Nurses and health care for gay adolescents

Abstract Objective: to analyze nurses’ statements about health care for gay adolescents. Method: qualitative study, anchored on the Thematic Analysis of Clarke and Braun, with adoption of Symbolic Interactionism as a theoretical framework, since it favors the understanding of the relationship between behaviors, interactions, and social meanings. Twelve nurses recruited using the snowball sampling technique were remotely interviewed via the Google Meet® video-conferencing app. Results: four themes were elaborated throughout the comprehensive-interpretative process: “Gay adolescents, agendas, and relation with health;” “The gay adolescent’s family and care;” “Relationship with gay adolescents in care,” and “Limits to nursing care for gay adolescents.” Conclusion: the statements denounce stigmas and symbols derived from cisheteronormativity as intervening in the relationship and indicate the urgency of investing in the intersubjective encounter with gay adolescents and their families in a horizontal, affective, and empathic relationship, with chances of favoring public defense of the right to health. There are comments on the nurses’ attitude and qualification of care for this population.


Introduction
Sex and gender dissidences, which include lesbian, gay, bisexual, transvestite, transgender, queer, intersex, asexual and other gender variability (LGBTQIA+) people, circumscribe a social field of struggle and power that is antagonistic to compulsory heterocisnormativity (preestablished patterns of gender and sexuality), and are related to the creation of subjective bodies and counterhegemonic experiences. In the LGBTQIA+ community, gays are male homosexuals, men who challenge machismo and patriarchy, and whose bodies, pleasures, desires, affections, and sociability are experienced with each other. In Brazil, gays represented 1.4% of men over 18 years of age who responded to the National Health Survey (PNS) in 2019 (1) .
In the time frame of the second decade of life (10 to 19 years of age), as defined by the World Health Organization (WHO) (2) , a concept also adopted by the Brazilian Ministry of Health, adolescents experience identity processes, changes and transitions in biopsychic issues and social relationships that mobilize understanding, feelings, and emotions (3)(4) . The condition of being an adolescent and a gay may mean double vulnerability and has repercussions on increased chances of not accessing or not being accepted in the health system due to stigmas.
Primary Health Care (PHC) is described as obstructing the right to health, promoting discrimination, and producing embarrassment for gay adolescents (3)(4) .
Access to the health care system, the identification of needs, and care negligence are pointed out (5) as barriers to openness and listening (5) and cause adolescents and young people not to seek health services (6) . In this context, the fragility of the bond with health professionals/services is highlighted (6) .
In this context, interpersonal nursing care, guided by the values of human dignity and social justice, appears as having great potential to welcome and provide care for gay adolescents within the PHC (7) .
On the other hand, nursing, despite having care in its genesis, may provide a reduced and technical "care," devoid of relational support (8)(9)(10) .
In line with the above and the guidelines of the

Study type
This is a qualitative study, guided by the Consolidated Criteria for Reporting Qualitative Research (COREQ) and anchored on the Thematic Analysis of Clarke and Braun (32)(33) , taking Symbolic Interactionism (SI) as a theoretical framework, since it favors the understanding of the relationship between behaviors, interactions, and social meanings (32) .

Setting
The study was developed in the context of PHC  recommended for situations of restrictions on identifying and inviting participants (34) . The technique favors the exponential chain of indications from participants (34) .
In the zero wave of recruitment, two participants (seeds) were included to start the referral chain, randomly selected after dissemination of the research on social networks (WhatsApp ® , Facebook ® , Instagram ® , Twitter ® ), via cards -informative texts and invitations to participate -, where the candidate was asked to contact one of the researchers. The seeds were encouraged to refer or invite new candidates in other cities and states of the Federation, which resulted in the enrollment of 12 nurses. The final number of participants was defined according to the sufficiency criterion assigned by the authors, based on the understanding reached about the object of interest (35) .
None of the interviewees had a relationship with the authors. All nurses have been previously presented with the study by the first author, and no one refused to participate.

