The LGBT+ Individual Perspective of Aging in Brazilian Society

A Perspectiva do Indivíduo LGBT+ sobre o Envelhecimento na Sociedade Brasileira

Abstract

This study describes the perceptions of aging and the health care received by 101 LGBT+ individuals in Brazil (São Paulo, Mato Grosso, and Rio Grande do Sul). Participants completed an online 13-item demographic and LGBT+ perception questionnaire. The age ranged from 18 to 55 years, 75.5% were Caucasian, 92% self-identified as cisgender and 55% were homosexual. Most did not stop seeking healthcare (59.8%) because of fear, but they avoided revealing their sexuality to health professionals (65.7%). Participants had negative views about aging and regarded the health system as caustic, and health professionals exhibited unethical behaviors and gaps of knowledge related to LGBT+ practice. Continuing education about the LGBT+ community should be prioritized to mediate discriminatory healthcare.

Keywords:
sexual and gender minorities; health personnel; health equity; aging

Resumo

Este estudo descreve as percepções sobre o envelhecimento e os cuidados de saúde recebidos por 101 indivíduos LGBT+ no Brasil (São Paulo, Mato Grosso e Rio Grande do Sul). Os participantes preencheram um questionário online de 13 itens, dados demográficos e sobre a percepção LGBT+. A idade variou de 18 a 55 anos, sendo 75,5% caucasianos, 92% auto identificados como cisgênero e 55% homossexuais. A maioria não deixou de procurar o serviço de saúde (59,8%) por medo, mas evitou revelar sua sexualidade aos profissionais de saúde (65,7%). Os participantes tinham visões negativas sobre o envelhecimento, consideravam o sistema de saúde não acolhedor e os profissionais de saúde apresentavam comportamentos antiéticos e lacunas de conhecimento relacionadas à prática LGBT+. A educação continuada sobre a comunidade LGBT+ deve ser priorizada para mediar cuidados discriminatórios.

Palavras-chave:
minorias sexuais e de gênero; pessoal de saúde; equidade em saúde; envelhecimento

Restricted access to comprehensive health care for individuals within the LGBT+ community indicates that sexual diversity and human sexuality are still poorly covered in the health education of professionals. This demonstrates that the socio-historical context is still supported by entrenched concepts and debates that date back to antiquity (Chapman et al., 2011; Costa et al., 2016; Lopes et al., 2023). It is observed that the binary heterosexual matrix remains the dominant reference point clinicians continue to use and serves as a regulatory system of sexuality and subjectivity (Chapman et al., 2011; Costa et al., 2016). All these factors contribute to inadequate healthcare assistance for those who do not identify in the heterosexual matrix.

People with homosexual or bisexual orientation have long been stigmatized (Herek, 2000), and it still happening in Brazilian society (Lopes et al., 2023). Structural stigmas can be configured as a risk indicator for the physical and mental health of individuals who do not identify as heterosexual (Cicero et al., 2019; Costa et al., 2020; Hatzenbuehler, 2014; Stinchcombe et al., 2018). The Lesbian, Gay, Bisexual, Transvestite, Transsexual, and Transgender (LGBT+¹) population have a higher risk for unrecognized morbidities and health complications due to sexual prejudice in society, including in the health care system. They require good health care. However, the fear of being victims of prejudiced attitudes, stigmas, and sexual discrimination from health professionals result in diminished access to the health system for this at-risk clinical population (Jesus et al., 2023; Wilson et al., 2018; Wilson et al., 2021).

In Brazil, typically most people find it difficult to share the hospital admission site with transgender people, particularly undressing in their presence (Moscheta et al., 2016), also, some institutions allocate people requiring care according to their biological sex (Ferreira, 2023). Brazilian literature shows that healthcare professionals (HCP) avoid providing care to homosexual patients (Rondahl et al., 2004) and that sexual orientation, behavior, and manner of dressing are impermissible (Moscheta et al., 2016).

