is sustainable and up to what point it influences the recognition of the civil rights of LGBT people and MSM 21 .
In Brazil, the response to HIV and AIDS at the end of the 1990s is widely acknowledged as one of the most effective in the world 26 . Social movements played a crucial role in shaping the Brazilian response, beginning with the struggle to ensure access to quality care for people with HIV/AIDS on the way to guaranteeing the right to treatment 26 .
Based on Benford and Snow 8 , it is evident that the framings of the experiences of the social movements described in the literature had resonance, notably in relation to the movements' par-ticipation in access to HIV/AIDS care and treatment. These outcomes can be accredited to both the movements' mobilizing potency and alignment with government and non-governmental organizations.

Final considerations
The struggle for the right of gays and lesbians to health and AIDS activism are mutually beneficial. Despite certain limitations, AIDS activism has achieved success, partly by anchoring frames in the mobilizing potency of homosexual movements and partly by transforming these movements into integral parts of activism. In certain societies, these movements have gained exposure thanks to AIDS activism, bringing together actions and financial support from a range of national and international institutions.
The achievements of gays and lesbians in the field of health in some parts of the globe have been attained thanks to the linkages created between the gay and lesbian movements and other movements such as feminism. Moreover, in some societies gay and lesbian movements have aligned themselves with the frames of claims of other gender identities, such as bisexuals and transgender peoples, to enhance their mobilizing potency. We cannot ignore that within this alignment between organizations, in certain situations, the participation of social movements in homosexual health was regulated or gave rise to government actions in the form of specific programs.
Although the participation of social movements in the struggle for the right of gays and lesbians to health started at the beginning of the last century, it cannot be said, now at the end of the second decade of the 21 st century, that the outcomes were entirely solid. In some places, the claims of social movements have been transformed into political agendas that address the health of gays and lesbians, while in others precarious concessions have been made to these actors or much remains to be done in order to guarantee the right to health of non-hegemonic sexualities. Despite laws enshrining these rights in some countries, upholding the principle of non-discrimination remains a major challenge.
In the face of this multifaceted frame, we cannot ignore the continuing need for mobilization by autonomous social movements to ensure the protection of the right to health for all gender identities.