Selection criteria
For inclusion in the study, participants should: be a nurse and working in the Health Care Network (RAS) of the Unified Health System (SUS), within PHC or in SC/ LGBTQIA+; have professional experience of more than 1 year, considered to be enough time to create bonds with the community, and declare to have experience as a health professional in care for gay adolescents. Candidates who were on maternity leave, vacation, and any other type of absence from work were excluded.

Data collection
The interviews were scheduled after previous of not getting in-depth answers (35) are considered challenges to the study.
The interviews, recorded on the Google Meet ® video-conferencing app and stored on a hard drive reserved for this purpose, began with questions of sociodemographic characterization, to then explore the study focus from the request: "Tell me how you care for the gay adolescent in your daily work". Questions articulated with what was being exposed were presented throughout the interview to broaden understanding and more details.

Data analysis and treatment
As data were collected, a Microsoft Office Word ® spreadsheet was filled out with sociodemographic data, and integrity, duplicity, and completeness were verified.
Data were analyzed using simple descriptive statistics.
The data extracted from the interviews were transcribed and organized using Microsoft Office Word ® from detection and correction of linguistic errors, when vocabulary, grammar, and language vices were revised.
Statement content analysis started during transcription, by writing descriptive memos that supported coding and establishment of the themes. Then, the interviews were analyzed systematically from the following steps: reiterative readings of the interview transcriptions for familiarization, highlighting excerpts that were later taken for coding; grouping of codes in order to generate initial themes from the central construct, and articulation of the elements that composed it (32)(33) .
With the data analysis completed, one sought to

Ethical aspects
The study followed the recommendations of the

Participants' profile
Twelve nurses participated in the study, nine women and three men, all with cisgender identity, 10 identified as heterosexual, and the mean age was of 36 years. They worked mainly in PHC (67%) and their professional experience ranged from 1 year and 5 months to 22 years; most attended postgraduate studies ( Figure 1).
Four themes were elaborated throughout the comprehensive-interpretative process: "Gay adolescents, agendas, and relation with health;" "The gay adolescent's family and care;" "Relationship with gay adolescents in care," and "Limits to nursing care for gay adolescents."  Care presented itself as derived from a shared process. The participants undertook efforts to provide the information that the nurse is a professional who respects, does not judge and intends to welcome them, a professional they can count on.

Visibility for care intention
The interviewees were concerned about transmitting the message that they were focused on the adolescent's needs.