The study conducted by Carvalho and Philippi (2014) described the perception of LGBT+ persons when seeking health services. The participants described situations such as the unpreparedness of professionals to deal with the gay public; their use of inappropriate jokes and debauchery; disdainful looks; being unaccepting and judgmental of practices among lesbians; exclusionary gynecological care of LGBT+ patients; lack of adequate professional training; and lack of attention to the needs of the LGBT+ population, among others. These prejudiced behaviors result in LGBT+ individuals avoiding seeking healthcare (Crenitte, 2021; Crenitte et al., 2023).

Others have corroborated these findings. In a previous study, individuals who identify as transgender (Costa et al., 2018; Jesus et al., 2023) and lesbian (Silveira & Cerqueira-Santos, 2021) reported that they avoided seeking the help of a healthcare professional due to the prejudices expressed by professionals. Understandably, a relationship is observed in the explicit behavior between avoiding seeking health care assistance from LGBT+ individuals and the prejudice established by HCP in various contexts (Crenitte, 2021; Jesus et al., 2023).

These problems are compounded by the detrimental impacts and restrictions during the COVID-19 pandemic. Multiple negative effects on the health and health care experienced by LGBT+ individuals have been reported. LGBT+ individuals experienced financial difficulties. Some reported the emergence of health problems and deterioration in their physical and mental health. Moreover, individuals expressed feelings of distress, insecurity, fear of daily life, depression, and suicidal ideation (Kamal et al., 2021; Linhares et al., 2021). One of the complicating factors mentioned was the fact that LGBT+ individuals remained at home, respecting quarantine public health policies, with their unreceptive families. This resulted in increased rates of physical and emotional aggression, domestic violence, and mental health damage (Kamal et al., 2021; Linhares et al., 2021; Santana & Melo, 2021; Suen et al., 2020).

The resistance of LGBT+ individuals to seek help regarding care in health services is due to encountering homophobic, transphobic, and neglectful reactions of HCP, not to mention the unrecognized and untreated fatal health risk consequences that are unique to this population (Lopes et al., 2023; Moe & Sparkman, 2015; Rondahl et al., 2004). Many of these people are reluctant to disclose their sexual identity for fear of not getting appropriate health treatments and care (Costa et al., 2018; Rondahl et al., 2004).

These disturbing findings point to the paucity of accurate education and training of health professionals concerning the health and health care required of individuals who identify as LGBT+. Such education is essential to provide a more humanized approach to healthcare (Carvalho & Philippi, 2014; Moscheta et al., 2016; Wilson et al., 2018), where understanding of LGBT+ populations can be fostered (Chapman et al., 2011; Mayer et al., 2008). We situate this study within the context of the humanistic value framework as described by Todres et al. (2009). They posit that HCPs have the potential [power] to deliver health care along a continuum of humanizing or dehumanizing actions of care. To provide care for individuals, respecting their lived experiences, right to self-determination, and each person’s subjective authority concerning their view of self and health, rather than caring exclusively from a biomedical perspective is an example of providing humanized care (Todres et al., 2009). In this way care rendered acknowledges and takes into account the uniqueness of the person thus, humanizing the healthcare interaction. This study investigates the extent to which humanized healthcare interactions are experienced by LGBT+ Brazilians.

The purpose of this study was to describe the self-perception of LGBT+ people about aging and the care received from health professionals in the Brazilian context. The research questions that guided this study were: 1- Did the Brazilian LGBT+ individuals suffer from LGBTphobia by a healthcare professional? and 2 - What is the Brazilian LGBT+ individual’s perception regarding their human aging process in the Brazilian context and the health care they were provided?

Method

This was an observational, online survey, mixed methods study (Creswell, 2010; Oliveira et al., 2018). Research data is available upon request to the authors.

Participants

Participants included in the study who were users of the Brazilian private or public healthcare system (in the primary, secondary, and tertiary care), were 18 to 70 years old, identified as LGBT+, lived in the Brazilian states of São Paulo, Mato Grosso, or Rio Grande do Sul, and provided consent to participate. Individuals were excluded if they did not have access to an internet connection and a cell phone, computer, notebook, or tablet and if they had difficulties using/completing online forms due to self-reported visual, motor, or comprehension difficulties.

