The invisibility of the LGBTQIA+ people in the databases: new possibilities in the 2019 National Health Research?

The availability of information about population minorities, in this case, the LGBTQIA+ population (Lesbians, Gays, Bisexual, Transvestite/Transsexual, Queer, Intersex, and Asexual), and the possible intersections with other variables on population bases is essential for understanding the similarities and specificities of the reality experienced by these groups, and the establishment of focused public policies. In this sense, this paper aims to reflect on the problems related to research about the sex and gender orientations/performances and, consequently, the lack of information on this topic available in population databases. From the inclusion of the question about sexual orientation in the 2019 National Health Survey database, despite the limitations, this paper presents possible opportunities for investigations on the topic from different perspectives.


Introduction
When reflecting on dissident sexualities, that is, different from that characterized by heterosexual practice, we can think of a multiplicity of sexual behaviors that differ from what is expected as a standard by society. As a result, individuals who self-identify with such identities, namely, people called LGBTQIA+, have been made invisible due to existing discrimination against them.
The use of the acronym LGBTQIA+ is, as reported by Soliva and Gomes Junior, a choice aligned with the current Brazilian LGBTQIA+ Movement positions, representing Lesbians, Gays, Bisexuals, Transvestites/Transsexuals, Queers, Intersex and Asexual. It should be noted here that this acronym encompasses identities related to sexual orientation, that is, to the affective-sexual attraction to someone of any gender, which can be classified as heterosexual, homosexual, bisexual, asexual, and pansexual, which is the focus of this work. At the same time, it also considers other identities such as gender-related, which is how people identify or recognize themselves, and includes categories such as cisgender, transgender, transsexual, bigender, pangender, and drag queen). This acronym aims to promote, include, and make visible the most significant possible number of people with sexual orientation, gender identity, or expression (how one publicly expresses own gender identity) who deviate from the cisheteronormative and binary standard. It is noteworthy that this acronym has its historicity and is the result of debates by the movement itself. Its current form is a place of dispute both in militancy and in academia, dividing the opinion of researchers, authors, and militants/activists 1,2 .
This population has historically been treated under theological, moral, or even medical aspects. For example, the term homosexual appeared in 1869, defined by the physician Karoly Maria Benkerdsua, and the approach to homosexuality led, for many decades, to the idea of searching for causes and treatments for something, until then, seen as a pathology. After much struggle by the LGBTQIA+ movement, the use of this term has been fought since the removal by the World Health Organization, in 1990, of homosexuality from the lists of diseases in the International Classification of Diseases 3 .
Talking about LGBTQIA+ subjects is going through several sex, gender, and sexuality intersections. At this point, Salih 4 highlights the interaction of institutions, that is, society as a whole, in determining these categories, in which the "constitution of the subject assumes that sex and gender are effects -not causes -of institutions, discourses, and practice". That is, "we, as subjects, do not create or cause institutions, discourses, and practices, but they create or cause us, by determining our sex, our sexuality, our gender" (p.21).
In light of the above, it is worth exposing here, as an example, the perspective of the homosexual subject, as being one who has not only a sexual attraction for someone of the same sex, and his affective perspective should be considered, making homosexuality understood as something that underpins the identity of that subject. In this sense, being homosexual is not just about having sex with someone of the same sex, but also allowing for an emotional/affective involvement or even adopting specific postures that can range from using a particular vocabulary -pajubá 5 -, to visiting LGBTQIA+ social interaction spaces.
Despite some advances regarding acceptance and formulation of public policies for the LGBTQIA+ population, due to its history of prejudice and the complexity of addressing the issue freely, data on this population is still rare. In other words, we have great invisibility of issues related to these subjects in society. This invisibility is reflected in the inexistence, so far, of national studies that consider the inclusion of variables that can quantify and qualify these subjects. This information is essential not only to understand the profile of this population but, above all, to list their needs and develop effective public policies.
Based on these justifications, this paper seeks to reflect on the problems related to research on this topic in population surveys and, consequently, the lack of questions on sexual orientation available in nationally-represented databases. With the inclusion of the question of sexual orientation in the 2019 National Health Survey database, some discussions are made about the possibilities for further investigations, especially the relationship of this group with sexual and reproductive health and homophobia.

