GENERAL HEALTH AND PERCEIVED/FEARED DISCRIMINATION IN THE LGBT+ COMMUNITY

SAÚDE GERAL E DISCRIMINAÇÃO PERCEBIDA E TEMIDA NA COMUNIDADE LGBT+

ABSTRACT

Objective:

to analyze the relationship of perceived and feared discrimination with general health in LGBT+ people according to schooling level, gender identity and socioeconomic level.

Method:

a cross-sectional and correlational study was conducted. The sample consisted of 120 participants of legal age from the Maule region (Chile) who belonged to the LGBT+ community and answered an online survey due to the SARS-CoV-2 pandemic. The survey also included an open question for the participants to share discrimination experiences regarding the treatment received from the Nursing personnel. The quantitative data were examined by means of descriptive and inferential analyses (means difference and correlation tests). The results extracted were analyzed following the thematic and discursive analysis techniques.

Results:

although perceived discrimination had low prevalence in the sample, 44.17%, 38.33% and 32.51% manifested fear of not being loved, of not finding a job and of being rejected by their family for being part of the LGBT+ community, respectively. Likewise, discrimination was higher in the group of trans people and was mainly reflected in unjustified dismissals, difficulties finding a job or ill-treatment in the provision of health services. Finally, it was found that the participants exposed to more discrimination also reported worse general health.

Conclusions:

discrimination is a problem that affects the LGBT+ community, particularly the trans collective. The severe implications of discrimination for people's health evidence the need to design strategies, policies and regulations aimed at fostering tolerance and integration.

DESCRIPTORS:
Gender analysis in health; Social discrimination; Health; Sex and gender minorities; Nursing care

RESUMO

Objetivo:

analisar a relação entre a discriminação percebida e temida e a saúde geral das pessoas LGBT+ de acordo com seu nível educacional, identidade de gênero e nível socioeconômico.

Método:

realizou-se um estudo transversal e correlacional. A amostra foi composta por 120 participantes adultos da região de Maule (Chile), pertencentes à comunidade LGBT+, que responderam a uma pesquisa virtual devido à pandemia de SARS CoV-2. A pesquisa também incluiu uma pergunta aberta que proporcionou um espaço para os participantes compartilharem experiências de discriminação em relação ao tratamento recebido da equipe de enfermagem. Os dados quantitativos foram examinados por meio de análises descritivas e inferenciais (testes de diferença de médias e correlações). As histórias extraídas foram analisadas segundo técnicas de análise temática e discursiva.

Resultados:

embora a discriminação percebida tenha uma baixa prevalência na amostra, 44,17% expressaram medo de não serem amados, 38,33% de não encontrar emprego e 32,51% de serem rejeitados pela família por fazerem parte da comunidade LGBT+. Da mesma forma, a discriminação foi maior no coletivo de pessoas trans e se refletiu principalmente em demissões injustificadas, dificuldades em encontrar emprego ou maus-tratos na prestação de serviços de saúde. Por fim, verificou-se que os participantes expostos a mais discriminação também relataram pior estado geral de saúde.

Conclusões:

a discriminação é um problema que afeta a comunidade LGBT+, principalmente o coletivo de pessoas trans. As graves implicações da discriminação para a saúde das pessoas evidenciam a necessidade de desenhar estratégias, políticas e regulamentações que visem promover a tolerância e a integração.

DESCRITORES:
Análise de gênero em saúde; Discriminação social; Saúde; Minorias sexuais e de gênero; Cuidados de enfermagem

RESUMEN

Objetivo:

analizar la relación entre la discriminación percibida y temida, y la salud general de personas LGBT+ de acuerdo a su nivel educativo, identidad de género y nivel socio-económico.

Método:

se realizó un estudio transversal y correlacional. La muestra constó de 120 personas participantes mayores de edad de la región del Maule (Chile), pertenecientes a la comunidad LGBT+, que respondieron una encuesta de manera virtual debido a la pandemia por SARS CoV-2. La encuesta también incluyó una pregunta abierta que proporcionó un espacio para que las personas participantes compartieran experiencias de discriminación con respecto al trato recibido del personal de enfermería. Los datos cuantitativos se examinaron mediante análisis descriptivos e inferenciales (pruebas de diferencia de medias y correlaciones). Los relatos extraídos se analizaron siguiendo técnicas de análisis temático y discursivo.

Resultados:

si bien la discriminación percibida tuvo una prevalencia baja en la muestra, un 44,17% expresó temor a no ser querido, 38,33% a no encontrar trabajo, y 32,51% a ser rechazado por su familia por ser parte de la comunidad LGBT+. Asimismo, la discriminación fue mayor en el grupo de personas trans y se reflejó principalmente en despidos injustificados, dificultades para encontrar empleo o maltratos en la provisión de servicios de salud. Finalmente, se encontró que las personas participantes expuestas a mayor discriminación también reportaron una peor salud general.

Conclusiones:

la discriminación es un problema que afecta a la comunidad LGBT+, particularmente al colectivo trans. Las serias implicaciones de la discriminación para la salud de las personas ponen de manifiesto la necesidad de diseñar estrategias, políticas y reglamentaciones tendientes a fomentar la tolerancia y la integración.

