Gay and lesbian health agendas

The aim of this study was to validate gay and lesbian health agendas pushed by organizations representing these groups. To this end, we created a health agenda matrix based on 25 narratives of representatives from 16 different gay and lesbian groups in ten state capitals in Brazil collected in another study. Each agenda was considered to have reached consensus when the mean score was equal to or greater than seven and SD was equal to or less than two. The validated agendas addressed the following themes: physical and psychological violence; the care needs of lesbians related to uterine and breast cancer; mental health; training of health care professionals; AIDS prevention and care; assisted reproduction for lesbians; the urological and proctological care needs of gays; development of informative material on general health; and information and treatment of sexually transmitted diseases. It is concluded that gay and lesbian movements are potentially important actors in the public health arena, not only proposing important issues that need to be considered in public policies and actions to improve health care for LGBT people, but also mediating between health professionals and homosexuals seeking health services.

introduction This paper discusses the gay and lesbian health agenda. Kingdon 1 observes that the word "agenda" can have various meanings, including: (a) an announced subject for a meeting; (b) a kind of plan an organizer wants participants to adopt; and (c) a coherent set of interrelated proposals. Given the many uses of this word, the author defines agenda as a list of subjects or problems to which people from inside or outside of government are paying attention at any given time.
With regard to actors outside of government, assuming that agendas are made up of problems, solutions, participants and opportunities, Joachim 2 maintains that, by drawing attention to their issues in a strategic manner, non-governmental organizations can influence the content of emerging agendas. Gould 3 observes that although the terms "lesbian" and "gay" were commonly used during the period addressed in her study, they obscured other sexual minorities customarily included in these categories. She also points out that naming the members of a social group is an imperfect undertaking. In this paper, we use the terms "gay" and "lesbian" instead of "male homosexual" and "female homosexual" because this is the nomenclature employed by various groups in Brazil created with a common purpose to represent the interests of these subjects and by the country's national health policy directed at the LGBT population 4 .
The gays and lesbians we focus on here are cisgender. Unlike transgender people (people whose sex assigned at birth is incongruent or different from their current gender identity), cisgender refers to people whose gender identity and expression are concordant with the sex assigned at birth 5,6 .
In some countries, gay and lesbian movements have managed to push forward health agendas mainly by joining forces with other movements, such as AIDS activists and the feminist movement. The engagement of gay and lesbian groups with other gender identities such as bisexuals and transgender people has also helped strengthen mobilization in support of non-hegemonic sexual rights 7 . Rodrigues and Hernandes 8 point out that even those countries without discriminatory laws witness violations of LGBT rights, ranging from discriminatory attitudes to murder. According to these authors, to help address this situation, debates are needed over a research agenda for LGBT (lesbians, gays, bi-sexuals, transvestites and transsexuals) rights in international relations.
The need for these debates reinforces the fact that the realization of general sexual rights and addressing the specific health concerns of this population remain a challenge for LGBT movements in various places around the globe 7 .
Based on a national survey of sexual and gender minority (SGM) adults living in the US, Boynton et al. 9 observed that, in the twenty-first century, little is known about how lesbians, gays and other SGM adults view and cope with the health problems facing SGM populations. The authors also suggest that, although important, the focus on HIV/AIDS may hinder efforts to address other health problems affecting these minorities. In a similar vein, Trevisan 10 suggests that efforts need to extend beyond AIDS prevention programs to address the health needs of the homosexual community.
In Brazil, these social actors have been partners in the Ministry of Health's response to the HIV epidemic since the 1980s. Discussions between these social movements and the ministry also addressed other health concerns, leading to the creation of the National Policy for Comprehensive Healthcare for Lesbians, Gays, Bisexuals, Transvestites and Transsexuals in 2013, known as "the LGBT policy". This policy recognizes the importance of the participation of these movements for addressing the health concerns of this broad spectrum of sexual minorities 4 . The various guidelines set out in this legal document may be seen as a national agenda for health care for the LGBT population.
Bezerra et al. 11 highlight that, although a number of achievements have been made possible by the institutionalization of public policies directed at the LGBT population, especially by bringing new visibility to these groups, the debate about salient themes for this population has received sparse attention in journals in the field of public health.
Building on these initial considerations, with the aim of contributing to the debate on LGBT health, this article seeks to validate the health agendas pushed by representatives of gay and lesbian groups in Brazil.

