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OS MOVIMENTOS SOCIAIS E A GÊNESE DE PROPOSTAS PARA A SAÚDE DA POPULAÇÃO LGBT NA BAHIA (1979-2014): DISPUTAS INICIAIS E ALTERNATIVAS POSSÍVEIS
SOCIAL MOVEMENTS AND THE GENESIS OF LGBT HEALTH POLICY IN BAHIA (1979-2014): INITIAL DISPUTES AND POSSIBLE ALTERNATIVES

Camila Amaral Moreno Freitas – Universidade Federal da Bahia – Instituto de Saúde Coletiva (camilamaralmoreno@gmail.com) ORCID: 0000-0002-1841-2260
Nilia Maria de Brito Lima Prado - Universidade Federal da Bahia – Instituto Multidisciplinar em Saúde (nilia.ufba@gmail.com) ORCID: 0000-0001-8243-5662.
Vinicius Nunes Carvalho - Universidade Federal da Bahia – Instituto Multidisciplinar em Saúde (viniciusnc.farma@gmail.com) ORCID: 0000-0002-7456-7099
Clavdia Nicolaevna Kochergin - Universidade Federal da Bahia – Instituto Multidisciplinar em Saúde (clavdian@yahoo.com.br) ORCID: 0000-0002-3272-3030
Adriano Maia dos Santos - Universidade Federal da Bahia – Instituto Multidisciplinar em Saúde (maiaufba@ufba.br) ORCID: 0000-0001-9718-1562

RESUMO
Com o objetivo de descrever a gênese de propostas para a saúde da população de LGBT na Bahia, foi realizado um estudo sócio histórico entre 1979 e 2014. Adotou-se as proposições de Patrice Pinell para a análise sociológica de políticas públicas. A análise do espaço social compreendeu a identificação das trajetórias dos agentes envolvidos com as propostas no estado da Bahia e as relações entre esses agentes e o espaço social nacional, assim como, o campo do poder do Estado. Na Bahia, destacaram-se agentes com trajetórias vinculadas ao campo científico, dos direitos humanos, dos direitos sexuais, do feminismo e do espaço AIDS, com alto capital burocrático e militante, que propiciou aproximação às questões relacionadas a saúde LGBT local. As condições de possibilidade que permitiram a formulação de propostas políticas baseadas na integralidade e na universalidade da atenção à saúde foram a formalização do Comitê Técnico Estadual de Saúde Integral LGBT da Bahia, em 2014, onde buscou-se ampliar a Atenção Integral à Saúde voltada às populações de maior vulnerabilidade; e o Plano Bahia sem homofobia, que permitiu ampliar o diálogo com a sociedade civil e os movimentos sociais e abarcar as principais críticas para a formulação de propostas políticas, que residiam na ausência de resposta assistencial alinhada às reais necessidades em saúde da população LGBT.
PALAVRAS-CHAVE: Sociogênese; Movimento LGBT; Política de saúde Integral; Sociologia Médica; Equidade em Saúde; Bourdieu.

ABSTRACT
We conducted a socio-historical study covering the period 1979-2014 to explore the genesis of LGBT health policy in Bahia, Brazil, drawing on Pinell’s theoretical framework for the sociological analysis of public policy. To analyze the social space, we investigated the trajectories of the agents involved in policy formulation and the relations between these agents and the national social space and field of State power. The agents were predominantly from the scientific, human rights, sexual rights, feminism and AIDS fields, and had a high level of bureaucratic and militant capital, meaning they were well-versed in LGBT health issues. The historical conditions of possibility underlying the formulation of LGBT health policy included the formalization of the State Technical Committee on LGBT Health in 2014, in an effort to improve access to comprehensive health care for vulnerable groups; and the Bahia without Homophobia plan, which helped expand dialogue around with civil society and social movements and address the main criticisms of policy making, focusing on the lack of a care response tailored to the real health needs of LGBT people.
KEY WORDS: Sociogenesis; LGBT Movement, Comprehensive Health Policy. Medical Sociology. Equity in Health. Bourdieu.