DESCRIPTORES:
Análisis de género en salud; Discriminación social; Salud; Minorías Sexuales y de género; Atención de enfermería

INTRODUCTION

The LGBT+ community, a collective that groups individuals identified with the lesbian, gay, bisexual, transgender and other gender identities and sexual orientations, has historically struggled for the right to social acceptance, non-discrimination and overcoming of the stigmas thereby related.1 In this sense, different studies around the world evidence cases of disparity in health care, reduction of the job opportunities and even inequalities in access to civil rights, among others.2 Specifically, the American Academy of Nursing acknowledges that there are disparities and inequalities in LGBT+ people's access to health worldwide, characterized as a global problem affecting the community.3 According to data from the Homosexual Integration and Liberation Movement (Movimiento de Integración y Liberación Homosexual, MOVILH) presented in its XVII Annual Report on Human Rights for Sexual and Gender Diversity,4 76.1% of the Chilean population self-declared as transsexual has suffered discrimination regarding their gender identity, whereas 64.3% of the surveyed individuals have been victims of at least one explicit and evident episode of discrimination due to their sexual orientation, mainly in the form of mockery, psychological harassment, insults and threats. The aforementioned data show the LGBT+ community as a vulnerable population in relation to the rest of society because discrimination, whether covert (e.g., social exclusion) or explicit (e.g., physical and/or verbal aggression), directly affects their physical, psychological and social spheres, that is to say, their Quality of Life.5

Given this situation, one of the Sustainable Development Goals (SDGs) included in the World Health Organization's 2030 Agenda6 aims at improving people's Quality of Life by reducing inequalities and enhancing social, economic and political inclusion of all individuals regardless of their age, gender, disability, ethnicity or any other condition to ensure a healthy life and promote well-being for people of all ages. However, the Agenda fails to explicitly consider the LGBT+ community, reason why the United Nations' Program for Development7 prepared the LGBTI (Lesbians, Gays, Bisexuals, Transsexuals and Intersexuals) Inclusion Index, which seeks to adapt the efforts in compliance with the SDGs by betting on visibility of the collective. Unfortunately, these efforts are still insufficient, as studies around the world keep evidencing high discrimination levels against the LGBT+ community that exert negative effects on their health.

The studies linking discrimination with physical and mental health in the LGBT+ population have more frequently done so from the investigation of constructs, or dimensions of constructs, such as Quality of Life (QoL) and Health-Related Quality of Life (HR-QoL).8 In recent years, research studies in this filed have addressed topics such as the experiences related to the stigma during adolescence and the negative effects on HR-QoL in adulthood among LGBT+ people, when compared to heterosexual individuals.9 Other studies have investigated the relationship of conscious acceptance, stress and self-esteem with Quality of Life in this psychological sphere,10 as well as of QoL with functionality in healthy trans children and young people and in those with chronic diseases11 and between QoL and disability.12 In this context, several of these studies highlight the fundamental role of health care and access to it in terms of managing inclusive policies or, to the contrary, of perpetuating discriminatory and stigmatizing behaviors against the LGBT+ population.13

In this sense, a number of studies show that LGBT+ people are 1.5 times more prone to reporting unfavorable experiences related to Primary Health Care than cisgender heterosexual individuals.14 Other studies examine various general aspects inherent to the health context such as the degree of access to health institutions,12 administrative bureaucracy and provision of information for disease prevention,15^-16 among others. However, most of these studies have targeted their samples at HIV-immunosuppressed patients17 and at those with certain aging-related comorbidities,15 thus invisibilizing the rest of the LGBT+ community.

In addition, although with the exception of a few ones18 these studies establish that health institutions usually operate administratively from a heteronormative logic, the literature in the area addresses discrimination 1) in a general way and only considering perceived discrimination19 and 2) avoiding linking it specifically to experiences regarding treatment by a particular group of health professionals.13 Specifically in Chile, although it is known that the LGBT+ community perceived Primary Care as of ‘poor quality’ and ‘discriminatory’,13 the characteristics of health care in relation to the treatment by the Nursing personnel are ignored. This situation is similar to the one observed in the international literature on Nursing.20 In this sense, it is worth noting that a study shows that 52.9% of the Chilean students attending the Nursing course who were surveyed presented homophobic and prejudiced attitudes towards the LGBT+ community when they were applied the homophobic attitude scale (EHF - 6).21 However, it is not known how the LGBT+ population perceives the treatment received from the Nursing personnel and how this is related to their own perceptions regarding health and perceived/feared discrimination.

Considering the aforementioned antecedents, this study analyzed the relation between perceived/feared discrimination and general health in LGBT+ people from the Maule region (Chile) according to their schooling level, gender identity and socioeconomic level. In this context, the study focuses specifically on the care provided by the Nursing personnel and analyzes reports of discrimination experiences made by LGBT+ people in terms of the treatment received from the Nursing personnel by using the Explicit and Covert Discrimination Microaggression taxonomy proposed by Nadal et al.22 The study contributes to conferring visibility to problems linked to discrimination and health in the LGBT+ community through a holistic view that addresses different types of discrimination in a heterogeneous sample in sociodemographic terms, both from quantitative and qualitative data. In addition, it offers suggestions from the Nursing area that may contribute to improving the care provided to LGBT+ individuals. From the ethical point of view, the study emerges as a facilitator in the creation of a space to express ideas, feelings and life experiences related to discrimination and health among LGBT+ people.

METHODS

This study is descriptive because it describes the behavior of the variables of interest in the sample and correlational because it examines the relationships between them, particularly between discrimination and general health. In addition, the variables were measured with no intervention or manipulation by the authors, therefore corresponding to a non-experimental design. Finally, measurement is grounded on data collected at a single moment in time (cross-sectional design).

