The impact of homophobia on adolescent health

Objective: This study had the purpose of recognizing the types of violence suffered by homosexual adolescents and understanding the effects of homophobia on the health of this group. Methods: In-depth interviews were conducted with nine adolescents that live in a country town on the state of São Paulo who declared themselves homosexuals. Results: The respondents reported cases of physical, verbal, psychological and sexual violence. Homophobia causes negative perceptions about themselves and the non-adoption of healthy lifestyle related to their nutrition, physical activity practice, sleep patterns and suicidal ideas. Homophobic situations were also described at health units. Conclusion: Homosexual adolescents are more vulnerable to different types of violence and the difficulty of access to health services increases the vulnerability. The relevance of this study is on the problematization of topics that can promote the construction of comprehensive care of this group.


INTRODUCTION
Adolescence is a period of human development understood chronologically between the ages of 10 and 19 years old 1 , cultural and socially defined and marked by the aspects of physical and behavioral changes.All these changes are essential for the human reaching maturity and being part of society as an adult, but, above all, adolescence is a stage of life that combines right holders subjects which deserve to be seen as active actors in society, able to have and incorporate citizen values and attitudes that will enable them to live independently 2 .At this stage of life, there is also a larger exposure to different situations of conflict, violence and exclusion 3 , considering the increase of conviviality and social contact.Thus, adolescence refers to the meeting of social, historical and cultural situations with the subject transformation, making them individual and collective at the same time, looking for their identity, including sexual, and relevance in the world.On this search, the sexuality is revealed as a constitutive element of development and the process of adolescence.
In this context, homophobia appears as a polysemy concept and a plural phenomenon, referring to a set of negative emotions and behaviors of a person or group against homosexuals.Homophobia is also a control device that reinforces the idea of naturalization of normality related to heterosexual orientation and that manifests itself in social relations through physical, verbal, psychological and sexual aggressions 4 .If it is associated with psychological symptoms and negative feelings (fear, annoyance, anger, disgust), but also with prejudice, discrimination and violence against lesbians, gays, bisexuals, transvestites, transsexuals and transgender, homophobia is related to power and gender relations that are presents in the society 4,5 .
Violence as a complex process related to social dynamic that affects physical, moral, mental or spiritual integrity have many causes and is related to the evolution of civilization and the survival instincts.The subject assumes an eminently social character, resulting from the differences and inequalities that exist between people.
Violence as a social process is the main topic that matters most for the health area discussions.This debate cannot be reduced to the area's approach about the assistance types of problematization to the victims of different violence; it seeks to assist in developing strategies for the prevention of the phenomenon, including how to intervene to this complexity.This perspective goes beyond the curative and biomedical health model, emphasizing the holistic and expanded health conception and its corresponding to the completeness, the intersectorality and the health promotion 6 .
From another perspective, the Statute of Children and Adolescents 7 (ECA) ensures that any child or adolescent should not be subject to discrimination or violence, within or outside their families.That is not the reality for certain groups of Brazilian adolescent, especially the homosexuals, exposed to human rights violations and many other types of violence 8 .According to the Ministry of Health 9 , in 2012 were registered 4,851 cases of homophobia, where the majority (61.16%) of victims was between 15 and 29 years old.That information shows the relevance and magnitude about homophobia problematic and the homosexual adolescents as members of a vulnerable group.In a global analysis, it can be inferred that the liberty and security rights seem denied to LGBT population in general and mainly to the adolescents.
Referring to the expanded health concept, where, besides the biological aspects, it is also understood that the subjects present on their health and quality of life, the characteristics of personality and the non-dissociation of physical, mental and social.Considering it, the comprehensive health is the result of many different conditions and determinants 10 .In addition, homophobia may interfere in the socialization process, in daily habits and behaviors, food, leisure, access to health assistance, for examples, culminating in some situations, in damage to the well-being of adolescents.
The scientific literature indicates that homophobia is one of the determinants of adolescent's health.A study with 300 non-heterosexual adolescents, developed in Canada in order to identify different forms of homophobic bullying and model relations between the phenomenon and its process of internalization and self-esteem issues, found that homophobia causes negative effects on well-being, quality of life and health of adolescents 11 .It also highlights the association between sexual orientation and suicidal thoughts in adolescence, since homosexuals are more vulnerable to think about and attempt suicide compared to heterosexuals 5 .
The relevance of this study is given by the deepening of the issues involved on homophobia's impacts on adolescents' health.In addition, it discusses the nurse actuation on direct or indirect care to homosexual adolescent user, according to the values and guidelines of the Unified Health System (SUS).These professionals must also know and consider the specific demand of homosexual adolescents, action that requires attention about the processes that lead to their exclusion in society, the types of violence to which they are subjected of and its risks.Developing, in this way, the Brazilian scientific production in this direction, since there are gaps in national studies on the subject, especially in the nursing knowledge area.
It assumes homosexual adolescents are considered as a vulnerable group by the adolescent condition and by the violence and exclusion to which they are exposed because of their different behavior and sexual orientation of the hegemonic standard fixed social, cultural and historically.Thus, it was aimed to know the types of violence suffered by homosexual adolescents and the impact of homophobic practices in the health of this population.