Data Collection and Instruments

The 13-item demographic and LGBT+ perception questionnaire included 11 questions with multiple-choice answers and two questions with descriptive and personal answers. See ^{Appendix A} (Demographic and Perception Questionnaire). The questionnaire addressed the demographic characteristics of the sample and questions related to practices of seeking health care services and interactions with HCPs. Two qualitative questions addressed the participant's perception related to the aging of LGBT+ individuals in Brazil how they understand their aging and the assistance provided by HCP.

The data were collected through the snowball modality (Biernacki & Waldorf, 1981), with a self-administered questionnaire available online, via a specific platform (Google Forms) for open virtual data collection during March and April 2022. A card with an invitation and the link was shared on social media and the university departments to share the invitation with students.

Data Analysis

Data were analyzed, using the Excel Program version 16.16.27. Descriptive statistics, frequencies, and proportions were compiled. Descriptive qualitative analysis as described by Sandelowski (2000) was used in this study. This qualitative descriptive approach uses content analysis to extract data that describes the perceptions, sensibilities, sensitivities, and inclinations of the participants staying close to the raw data. Qualitative description used in this way produces high-quality data that is derived from the information given to the researcher from the participants with minimal interpretation by the researcher (Bardin, 2016). This study was approved by the Research Ethics Committee of the University of Passo Fundo (CAAE 55484521.4.0000.5342).

Results

Sample

The study recruited 115 participants. For this study, the data is composed of 101 participants and the 14 participants were excluded as they did not complete the survey. See Table 1 for the sample demographic characteristics.

Table 1
Sample demographic characteristics

Variable	n	%	Variable	n	%
Gender identity			Ethnicity
Cisgender	93	92.1	Caucasian	76	75.5
Non-binary	7	6.9%	Brown	19	18.6
Transgender	1	1	Black	5	4.9
			Indigenous	1	1
Age
18 to 25 years old	60	58.8	Sexual orientation
26 to 35 years old	28	28.4	Homossexual	56	55.4
36 to 45 years old	11	10.8	Bisexual	33	32.7
46 to 55 years old	2	2	Pansexual	7	6.9
			Others	5	5
Level of education
Undergraduate	64	63.4	Religion
High school	19	18.8	Atheist	27	28.1
Master degree	8	7.9	Catholic	25	26
College degree	5	5	Spiritist	16	16.7
Others	5	4.9	Lutheran	10	10.4
			Others	18	18.8
State of residence
Rio grande do sul	74	73.3
São Paulo	18	17.8
Mato Grosso	9	8.9
Have you ever stopped seeking health care services because of fear/rejection of the behavior of health professionals?			Have you ever been embarrassed during a healthcare professional's care?
No	60	59.8	No	67	65.7
Yes	41	40.2	Yes	35	34.4
Have you ever experienced lgbtphobia in the environment of a healthcare institution?			Have you ever experienced lgbtphobia by a health care professional?
No	85	84.2	No	83	82.2
Yes	16	15.8	Yes	18	17.8
Have you ever failed to disclose your sexual and gender orientation to a healthcare provider because you were afraid of how the provider would react?
Yes	67	65.7
No	34	34.3

In summary, the quantitative data shows that the main sample is composed of cisgender, homosexual, Caucasian, younger adults, with an undergraduate level of education, who are atheists, and who reside in the state of Rio Grande do Sul. Most of the participants did not stop looking for health professional services because of the fear of being embarrassed. Most of the sample did not report discrimination, although 15.8% did suffer LGBTphobia in the health environment and 17.8% reported experiencing discriminatory treatment from an HCP. Most of the sample (65.7%) did choose to hide their sexual and gender orientation from an HCP.

Perceptions About Aging in the LGBT+ Community

Seventy-five individuals of the sample (74.2%) answered the qualitative questions. When asked about their perceptions of the human aging of an LGBT+ person, five themes emerged from the data. Participants shared their perspectives on human aging in Brazilian society from the respective themes: the LGBT+ individual, LGBT+ community, Brazilian society, health policies, and health professional level, see Figure 1-visual Schemata of the LGBT+ Individual Perspective of Human Aging in Brazilian Society.