The participants of this research were 120 individuals who voluntarily identified as belonging to the LGBT+ community and lived in the Maule region, Chile. The sample size is similar to those of other studies on this theme conducted with the LGBT+ community.10^-11^,19This is possibly due to the fact that the LGBT+ community constitutes what is called a ‘hidden population’,23 which is usually difficult to access to for research purposes, oftentimes due to privacy and personal protection reasons.24 The data were collected between June and October 2021 by applying an online survey through the Google Forms platform. This decision was grounded on the need to preserve data anonymity and to reduce in-person contact due to the sanitary alert and pandemic situation imposed by COVID-19. The participants were contacted by means of the “snowball” sampling technique.23 The procedure consisted in contacting various groups and associations with reach to the LGBT+ community, as well as several Higher Education institutions. These organizations were asked to share and disclose the invitation to participate in this study through their social networks and email messages to potentially interested people. In order to be included in the research, the individuals should (a) be at least 18 years old and (b) identify themselves as belonging to the LGBT+ community. It is worth noting that, although 120 members of the LGBT+ community voluntarily participated in this study, a total of 101 individuals answered the sociodemographic questionnaire in full.

Regarding the instruments used, feared and perceived discrimination were examined by using an adaptation of the DTP-48 MV scale by Moral and Segovia.25 Although this instrument was originally designed to study discrimination against women with HIV/AIDS diagnoses,25 it is also applicable to the reality of the LGBT+ community due to the discrimination usually suffered by this group in countless life situations. The adaptation consisted in replacing the instructions offered to the participant in each section and in slightly modifying some of their items. As an example, the instruction for items 1 to 11 that originally read “Por tu condición de vivir con VIH/SIDA” (“Due to your condition of living with HIV/AIDS”) was substituted by “Al ser una persona LGBT+, ¿cómo te identifican las siguientes situaciones?” (“For being an LGBT+ person, how do the following situations identify you?”). Likewise, the items that were linked to the treatment received in health institutions in general were changed to make a more explicit reference to the treatment by the Nursing personnel, alluding to the consultations in the Community Family Health Center (Centro Comunitario de Salud Familiar, CESFAM) and in hospitals. On this specific aspect it is important to note that, in Chilean public health institutions such as CESFAMs and hospitals, the patients are welcomed by the Nursing team performing their first evaluation before referring them to the generalist physician or specialist on-duty (as pertinent). This type of adjustment to the scale (together with clear instructions to answer the survey) allowed the participants to reflect on the treatment received from the Nursing personnel, as their reports about personal experiences on the topic will illustrate. Finally, the adapted version of the instrument maintained the 40-item structure, with an answer scale that varied between “Nothing” (1) and “Totally” (5).

The participants' health status was assessed by means of the ‘general health’ scale included in the Short Form-36 Health Survey V.2.26 This scale contains the following dimensions: a) the participant's assessment regarding their current health status; b) the future health perspectives; and c) resistance to falling ill. It consisted of 5 items with a five-level answer scale. Finally, the survey included the following final part: ‘Comentarios: En este espacio usted puede compartirnos sus experiencias en torno a los temas reflexionados, o bien puede reflexionar en mayor profundidad sobre alguna pregunta realizada en este cuestionario.’ (‘Comments: Here you can share your experiences related to the topics reflected on; you can also reflect in more depth about any question asked in this questionnaire.’) The purpose of this part was to provide a space where the participants could express their opinions and/or experiences on the topic researched in a qualitative way, sharing points of view and life experiences when they considered it pertinent. This space had not been offered in previous applications of the scales herein used, but we consider that it is of utmost importance to do so for the participants to have room for free expression.

The study was approved by the Scientific Ethics Committee of Universidad Católica del Maule(Proceedings 16/2021). All the participants signed an informed consent form that: a) contained a brief description of the study topic and objective, as well as of the procedures to answer the survey; b) explained the free, voluntary, private and anonymous nature of their participation; and c) explained that only the researchers would have access to the answers given in the survey, as they are stored in their own computers protected by passwords, and that the research results would only be used for scientific purposes. It is worth noting that no sensitive data that might identify the participants was collected, such as name, email address, street address, identification number or telephone number.

Analysis

The quantitative data were analyzed by means of descriptive and inferential statistical techniques. In the first place, the prevalence of perceived and feared discrimination in the sample was examined through calculations of percentage frequencies, arithmetic means and standard deviations. Secondly, means difference tests (Student'st and One-Way ANOVA) were performed to explore the incidence of socioeconomic level, schooling level and gender identity on feared and perceived discrimination. Finally, the relationship between discrimination and the participants' general health was analyzed by calculating Pearson's product-moment correlation coefficients.

Regarding the analysis of the reports provided by the participants to the open question of the survey, those that are explicitly linked to the treatment received in the care provided at the CESFAM and the hospitals were selected; subsequently, all the excerpts were classified into explicit and covert discrimination events,25 following thematic and discursive analysis recommendations found in the literature.27

RESULTS

Regarding the sociodemographic results, in terms of gender, 47.52% of the participants self-perceived as cisgender women, 32.67% as cisgender men, 3.96% as trans men, 1.98% as trans women, and 12.87% as non-binary individuals. As for sexual orientation, 62.37% of the participants reported being homosexual, 22.77% bisexual, 8.91% pansexual, 3.96% heterosexuals and 1.98% asexual (1 individual stated being non-binary, although this category more strictly reflects a gender perception and not a sexual orientation). 41.58% were aged between 18 and 25 years old, 43.56% were between 26 and 33, 9.90% between 34 and 41, and the remaining 4.95% were aged between 42 and 49 years old. Regarding the socioeconomic level, 9.90% belonged to the ABC1 level (high level, average-high level and emerging average level), 36.63% to C2 (typical average level), 28.71% to C3 (low-average level), 13.86% to D (vulnerable average level) and 10.89% to E (low level). Finally, with regard to the schooling level, 53.47% of the participants stated having Complete Higher Education, 13.86% reported Complete Technical Education, 29.70% had Complete High School and 2.97%, Incomplete High School.

