Aging and vulnerability: perspectives of LGBTQIA+ elderly persons

Objective: to understand the perception of the LGBTQIA+ elderly person about social and programmatic vulnerability. Methods: qualitative study developed with ten elderly persons. The collection was done through an interview supported by a semi-structured instrument. Elderly people of both sexes and non-binary assisted in a reference center were included. We adopted content analysis through the thematic modality for data systematization.


Introduction
Population aging is seen as one of the most important demographic transitions. In developed countries, it occurred gradually and slowly, however, in developing countries, such as Brazil, an accelerated process is evident, in which about 13% of the population is already composed of individuals aged 60 years or more, with projections that indicate a significant increase in the coming decades (1) . The United Nations estimates a population aging with a growth rate ranging from 25 to 29% by the year 2050 (2) . According to the Brazilian Institute of Geography and Statistics (IBGE), in 2055, the number of elderly people in Brazil will be higher than the number of Brazilians under 30 years of age, with representative projections of reaching the sixth elderly population in the world (3)(4) .
In this context, recognizing that senescence is an individual process is the first step towards preserving the autonomy of the elderly. Understanding human aging as a homogeneous process is a mistake, especially in relation to sex. Sexuality needs to be analyzed systematically, since, throughout life, there are important gaps on the theme, such as the absence of sex education, either at home or at school, the punishment at the beginning of the discovery of sexuality, and even the shame of desire. These taboos intensify even more during old age, in which many classify them as asexual, increasing the myths and prejudices, which hinder the implementation of preventive measures in the health field (5) .
Considering this, being elderly and sexually active and still belonging to the lesbian, gay, bisexual, transgender, intersex, queer, asexual, pansexual, and non-binary identities (LGBTQI+) population increases the challenges, even in the face of undeniable advances in civil rights achieved in recent decades. For the first time, contemporaneity witnesses LGBTQIA+ elderly people reaching middle and old age without being submitted to the context of extreme persecution, control and stigmatization evidenced throughout the 20th century (6)(7) . The LGBTQIA+ persons represent a sexual minority that is often stigmatized, discriminated, abused, or has a history of LGBT phobic violence. Such experiences can cause high levels of stress and anxiety, which culminate in social isolation and invisibility (4)(5)(6) .
Corroborating this, it is important to highlight that aging itself already implies in increased risks for the typical vulnerabilities of senescence and, in the elderly LGBTQIA+ population, this context can be accentuated, especially when facing discrimination due to sexual orientation and gender identity (7) . In this scenario, the human aging process is permeated by several challenges, especially in the field of sexuality. Society sees the aging body as devoid of sensuality and desire, stigmatizing the elderly as an asexual being. Besides this problem, the LGBTQIA+ community deals with negative stereotypes, discrimination, and intolerance from society. Health professionals should seek to dispel the myths about sexuality, understanding that the elderly have sexual interests and, thus, fighting against taboos perpetuated over the years in society. Furthermore, there is a need to demystify heteronormative standards, recognizing the plurality and individuality of each elderly person.
Given the above, the following guiding question arises: what are the difficulties experienced, in the social and programmatic spheres, by the elderly belonging to the LGBTQIA+ community? Therefore, this study aims to understand the perception of the LGB-TQIA+ elderly person about social and programmatic vulnerability.