Figure 1.
Visual schemata of the LGBT+ individual perspective of human aging in Brazilian society

In Figure 2, we provide a visual representation of the overarching themes and corresponding descriptions of the perceptions of LGBT+ human aging in Brazil.

Figure 2.
Five themes about LGBT+ human aging in Brazil

The first theme was “Personal perceptions of aging” From the LGBT+ individual perspective of human aging in Brazilian society, the participants reflected that they had never thought about it before, and human aging comes accompanied by loneliness, fear, violence, prejudgments, insecurity, abandonment, and the lack of support from their family. Participants described to get the support they needed and not experience discrimination, many felt they needed “to be back in the closet”.

The LGBT+ participants articulated that there is a lot of insider prejudice from the LGBT+ individual and within their community. Some expressed that the person may have prejudices against older individuals (e.g., gerontophobia). Gerontophobia, as an example, was discussed as one of the reasons for feeling lonely and excluded. This was attributed to the LGBT+ community overvaluing and giving preference to its younger members.

Participants described Brazilian society as a very caustic, violent society towards LGBT+ individuals. Participants commented that trans people were ostracized and targeted for acts of violence, often leading to murder. Others brought attention to the lack of a supportive environment in terms of policies that support LGBT+ individuals aging in place. The lack of policies in this area was regarded by participants as an example of the way Brazilian society rendered older LGBT+ people invisible to those in power providing health care.

The second question inquired about how LGBT+ people view their aging process and the health care that they receive. The answers were divided into three main themes, from the LGBT+ individuals, health professionals, and the healthcare system in Brazil perspective (See Table 2).

Table 2
Results of the human aging process and the health care received

Question	Theme	Participant Quotes
How do you imagine your aging and the assistance provided by health professionals?	LGBT+ person	“I can’t imagine, I believe I will live no more than 45 years old - Não imagino, acredito que não passo dos 45”. I can’t imagine it…., that’s sad, I don’t know if someday I will have courage to search for health assistance related to my sexuality - Simplesmente não consigo imaginar…., o que é triste, não sei se algum dia terei coragem de buscar ajuda médica em caso de situações que envolvam a sexualidade.” “I see it [aging] as a suffering because health assistance to the lgbtqi+ person is unconfortable because of the way the health professionals are not confidential when talking about us and ended up embarrassing us - Vejo como sofrimento pois assistência devida a pessoa lgbtqi+ é de forma desconfortável pois muitos profissionais escancaram sem ver a proteção de sigilo e acabam nos envergonhando”
	Health Professional	“I see that the health professionals are not learning to provide care to this population - Vejo que os profissionais de saúde não estão sendo formados para atender essa população” I hope it [health care] will be better, and the health professionals don’t bring with them their beliefs and prejudices - espero que se seja melhor, e que os profissionais não tragam paea a profissão suas crenças e precpnceitos” “As a woman, I have always suffered retaliation regarding my body and my health, this will only get worse when we deny terminologies and science. Menstruation, pregnancy, contraceptives have always been issues that even health professionals sometimes treat with contempt, prejudice, because it is about women's sexuality, which has always been rejected. - Como mulher, sempre sofri retaliação quanto a meu corpo e minha materialidade na saúde, isso so vai piorar quando negamos nomenclaturas e a ciência. Menstruação, gestação, contraceptivos sempre foram questões que mesmo profissionais da saúde algumas vezes tratam com desprezo, preconceito, pois se trata da sexualidade da mulher, que sempre foi rechaçada.”
	Health System	“Public Health System (SUS) should establish health care manuals for the LGBTQI+ public in all áreas of health care - Sistema Único de Saúde (SUS) deveria estabelecer manuais de assistência em saúde para o público LGBTQI+ em todos os ambitos como obrigatoriedade.” “If I belong to the upper class, I will receive more adequate care, if I need the public health system, I will not receive adequate assistance - Se eu pertencer a classe alta vou receber atendimento mais adequado, se eu precisar do sistema único de saúde, não receberei assistência de forma adequada”

The participants described negative perceptions about themselves, about HCPs, and from within the healthcare system. Participants were afraid, feeling that they would suffer prejudices in their aging process. Participants attributed this to healthcare professionals' lack of appropriate LGBT+ knowledge and not having access to education that is underpinned by an equity, diversity, and inclusion perspective. One respondent articulated that they hoped that this education that recognized the LGBT+ community would result in a more peaceful life, living with the dignity that everyone deserves.