In turn, Table 1 reports the feared discrimination levels in the study sample. As can be seen, an important percentage of the participants stated fear of being discriminated for belonging to the LGBT+ community. This fear was mostly reflected in the concern about the possibility of not being loved (44.17%), of not finding a job (38.33%), of being victims of rumors or gossip (38.33%), of being rejected by their family (32.51%) or even of being dismissed (30.00%). Despite these levels of fear reported by the participants, the results indicated that perceived discrimination, that is, the discrimination level that the participants explicitly declare experiencing, had low prevalence in the sample (Table 2). However, a relevant percentage indicated that they were dismissed from their job (17.50%) or were ill-treated in health centers (31.67%) for being members of the LGBT+ community. Furthermore, several participants indicated that they feel criticized (37.50%), that their opinion is not taken into account (39.17%) or that they are ill-watched in their everyday life (30.83%). In addition, 15.83% of the study participants reported that they were expelled from their house (or were at risk of being expelled) due to reasons related to their sexual orientation, gender perception and/or gender expression.

Table 1 -
Perception of Feared Discrimination in the LGBT+ community. Maule Region, Region VII, Chile, 2021. (n=101).

Situations of discrimination	Frequency level (%)					M*	SD†
	Nothing	A little	Pretty much	A lot	Totally
I'm afraid that they stop loving me.	27.50	28.33	16.67	14.17	13.33	2.58	1.38
I'm afraid that they find out.	40.83	29.17	10.83	8.33	10.83	2.19	1.34
I'm afraid that they will tell other people.	50.83	23.33	10.83	7.50	7.50	1.98	1.27
I'm afraid that my family rejects me.	50.00	17.50	6.67	9.17	16.67	2.25	1.55
I'm afraid that they fire me.	45.00	25.00	9.17	7.50	13.33	2.19	1.42
I'm afraid that they gossip about me.	39.17	22.50	20.83	10.00	7.50	2.24	1.28
I'm afraid that they kick me out my house.	70.00	12.50	6.67	3.33	7.50	1.66	1.21
I'm afraid that my friends stop talking to me.	68.33	12.50	6.67	6.67	5.83	1.69	1.21
I'm afraid that my mom/dad find out.	66.67	10.00	5.00	5.00	13.33	1.88	1.46
I'm afraid of not finding a job.	44.17	17.50	14.17	10.83	13.33	2.32	1.46

• *M=Mean; ^†SD=Standard Deviation.

Table 2 -
Perception of Perceived (or experienced) Discrimination in the LGBT+ community. Maule Region, Region VII, Chile, 2021. (n=101).

Situations of discrimination	Frequency level (%)					M*	SD†
	Nothing	A little	Pretty much	A lot	Totally
They don't share social activities with me.	70.83	21.67	5.83	0.83	0.83	1.39	0.71
They don't let me speak.	70.00	19.17	5.83	3.33	1.67	1.48	0.88
My neighbors criticize me.	62.50	26.67	6.67	0.83	3.33	1.56	0.91
I was fired.	82.50	8.33	2.50	2.50	4.17	1.38	0.97
They don't want to come close to me.	71.67	21.67	5.00	1.67	0.00	1.37	0.66
They withdraw.	75.00	19.17	3.33	1.67	0.83	1.34	0.70
They don't respect me and don't take my opinion into account in my house.	60.83	20.00	6.67	5.83	6.67	1.78	1.21
They don't respect me and don't take my opinion into account in my social circle.	77.50	14.17	4.17	1.67	2.50	1.38	0.85
I'm ill-treated when I attend appointments at the CESFAM or Hospital.	68.33	20.00	5.83	4.17	1.67	1.51	0.91
They don't treat me at the CESFAM or Hospital.	85.00	8.33	4.17	1.67	0.83	1.25	0.69
My peers look at me badly.	69.17	22.50	5.00	1.67	1.67	1.44	0.81
They kicked me out of the house.	84.17	5.83	4.17	1.67	4.17	1.36	0.96

• *M=Mean; ^†SD=Standard Deviation.

The situation of discrimination was examined in terms of three components: the actors that practice it (who), the place in which it occurs (where), and its onset (when). As can be seen in Table 3, the discrimination behaviors seem to come mostly from strangers (64.17%), although an important number of participants indicated that they are discriminated by their own closest environment, constituted by their parents (30.00%) and other family members (38.33%). Likewise, the results showed that discrimination seems to be more frequent in the neighborhood (22.50%), at the parents' or family members' houses (20.00%), at work (18.33%), in the health centers (13.33%), on the street (10.83%) or even at the participants' homes (15.83%). Finally, many participants coincided in that the discrimination behaviors seem to start when the victimizers recognize them as members of the LGBT+ community.

Table 3 -
Elements of the situations of discrimination faced by the LGBT+ community. Maule Region, Region VII, Chile, 2021. (n=101).