Methods
This is qualitative research that used the social phenomenology proposed by Alfred Schütz as a theoretical and methodological reference, which allows the understanding and interpretation of human phenomena in their social relationships and in their daily lives, based on established concepts, such as natural attitude and intersubjectivity (8) . We chose to use this method because the present study aims to understand the difficulties experienced by the LGBTQIA+ elderly person (subjects) in the context of social vulnerability (intersubjective relationship) and programmatic (life world). To guide the construction of the study, we chose to develop the research as recommended by the Consolidated Criteria for Reporting Qualitative Studies (COREQ). The research was developed in a state reference center for the LGBTQIA+ community, located in João Pessoa, Paraíba.
After presenting the project to the unit's managers and their agreement to develop the research, data collection was carried out between August and September 2021, through an interview supported by a semi-structured instrument, containing objective questions that investigated general data and the participants' profile, such as sex, gender, age, sexual orientation, profession and family income, as well as the following question: How do you perceive the social support network and health care for the LGBTQIA+ elderly person? Thus, it sought to apprehend information about the family and social support network and the access to health services and the perception of the quality and adequacy of services to individual and collective needs.
The invitation to participate in the research was made by telephone, as available in the registry. After clarification about the research objectives, the individuals were invited to go to the reference service and, thus, proceed to the interview in person. The study included all individuals aged 60 years or older, of both genders or non-binary, seen or who at some point sought assistance at the referred state service. Those elderly who had hearing deficits and severe speech problems that severely hindered communication were excluded from the study.
About 20 elderly people were registered in the reference service at the time of the research. Then, to compose the selection of participants, the method of empirical and theoretical saturation was listed, which allowed the researcher to terminate the interviews when no new findings were observed in the speeches. During data collection, only three invited elderly pe-ople did not participate in the study, as they did not show up at the service for the interview, as previously scheduled. Thus, the sample was composed of ten elderly people who agreed to participate in the study. All interviews were recorded and transcribed in full, with an average duration of 25 minutes.
For the systematization and treatment of the data, we adopted content analysis through the thematic modality. To do so, we followed the three stages listed by the author: pre-analysis, exploration of the material, and treatment of the results obtained, analyzed considering the literature. The first phase was composed of the strenuous reading of the interviews by two independent researchers, with the purpose of identifying the thematic axes arising from the reports of the elderly people. In this way, the themes that showed similarities were grouped into three empirical categories. Finally, with the results, the interpretation of the findings began, based on scientific articles published on the theme. The interpretation of the content was performed through phenomenology and symbolic interactionism, from the narrative review subsidized by the interviewer's perceptions and evidence from the field diary (9) .
To ensure the anonymity of the participants, the names were replaced by the letter "I" followed by the numerical code referring to the order of data collection. Thus, the research was submitted and approved by the Ethics Committee of the University Center of João Pessoa, under Certificate of Ethics Appreciation Presentation 49410721,0.0000.5176, approved under opinion 4,858,802/2021.

Results
When considering the sociodemographic aspects, five elderlies were men, while four recognized themselves as women, and one elderly person reported being intersexual, aged between 60 and 71 years. Regarding the sources of income, there were only two retired people, four with no fixed income and four in paid activities, all with monthly earnings around one to two minimum wages. None of the interviewees were married or had children; all lived alone. Religiosity was a practice of all interviewees, who mentioned faith and divine protection as something strengthening and hopeful throughout life in facing life's adversities.
From the set of speeches, the following categories emerged: programmatic vulnerability: gaps in the assistance provided to the LGBTQIA+ elderly person; social vulnerability: the prejudice and lack of social and family support that plague the elderly person in relation to sexual orientation and gender; and strategies for welcoming and ensuring equity in health care.

Programmatic vulnerability: gaps in care for LGB-TQIA+ elderly person
The assistance provided by health and social services still presented important gaps, especially when facing the needs of LGBTQIA+ elderly people, which denoted a risk to their physical, psychological and social integrity and well-being. Programmatic vulnerability was evidenced in the speeches of all the interviewees, in which they reported feeling less welcomed in relation to their complaints and wishes.
Thus, users reported difficulties in accessing health care, as well as the absence of reference spaces, not identifying the offer of health care that could contemplate the peculiarities that affected the LGBTQIA+ elderly population. Considering the stigmas related to sexuality, associated with low access to health services throughout life, as well as the suffering and barriers to the expression of their identity, the interviewees showed difficulty in caring for themselves and getting qualified attention: I need health care to really assist the elderly, Social vulnerability: the prejudice and lack of social and family support that plagues the elderly in relation to sexual and gender orientation The lack of opportunities intensified in groups of people belonging to sexual and gender minorities, added to the prejudice against the elderly, known as ageism. Users reported the existence, at some point in their lives, of discriminatory episodes due to gender and sexual orientation, intolerance, and various other types of violence, which resulted from a heteronorma-

Strategies for welcoming and ensuring equity in health care
The strategies of welcoming and ensuring equity in health care were directly related to the quality of care provided. Thus, the welcoming began with the first contact between the health professional and the patient, involving not only doctors or nurses, but all those who provide health services.
Thus, identifying the strategies of welcoming and promoting health for the LGBTQIA+ elderly population helped to ensure equity in care, understanding the inequalities and barriers faced by users when seeking services. Issues such as lack of trust in services and heteronormativity in health-illness processes are still present in health care spaces: There is a lot missing for a more specific assistance to the LGBT

