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COVID-19, social vulnerability and mental health of LGBTQIA+ populations

A significant aspect observed during the evolution of the COVID-19 pandemic is the relationship between social vulnerability and higher prevalence and lethality of the virus 1. The contrasts of this mortality between the poorest and richest show how social inequalities directly affect the Brazilian population’s health and make certain social groups more vulnerable 1. In addition to the damages to health already known, the pandemic can be considered a traumatic event and thus generate serious consequences for the mental health of the population as a whole, namely: insomnia, depression, fear and anger reactions, substance abuse, acute reactions to stress, and posttraumatic stress disorder 2. Thus, the pandemic can be understood as a catalyst for mental illness, especially for the most vulnerable populations. Sexual and gender minorities, i.e., lesbian, gay, bisexual, transvestite, transsexual and transgender, queers, intersex, asexual, and other (LGBTQIA+) have suffered, and still suffer, a serious process of social exclusion throughout the history of contemporary societies 3. One of the consequences of this fact is the worsening of the mental health status of these groups. Aspects such as low schooling level, low socioeconomic status, violence, and difficulties in accessing health services are closely related to social minorities and, at the same time, they have been considered risk factors for common mental disorders in the general population 4,5. Furthermore, other risk factors for mental health are specific to these marginalized groups: prejudice (or LGBTQIA+phobia) 6, lack of institutionalized protection, family rejection, and bullying 7. This whole social conjuncture cooperates for the fragility and vulnerability of these minorities. Therefore, national and international studies 8,9,10,11,12,13,14 reveal that sexual and gender minorities – when compared to the non-LGBTQIA+ population – present higher prevalence of depression and anxiety, higher risk for suicide and they make a more intense use of psychoactive substances.

A significant aspect observed during the evolution of the COVID-19 pandemic is the relationship between social vulnerability and higher prevalence and lethality of the virus 1 . The contrasts of this mortality between the poorest and richest show how social inequalities directly affect the Brazilian population's health and make certain social groups more vulnerable 1 .
In addition to the damages to health already known, the pandemic can be considered a traumatic event and thus generate serious consequences for the mental health of the population as a whole, namely: insomnia, depression, fear and anger reactions, substance abuse, acute reactions to stress, and posttraumatic stress disorder 2 . Thus, the pandemic can be understood as a catalyst for mental illness, especially for the most vulnerable populations.
Sexual and gender minorities, i.e., lesbian, gay, bisexual, transvestite, transsexual and transgender, queers, intersex, asexual, and other (LGBTQIA+) have suffered, and still suffer, a serious process of social exclusion throughout the history of contemporary societies 3 . One of the consequences of this fact is the worsening of the mental health status of these groups. Aspects such as low schooling level, low socioeconomic status, violence, and difficulties in accessing health services are closely related to social minorities and, at the same time, they have been considered risk factors for common mental disorders in the general population 4,5 . Furthermore, other risk factors for mental health are specific to these marginalized groups: prejudice (or LGBTQIA+phobia) 6 , lack of institutionalized protection, family rejection, and bullying 7 . This whole social conjuncture cooperates for the fragility and vulnerability of these minorities. Therefore, national and international studies 8,9,10,11,12,13,14 reveal that sexual and gender minorities -when compared to the non-LGBTQIA+ population -present higher prevalence of depression and anxiety, higher risk for suicide and they make a more intense use of psychoactive substances.