Situations of discrimination	Percentage frequency
Who?	Strangers	64.17%
	Other family members	38.33%
	Parents	30.00%
	Health personnel	16.67%
	Neighbors	10.83%
	Nobody	4.17%
	Work colleagues	2.50%
	Study peers	1.67%
	Friends	1.67%
	LGBT+ community	0.83%
Where?	In the neighborhood	22.50%
	In your parents'/family members' house	20.00%
	At work	18.33%
	In your house	15.83%
	In the health center	13.33%
	On the street	10.83%
	Nowhere	8.33%
	Social networks	3.33%
	Educational institution	2.50%
	Shops	1.67%
When?	When they find out that I belong to the LGBT+ community	29.17%

Means difference tests were performed in order to explore the presence of potential differences in the feared and experienced discrimination levels. Specifically, it was examined if the discrimination level reported was different according to the participants' schooling/socioeconomic levels or to their gender identity. The “schooling level” variable involved two categories (having or not Higher Education studies), reason why the Student'sttest for two independent samples was applied. In turn, the “socioeconomic level” variable implied three categories (low, average and high level), therefore resorting to the One-Way ANOVA test. Regarding gender identity, a data which consisted in four categories (cisgender woman, cisgender man, non-binary person or trans person), the One-Way ANOVA test was applied again. In the cases where statistically significant differences were detected, Scheffe's post-estimate contrast test was employed.

Although the socioeconomic level did not exert any influence on the feared discrimination variables, differences were indeed identified in them according to schooling level and gender identity. As can be seen in Table 4, trans people reported the highest feared discrimination levels of the sample. However, the results obtained in the statistical tests performed revealed that only the fear of not finding a job due to belonging to the LGBT+ community recorded statistically significant differences according to gender identity (p<0.05). More specifically, Scheffe's post-estimate contrast test indicated that this fear was significantly higher in the group of trans people. With regard to the schooling level, it was observed that, in general, feared discrimination was higher in the participants with no Higher Education studies (technical and/or university levels). More specifically, the fears that people find out about their LGBT+ identity (p<0.10), that they talk about their identity with others (p<0.10), of being rejected by their family (p<0.01), of being expelled from their house (p<0.05), of losing their friends (p<0.10) and that their parents find out about their LGBT+ identity (p<0.05) were the variables that recorded statistically significant differences. In all the cases, the ttest results revealed that these fears were significantly higher in the participants who did not have Higher Education studies.

Table 4 -
Feared discrimination levels according to schooling level and gender identity in the LGBT+ community. Maule Region, Region VII, Chile, 2021. (n=101).

Feared discrimination	Gender identity				p*	Schooling level		p*
	Cisgender man	Cisgender woman	Non-binary person	Trans person		No Higher Education	Higher Education
I'm afraid that they stop loving me.	2.73	2.45	2.79	3.00	N.S.†	2.69	2.49	N.S.†
I'm afraid that they find out.	2.15	2.17	2.36	2.17	N.S.†	2.46	1.99	0.0538
I'm afraid that they will tell other people.	1.82	2.02	2.00	1.83	N.S.†	2.23	1.78	0.0527
I'm afraid that my family rejects me.	1.91	2.34	2.36	2.17	N.S.†	2.69	1.91	0.0056
I'm afraid that they fire me.	2.18	2.15	2.36	3.17	N.S.†	2.23	2.16	N.S.†
I'm afraid that they gossip about me.	2.24	2.23	2.21	2.17	N.S.†	2.33	2.18	N.S.†
I'm afraid that they kick me out my house.	1.33	1.81	1.78	1.83	N.S.†	1.94	1.44	0.0242
I'm afraid that my friends stop talking to me.	1.39	1.77	1.79	2.50	N.S.†	1.90	1.53	0.0925
I'm afraid that my mom/dad find out.	1.48	2.00	2.07	2.00	N.S.†	2.33	1.54	0.0031
I'm afraid of not finding a job.	2.27	2.31	2.21	4.17	0.0231	2.44	2.22	N.S.†

• *p=p-value; ^†N.S.=Not Significant relationship.

The previously described procedure was also used to explore the presence of potential differences in experienced discrimination according to socioeconomic level, gender identity and schooling level (see Table 5). Again, no statistically significant differences were identified based on the socioeconomic level. Regarding gender identity, the results revealed that the group of trans people presented the highest discrimination levels. This latter was mainly manifested in the form of criticism by the neighbors (p<0.01), dismissals (p<0.05), physical contact rejection (p<0.01), disregard for their opinions (p<0.05), improper stares (p<0.01) and even ill-treatment in the health system (p<0.01). These assessments were subsequently confirmed by means of Scheffe's post-estimate contrast test. Regarding the incidence of schooling level, the results indicated that experienced discrimination was slightly higher in the participants with no Higher Education studies. However, only a few discriminatory behaviors such as refusing to talk to them (p<0.05) or not respecting their opinions (p<0,05) recorded statistically significant differences.

Table 5 -
Experienced discrimination levels according to schooling level and gender identity in the LBGT+ community. Maule Region, Region VII, Chile, 2021. (n=101).