Discussion
This research identified difficulties experienced by the LGBTQIA+ elderly person, which influence aspects of gender and sexuality and have a direct impact on their health and well-being. Social and programmatic vulnerability is perceived through the gaps reported in the environments that provide care to the elderly, as well as in the prejudice and lack of support in relation to the social and family environment experienced by this population, thus providing an overview of the problem.
Moreover, the strategies for embracement and ensuring equity in the services that provide care to the elderly population are still widespread and weakened, making the embracement and conduct of the provision of health services to users over 60 years old vulnerable and with low resoluteness.
Aging itself already brings challenges and stigmas, among them the social invisibility and the interpretation of the elderly as a being without sexuality, disregarding their struggles and their life stories. The elderly population constitutes a group exposed to vulnerability, considering its physiological, psychological, and sociocultural changes, arising from human aging (8,10) . There is a decline in functional capacities and the influence of collective and contextual aspects, in which we observe a political and social disinvestment and marginalization of the individual (11)(12) .
Shrouded by prejudice and lack of representation, the elderly who are not part of the heterosexual profile of society also face the lack of social acceptance and health system (13) . The constant violations of their rights, institutional prejudice, precarious access to health services and social exclusion cause suffering, illness, and worse health conditions for the LGBTQIA+ elderly population, when compared to the general population.
Thus, it is noteworthy that the elderly who recognize themselves as LGBTQIA+, in comparison to heterosexual individuals of the same age, present a higher risk of disabilities, mental health decline and decreased adherence to prevention practices and health promotion (14) . Discrimination reduces older people's access to the resources they need to age actively and healthily. Regarding sexual minorities, there are reports of numerous organizational barriers in health services, which are directly influenced by the heteronormative orientation established in society. The lack of awareness of professionals is one of the barriers established during the reception, which hinders the access of LGBTQIA+ elderly people to health care (15)(16) .
Transsexuals, for example, sometimes experience the denial of their identity by others, which implies discomfort. Unfortunately, there are health services that still do not recognize the social name in communications and often present a mistaken way of receiving and directing care, thus building a barrier to access (17) . It is worth emphasizing the need to establish an effective reception, which provides a sense of belonging, especially among those who identify themselves as transsexuals, since, in general, their life expectancy is around 35 years, which is significantly lower than the average life expectancy of the general population (18) .
Invisibility is described as one of the main problems in the provision of care since the non-heterosexual elderly person does not feel welcomed in relation to their demands. As for lesbian or bisexual women, it is reported that, by informing about their sexuality, they realize that care becomes faster, with the absence of requests or necessary referrals (19)(20)(21) .
There are also communication failures, such as, for example, misinformation about the prevention of Sexually Transmitted Infections (STIs) by lesbian women, due to the stigma that women who have sex with other women cannot be infected by this type of infection. As portrayed in the interviews and in the literature, besides the lack of representation and prejudice, the healthcare system and its professionals are not prepared to meet the specificities related to the health of LGBTQIA+ elders (22)(23) .
In turn, homosexual men suffer from the stigma of HIV transmission, while transgenders usually go through the continuous pathologization of transsexuality. The psychic suffering generated in these individuals is unquestionable (23)(24) . In the same thought, unfortunately, women also experience such stigma, since the prevalence of HIV in transgender women is higher compared to the general population. A meta--analysis study indicates that such prevalence is 48.8 times higher (24) .
Moreover, the elderly LGBTI+ population is more prone to mental disorders. The difficulty of assuming their sexual orientation can generate several complications to psychological suffering, and seeking psychological support can bring greater well-being (22) . Furthermore, it is not only the moment of assuming social orientation that brings suffering because, daily, the LGBTQIA+ population goes through situations of humiliation, apathy, and prejudice, which reinforces the need for welcoming by the healthcare team, which needs to consider the elderly individual in their multidimensionality, including sexual orientation (14,22) .
About a quarter of respondents chose not to inform their sexual choice during care in health services, due to fear of prejudice and stereotypes. Thus, issues such as sexual identity and advancing age interact with each other and increase the unique concerns about access to social and health services, in which the double stigmatization presents a negative impact on health care (14) .
Thus, it is necessary to remember that, besides being elderly, which already places users as a population in potential vulnerability, these individuals are also part of the LGBTQIA+ group; while certain elderly people can express their sexuality and live it fully, others are stuck hiding their desires and expressions, since they need to return to live with their families or reside in Long Stay Institutions (25)(26) .
Prejudice and discrimination reach even higher degrees in the situations of LGBTQIA+ elderly. The agendas of LGBT social movements defend their flags and political agendas directed at young adults, contributing to the generation gap. Moreover, due to stigma and discrimination, they have a restricted social support network and low economic resources, due to reduced professionalization and low education (14,24,26) .
Elderly people who recognize themselves as LGBTQIA+ when inserted in supportive communities, living with other individuals belonging to sexual minorities, enjoy good health and social support, engaging in practices of health promotion and prevention, besides presenting satisfaction with their lives. This fact demonstrates the importance of strengthening social and family support and resources necessary for the development of resilience in the face of adversity and historical marginalization (27) .
Identifying the strategies for welcoming and promoting health for the LGBTQIA+ elderly population helps to ensure equity in care, understanding the inequalities and barriers faced by users when seeking services. Issues such as lack of trust in services and heteronormativity in health-illness processes are still employed in health care spaces. Care practices based on social determinants of health are being offered, but still in an incipient way (28) .
Therefore, Primary Health Care shows itself as an instrument to enable inclusive practices, for being composed of a complex interaction between technical, political, ideological, and economic issues, dealing ethically with the diversity of everyone. Therefore, the user-professional bond is strengthened when there is respect and trust and is weakened in the face of the current reality (29) .
Thus, the expansion of the field of qualified professionals who serve patients in a humanized way, respecting the specificities of everyone, emerges as a strategy for welcoming this population group. A policy to confront inequities requires a process in which the training of health professionals is based on the understanding of human rights and health of this population, ruling out inadequate conducts of discrimination and social exclusion (22) . It is worth highlighting the need for collective deconstruction, from the construction of democratic and plural spaces, in which health workers, students, class representatives, and users themselves are committed to building a solid knowledge that can foster new care practices, not restricted to creating spaces where differences are tolerated (15) .
Although the health area has the potential to break stereotyped practices focused exclusively on heteronormative and cisgender standards, it is still possible to evidence care practices embittered with prejudice and resistance, especially in a veiled way. The lack of professional commitment to the specific demands of the LGBTQIA+ elderly population, negli-gence during care, and the lack of public spaces for social support make an equitable care unfeasible, putting at risk safety, effective care, and respect for vulnerable minorities.
Such factors directly influence the access to health care, especially those of disease prevention and health promotion, resulting in higher rates of illness, whether physical or mental, in this niche population. Thus, the importance of strengthening public health and social policies aimed at sexual minorities stands out, as well as the training of professionals for the care of this public, to ensure the achievement of a better quality of life and to implement the principle of equity proposed by the Unified Health System.