METHODS
Considering the objectives of this study, the development of the research came through a qualitative approach.The field of study was a municipality in the State of São Paulo in Brazil.The inclusion criteria of the participants were: be an adolescent

Impact of homophobia on adolescent health
Natarelli TRP, Braga IF, Oliveira WA, Silva MAI between the ages of 10 and 19 years old, residents in a country town on the state of São Paulo and who declared themselves homosexuals of both sexes.
The methodology adopted through which the participants were selected was the snowball technique 12 .This practice starts from an actor or a group of actors that indicate new subjects to participate in the study, these indicate other and so on, allowing the researchers to immerse themselves in their social circle.The snowball technique can be particularly efficient to study hard-toreach populations and in vulnerable situations or in addressing sensitive topics and themes, such as is the case of this research and its object of study 12 .
The approach with the first participant was possible since the researchers already had a relationship with this population through a systematic prevention work that occurred in a square in the studied city in the past.In a first contact were detailed the objective of the research, the conditions of participation, the need for the TCLE (Term of Consent) and, upon their agreement, the conducting of interview in a place of their preference.
Data were collected through semi-structured interviews.The researchers used a script that included questions about the adolescent's perception concerning: violence against homosexuals routinely; violence against the interviewed; the causes of this violence and how it can impact adolescent health.The individuals' interviews were recorded and transcribed.
The researchers conducted nine individual in-depth interviews, lasting about an hour each, between November 2013 and July 2014.The age of the group, composed by five male gender people (55.6%) and four female (44.4%), ranged between 10 and 19 years old, resulting on an average age of 17.4 years.All the interviewed were students: one (11.1%) of them was in the Elementary School, five (55.6%) in High School and the three (33.3%) in College.Three adolescents (33.3%) reported working as an actor/makeup, service representative/tattoo artist and baker's assistant.For this presentation and to preserve the identity of the participants, they will be designated by the letter A followed by the number assigned to each adolescent (Adolescent 1 = A1, and so on).
The processing and analysis of the data collected were developed based on the Content Analysis Referential in its thematic mode.The analysis led to the ordering and classification of the data by record units.Referenced by themes and refined in synthetic expressions, the empirical categories made explicit the reality according to the interviewees.Theoretical saturation of answers was used as a determinant of the sufficient number of participants.In this way, the following themes have been identified: "Types of Violence" and "Influence on Health".
The research project was analyzed and approved by the Ethics Committee in Research with Humans (CEP) from EERP/ USP, Protocol CAAE n. 16304213.3.0000.5393,respecting the ethical issues necessary for its realization.The participation of these adolescents was voluntary and for the children under 18 years of age, in addition to their consent, it was also requested consent of their parents or guardians.

Types of violence
Adolescents declared themselves victims of different types of physical, verbal, psychological and sexual violence.The main scenarios for the occurrence of homophobia according to the adolescents are: school, family and community.
Physical violence was not considered as recurrent as the verbal and psychological types, being more frequent against male homosexuals.Meanwhile, not only physical violence was identified, but also personal and third-party testimonials referring to threats of aggression and homicidal attempts.

