Head and Face Injuries in Brazilian Victims of Homophobic Crimes

Crimes against homosexuals are mostly hate crimes, and should be referred to as homophobic crimes. Objective: To investigate the occurrence of head and face injuries in victims of homophobic crimes. Methods: A retrospective study was conducted at the Specialized Police for Homophobic Crimes. Data were collected from the 56 police and medical reports corresponding to reported cases of homicide against lesbian, gay, bisexual, transsexual and transgender (LGBT, or sexual minority) in the period from May 2009 to July 2013. Variables studied related demographic profile of victims and patterns of trauma (type of arms, number of injuries and anatomical regions) were assessed. For bivariate analyses, the Chi-square and Fisher’s exact, with significance level of 5% were used. Results: 89.3% were homosexuals and 42.9 were gays. Firearms were the type of arms most used (46.4%), followed by cold steel (30.4%). Most victims presented multiple lesions (87.5%) and 44.6% presented injuries in the head and face. There was a statistically significant association between injuries in the head and face and the type of arms (P=0.001). Conclusion: Victims of homicide were mostly homosexuals and the main types of arms were firearms and cold steel. Most victims presented multiple lesions and injuries in the head and face were common and more frequent among lesbians and transvestites.


INTRODUCTION
External causes (accidents and violence) are of substantial importance in public health, given their magnitude and impact on people's lives. [1][2][3] Violence is widespread throughout Latin America and others countries of the world. According to the Transgender Europe's Trans Murder Monitoring, Brazil is the country with the highest number of homicides against sexual minorities. 4 With regarding to violence against homosexuals, it is closely related to 'machismo' culture and widespread homophobia found in Brazil, specifically in the northeastern region.
The sexual orientation of an individual relates to the sense of sexual desire, be it with people of the opposite sex, the same sex or both; thus, a person can be considered heterosexual, homosexual or bisexual. Through another perspective, gender identity refers to how individuals recognize themselves within the gender patterns that are socially established. 5 Therefore, gender is a social construct that varies with the roles, norms, and values of a given social context. 6 It is noteworthy that among the population of Lesbian, Gay, Bisexual and Transgender persons (LGBT), transvestites and transsexuals are the most affected by prejudice and discrimination within the family and social environment. 5 Scholars posit that sexuallyprejudiced aggression toward gay men functions to enforce traditional gender roles. Specifically, male homosexuality represents a threat to the traditional masculine identity. 7 Some authors showed that many sexual minorities experience hate crimes. 8 Crimes against homosexuals are mostly hate crimes, and should be referred to as homophobic crimes, based on the non-acceptance and hatred of the perpetrator for the victim for being gay, lesbian, transvestite or transsexual. In 2012, official data on the human rights violations of the lesbian, gay, bisexual, transvestite and transgender (LGBT) population were released in Brazil. According to this report, the number of homicides of LGBT people increased 11.51%, and transvestites and transsexuals are the main victims of homophobic violence and the most serious violence, such as homicides. 9 The maxillofacial region occupies the most prominent position in the human body, making it vulnerable to the occurrence of lesions. 1,10 Epidemiological research seeks to understand the multifactorial aspects related to oral and maxillofacial injuries with the purpose of determining types of injury. 11,12 Understanding the patterns of violence against minority groups related to head and face injuries is essential once these injuries have been known as a significant indicator of interpersonal violence. Therefore, the objective of this study was to investigate the occurrence of head and face injuries in victims of homophobic crimes. We hypothesize that head and face injuries are more frequent in gays and involving firearms.

Study design
This is a retrospective study that was conducted in the Specialized Police for Homophobic Crimes (DECCH), located in the city of João Pessoa, Brazil. The DECCH is the first specialized service in Brazil, being a reference for the care of gays, bisexuals, transsexuals and transvestites.

Data collection
Data were collected from the 56 police and medical reports corresponding to reported cases of homicide (homophobic crimes) against lesbian, gay, bisexual, transsexual and transgender (LGBT, or sexual minority) in the period from May 2009 to July 2013. Hate crimes refer to "unlawful, violent, destructive or threatening conduct in which the perpetrator is motivated by prejudice toward the victim's putative social group". 13 Before the performance of the research, a pilot study and calibration procedures were carried out in order to correct any failures and standardize the form of interpretation. Data collection was performed by a single examiner trained by an experienced researcher. Variables studied related demographic profile of victims and patterns of trauma (type of arms, number of injuries and anatomical regions) were assessed.

Data analysis
The descriptive statistical analysis was performed, which corresponded to the calculation of absolute and relative frequencies. Pearson's chi-square and Fisher's exact test (p <0.05) was used to identify associations between the occurrence of head and face injuries and independent variables. The level of significance was set at 5%. All statistical analyses were performed using SPSS version 20.0.