Materials and methods
This work draws on data from a broader study investigating gay and lesbian group representatives' narratives of health 12 supported by the National Council for Scientific and Technological Development (CNPq, acronym in Portuguese). The dataset comprises 25 narratives collected between February 2019 and February 2020 from representatives of 16 different groups in ten state capitals, representing Brazil's five regions (Chart 1). The broader study was approved by the research ethics committee at the Fernandes Figueira National Institute for Women's, Children's and Adolescents' Health, Oswaldo Cruz Foundation (approval number: 88058518.5.0000.5269).
First, the narratives were reread to identify health agendas using the concept proposed by Kingdon 1 -subjects or problems that, in the opinion of the narrators, should be taken into account in gay and lesbian health care. All the subjects appeared in various different narratives, meaning that no subject featured solely in one single narrative. The agendas were recorded using direct plain language without losing the meaning present in the narratives. To this end, related subjects were categorized under the same broader agenda, placing their specific meaning inside parentheses when necessary.
We then created a matrix of gay and lesbian health agendas to be sent to the narrators for validation.
In September 2020, we emailed the matrix to the 25 group representatives together with a brief explanatory introduction containing three instructions: the first asking participants to score each agenda on a scale of zero to ten, where zero was unimportant and ten was very important; the second stressing that all agendas (those targeting both gays and lesbians) should be scored regardless of the participant's sex; and the third asking participants to use the blank spaces provided to add other agendas that were not mentioned in the matrix.
A month after sending the email, less than one-third of the representatives had returned the matrices with the scored agendas. We therefore telephoned the participants who had not replied and resent the matrix using WhatsApp. We were unable to contact three of the representatives. At the beginning of November, two months after the initial sending of the matrix, we concluded the first round of the validation.
Using the consensus criteria proposed by Souza et al. 13 , we calculated the mean score for each agenda and respective standard deviation (SD). The agenda was considered to have reached consensus when the mean score was equal to or greater than seven and SD was equal to or less than two. It was originally intended to run a second round of validation with a modified matrix including the new agendas added by the participants in the blank spaces and excluding those that had not reached a consensus.

results
Thirteen of the 22 representatives that confirmed participation returned the scored matrices. These participants represented all of Brazil's five regions.  Evans and Mathur 14 highlight that online surveys tend to have a lower response rate than other survey formats, suggesting that further research is needed to explore the factors affecting response rates.
Only one of the 13 respondents added a new health agenda to the matrix. However, the suggested subject referred to LGBT health care in general, without specifying a specific agenda for gays or lesbians. It is also interesting to note that none of the agendas showed a lack of consensus among the respondents. As a result, it was not necessary to create a modified version of the matrix for revalidation by the group.
All the agendas obtained a mean score equal to or greater than seven and SD equal to or less than two (Table 1). Agenda 1 (Combating physical and psychological violence against homosexuals) and Agenda 2 (Addressing the specific gynecological care needs of lesbians, including uterine and breast cancer prevention and treatment) attained absolute consensus among both gay and lesbian respondents.
The fact that all the agendas obtained high mean scores (equal to or greater than 9.8) and low SD (equal to or less than 0.5) may be explained by the fact that their content was based on the narratives of the group representatives who participated in the validation process. Although located in states across Brazil's different regions, at the time of the study these groups were part of the Brazilian Lesbian, Gay, Bisexual, Transvestite and Transsexual Association. Based on Schutz's concept of typicality 15 , the fact that these groups are members of the same association and therefore in alignment when it comes to lived knowledge and practices may mean that their collective experiences acted as a schema of reference.