It always happens, people say, 'Oh I'd rather be here [square/
LGBT point] at night because at home my father hits me, discusses with me, everyday' (A1).
The physical aggressions are predominating too.On TV, in the newspaper, frequently, every day we heard a story, a testimonial.[

...] I am really afraid to 'go to school to be beaten or humiliated all the time' (A4).
It is worse with the man, I think they suffer more aggressions than women, and they cannot go outside as a couple, clutching hand, kiss each other, to be sure they will suffer more physical violence than verbal [...] (A5).
Two security guards and another man put the guy [homosexual adolescent] there, they told him that this third person was hired to exterminate the 'little grils' to the shopping mall, they beat him, threw punches, [...] beat, I think they threw a punch in his stomach, kicked him [...] and told him never to return there (A6).
Verbal aggression was the kind of violence that the adolescents described as causing much suffering.In these cases, this violence was mainly characterized by the insults and pejorative terms referring to their sexual condition, but also the use of words to oppress and press the adolescent.

[At school] There are always insults such as 'hey, pussy' (A1). If I've suffered an event of homophobia it was just verbal, it is more and continuous, such as you are on the street and people scream 'dyke', it's normal for me (A2).
Once we were on the street and for some reason she was not feeling well, and then I hugged her [girlfriend], [...] and there came a man all crazy, hallucinating, and talking 'are you thinking you are man and woman?You're not!', and I was just giving her a hug, so started getting that tense atmosphere (A5).
Verbal violence is more common and its affect a little the person's psychological, so that it's not easy for a homosexual to be humiliated in front of other people Impact of homophobia on adolescent health Natarelli TRP, Braga IF, Oliveira WA, Silva MAI because of their choices, it impacts a little bit with his self-esteem, the person start getting lessening a little more (A8).
The psychological violence, or symbolic, was considered the most predominant and also the one that makes up the homosexual adolescent's every day, who also faces in their daily lives situations of prejudice, oppression, differential treatment, among other forms of exclusion.
On the street everyone faces us, people are not discreet, sometimes they look strange, is something like that, people close the eye, face you and you're like feeling uncomfortable, sometimes a little, you know?Too hard (A2).
Sometimes, for example, there is a chair to sit down, just one chair, but where they fit two people.If a man and a woman sit, the security guard be quiet, but if we are sitting together in two minutes they appear and say 'Oh, please, stand up, this chair is for one person only', that so boring, you know?(A5).

I lost some friends [...] I even had a best friend who was with me always, but he stopped talking to me when I let him know my choice, it was really bad (A6). I had a big rejection, [...] my biological father did not accept my option [...] he stopped talk to me for a year. [...] I suffered this rejection, he scolded me, did not want to talk to me anymore (A7).
Sexual violence was not present on the majority of the testimonials, but it was emphasized as a potential risk to homosexual adolescents, especially with the females, even assigning a higher prevalence in cases of sexual harassment, threats and abuse attempts.
The man in a way, he has a fetish for two women together [...], so the women are discriminated, but in a more abusive way [

Influence on Health
Adolescents revealed in interviews the dimension and complexity of homophobia situations with which they live through different forms of manifestation, which result in problems to their health.This conclusion can be measured in terms of impairment of mental health and in the difficulties to adopt healthy lifestyle habits.
Homosexual adolescents disclosed a negative perception of themselves, which could contribute to the neglecting of selfcare practices, not keeping healthy habits and also developing suicidal thoughts.These aspects became evident in the following testimonies: The stress related to that is too big [...] I even threw up because, you know, when you're so... Crying and down, and you looking really bad, and then happens that twist in the stomach and the food returns, I threw up once, it was strange and it's stress, it is too hard (A2).

When I was 13 years old I went into depression, [...] I started feeling bad, I started getting sick, I had anemia, because I started to stop eating. And it was right after I had cancer. I finished the therapy and started going on these things, so I cannot getting sick, this situation damaged a lot my health, because it happened in a time that I was supposed to be the best with my body, take care of my body, and I did the opposite. I had embarrassed to work out, so I started having problem with fat, and what's it called? Diabetes [...]. I couldn't sleep because I knew I would suffer prejudice in the other day and I was thinking about it the whole time, so it, you know, makes you down, if you give attention to prejudice, makes you very bad, that affects the health, it affected my health (A3).
Some people try to kill themselves; there are a lot of people suffering it (A6).