Study limitations
We highlight as a limitation of the study the difficulty in accessing the interviewees, since, despite the data collection being carried out in a reference service focused on the LGBTQIA+ population, there was a limited number of registered elders. Furthermore, the face-to-face interviews were conducted during the period of the 2019 coronavirus disease pandemic (COVID- 19), which resulted in delays in the execution of the steps and the non-attendance of some invited elderly persons. The researchers chose not to conduct the interviews remotely because of the importance of an empathetic and welcoming environment during data collection.

Contributions to practice
According to searches in scientific databases, research on the social and health service experiences of sexual minority elders is still scarce, resulting in limited understanding of unique issues and concerns about programmatic and social vulnerability experienced by this population group. Knowledge about the influence of sexual orientation and gender differences, associated with perceptions about aging, still presents important gaps, especially regarding access to health services, experiences, and well-being. This research presents relevant data on the perception of LGBTQIA+ elderly persons about aging, health practices, and social and family support, providing subsidies for the readjustment of the reception and professional care provided by nurses.

Conclusion
The data presented here points out the difficulties experienced by LGBTQIA+ elderly people and the impact exerted regarding gender and sexuality of these individuals. Such problems are widely discussed in the gerontological literature, such as lack of social support, loneliness, difficulty in accessing health services, unpreparedness of health professionals and stigmatization, commonly faced in old age. Such aspects are increased when they involve the elderly belonging to the LGBTQIA+ group. These individuals live on the margins of society throughout their lives and, when they reach old age, they accumulate such losses with those common to senescence, such as difficulty in accessing health services and practices that do not consider the specific demands of this population group.

Authors´ contribution
Conception and design or data analysis and interpretation: Espínola IER, Oliveira FMRL. Writing of the manuscript or relevant critical review of the intellectual content: Carvalho LF, Silva DF, Souza JMM. Final approval of the version to be published: Galindo Júnior JUF, Barbosa KTF. Agreement to be responsible that all aspects of the manuscript related to the accuracy or completeness of any part of the manuscript are properly investigated and resolved: Barbosa KTF.