The sexual orientation variable in quantitative research
When differing from the heterosexual, self-declaring sexual orientation to someone is not something simple in a country known to be homophobic/biphobic/transphobic and can be considered a political act. Investigating this issue in household surveys, therefore, is not an easy task. According to Judith Butler 6 , when people affirm their homosexuality, for example, either publicly or directly to someone, this message does not reach the interlocutor as a simple description of that subject, but of their acts as homosexual and their practice. When people reveal their sexual orientation, they perform the [act] they describe, as they establish the statement as homosexual behavior 6 (p.180).
For many years and even today, in some situations, homosexuality and bisexuality are concealed by individuals belonging to these groups, in many cases, as a way to protect themselves and, in order to do so, exercise their other identities, fleeing from the stigma that this represents. Bringing homosexuality as an example, Butler 6 shows us that its public denial could offset the public threat of a public act of homosexual self-definition (p.193). However, the author questions that the subject who once affirmed his homosexuality but later denied it would, in turn, be denying his acts but would not be denying his desire.
Furthermore, fearing the interpretation that the declaration of homosexuality and bisexuality may have may even lead many men to refuse to answer a question that involves their sexual orientation, increasing, for example, the non-answer rates to these questions. Intensifying barriers are well known in cases of demand for health services, especially those linked to testing and counseling in the field of Sexually Transmitted Infections (STIs), given the fear of moral judgments or even being associated with populations that are at-risk groups or harm the quality of care 7 (p. 2).
Given this difficulty, the adoption of the term Men who have Sex with other Men (MSM) has been adopted to approach men who have sex with other men and do not identify with the homo-affective universe. The adoption of this term could be an option for this type of question in the databases. However, as highlighted by Carrara and Simões 8 , such definition aims to transcend the identity scale, facilitating the implementation of public policies without excluding individuals for not being -or not feeling -included in a specific identity.
In the same sense, other approaches can be used to mitigate research underreporting resulting from a possible non-declaration of sexual orientation, such as the inclusion of variables that ask whether the subject has had same-sex relationships in the past twelve months. Such a perspective would shift self-identification to a specific identity. We emphasize here that such variable would not indicate that this subject would be homosexual or bisexual, as this is an identity category. It is also possible to use other nomenclatures, such as the terms gay/lesbian, to prevent possible failures in the answers due to a possible lack of knowledge of the other terms. However, the informant's adoption of these terms and self-declaration encompasses their recognition as a subject belonging to this sexual identity.
That said, one imagines the existence of a great fear of producers of public statistics in including questions on sex and gender-related orientation and performance in their national surveys. This is so true that Brazil does not have any variable on this topic in the primary household surveys in the country, such as the Demographic Census, Continuous National Household Sample Survey (PNADC), and Household Budget Survey (POF). The first nationwide survey that, while not using the sexual orientation variable, included the possibility of finding a part of these subjects was the 2007 Population Count, in which the Brazilian Institute of Geography and Statistics (IBGE) included the variable same-sex spouse. This variable allows verifying those same-sex couples who reveal to be in a common-law marriage status. This variable was maintained in the 2010 Demographic Census. Although it can be considered an advance towards understanding these subjects from the perspective of new family arrangements, among other developments, it leaves out the possibility of researching other subjects who live their orientation non-heterosexually.
Finally, it is noteworthy that, in an unprecedented way, the 2019 National Health Survey (PNS) included a question on the topic in block Y about Sexual Activity for people over 18, namely: "Y8. What is your sexual orientation?" with the possibility of answering "heterosexual", "bisexual", "homosexual", "another", "doesn't know", and "refused to answer". This question encompasses men and women and opens up an excellent possibility for investigations, as it overcomes the limitation of information on same-sex spouses, also found in the PNS. Thus, in the next section, some of the different themes that can be explored from the perspective of sexual orientation are glimpsed and can contribute to studies of the LGB population. Adopting this acronym from that moment of the work will occur since the variable investigated in the PNS cannot break down people into transvestite, transsexual, and intersex gender categories.