Discussion
The nurse is the professional usually involved in care for gay adolescents, and the relationships established with him and his family affects how this care will be provided (36) . This study found that nurses want to establish interactions favorable to dialogue, demonstration of needs and that enable the adolescents to talk about themselves.
www.eerp.usp.br/rlae Suffering considered particular to this population was highlighted, attributed to prejudice and social judgments.
In view of this, the professionals appeared to demonstrate compassion, an element that can favor the encounter and also be a driver of care, contributing to fluid and appropriate relationships (37) .
The results showed an intention to alleviate suffering, but without a description of a significant and unique reach in care interactions. There were intentions to understand the uniqueness of the adolescents' situation, as well as strategies to increase the understanding of life and other health issues. They denounced a priori representations related to homosexuality that obscured and/or neglected needs. Stigmas acted as relational obstacles to the provision of care and, when perceived by gay adolescents, generated uncertainties and ambivalence (38) . The action of interacting involved assuming the role of the other and triggering processes in the adolescent's self.
The lack of attention to the gay adolescents' individuality and the professional's heteronormative behavior drove the adolescent away from the service and professionals (39) , an aspect highlighted by the interviewees. A Spanish study revealed that LGBTQIA+ people described discriminatory attitudes by health professionals, as well as their distrust and fear in this scenario (28) . The deconstruction of heteronormative for the fulfillment of unique needs (40) .
Stereotypes and stigmas crossed our results. This is visible when, for example, being gay is almost immediately associated with STIs, psychological distress, and family issues. These stereotypes go in the opposite direction of the openness to the other presupposed in the effectiveness of a care encounter.
STIs are on the agenda claimed for the health care for homosexuals; therefore, there is sense and meaning in considering them. One verified criticism of how this symbol directs the professional in care, with reduced opportunities to reveal needs and relational quality (41) . There is a danger of restricting the care service agenda to STIs, especially due to the tendency of stigma intersectionality when nonnormative sexuality is present in the care scene (42) . It is urgent to break with the care protocol tendency and the valuation of social labels in its provision, in order for the particular to emerge in and from the relationship.
Another point highlighted was related to the adolescents seeking privacy in health appointments and confidentiality of the information provided there, elements reiterated in the literature, added to the relevance of listening and establishment of a reference professional (43) .
In this context, being accompanied by family members is perceived as an obstacle because it generates discomfort and does not allow the adolescent to reveal himself (44) , perception supported by the participants of this study.
Depending on the relationship between these adolescents and their families, this aspect may or may not contribute to the care for gay adolescents (45) , an important focus of attention for nurses.
Discovering and coming out as homosexual to the family can lead to fear, guilt, and repression (46) .
In addition, the family context is linked to violence against this population (47) . Thus, considering the family in the establishment of support for gay adolescents is essential, with emphasis on the effects that the cisheteronormative model and homophobia can have on family relationships (36) . Given these considerations, the adolescent's family is also a health care demander, beyond a companion or a probable support (48) . Knowledge derived from family nursing is useful for nurses to assess and intervene with these families (49) . (Not)including family members can promote interactional discontinuity for care (adolescent, family, and professional), weakening its practical success.
Family resistance to approaching gender and sexual orientation with adolescents can act as a determinant for the refusal of gender diversity, favoring a social context that reinforces, reiterates, and leads to prejudice and violence (47) . In turn, nurses and professionals themselves are social actors who act in the opposition or reinforcement of such symbols from their actions.
The interviewees denoted discomfort in addressing issues related to care involving gender identity and sexuality. This difficulty is linked to the lack of understanding, knowledge, and preparation necessary for the incorporation of the LGBTQIA+ culture in care, which are not present in health training (11) . Continuing education related to care for LGBTQIA+ adolescents expanded knowledge and qualified nurses' behaviors (12) .  (50) . Thus, it is up to nurses to seek insertions anchored on the PSE and propose discussions related to gender, gender identity and sexuality in the thematic agenda, enabling dialogues perceptions to be exposed (28) . Health actions at school are identified as vertical, disconnected from the school curriculum, supported by a medicalizing paradigm (51) and cisheteronormative perspectives of little contribution to behavioral sensitization and welcoming diversities.
In view of the above, the way in which professionals incorporate protocols and guidelines from guiding documents in care for gay adolescents needs to be reviewed, providing the effective reception of adolescents and their families. Comprehensive efforts to understand and support the identity process of gay adolescents in the particularity of their social context should be on the agenda of health services and the centrality of care. The bond is created and strengthened depending on the interaction and is related to the transformation of practices to fulfill the adolescents' health needs (52) .
The incipience and weaknesses that nurses carry to care for this population, which has double vulnerability, that is, being teenagers and gays, may be more related to how one educates than about what one educates.
Reproduction of protocols in teaching without betting on the encounter and effective exposure to the experience of those who demand care reduce perspectives and sensitivity. It is necessary to investigate the validity of the knowledge that emerges and directs the intersubjective relationships between nurses-care demanders (54) . There is no doubt that nurses need knowledge and skills necessary to act safely and competently, but to gain representation as care, practical success, it is necessary to put oneself in the other's shoes, and professional training leaves much to be desired in this equation.
Few studies address specifically one of the populations

Conclusion
Nurses revealed a tendency to de-subjectify gay adolescents due to the objectivity with which they conducted care and the cisheteronormative stigmas and attitudes that influenced meanings and behaviors.