Experienced discrimination	Gender identity				p*	Schooling level		p*
	Cisgender man	Cisgender woman	Non-binary person	Trans person		No Higher Education	Higher Education
They don't share social activities with me.	1.39	1.40	1.50	1.33	N.S.†	1.42	1.37	N.S.†
They don't let me speak.	1.33	1.48	1.50	1.67	N.S.†	1.67	1.32	0.0303
My neighbors criticize me.	1.36	1.54	1.79	2.83	0.0020	1.63	1.50	N.S.†
I was fired.	1.24	1.33	1.29	2.50	0.0301	1.54	1.25	N.S.†
They don't want to come close to me.	1.24	1.35	1.43	1.83	N.S.†	1.42	1.32	N.S.†
They withdraw.	1.15	1.29	1.50	2.33	0.0002	1.46	1.25	N.S.†
They don't respect me and don't take my opinion into account in my house.	1.30	1.98	2.07	2.33	0.0366	2.06	1.56	0.0249
They don't respect me and don't take my opinion into account in my social circle.	1.30	1.40	1.36	1.67	N.S.†	1.42	1.34	N.S.†
I'm ill-treated when I attend appointments at the CESFAM or Hospital.	1.33	1.50	1.43	3.17	0.0001	1.62	1.43	N.S.†
They don't treat me at the CESFAM‡ or Hospital.	1.12	1.33	1.00	1.50	N.S.†	1.27	1.24	N.S.†
My peers look at me badly.	1.33	1.29	1.71	2.67	0.0001	1.56	1.35	N.S.†
They kicked me out of the house.	1.15	1.50	1.50	1.17	N.S.†	1.40	1.32	N.S.†

• *p=p-value; ^†N.S.=Not Significant relationship. ^‡‘CESFAM’ means ‘Centro Comunitario de Salud Familiar’.

In order to examine the implications of discrimination on the health of the people from the LGBT+ community, the correlations observed between the discrimination levels (feared and experienced) and the reported general health were analyzed. As can be seen in Table 6, all of the items that reflect feared discrimination presented negative and statistically significant correlations with general health. Furthermore, the fear of being dismissed, of not finding a job, of people not loving them any longer, of losing friends or of being victims of gossip presented the strongest correlations with health.

Table 6 -
Correlations between feared discrimination and general health in the LGBT+ community. Maule Region, Region VII, Chile, 2021. (n=101).

Feared discrimination	General Health
	GH1	GH2	GH3	GH4	GH5	Global GH
I'm afraid that they stop loving me.	-0.33‡	-0.33‡	-0.34‡	-0.35‡	-0.35‡	-0.42‡
I'm afraid that they find out.	-0.20†	-0.24‡	-0.26‡	-0.24‡	-0.29‡	-0.31‡
I'm afraid that they will tell other people.	-0.27‡	-0.21†	-0.26‡	-0.25‡	-0.30‡	-0.32‡
I'm afraid that my family rejects me.	-0.18†	-0.10	-0.18†	-0.12	-0.23†	-0.20†
I'm afraid that they fire me.	-0.29‡	-0.20†	-0.29‡	0.35‡	-0.31‡	-0.36‡
I'm afraid that they gossip about me.	-0.17*	-0.21†	-0.26‡	-0.33‡	-0.27‡	-0.31‡
I'm afraid that they kick me out my house.	-0.19†	-0.13	-0.30‡	-0.16*	-0.27‡	-0.26‡
I'm afraid that my friends stop talking to me.	-0.23†	-0.12	-0.35‡	-0.28‡	-0.33‡	-0.33‡
I'm afraid that my mom/dad find out.	-0.14	-0.17*	-0.22†	-0.12	-0.24‡	-0.23†
I'm afraid of not finding a job.	-0.32‡	-0.18†	-0.33‡	-0.34‡	-0.33‡	-0.38‡

• *p<0.10; ^†p<0.05; ^‡p<0.01.

The procedure described in the previous paragraph was also used to analyze the relationship between experienced discrimination and the participants' health status. As indicated in Table 7, all twelve discrimination behaviors considered in the study showed negative and statistically significant correlations with general health. Specifically, criticism by the neighbors, dismissals, rejection by others, disregard for their opinions and ill-treatment in the health service were the discrimination behaviors that presented the strongest correlations with health.

Table 7 -
Correlations between experienced discrimination and general health in the LGBT+ community. Maule Region, Region VII, Chile, 2021. (n=101).

Experienced discrimination	General Health
	GH1	GH2	GH3	GH4	GH5	Global GH
They don't share social activities with me.	-0.12	-0.16*	-0.29‡	-0.24†	-0.27‡	-0.27‡
They don't let me speak.	-0.12	-0.15	-0.26‡	-0.19†	-0.24‡	-0.24‡
My neighbors criticize me.	-0.40‡	-0.20†	-0.44‡	-0.31‡	-0.37‡	-0.43‡
I was fired.	-0.32‡	-0.15	-0.27‡	-0.21†	-0.25‡	-0.29‡
They don't want to come close to me.	-0.30‡	-0.16*	-0.23†	-0.23†	-0.28‡	-0.30‡
They withdraw.	-0.42‡	-0.20†	-0.33‡	-0.28‡	-0.36‡	-0.40‡
They don't respect me and don't take my opinion into account in my house.	-0.31‡	-0.19†	-0.32‡	-0.33‡	-0.40‡	-0.39‡
They don't respect me and don't take my opinion into account in my social circle.	-0.18†	-0.05	-0.25‡	-0.05	-0.23†	-0.19†
I'm ill-treated when I attend appointments at the CESFAM§ or Hospital.	-0.46‡	-0.20†	-0.36‡	-0.32‡	-0.32‡	-0.41‡
They don't treat me at the CESFAM§ or Hospital.	-0.31‡	0.00	-0.23†	-0.16*	-0.15	-0.21†
My peers look at me badly.	-0.26‡	-0.09	-0.27‡	-0.16*	-0.13	-0.22†
They kicked me out of the house.	-0.33‡	-0.25‡	-0.12	-0.21†	-0.27‡	-0.29‡

• *p<0.10; ^†p<0.05; ^‡p<0.01. §‘CESFAM’ means ‘Centro Comunitario de Salud Familiar’.

