The Brazilian LGBT+ Health Survey: methodology and descriptive results

The understanding of health care demands and possible access barriers may support policymaking and best practices targeting the lesbian, gay, bisexual, transgender, and related identities (LGBT+) population. The aims of the Brazilian LGBT+ Health Survey were to characterize the LGBT+ population during the COVID-19 pandemic and to specify the characteristics of the COVID-19 pandemic in this population. This is a cross-sectional online study, with a convenience sample of 976 individuals identified as LGBT+, aged 18 years or older from Brazil. It allows investigations of sexuality, discrimination, internal homophobia, health-related behaviors, and health care access. The study adopts a conceptual framework (i.e., validated tools and measures) common to other epidemiological studies, allowing comparisons. We describe the study methodology, some descriptive results, and health-selected indicators compared with the Brazilian National Health Survey . Most of the respondents were from Southeast Region (80.2%), mean aged 31.3 (± 11.5 years). Regarding COVID-19, 4.8% tested positive. Both weekly episodes of discrimination (36%) and depression prevalence (24.8%) were high among the LGBT+ population in Brazil, highlighting mental health and ho-mophobia as major concerns in the LGBT+ context during the pandemic. Although a decade has passed since the institution of the Brazilian National Policy for Comprehensive LGBT Health, appropriate training of health professionals to offer adequate services is still needed. Knowledge of the specific health demands of this group might guide person-centered best practices, promote sexual minority high-acceptance settings, and contribute to higher eq-uity during the pandemic.


Introduction
In 2011, Brazil instituted the National Policy for Comprehensive LGBT Health (PNSI-LGBT) 1 .According to the policy, there is a need for a further guarantee of health access, vigilance, and adequate training of health professionals to offer the appropriate services to the lesbian, gay, bisexual, transgender, and related identities (LGBT+) population.However, homophobic practices 2 are still present among health professionals in various contexts, including the use of the derogatory terms toward members of this group and the disrespect of the social name 3 .
The health needs of the LGBT+ population differ from those of heterosexual individuals due to particular characteristics of its members, as well as due to considerable levels of stress experienced by

Measurements
The researchers and a consultant team, composed of students, primary health professionals, and LGBT+ individuals, constructed the questionnaire.Measurements included sociodemographic characteristics, health-related measures (i.e., diseases, behaviors, health care access, and experiences with health care 30 ); sexuality; 19-item Internalized Homophobia Scale 31 , including the perception of internal stigma and social oppression; violence; 6-item Perceived Everyday Discrimination Questionnaire 32 , including being treated with less courtesy or respect, receiving poorer service at restaurants or stores, receiving poorer service from doctors or hospitals, people acting as if you were not clever, people acting as if they were afraid of you, and being threatened or harassed; 3-item UCLA Loneliness Scale 33 ; and social network.

Quality assurance and control
A small pilot study with three respondents of different ages (21, 35, and 54 years old) and genders (transgender male, cisgender male, and cisgender woman) was conducted to identify potential problems with the instruments and procedures.Based on their feedback, some terms were modified for better adequacy and understanding.For example, regarding gender-related questions, the item "I don't know" was removed from the gender identity question and replaced with the word "Other".We also added terms such as "sexual and romantic experiences" and "sex reassignment surgery" and included a brief definition of the gender identities included in the questionnaire (cisgender, transgender, transvestite, and non-binary).Moreover, the questions option "I do not agree" were changed to "I disagree".
Cad. Saúde Pública 2021; 37(9):e00069521 Two versions of the questionnaire were constructed using MEDQuest (http://medquest.medicina.ufmg.br)and Google Forms (https://docs.google.com/forms).Respondents from the pilot study voted on the most suitable version (i.e., in terms of layout, font size, and usability).Therefore, an online link to Google Forms was used to collect data (http://bit.ly/inqueritosaudeLGBT+).These respondents were invited to access the final version of the questionnaire and participate.

Study management
Two federal universities conducted the Brazilian LGBT+ Health Survey.The study's steering committee included researchers from these institutions and other consultants in Rio de Janeiro, health professionals working in primary care units, and LGBT+ individuals.

Ethical approval
This study followed all ethical aspects required by scientific studies involving human beings.Since it was anonymous, informed consent was not taken.However, the researchers included a brief explanation of the research objectives and design, provided contact information of the researchers, and informed respondents about the risks and benefits of participating.Individuals who agreed to participate were included in the study.This study was approved by the Research Ethics Committee of the Minas Gerais Federal University (protocol CAAE 34123920.9.0000.5149).