Pandemic, mental health and LGBTQIA+ populations
In a recent national survey 13 , conducted with about 9,000 participants, which aimed to investigate the greatest effects of the pandemic for the LGBTQIA+ population, 42.72% of respondents indicated mental health as the main effect experienced during this period, followed by "new rules of conviviality", "loneliness", "family life", and "lack of employment and money". Among the reasons that make LGBTQIA+ more vulnerable at times like the current one, we can mention the high rates of violence to which they are subjected daily. Despite the lack of data, figures collected by the Institute for Applied Economic Research (IPEA) in the Atlas of Violence 15 show a 127% increase in reports of LGBTQIA+ homicide in 2018 in Brazil. Moreover, one of the most important health measures recommended by health agencies has been social distancing that, in the case of LGBTQIA+, may mean remaining confined to potential aggressors, often their own families or intimate partners 11,12,13,16 .
The increase in domestic violence due to social distancing has been brought to the discussions 17 , but generally with an exclusive focus on heterosexual cisgender women. However, it is noteworthy that among the homicides by LGBTQIA+phobia in Brazil, the victim's residence is the second place of highest occurrence of murders 18 , with transsexual, transgender, and transvestite people being preferred targets of this type of violence, followed by lesbians and then gay men 16 .
Socioeconomic vulnerability is also a relevant aspect, permeating income and labor bonds. It is known that the pandemic has caused job losses and precarious employment ties -that were already fragile -which may aggravate the socioeconomic situation of these populations 11,12 . An North American study indicates that the largest portion of this population in the country is part of the informal market and also has occupations potentially more exposed to SARS-CoV-2, such as work in bars and restaurants, in addition to having lower income and lower conditions of access to health 19 . In Brazil, when considering only the populations of transgender, transsexual and transvestite, vulnerability is even greater given the specificities of these groups 12 . A study conducted with 672 transsexuals in the State of São Paulo revealed that, from 2014 to 2015, only 16.7% were in the formal market 20 and, still, many worked as sex workers 21 . Regarding the homosexual and bisexual population, an international systematic review 22 indicates that gay and bisexual men receive less than their heterosexual colleagues. Furthermore, the unemployment rate in this population, found by a survey 13 , is 21.6% in Brazil and, during the pandemic, 44.3% suffered a total shutdown of their activities.
Social life is another significant aspect placed on frailty for LGBTQIA+ during the pandemic. As they are sometimes rejected in the family nucleus, a significant mechanism of resistance and survival of these groups lies in the bond they establish with their communities, so that, considering the social distancing measures, these individuals experience a serious impact because of the impossibility of a more active and face-to-face contact with their affections and familiar places, which leads to an experience of isolation and loneliness 11,12,13 .
Considering so many aspects that compromise LGBTQIA+ individuals' mental health, it is indispensable that the authorities define care strategies for this moment.
The Brazilian Ministry of Health -in its booklet on suicide in the COVID-19 pandemic 23 -lists some warning factors that deserve special attention, among them: preexisting mental health disorders, with emphasis on depression and anxiety; use of alcohol and/or other drugs; lack of social support; existence of hostility in the family environment; and suffering and concerns about one's own sexuality. In another booklet 24 that deals with recommendations for public administrators, the Brazilian Ministry of Health indicates that one of the points that should receive attention is the identification of vulnerable groups from the psychosocial point of view, and it highlights several recommendations that can be put in force by public administrators during the pandemic to ensure access to mental health in this population. However, it is clear that despite its significance, the existence of legal instruments, guidelines and regulations, it is not enough to assure the population's access to their rights.
Often these groups are exposed to prejudice even in health services, which can lead to decreased demand and adherence to treatments 25,26 . Thus, it is observed that the heteronormativity present in several care fields produces a devaluation or non-recognition of these identities, contributing to the perpetuation of violence and discrimination that affect the conditions of access and quality of health care 27 . A study 27 reports that the main difficulties in accessing health services for this public are related to the fear of suffering prejudices and the fear of revealing sexual orientation, thus, this information is often omitted in care.
In the Brazilian Unified National Health System (SUS), specialized mental health care is provided by the Psychosocial Care Network (RAPS), which is one of the main services provided in psychosocial care centers (CAPS). However, it must be emphasized that the RAPS faces significant obstacles, such as insufficient equipment in some Brazilian regions and municipalities 29 , which leads to long waiting Cad. Saúde Pública 2021; 37(3):e00287220 lines, and reference and counter-reference problems 30 . It is also noteworthy, considering the great percentage of discrimination suffered in health services, demonstrated in studies 31 , the lack of qualification of health professionals to deal with the sufferings related to sexuality.
Considering these data, it is possible to say that the mental health of sexual and gender minorities lacks, not only specific attention in terms of emergency public health policies during the pandemic, but, above all, mobilization and concrete actions. However, this data attest a profound invisibility of the issue by the State and sometimes also by academia 32 , even during a time of extreme need. Moreover, it is urgent that such discussion reach social spaces and that the LGBTQIA+ population achieve more visibility. Also, that the current situation be a lesson for future moments.

Contributors
G. Bordiano contributed to the project design, analysis and interpretation of data, writing, critical review of the intellectual content, and approval of the final version of the article; and is responsible for all aspects of the work. S. P. Liberal and G. M. Lovisi contributed to the project design, analysis and interpretation of data, writing, critical review of the intellectual content, and approval of the final version of the article. L. Abelha contributed to the critical review of the intellectual content and approval of the final version of the article.