Multiple participants cited the lack of knowledge and understanding of LGBT+ people and their unique healthcare needs were a problem that could easily be fixed if proper education were provided to healthcare professionals. It was suggested that annual education with standardized manuals could narrow the knowledge gap about providing the different levels of care and assistance to the members of this community.

Discussion

This study sought to describe the perceptions of LGBT+ individuals of what it was like to age and access healthcare in the Brazilian context. For the most part, LGBT+ individuals indicated they would not stop accessing health care. Only a moderate proportion of the sample (40.2.%) reported that they would defer engaging in health care due to feeling insecure, experiencing unprofessional and discriminatory actions from HCPs, and that HCPs were uneducated and unprepared to care for individuals within this community in a society where is unaccepting of sexual and gender minorities.

The participants’ perceptions and thoughts about human aging were mixed and complicated. For some, living within the LGBT+ community was not comfortable as prejudice-targeted negative interactions also were common experiences within the LGBT+ community. These inter-community discriminatory actions act to further ostracize and restrict appropriate assessment of the LGBT+ person. Regrettably, gerontophobia is a reality within the LGBT+ community. Colleagues Parmenter et al. (2021) concur that discrimination is prevalent amongst the LGBT+ community. Participants described frustration at their experiences of exclusion, alienation, and prejudgment because their sexual or gender identities fell within the bisexual, asexual, or transsexual orientation (Parmenter et al., 2021).

Generally, participants hadn’t thought a lot about their aging as they indicated that they probably would not live to an old age. Aging for the participants wasn’t perceived as a priority. Participants described more so, being afraid and lonely accounting that they lived in a very violent culture where members of the LGBT+ community were targeted for criminal acts and violence and some were murdered for being a sexual and gender minority person. Although current mortality statistics are under-reported, in 2021 there were 140 deaths of trans-people attributed to murder reported in Brazil (Valente, 2022). Many participants reflected that they had to put themselves in hiding, chose not to reveal their sexuality and gender preference to people, and HCP to protect themselves from discriminatory health care treatment.

Our results are reinforced by colleagues Moe & Sparkmen (2015), Rondahl et al, (2004), and Lopes et al. (2023) who indicate that LGBT+ individuals resist seeking medical assistance is related to homophobic encounters and neglectful reactions in delivery of healthcare. Other research documents that many LGBT+ people are reluctant to disclose their sexual identity for fear of not getting appropriate care (Costa et al., 2018; Rondahl et al., 2004). Furthermore, individuals who identify as transgender (Costa et al., 2018) and lesbian (Silveira & Cerqueira-Santos, 2021) reported that they avoided seeking the help of a hea care professional due to the prejudices expressed by professionals (Costa et al., 2018; Silveira & Cerqueira-Santos, 2021).

As was found in this study, aging individuals who identify as LGBT+ requiring various levels of physical or social assistance were faced with difficult decisions. Participants felt they had to forgo their sexuality and gender to obtain safe, unprejudiced healthcare. Participants in our study saw it necessary “to be back in the closet”, as a method to get adequate support. This is corroborated in the literature as the quality of care received by LGBT+ older adults living in a Long-Term Care Institution for the elderly reported fear of homophobia, stigma, and discrimination from health professionals working in this context (Wilson et al., 2018).

This study aligns with research that continues to document the negative and lethal implications of unrecognized implicit biases within health care (Fitzgerald & Hurst, 2017; Pritlove et al., 2019). Implicit biases are those unconscious thoughts, associations, and microaggressions we make that perpetuate unethical evaluations of a person based on irrelevant characteristics such as color, race, age, or sexuality. Implicit bias demonstrated by healthcare professionals results in inequitable care, misdiagnosis, and treatment decisions that either serve to privilege or marginalize people (Avellar & Rodrigues, 2023; Banks et al., 2006; Fitzgerald & Hurst, 2017). A specific example of this was found in sexual minority women and Agénor and colleagues (2020) confirm this reality.