The next research step involved analyzing the participants' reports when answering the last question of the survey. In particular, the analyses were focused on the reports made by the 42 participants who shared experiences and/or reflections related to discrimination regarding the treatment received from the Nursing personnel and the perceived effects on their health. From the thematic and discursive analysis, it was found that all the reports shared by the participants that make an explicit reference to how they were treated when entering the CESFAM or hospital correspond to what Moral and Segovia25 would classify as perceived discrimination, without finding excerpts that could be associated with feared discrimination. In other words, all the reports selected refer to events that did happen and not to projected or imagined discrimination cases. Likewise, when subclassifying the perceived discrimination reports according to the description proposed by Nadal et al.,22 it was found that no report corresponds to explicit discrimination, that is to say, the one that refers to a direct experience of physical and/or verbal violence, but that all the excerpts represented covert discrimination events, that is to say, the one that is reflected in discriminatory behaviors which occur unconsciously (generally due to historically reproduced social stigmas), and sometimes unintentionally, through which a person or group is segregated or excluded.

In turn, these covert discrimination reports were subclassified using the Microaggresions towards LGBT+ people taxonomy22 (Chart 1), finding examples for 3 of the 8 subclassifications proposed in such article and identifying two new subcategories from the data collected in the current study.

Chart 1 -
Classification of covert discrimination reports made by LGBT+ individuals. Maule Region, Region VII, Chile, 2021. (n=101).

Types of covert discrimination	Brief explanation of the category and illustrative reports
1) Support of the heteronormative or gender-compliant culture/behaviors	Non-recognition of the name chosen to reflect gender identity and/or sexual orientation: In the hospital, despite having my name legally changed for a year now... They still call me by my deadname and shield themselves in that "he/she has to ask for it (the name) to be changed in the system", when my name is updated in the system since March 2020.
2) Acceptance of the sexual pathology/ abnormality	Denial of access to health spaces and social participation: The first time I was discriminated against, the one that hurts the most, was in a health center; they didn't allow me to donate blood due to my sexual orientation, that was in the [name] Hospital, nothing surprises you from then on.
3) Uneasiness/Disapproval regarding the LGBT+ experience	Level of seriousness in the dealings, discriminatory treatment through uncomfortable stares and laughs: It's really unpleasant to attend a gynecological appointment [at the hospital] and speak out my sexual orientation, they laugh at me or keep staring, they've never treated me well, they only get more serious when I tell them that I also work in health.
4) Indirect manifestation of the hate discourse*	Instances in which people speak about LGBT+ individuals in a mocking and derogatory way behind their back, although with them present so that they can hear: When I was an adolescent, a homosexual assaulted me with other guys, they broke me some teeth and, due to that, the Police took me to the hospital for care (they mocked at me in the way without even knowing that had happened and not the least interested in making justice) but, once there, it was very sad to hear everyone talking and laughing about what had happened to me. It was the worst experience by far.
5) Stigmatizing questions against the relevance principle*	Questions about the patient's sexual orientation when it is not considered a relevant aspect for clinical care: I don't generally go the CESFAM for treatment, I usually see doctors from some other health center, I don't feel discriminated with them because they're mostly people with studies and see homosexuality as normal, it's only when I go to the gynecologist that I have to speak it out and I've never had problems with male or female doctors.

• *Types of covert discrimination found in this study and not included in the taxonomy of microaggressions by Nadal et al.22 or similar ones.

The microaggressions described in the covert discrimination reports that reflect the type of treatment received in health institutions illustrate the significant results already presented in relation to the following: 1) improper stares (see report in category 3); 2) being victims of gossip and that people speak about their identity (see report in category 4); and 3) other ill-treatments in the health system (see reports in categories 1, 2 and 5).

DISCUSSION

This research showed that an important percentage of the participants stated fear of being discriminated for belonging to the LGBT+ community, for example, through unjustified dismissals or rejection by their families or other people. In addition, although the results indicated that the discrimination suffered by the participants had low prevalence in the sample, a relevant percentage also stated having being dismissed from the job or ill-treated in health centers for reasons linked to their sexual orientation, gender identity or gender expression. Several participants even stated feeling criticized or ill-watched in their everyday life. The findings of this study also pointed out that trans people are exposed to higher discrimination levels than the cisgender participants. Discrimination was mainly reflected in unjustified dismissals, difficulties finding a job or ill-treatment in the provision of health services.

The findings presented in this study in relation to perceived discrimination coincide with those reported in previous studies on the LGBT+ community,12^,16 also confirming that the LGBT+ individuals who perceived themselves as exposed to higher discrimination levels also reported worse general health.19 However, the study contributes new knowledge on this research field because it also explores feared discrimination and its relationship with general health in LGBT+ people. Thus, the current study emphasizes that feared discrimination might play an equally important role than perceived discrimination on the health of LGBT+ people, reason why it is recommended that future research studies relate feared discrimination to other HR-QoL dimensions in LGBT+ people through multivariate analyses and also distinguishing between the different teams of health professionals in order to devise recommendations pertinent to each of them.