INTRODUCTION
The genesis of LGBT health policy appears to be associated with the participation of social movements seeking to get this issue onto the government1,2 and global agenda3.
In Brazil, the LGBT movement emerged in the 1970s along with the student movement, feminist movements and counter-hegemonic and counterculture movements. Imbued with an anti-establishment and anti-authoritarian spirit, this movement sought to affirm multiple sexual orientations, engendering a discourse of cultural transformation and struggle for equality and democracy4,5. Yet it was only in the 1980s that the trajectories of agents involved in the fight against violence, discrimination and the pathologization of homosexuals favored a convergence between the struggles of the LGBT community and the fight against HIV/AIDS6. Although the efforts to control the HIV epidemic created greater visibility to the discussion of LGBT health, reservations have been aired about the stigmatizing nature of the association between AIDS and the social and health needs of LGBT people7.
The beginning of the 1990s saw a shift in the concentration of groups from the Southeast to the Northeast and a marked presence of activists who adopted a more pragmatic approach aimed at guaranteeing civil rights and fighting discrimination and violence against homosexuals8. These developments were important as they delineated the involvement of social movements in the state of Bahia; however, we were unable to find studies discussing the organization of the LGBT movement by groups of activists and NGOs and its participation in policy-making arenas. Existing research provides perspectives on the consolidation of the movement and the push for the recognition of citizenship. Studies by Camarotti9 and Bezerra et al.10, for example, address the trajectory of the LGBT movement in Bahia and its struggle for citizenship and social rights.
This article therefore describes the genesis of policies in the state of Bahia focusing on the health of lesbians, gays, bisexuals, transvestites and transsexuals (LGBT) as a social problem that requires a specific government response11,12. It does so to gain insight into realized and exclude possibilities, considering that initial disputes and potential alternatives tend to be forgotten during the policy institutionalization process11,13.
METHODOLOGY
Study design
We conducted a study of the genesis of LGBT health policy in the state of Bahia focusing on the period 1979-2014. This period encompasses key events in the configuration of LGBT health policy in Bahia, beginning in 1980 with the foundation of the Group Gay da Bahia (GGB) and culminating in the creation of the State Technical Committee on LGBT Health in 2014.
This study is part of a larger study titled “Implementation of the National Policy on Comprehensive Health Care for Lesbians, Gays, Bisexuals, Transvestites and Transsexuals (PNSI-LGBT) in the state of Bahia”, approved by the Research Ethics Committee of the Multidisciplinary Health Institute, Federal University of Bahia on 13 December 2018. The study was conducted in accordance with the ethical norms and standards for research involving human subjects set out in national health council resolutions 466 and 510, and all participants signed an informed consent form.
Study location
The study was undertaken in six municipalities in Bahia: Feira de Santana, Ilhéus, Itabuna, Jequié, Salvador, and Vitória da Conquista. These municipalities were chosen based on the following criteria: 1. Municipalities that have groups who promote prominent discussions to influence the formulation of health policy; and 2. Municipalities located in different regions of Bahia, with the aim of obtaining a representative sample of the state.
Attempts were made to conduct interviews with other agents involved in LGBT movements in other municipalities; however, this was not possible due to lack of availability and/or interest in the study.
Study participants
Interviewees consisted of militants from LGBT groups and officials from the Bahia State Department of Health, categorized as policy-makers, key informants, LGBT activists/militants and bureaucrats, based on a preliminary analysis of the main normative and technical documents that make up the LGBT policy framework.

Data collection
We analyzed normative and technical documents related to LGBT health policies, documents provided by the interviewees that could help provide an understanding of the policy making process, and publications critically reflecting on the history of the policy-making process in the state of Bahia.
Semi-structured interviews were conducted with a total of 25 agents, comprising individuals who were currently working/had worked in state or municipal health departments, state government managers and coordinators, groups of agents from the bureaucratic field and agents from the militant field, such as representatives of LGBT movements in Bahia.
All interviews were administered by the lead researcher with the support of previously trained researchers from the Bahia Health Care Networks Observatory (OBRAS - CNPq). The interview guide was divided into the following sections: genesis of state policy; interviewees’ perceptions of the needs and demands of LGBT people; involvement/participation of professional bodies in the genesis/emergence of policy; and the interviewee’s life trajectory. Sample size was determined using the data saturation technique. All interviews were recorded using a digital voice recorder and all participants signed an informed consent form.
Data analysis
For document analysis purposes, excerpts from the documents were synthesized in an electronic spreadsheet under the following categories: a) document identification code; b) full bibliographical citation; c) document source (name of the bibliographic database, site, etc.); d) type of document (article, book chapter, technical document, position paper, media news); e) summary of main results; and f) preliminary assessment of the relevance of the document to the study objectives. All duplicate documents were excluded before completing the spreadsheet.
The interviews were transcribed in full and the collected empirical material was read systematically and organized into a summary table.
The document analysis and interviews were triangulated to gain insights into the timeline of events that culminated in the formulation of policy. The triangulation of the data sources allowed us to collate the data, ensuring the consistency of the collected evidence. The content of the interviews was also used to create a network of relations between the agents involved in the genesis of the policy.
For the purposes of this article, we adopt the concept of public policy as a course of action or omission of the state in response to a given health problem14 and the perspective presented by Pinell15 for the sociological analysis of public policies based on theoretical elements of Bourdieu\'s reflective sociology13 (Box 1).
[Inserir box 1]
The classification of agents into fields and social spaces was based on the composition of the different species of capital, drawing on studies by Vieira-da-Silva and Pinell12, Souza24 and Barros25, and inspired by Bourdieu’s objectifications26 in Homo academicus (Box 2). We considered the following indicators: indicators of scientific capital – titles and publications in the area; indicators of symbolic capital – awards and recognition (notoriety) in the area; indicators of bureaucratic capital – positions occupied in the bureaucratic field and mobilized resources (here we draw on Bourdieu’s concept of field, which entails the identification of dispositions common to agents that constitute a habitus. These dispositions are acquired over the course of a trajectory, corresponding to successive positions occupied in the social space by the interviewee under specific historical conditions of possibility); indicators of political capital – political appointments and/or participation in political parties; indicators of militant capital – participation in unions and/or professional bodies, social movements and health movements; indicators of social capital – membership of one or more groups within the space, determined by relations between agents and other individuals and how these relations affect their choices and the positions they take. Symbolic capital was assessed only for group founders, referred to by the majority of interviewees as the leaders responsible for creating the social space in each location.
[inserir box 02]
Based on the results of the interviews, we delineated the positions taken up by the agents and create a network of relations between the agents involved in the genesis of the PNSI-LGBT in the state. We created a sociogram representing the channels of influence between agents, common goals and affinities, as well as the groups and/or subgroups present in the space in which the emergence and genesis of the PNSI-LGBT took place. The sociogram was created using Gephi 0.9.2 (GNU General Public License v3) and the ForceAtlas2 layout (Figure 1).