Agénor et al. (2020) study colleagues demonstrated that white, bisexual women had significantly lower chances of getting a mammogram compared to white, heterosexual women. When checking the incidence of the exam in black and lesbian women, it was noticed that these women had lower chances of getting mammograms compared to black and heterosexual women. For lesbian Latina women, the same restriction in performing the exam also occurred.

Participants in the current study have described HCP as employing unethical approaches, using pejorative body language, and casting negative judgments during healthcare interactions. This similar treatment and the recognition that there are limited effective training environments for professionals is echoed by Carvalho and Philippi (2014), Cruz et al. (2023), Feaster et al. (2021), Jesus et al. (2023), and Williams et al. (2021). This demonstrates the urgent need to target professional development and education on the health and healthcare needs specific to the LGBT+ individual using a more equitable and humanistic approach to healthcare and education in this area.

Implications for Practice and Research

Given the current climate described within this study of the prejudiced treatments received by the LGBT+ community, there are implications for clinical practice, education, and research. It is often espoused that healthcare provides patient/person-centered care. Results from this study and others report the exact opposite. Current healthcare practices do not embrace the whole person. Where the intersections of the body/psycho/social/spiritual aspects can be incorporated into the care they receive. Education of HCP needs to incorporate a humanized framework (Todres et al., 2009) that values intersectional care that can be brought into education and clinical practice environments (Cruz et al., 2023; Jesus et al., 2023). Dullius and Scortegagna (2021) argue that curriculum development needs to occur that will provide a comprehensive understanding of the requisite knowledge, skills, and attitudes necessary to care for individuals from the LGBT+ community. We further posit that education and practice need to incorporate a more holistic, humanized, and intersectional person-centered care approach and application to every human healthcare interaction; preserving basic human dignity.

To mediate the current climate facing Brazilian LGBT+ individuals, health education of HCPs needs to become the priority focus. A strategy to minimize these gaps in health care and qualify the training of health professionals, one should invest in health education supported by developing courses and offering training to expand and enhance humanized and bias-free health care to LGBT+ individuals.

Limitations

Some limitations are evident in this research study. The ability to generalize these data to the public may be limited. The period of collecting data needs to be considered as it happened in a short period (two months). Although the participants in this study are from three states of Brazil, most of the participants were from the state of Rio Grande do Sul. In addition, this sample was predominantly young adults. A more diverse sample would be required to gain the perspectives of all ages in the LGBT+ community.

Final Considerations

The process of human aging described by members of the LGBT+ community was referred to as a complicated existence. LGBT+ individuals faced external and internal levels of prejudiced treatment from society, health care professionals, and within their LGBT+ communities. Lack of access to health care was a normal occurrence having to hide their sexual and gender orientations to get appropriate non-discriminatory health care. Most thought that the longevity of life was improbable. Living as an LGBT+ person in a homophobic/transphobic society, their life was at constant risk for ostracization, targeted acts of violence, and murder. These results can contribute directly to the improvement and development of new public policies, also, giving an approach to health managers to promote continuing education to HCP. Education and training for health professionals that will equitably serve the LGBT+ population, so this minority group can have more humanized health care.

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• 1
  In this article, the acronym LGBT+ was adopted, although there are other acronyms such as GLS, LGBTT, LGBTTQ, LGBTTSQ, LGBTQIA+ and LGBTTTIS, which include and designate other groups such as sympatric, intersex, bisexual, transsexual, transvestite, transgender, queer, asexual, + sign for all forms of gender and sexuality that are in or out of the previous aspects.

• Data availability statement

  Research data is available upon request to the corresponding author.

• Funding information

  This study was carried out with the support of the Coordination of Improvement of Higher Education Personnel - Brazil (CAPES) - Finance Code 001.

Appendix A - Demographic and Perception Questionnaire

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Edited by

Responsible editor

Mônica Medeiros Kother Macedo

Data availability

Research data is available upon request to the corresponding author.

Publication Dates

• Publication in this collection
  07 June 2024
• Date of issue
  2024

History

• Received
  13 May 2022
• Accepted
  09 Oct 2023