It already damaged me, I went into depression because of it, and I've tried suicide several times because of this too, I'm starting to get over it, and the most serious episode happened many years ago. [...] I know people who had anorexic and bulimia, among other disorders, so it really affects people's health. [...] I was reaching a point that my bones were all appearing (A9).
Adolescents also reported the presence of homophobic thoughts and behaviors within health centers and among their professionals, considered as elements capable of difficulty the access to health and integral service.

Impact of homophobia on adolescent health
Natarelli TRP, Braga IF, Oliveira WA, Silva MAI

One time, a nurse refused to manipulate my blood, and asking someone else to do it, I believe she was afraid [...] The person that I know who has suffered this, she never drew blood anymore, she was never visited the doctor, everybody tell her to go, but she does not want to experience this again (A3).
She [gynecologist]

DISCUSSION
This study aimed to know what types of violence homosexuals adolescents are exposed to and understand the impact of homophobic practices on the health of this population.In this context, regarding the types of violence suffered by adolescents, homophobia appears in its most varied forms of manifestation and types of aggression: physical, verbal, sexual and psychological.The verbal and psychological violence were the most experienced by the interviewees.These aggressions happen in familiar, scholar and community contexts.Homophobia is frequent in the daily life of the adolescents.Health impact of this population can be appreciated from two aspects: 1) the homosexual adolescents' perceptions about the violence to which they are subjected; and 2) the impact of homophobic practices on adolescent health.
About the types of violence suffered, in an exploratory dimension, it should be noted that the physical type is defined by the aggressions used for "discipline" the child or adolescent, filed by someone who is has the power, may causing external or internal injury or both 13 .Thinking about the values of heteronormative society in which we live, physical aggression against homosexual adolescents appears objecting the punishment for a "wrong" behavior, looking for its change, in this case, the adolescents' own sexual identity.It can also be inferred in the adolescents' speeches about the occurrence and prevalence of lethal cases of physical violence against the homosexuals, for example, homicidal attempts, drowning and running over, reported by adolescents 7,8 .
Verbal violence, which uses words as a means of aggression, humiliation, exclusion, in the case of homosexual adolescent, is also based on the relationship of power and dominance over the victim and can make their non-acceptance of their own sexual orientation and have behaviors attitudes that indicate some distress.
According to a survey conducted with the participants of the Pride Parade, about the violence suffered, among the 320 respondents, 40% declared the occurrence of verbal discrimination at school or college.More than a half of the interviewees reported have been experienced in situations that they or closer friends were named by "queer" or "dyke" in childhood or early adolescence 14 .
Psychological violence, in turn, was mentioned by the adolescents, not only as the most prevalent, but also the one that causes most suffering, as well as major damages, potentially leading to suicidal thoughts and attempts.This conclusion is in line with other findings of scientific literature when compares statistically compare adolescents heterosexuals with nonheterosexuals, notes that the last have more chance to think and try suicide.
Sexual violence was cited by adolescents such as threats, abuse attempts and harassment, whether by their similar or adults.It should be noted that in these cases, the adolescents reported having feel violated at the time of the aggression.This kind of violence can be understood in two forms -sexual abuse and exploration -as every act, of any nature, offensive material to the human's right to sexual development of children and adolescents, practiced by agent in situation of unequal power and sexual development in relation to the victims 15 .Hate and rejection of homosexuals, as well as the idea of superiority to them especially to adolescents, who are particularly vulnerable, contribute to cause that kind of aggression.
Another relevant aspect in the analysis of results refers to the influence of homophobia on adolescent health, especially with regard to their mental health, because it contributes to the emergence of depressive behaviors, anxiety and excessive fears, suicidal thoughts and attempts, denoting psychical sufferings which origin is in episodes of violence experienced.This shows one of the perverse effects of homophobia that is the internalization process of violence.Such experiences affect the actions and way of thinking of the one who suffers, as well as interfere in adopting healthy lifestyle habits and self-care, such as nutrition, physical activity and inadequate sleep standards, causing signs and somatic symptoms such as pain in the head, stomach and body, nausea and fainting, among other reported by adolescents.
When adolescent starts to present behaviors considered inappropriate by the heteronormative society, the individual begins to be exposed to homophobic speeches, among other forms of violence, such as symbolic, with the intention to "coerce" the subject to assume its gender's (as a "man" or "woman" should act) 5 .The homosexual adolescent understand itself "different" from their peers, so they start to accumulate negative thoughts about themselves, internalizing the homophobia, which can take you to adopt risk behaviors, which are common among the Impact of homophobia on adolescent health Natarelli TRP, Braga IF, Oliveira WA, Silva MAI majority of adolescents, but that represent a big problem when it comes to homosexuals.It can be said that the LGBT condition incurs bodily habits or even sexual practices that can preserve some relation depending the vulnerability degree of these people.However, the largest and deepest suffering is that resulting from discrimination and prejudice 16 .
The reality reported by adolescents, referring to the homophobia in health services, has also been found in the scientific literature.The studies suggest that health professionals have difficulties to deal with adolescents in general, especially with the homosexuals.The staff is conservative and has inflexible positioning, negative attitudes and discrimination against homosexuals 17 .Attitudes like these influence the behavior of the professional, who often attends the homosexual patient quick and superficially, without delving into issues of sexual health and limit the possibility of providing integral care to these patients.Thus, homophobia can be characterized as an obstacle for LGBT population have access to health services and receive a specific care according their health needs 17 .
An integrative review of the scientific literature about the role of nursing leading to male homosexuality revealed a low number of publications on the subject and that, while the nursing area works with elements of health promotion, through the guidelines and listen qualified.However, gaps were still identified related to the need to offer a health care that improve homosexuals, transvestites and transsexuals.Explaining the role of nursing, the study revealed that the comprehensive care of this population should be reconsidered within the logic of the social commitment of the profession, their ethical aspects and the large contingent of professionals in primary health care 18 .
It should be noted that is the professional role belonging to healthcare institutions ensure the rights of children and adolescents, regardless of gender issues and sexual orientation.Meanwhile, reproduction of homophobic practices against the homosexual population is prominent.Health teams should be prepared for the attention to adolescent health, particularly the homosexual group, as regards health and violence, to build a network of prevention, and social support to this population, as pointed out by adolescents' participants of this study.The line of research in care for the integral assistance to the health of children, adolescents and their families in situations of violence, through the host, service, notification and follow-up on the network of care and social protection, aims at continuity of care, the articulation of the various sectors involved, as well as the strengthening of accountability and involvement of our professionals and services in cases of violence, as is homophobia.