Discussion
The narratives of the group representatives related to Agenda 1 show that this agenda emerges as a demand that has always been conjoined with the need to consider transvestites and transsexuals as well as gays and lesbians, involving these actors in actions to tackle violence.
Broadening the scope of this agenda is consistent with the position of Ramos and Carrara 16 . These authors suggest that the LGBT movement should make a greater effort to include not only homosexual organizations but also transvestite and transsexual organizations, as these are the groups most critically affected by violence.
Violence is a recurring problem for homosexuals. In Brazil between 2015 and 2017, there were 24,564 recorded acts of violence against the LGBT community, 57.6% of which involving homosexuals (32.6% against lesbians and 25% against gays) 17 .
Although a national program aimed at combating violence and discrimination against LGTB and promoting homosexual citizenship has existed since 2004 18 , it was only in June 2019 that the Supreme Court recognized the legislative omission and incorporated homophobic and transphobic behavior into the Racism Act. This ruling by the country's highest court in some way reflects the demands related to the agenda under question proposed by the group representatives 19 .
Agenda 2, which addresses the specific care needs of lesbians, including uterine and breast cancer prevention and treatment, is strongly tied to agendas 4 (Training health professionals to deal better with the specific health needs of gays and lesbians) and 7 (Addressing the urological and proctological care needs of gays, involving cancer prevention and treatment). These three agendas are directly or indirectly related to the training of health care professionals, focusing primarily on doctors.
The findings of a study 20 conducted with family health doctors working in two towns in the state of Minas Gerais reinforce the importance of promoting a training agenda to enable these professionals to meet the needs of LGBT people under their care. The authors identified three core medical discourses in the interviewees' accounts that can affect the delivery of care to this group. The first -the "Discourse of no difference" -reveals a hidden contradiction, as treating LGBT people as if they were "the same" as their non-LGBT counterparts downplays differences. One of the effects of this discourse is denial of the other. In the second -the "Discourse of not knowing"doctors are unaware of the demands of the LGBT population, while in the third -the "Discourse of not wanting" -doctors suggest that LGBT community members are absent from health services because of their own choice or because they have specific health needs. The authors suggest that these three discourses "are potentiators of the silencing of issues concerning the health of the LGBT population, alienating it from comprehensive, equitable and universal health care" 20 (p. 12). The findings of this study serve to illustrate the difficulties or barriers that gays and lesbians face when trying to access health services or when being treated by health care professionals.
Specifically referring to mental health, Agenda 3 addresses the need to support gays and lesbians so they can live their sexual orientation and cope with the discrimination they suffer based on their sexual identity. Meyer 21 observes that research has shown that, starting in childhood, people often demonstrate resilience in the face of stress and adversity. However, according to the author, social minorities such as LGBT populations may experience specific additional stressors in addition to normal everyday stressors. Meyer makes two important observations about minority stress. First, he highlights the importance of understanding resilience as a partner in the stress-to-illness causal chain in LGBT health research. Second, he suggests that individual and community resilience should be seen as a continuum and it is important to recognize the significance of community resilience in the context of minority stress. The groups that make up the LGBT community can therefore play an essential role in terms of community resilience.
HIV/AIDS prevention and care (Agenda 5) obtained a high mean score and evidently continues to be an important agenda for the group representatives. While AIDS is no longer automatically associated with homosexuality, Barp and Mitjavila 22 show that, although AIDS prevention methods have been made available to all through specialist health services since the 1990s, informative material and awareness-raising campaigns have over the years have tended to be directed towards gay men.
Agenda 5 focuses on information and awareness raising about prevention and living with HIV. In this regard, information should encompass both traditional methods -such as condom use and testing-and new strategies -such as PrEP and PEP.
Reinforcing the permanence of the AIDS agenda in contemporary times, the theme of the 25th edition of São Paulo's LGBT+ pride paradeone of the largest of its kind in the country -was "HIV/AIDS: Love + Care + Live +" 23 .
The right to assisted reproduction for lesbians (Agenda 6) is emphasized by the group representatives because they understand that this group encounters difficulties realizing this right in public health services. Talking about the use of reproductive technologies, Machin and Couto 24 suggest that in a context in which heterosexual couples are considered "legitimate", the aspirations of lesbians to access these technologies "challenge social norms about the importance and position of the paternal figure in the family and the rules relative to sexual intercourse in reproduction" (p. 1256).
Agendas 8 and 9 address the importance of information specifically related to sexually transmitted diseases and informative material about table 1. Matrix of gay and lesbian health agendas.

Health agenda
Mean SD 1. Combating physical and psychological violence against homosexuals. 10 0 2. Addressing the specific gynecological care needs of lesbians, including uterine and breast cancer prevention and treatment.  general gay and lesbian health concerns. Information, be it in the form of specific materials, informal conversations or on the internet and social media, serves two interrelated functions that can be inferred from the narratives. The first is strategic, whereby gay and lesbian group members and non-members can obtain information about their rights, disease prevention, access to health services and ways of tackling discrimination and prejudice. The second, which overlaps the former, has a political dimension, aimed at strengthening members of the LGBT community as citizens, ensuring that their rights are not deprived on the basis of their sexual orientation and gender identity.
LGBT movements or other social movements see information as a means of strengthening citizenship. To this end, as Giaretta and Di Giulio 25 observe, access to information is a sine qua non for conscious and responsible citizen participation.

Final considerations
The agendas validated by the gay and lesbian group representatives highlight issues that are consistently present in the general demands of the groups -such as AIDS and violence -but also bring up other themes, such as training health professionals to deal better with sexual orientations that do not fit into the heteronormative concept of sexual orientation.
In some of the places where these groups are located, pushing a given agenda may mean defending the permanence of a right or existing benefits, or amplifying the benefits so that they reach more people in need.
One of the limitations of this study is the fact that only a little over half of the representatives that agreed to participate in the study returned the completed matrix. It is important to highlight, however, that, although the respondents expressed their personal opinions, they are spokespersons for their groups, thus expanding the reach of the study.
It is also worth highlighting that the high mean scores obtained by the agendas suggest that the matrix managed to reflect the demands present in the representatives' narratives.
In conclusion, gay and lesbian movements are potentially important actors in the public health arena, not only proposing important issues that need to be considered in public policies and actions to improve health care for LGBT people, but also mediating between health professionals and homosexuals seeking health services.