Furthermore, the current research contributes to evidencing the LGBT+ community life experiences through their reports of discrimination situations with the health personnel, which correspond to covert discrimination. The study also contributes to classifying these covert discrimination situations regarding the health personnel using the taxonomy proposed by Nadal et al.22 and emphasizing two new categories of microaggressions. It is worth noting that, although these latter manifestations have been reported in previous studies as part of the frequent discriminatory behaviors towards the LGBT+28 population, they have not yet been given the space they deserve in the literature as a social segregation phenomenon, being attributed an analytical category, especially in public health contexts. Covert discrimination affects the LGBT+ community's health to a significant extent, particularly in the case of the individuals who have publicly admitted their sexual orientation.22 It is for this reason that it is necessary to know the different discrimination cases and how they have violated the fundamental human rights of the LGBT+ community. It is crucial that new studies review these taxonomies in order to constantly update knowledge on the covert aggression situations suffered by LGBT+ people in health centers.

Another important point to be noted in this research was the discrimination inside the health institutions linked to care according to the participants' sexual identity. The study shows discriminatory behaviors as preconceptions in the care provided to patients and microaggression actions, which directly undermines both health care and the health of the LGBT+ community. These findings are in line with those reported in other studies conducted in Chile, where it was evidenced that 95% of the participants stated that their sexual identity has been questioned in the health centers, that 27% have felt ignored, and that 25% were victims of mockery in such institutions.29 The facts reported in the current study suppose a violation of people's fundamental rights regarding health care and non-discrimination.

Therefore, this study shows that, despite the various efforts implemented from the training point of view (professional30 and academic31) and in terms of public policies (for example, through the creation of the Ministry of Health's Human Rights and Gender Department and of legislative frameworks such as Law 20,609 - Against discrimination, and Law 21.120 - Recognizing and protecting the right to gender identity), LGBT+ people continue being discriminated against in terms of the treatment they receive when they attend public health institutions. In this context, the knowledge gaps about various topics linked to the social and health reality of the LGBT+ community presented by nurses have been evidenced in previous studies, where 71% recognize lacking academic training related to mental health topics linked to sexual orientation, for example.32 In this sense, when answering the survey of this study, the participants themselves shared recommendations that make this point visible: “the health personnel from the CESFAMs should be trained on how to address LGBTIQ+ community topics with the patients, avoiding the provision of hostile, unsafe and discriminatory care (a fact that I experienced myself)”. It is important that health officers and the nurses in charge of veiling for compliance with protocols know the guidelines and seek adherence to these mandates (e.g., Circular No. 21 in Chile). The personnel should be trained on topics referring to sexuality and sexual identity, as well as it is also necessary to create a committee that, by means of a citizen survey applied to the people affected in the institution, manages to identify discriminatory behaviors in health care and proposes improvements to solve such gaps. It is therefore imperative to seriously address not only the training of the Nursing personnel on monitoring techniques regarding gender transition, comprehensive counseling in sexuality and gender identity discovery, but also to promote awareness raising actions about respect for gender identity and acceptance of the reality of the LGBT+ experience, for example, using the social name chosen, consulting the pronouns with which trans people feel identified, and dynamize the name/gender change processes in the health institutions' computer systems. These actions can contribute a benefit for the LGBT+ community and greater adherence to the health treatments, focused on respect and empathy.

Finally, the current study was not exempt from limitations. The fact that the paper was conducted with a non-probabilistic sample may have resulted in the exclusion of certain social groups, either because the survey did not reach them or because they lacked willingness and interest to participate. Likewise, online data collection due to the SARS-CoV-2 pandemic may have hindered participation of people with low connectivity and older adults in general. It is important that future research studies attend to these limitations to continue developing studies that confer visibility to the social and health reality of the LGBT+ community, in order to advance towards a more egalitarian and inclusive society and enable decision-making processes targeted at improving these people's Quality of Life. This might be accomplished by mitigating the discriminatory behaviors by the health personnel, specifically the Nursing personnel, due to people's sexual orientation and gender identity, conceiving them as subjects that deserve respect in terms of their rights.

CONCLUSIONS

The feared and perceived discrimination situations presented in this study and their relationship with general health of LGBT+ people evidence the need to devise strategies, policies and regulations that tend to eliminate the discriminatory behaviors and foster integration of the LGBT+ community and a positive appraisal of sexual and gender diversities in all life scopes. It is necessary to veal for compliance of the rights and norms that recognize the LGBT+ community as part of society and not as a minority. In addition, it is necessary that each and every research field defines scopes in this problem to attain better quality of life in the people affected. Health professionals, specifically Nursing personnel from the care paradigm, have the social responsibility of investigating and promoting changes in the different health environments aimed at improving health in the LGBT+ community.

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NOTES

• ORIGIN OF THE ARTICLE

  Extracted from the thesis - Discrimination and Health-Related Quality of Life (HR-QoL) in the LGBT+ population from Maule, presented to the Master's Graduate Program in Nursing of Universidad Católica del Maule, in 2022.

• APPROVAL BY RESEARCH ETHICS COMMITTEE

  Approved by the Research Ethics Committee of Universidad Católica del Maule, Proceedings No. 16/2021.

Edited by

EDITORS

Associated Editors: Jaime Alonso Caravaca-Morera, Monica Motta Lino. Editor-in-chief: Elisiane Lorenzini

Publication Dates

• Publication in this collection
  28 Oct 2022
• Date of issue
  2022

History

• Received
  01 June 2022
• Accepted
  15 July 2022