Data comparability
We used data from the recent Brazilian National Health Survey (PNS, in Portuguese), conducted in 2019, to compare the health-selected indicators of our LGBT+ health survey respondents with those of participants from the national survey.PNS data and descriptive results are publically available at (https://www.ibge.gov.br/estatisticas/sociais/saude/9160-pesquisa-nacional-de-saude.html).However, some 2019 microdata was not available at the time, precluding us from an individual-level PNS analysis.The PNS is a nationally representative study of the general Brazilian population aged 18 years and above, conducted in a probabilistic private household sample from urban and rural areas.The sample size was calculated according to 53% of the primary unit sample of Brazil, totaling 17,261 participants.Additional information can be found in the pertinent literature 34 .

Statistical analyses
We conducted descriptive analyses using proportions and the respective 95% confidence intervals (95%CI) and means and standard deviation (SD).Additionally, we used some health-selected aggregate data prevalence and the respective 95%CI to perform an initial comparison with the most recent representative data from Brazil, the PNS conducted in 2019.These analyses were conducted using Stata 14.0 SE (https://www.stata.com).

Results
Between August and November 2020, a total of 1,036 individuals agreed to participate.Of these, 60 respondents did not meet the inclusion criteria and were excluded: 44 cisgender females and 8 cisgender males who reported being heterosexual, and 8 individuals under the age of 18.The final sample comprised 976 respondents.Table 1 shows the selected characteristics of the respondents listed.
Most of the respondents were homosexual (72.1%), cisgender (41.5% female and 49.9% male), and white (60.1%).The mean age was 31.3 (± 11.5 years).Nearly 30% had post-graduate level education, and 27.1% were receiving government income support during the COVID-19 pandemic.Respondents were concentrated in the Southeast region (80.2%).Of these, 56.1% were from the State of Minas Gerais and 28.2% from the State of Rio de Janeiro.Regarding COVID-19 characteristics, 4.8% tested positive for COVID-19 and 61.5% reported full adherence to social distancing measures.

Characteristics % (n) 95%CI
Gender-related characteristics Furthermore, 36% reported at least a weekly episode of discrimination, and the respondents' mean internalized homophobia score were 22.3 (± 6.3), with higher proportional scores for the social oppression component than the internal stigma component.Table 2 shows the comparison of health-selected indicators with those of the PNS.Overall, the LGBT+ population reported a higher prevalence of medical diagnosis of depression compared with the PNS participants (24.8% vs. 10.2%).Regarding lifestyle, most of the LGBT+ respondents reported weekly alcohol ingestion (82.7%), and 20.9% were smokers.Both alcohol ingestion and smoking behavior prevalence rates were higher among the LGBT+ respondents than PNS among participants (26.4% vs. 12.6%).Lastly, the LGBT+ respondents reported using reference health services less compared with the PNS participants (50.2% vs. 73.8%).

Discussion
The Brazilian LGBT+ Health Survey in this study provides data from a population that is neglected in most of the nationally representative studies in Brazil.The covered topics included an array of characteristics.Despite the concentration of respondents in the Southeast region and the significant number of highly educated individuals compared to a previous published national study 35 , we demonstrate that both weekly episodes of discrimination and depression prevalence among the LGBT+ population were high in Brazil.Regarding the perception of homophobia, a higher proportional score for social oppression was found compared to the internal stigma component score.
Our data emphasize mental health, discrimination, and social oppression as major concerns in the LGBT+ context 36,37,38 and during the COVID-19 pandemic 20,22,23,24,25,28 .Even though the PNSI-LGBT was instituted in 2011 in Brazil, discrimination in health services is still a barrier to achieving better mental health 6 and health-related behaviors 7 , and complete health care access 3 for LGBT+ individuals.The LGBT+ population is likely to suffer from minority stress 4 , including both distal stressors (i.e., prejudice or discrimination events or conditions) and proximal stressors (i.e., concealment of sexual orientation, and internalization of societal stigma), generating allostatic over-

Table 2
Selected health indicators of the participants in the Brazilian LGBT+ Health Survey (August-November 2020, N = 976) and participants from the Brazilian National Health Survey (PNS; 2019, N = 17,261).