Ethical aspects
This research project was approved by the Ethics Research Committee of the State University of Paraíba (Protocol No. 18800513.0000.5187). Victims may have more than one affected region. Table 1 shows the sample distribution according to sexual orientation and LGBT identity. Eighty-nine point three percent were homosexuals and 42.9% were gays.  Table 3 shows the distribution of victims according to number of injuries and anatomical location. It was observed a significant association for the regions of chest (P=0.004) and abdomen (P=0.034).

RESULTS
Head and face injuries were more frequent among lesbians (71.4%) and transvestites (50%), but with no statistically significant difference (P=0.550). However, there was a statistically significant difference between the occurrence of head and face injury and the type of arms (P<0.001) ( Table 4).

DISCUSSION
The mortality by homicide represents one of the main dangers to the health of homosexuals; as a consequence, it is differentiated from the homicides in heterosexuals in that they are not murdered because of being heterosexuals, which adds to the series of risks, which this social group faces in comparison with the rest of the population. 14 Lethal violence against homosexuals -and especially against transgenders -is undoubtedly one of the most tragic faces of discrimination based on sexual orientation or homophobia in Brazil.
This study evaluated the occurrence of head and face injuries in victims of homophobic crimes. It is extremely relevant to highlight the uniqueness of this study, since no similar studies that have attempted to analyze their occurrence were identified in the international literature. Data were reliably collected over a 5-year period from the Specialized Police for Homophobic Crimes in Joao Pessoa, Brazil. We found that gays are the main victims and they are more likely to have head and face injuries and multiple injuries over different parts of their bodies.
In the context of inconsistent reporting of violence by specific sexual minority categories, the estimates of the prevalence of violence in this survey provide important evidence regarding the extent of discrimination and violence in this population. 6 The analysis of sexual orientation revealed that homosexuals were the most affected victims. Study developed in México showed that bisexual and gay males were more often victims of violence than bisexual and lesbian females. 15 According to some authors, homophobic assaults and gay bashing incidents are performed by individuals showing an intense hatred for homosexuals. 16 Regarding LGBT identity, gays and transgender were the most affected. A study developed in Brazil shows that 75% of transsexuals had suffered some kind of violence, 5 while among transgender women in Puerto Rico the prevalence of physical violence was 25%. 6 In the Guatemala City, Managua, and San Salvador the rates of physical violence to men who have sex with men (MSM) was 25%, 18.3% and 16.0%, respectively. 17 Firearms and cold steel were the type of arms more used. According to previous study, a cold steel was used in 54% of cases of homosexual homicides, and in 19% of cases a firearm was used. 18 Another work developed in the Mexico showed that the most used was cold steel. 14 The weapons that were more frequently used by the perpetrators of the crimes are cold steel; this takes more time in causing death than firearms, which tells us of a prolongation of pain. 14 The distribution of the injuries showed that although the chest was the most affected site, injuries in to the head and face were found in almost half of the victims.
Regarding the maxillofacial injuries, the head and face regions are the areas most commonly affected in victims of physical violence. 1,19-23 x The findings in this report are subject to at least three limitations. First, this research showed limitations with regard to the impossibility of obtaining information in full because the victim had gone to death and could not have his version reported. Second, some victims showed resistance to denunciate situations prior to the murder such as blackmail, threats, as well as non-lethal physical violence, introducing an important factor in the investigation. Third, hate crimes against LGBT victims are underreported to police departments. It is important to specify that the cases included in this study are a representative sample of the lethal violence affecting homosexuals in the city of João Pessoa, Brazil.
It is, according to available information, the first police station based on homophobic crimes ever established in Brazil; however, any generalizations based on data presented here must be done with caution. These limitations are intrinsic to the study of the phenomenon of violence, considering that it is a social and subjective phenomenon that is difficult to measure. 24 This research is significant in that it is the first to directly examine the occurrence of head and face injuries among LGBT victims of homicide in Brazil. Therefore, our findings are very important, and other studies should have been carried out in other Brazilian cities to analyze and to determine the magnitude of the problem and to allow comparisons of results.
Finally, this study with police and medical reports reveals two important aspects: the first presents a new field of study for researchers in the field of dentistry; the second confirms the importance of dentistry in the diagnosis of injuries in the head and face regions of victims of physical violence.

CONCLUSION
Victims of homicide were mostly homosexuals and the main types of arms were firearms and cold steel. Most victims presented multiple lesions and injuries in the head and face were common and more frequent among lesbians and transvestites.