RESULTS AND DISCUSSION
The identification of the historical conditions of possibility underlying the emergence of LGBT health policy in the state of Bahia permitted the, albeit partial, reconfiguration of the dynamics of the space, provided insights into the participation of agents from the bureaucratic and political fields and militant (associative) space and their relations, and allowed us to create a timeline of events culminating in the formalization of LGBT health policy. The analysis is structured around categories selected based on the assumptions of the sociological analysis of health policies proposed by Pinell (2010), considering the following contextual periods: 1. 1979-1999 – Need for problem-solving; 2. 2000-2008 – Social construction of the problem; 3. 2009-2011 – Social construction of proposals; 4. 2011-2014- Recognition of the problem and formulation of actions and propositions.
1. 1979-1990: Need for problem-solving
The main LGBT rights and health agendas in the state of Bahia arose from the participation of various LGBT groups operating in the state that organized themselves between the end of the 1970s and 1990s. Examples include: Grupo Lésbico da Bahia (GLB), Grupo Gay da Bahia (GGB), Quimbanda Dudu - Grupo Gay Negro da Bahia and Associação das Travestis de Salvador (ATRAS), from Salvador; Grupo de Ação e Integração Homossexual (GAIH), from Feira de Santana; Humanus, from Itabuna, and EROS, from Ilhéus. These groups initially fought against discrimination and stigma and to promote prevention/protection in response to the incipient HIV/AIDS epidemic4,9.
ATRAS was an association of transvestites and transsexuals; Quimbanda Dudu was a group that worked mainly with the Afro-Brazilian LGBT community, both of which operated in the GGB building, so they were three big NGOs. There were groups that were less LGBT, including the group Esperança, which worked with transvestites and transsexuals, [it was] through them [that] we realized the need to create a LGBT health policy in Brazil (E - 22).
During the 1993-1996 administration, the Salvador City Council Health Department established connections with entities and NGOs from the municipality to develop infection control plans. However, health promotion actions still remained scarce27.
A key agent was Luiz Mott, one of the founders of the GGB28,29, who played an important role in developing the infection control plans and bringing this proposal to Bahia. Sociologist and professor at the Federal University of Bahia, with a high level of scientific and militant capital, Mott transited through several organizations that he helped to build, including lesbian groups, ATRAS, Grupo Vida Feliz, made up of people with HIV/AIDS, and the black homosexual group Quimbanda Dudu9. He made a significant contribution to the initial strengthening of LGBT leader training at a time when the movement in Bahia faced major difficulties in training leaders due to the timid and “limited presence of the movement, and especially the GGB, in the university environment”9(p.90).
Years later, some of the theoretical elements developed by Mott were included in the final state policy proposal. Many agents mentioned having incorporated his theories into the proposal because they admired his work and trajectory or because they had a direct relationship with the researcher within the scientific field.
During this period, with the AIDS epidemic at its height and Mott being one of the pioneers in this state [promoting] the idea of prevention for the LGBT community, they had agreed with Carlete that it would be a condom distribution point. First, because a lot of transvestites lived there and condoms were the only form of prevention that we knew of at the time, and it was necessary to do that (E - 07).
Another key militant leader at this time was Keyla Sympson, a transvestite who founded ATRAS and gained the recognition of the transvestite movement, despite having only recently moved to Salvador.
Someone they recommended for handing out condoms, because he needed to extend coverage and perhaps Carlete couldn’t handle it anymore, since there was an endless number of people arriving in Salvador who were in need. So they ended up recommending me – I don’t know why – but they said: "Keyla can do that". I was on a corner working, not even I realized I had this leadership at the time; let me think, in 1990/91 (E – 07).
The main militant agents within the space of relations between agents, an associative environment that emerged between the 1980s and 1990s, were gay men’s groups, propelled mainly by the GGB and the development of transvestite leaders. However, these groups were still largely limited to the state capital, Salvador, and municipalities in or closer to the metropolitan region. The expansion of the LGBT movement to smaller towns and cities took place only at the end of the 1990s and beginning of the 2000s. In municipalities like Vitória da Conquista, militancy was still in its infancy in the 1980s, mainly due to discrimination and homophobia.
At the beginning of the 80s, militancy was still very timid. We didn’t have the benefits of technology nor many financial resources. I began to do some painstaking work here, discussing with my colleagues the importance of creating a movement in Vitória da Conquista that could become a reference and politicize our causes. Health, education, public security, cultural education, employment and income (E – 12).
In 98, we were articulating. We had a program here called Sons, which was presented by a psychologist on local TV. And they invited various leaders to talk about a range of topics. One of the topics was homosexuality. We were invited to take part in the debate. We went against the grain, and the city came down on us. It was a massacre, horrible. The more hardline pastors and priests began to say: "How terrible, you can’t defend that". From that point on we realized that we needed to create a movement that included everyone. So we brought nurses, architects, lawyers, garbage collectors. Only LGBTphobia is really brutal and people began to be threatened with losing their jobs. And only half a dozen people stayed (E – 12).
In view of the above and according to Pinell15, the need to create a policy to control the HIV epidemic and recognize LGBT rights in Bahia stemmed from the government’s acknowledgement of the ineffectiveness and inadequacy of public prevention, testing and health promotion campaigns, “as well as the need to organize the “associative environment” that was emerging at the time”.