Some research possibilities in the National Health Survey -pNS 2019 from the sexual orientation question
As part of the research focused on the health conditions of the population, one of the main themes to be explored with the sexual orientation variable is its relationship with the health of individuals in this group. Besides the leading chronic diseases, it is possible to analyze aspects of their sexual health since the PNS includes both a block on communicable diseases and another on sexual relationships and condom use. These are closely related to studies on the LGB population and are essential for thinking about programs dedicated to the prevention of Sexually Transmitted Diseases, such as the National STD/AIDS Program.
Although we are currently experiencing a period of dismantling some policies, we cannot fail to mention advances such as the availability of Pre-Exposure Prophylaxis (PREP) for people vulnerable to HIV infection 9 . According to information from the Department of Chronic Diseases and Sexually Transmitted Infections (DCCI), populations at risk of frequent exposure to HIV are gay men and other men who have sex with men, trans people, sex workers, and serodiscordant partnerships (when one of the partners is someone living with HIV). This choice is made because these groups concentrate a more significant number of HIV cases in the country, and it should also be necessary to observe sexual practices, sexual partnerships, and specific contexts associated with a higher risk of infection 10 (p. 14). The knowledge of this reality is due to the sexual orientation variable in the surveys of HIV case notifications made available by DATASUS.
However, we should bear in mind that, as pointed out by Barp and Mitjavila 3 , adherence to PREP requires the subject to perceive himself as belonging to a vulnerable population, re-signifying the old notion of risk group to resume sexual freedom curtailed as a result of the arrival of HIV.
Besides issues related to health itself, another topic of great relevance is the profile of access to and use of health services and the quality of health services by the LGB population. Analyses that explore how the PHC service and other health services have been used and provided to this population are essential because, as highlighted by Lionço 11 , the predominant medical discourse supports the pathologization of socially discordant sexual identities and practices, which legitimizes and reproduces discriminatory processes. At the same time, according to Moscheta 12 , assistance to the LGBTQIA+ population challenges professionals to develop care actions that overcome the historical stigmatizing approach associated with the very construction of these identity categories as belonging to the list of pathologies by the medical-scientific discourse. Finally, Rufino et al. 13 and Mello et al. 14 conclude that medical work in issues associated with guidelines/performances related to sex and gender is limited to comprehensive and humanized care in situations of sexual violence and general health for the LGBTQIA+ population. This is because prejudice in health facilities and invisibility among professionals further concealed this population, making spaces to promote local health incapable of meeting the real needs of the LGBTQIA+ community. Aware of this differentiated treatment of the group, we have the National LGBT Comprehensive Health Policy 15 . One of its objectives is the analysis of care provided to individuals in this group concerning reception, humanization, and comprehensive care.
Another critical issue for the struggle of the LGB population is homophobia, which can be analyzed from the experience of different types of violence to which this group is exposed. In the PNS, several types of violence were investigated for people aged 18 and over in module V, as were the identification of the perpetrator and the place of this violence. The possibility of this type of analysis is essential to understand the different types of vulnerabilities this group is exposed to and promote and strengthen policies to combat homophobia, sexism, and gender violence in general. In this sense, Benevides and Nogueira 16 reveal that belonging to a socially excluded group, such as the LGBTQIA+ population, is to be daily exposed to the hatred and intolerance of all those who believe they have the right to "disagree" with sexual and gender identities that escape the heterosexual, cisgender norm.
Finally, although without intending to exhaust the vast multiplicity of approaches allowed by the PNS, there is still a glimpse of possible unprecedented studies relating sexual orientation and lifestyle of this population. Module P of the research discusses eating habits, physical activity, and alcohol and tobacco use. Also unprecedented will be the analyses of block Z, which cover issues about paternity, such as male fertility and adoption. Both themes open up a broad research agenda for the Brazilian LGB population.

Final reflections
So far, the LGBTQIA+ population has been invisible in Brazilian population surveys, which hinders and limits the understanding of the similarities and specificities of the reality experienced by these individuals and the establishment and success of many of the existing targeted public policies. A novelty proposed in this paper was showing the inclusion of the sexual orientation variable in the 2019 National Health Survey. Although microdata from the Y block of the survey have already been made available, the IBGE has not yet released this variable, which makes us apprehensive about its release in the future.
The possible investigations based on the availability of this information in the PNS can be diverse, as shown in this work. An essential current of studies could be carried out in the health field through analyses related to the health profile, especially the sexual health of the LGB population and the access and use of health services by these individuals, bringing a valuable contribution to the field. In parallel, studies could still be carried out on the occurrence of violence and its impacts on this group's physical and emotional health. Another niche of studies of a rather social and cultural nature could be carried out based on exploring the relationship between sexual orientation and themes such as lifestyle and the exercise of fatherhood/maternity. In other words, the availability of this information generates a range of research opportunities on the LGB population from different perspectives and may serve as a reference for expanding research that includes this variable in their surveys.
Finally, we emphasize that, despite the possible issues of underreporting that may contain this estimate and the perpetuation of the invisibility of the transvestite and transsexual population as it does not include variables that promote self-declaration of gender identity in the research, the variable investigated in the PNS 2019 will be the only one with existing national representation that could measure data related to the LGB population. Therefore, IBGE's release of this information to the public overly contributes to the advancement of studies on guidelines/ performances related to sex and gender of Brazilians. We reinforce the importance of advancing in this type of investigation and having variables that can accommodate the variety of expressions and practices so that its practitioners are not "labeled" in one word or another, allowing a broader understanding of these complex choices, orientations, identities, and performances.

Collaborations
The authors participated equally in all stages of writing this paper.