CONCLUSION
Homosexual adolescents are in vulnerably situations because they are most exposed to different types of violence.The health of this population is affected by homophobia, which causes mental suffering and interferes with the adoption of behaviors and healthy lifestyle habits.The original contribution of this study therefore in the problematization of integral healthcare practices and attention to homosexual adolescents, highlighting the nurse as a professional strategy for the propagation of these practices.
This way, it is observed that these practices should follow the needs of this audience for therapeutic approaches that value the exclusivity and the expression of sexuality, while guiding and assess the need for support or formal mental health services.To this end, health professionals who deal with adolescents, especially primary care, nurses should be trained and oriented to deal with homophobia, adopting postures marked by prevention, identification, shelter, care, notification and referral of cases of violence against homosexual adolescents, targeting an integral and free of prejudice, as advocated by the SUS.This perspective extends the approach of this contemporary theme, studies focusing on the use of psychoactive substances or sexually transmitted diseases related to LGBT population.
The results of this study should be interpreted considering some limitations.The type of recruitment used favors the approach to issues related to vulnerable groups, and may build a deeper approach to the context of social relations, specifically, but may have included adolescents with greater exposure to violence, for example, which may not reflect the experience of most homosexual adolescents.It was not possible to profound aspects of gender in the analysis of the data, it means, if the way that boys and girls experience homophobia differs or has similarities and how the genders interprets these situations.
It is recommended that in further research with different guidelines, the researcher explore these and other aspects related to the health of the adolescent homosexual.For example, for systematic research on the subject of homophobia, specifically, suggests the formation of focus groups with homosexual girls and boys and heterosexuals too.These initiatives can overcome the lack of studies that are able to support the professional practice which provides direct assistance to adolescents and also the implementation of public policies aimed to health promotion and protection of homosexuals.