Characteristics
LGBT+ survey PNS

% (95%CI) % (95%CI)
Self-rated health Very good/Good 77. 5  load (i.e., negative health consequences due to chronic stress exposure) 5 .Countries with higher levels of aggregate LGBT+ acceptance show better individual self-rated health and well-being 39 .In Brazil, higher social oppression related to homophobia explains the increased rate of both physical violence against the LGBT+ population 40 and suicidal ideation among its members 41 .However, we cannot discard the possibility of overreporting discrimination in online surveys 42 .One mechanism related to heightened stress during the COVID-19 pandemic, coupled with social distancing, loss of social support, and increased social media use, is the higher alcohol 43 and tobacco misuse reported by respondents during this time.After three months of social distancing measures, LGBT+ women's social media postings related to alcohol use moved from only "associated with parties" to "socialization" and "dealing with COVID-19" 43 .In an online survey of alcohol and tobacco use in Brazil, LGBT+ respondents who reported alcohol and tobacco use before the COVID-19 pandemic, showed an increase in the consumption of these substances during the pandemic (29.7% vs. 49.4%) 28, which partially explains the higher rate of their consumption in our sample, compared to that among the PNS participants.
Another mechanism to alleviate stress among LGBT+ individuals is the adequacy of interventions to protect the affected persons 16 and to generate more appropriate health care use 11 .However, we demonstrated that fewer LGBT+ individuals have been using a reference health service, probably due to difficulties in health care access during the pandemic 28 or poor inclusivity approaches of health professionals 12,44 .Therefore, knowledge of specific health demands of the LGBT+ population is the key 1,44,45 to strengthening patient professional connectedness and promoting high-acceptance settings for sexual minorities.Our results might guide person-centered best practices in primary health care, such as creating welcoming conditions inclusive of LGBT+ patients, fostering an environment that supports and nurtures all patients and families; facilitating the disclosure of sexual orientation and gender identity, advancing effective communication; and promoting community involvement and advocacy 45 .
Regarding testing positive for COVID-19, we found a higher prevalence (4.8%) than previously reported by Torres et al. 28 in a Brazilian LGBT+ sample (1.7%).However, Torres et al. conducted an online survey from April to May 2020, whereas our study was conducted from August to November 2020; therefore, the increased infection rate in our study was expected.In November 2020, the COVID-19 prevalence among the general Brazilian population accounted for nearly 3% (https://www.worldometers.info/coronavirus/country/brazil/,accessed on 03/May/2021), close to the prevalence found in our sample.Data from the United States did not find any difference in testing positive for COVID-19 between LGBT+ and non-LGBT+ individuals (10.3% vs. 8.6%) 20 .Nevertheless, the LGBT+ population in Brazil 28 and other countries 20,22 reported difficulties in adhering to social distancing measures, mainly due to socioeconomic vulnerability 28 and adverse psychological distress 20,22,23,24,25,28 .
Our study has limitations that must be acknowledged.First, the LGBT+ health survey was conducted online, decreasing the response rate, which is inherent to online surveys.Second, only respondents with Internet access were included.In Brazil, Internet access has not yet reached the whole population (79.1% of Brazilians had Internet access in 2018 46 ) and it is not available among the most vulnerable groups.Third, comparing data from a non-representative online sample with those from a representative household sample might introduce both selection and information bias, precluding us from further interpretation.However, considering the unavailability of nationally representative datasets and the difficulty in developing a nationally representative study of the LGBT+ population, this study might contribute to the beginning of an understanding of the health needs of its members and the obstacles they face when using health care services.Further online studies should consider weighting in their surveys, considering all Brazilian regions to achieve national representativeness and avoiding overrepresentation of some states, as we found in the case of Rio de Janeiro and Minas Gerais, the states with the highest number of respondents and where the participating universities were placed.Additionally, we encourage a face-to-face recruitment in different vulnerable settings, providing the appropriate material to access the questionnaire.Further, the strengths of this study include anonymous recruitment, which is considered at more effective way of increas-Cad.Saúde Pública 2021; 37(9):e00069521 ing adherence in this population.Moreover, this is the first study in Brazil with a broad coverage of respondents from the five geographical regions of the country and questions regarding a wide range of health dimensions.
In conclusion, our data emphasize that mental health, discrimination, and social oppression are major concerns in the LGBT+ context and during the COVID-19 pandemic.Although a decade has passed since the institution of the PNSI-LGBT in Brazil and appropriate training of health professionals to offer services to the LGBT+ population is still needed.Knowledge of the specific health demands of this group might guide person-centered best practices in primary health care and promote sexual minority high-acceptance settings.