2. 2000-2008: Social construction of the problem
The social construction of the problem in Bahia was driven by a range of agents from the militant, bureaucratic and scientific fields, who brought together concerns about the health needs of LGBT people in a variety of social spaces15. There key milestones marked the social construction of the problem: 1. The “NGOization” of LGBT groups and AIDS prevention support groups (GAPAs); 2. The development of the “Projeto SOMOS” by the GGB and impetus for the interiorization of the LGBT movement in Bahia; and 3. The launch of the Brazil without Homophobia program by the federal government and local and state conferences preceding the 1st National LGBT Conference.
1. The “NGOization” of LGBT groups and GAPAs
The end of the 1990s and beginning of the 2000s saw the “NGOization” of social movements. The most prominent LGBT organizations in Bahia were located in Itabuna, Ilhéus, Feira de Santana and Salvador30. It is important to underline that the legal constitution of LGBT NGOs and associations reinforced the positions occupied by these agencies (movements and institutions) with the aim of transforming power relations and the rules of the game in the interests of the groups13. In other words, through legally constituted NGOs, the movement was able to raise funds to develop their actions and participate in more wide-ranging spheres of discussion. Thus, NGOization was both a mode of political organization and way of getting funding.
So in the 1990s and beginning of the 2000s, up to 2010, homosexuals, homosexual groups were still very focused on AIDS, AIDS prevention; for us it was interesting because the AIDS agenda opened up a range of opportunities in other areas (E - 10).
When GAIH was created... It was initially created as a voluntary association and later began to make applications for calls for proposals from the Ministry of Health, becoming part of that public policy area, especially in the 1990s, which was the decade of the "NGOization" of the treatment of AIDS. Not so much the treatment, but rather STI, HIV, AIDS prevention campaigns. So it got a foothold within this policy as an agent promoting prevention among risk populations, which were gays, lesbians, transvestites (E - 11).
This articulation brought the social movements and in vogue agendas closer together.
2. Development of the “Projeto SOMOS” by the GGB and impetus for the interiorization of the LGBT movement in Bahia
A second crucial moment for the social construction of the problem was the growing interiorization of the LGBT movement in Bahia, driven by the Projeto SOMOS led by the GGB. The project involved two phases. The first phase was implemented between 1999 and 2000 with the participation of groups such as ATRAS and GAIH. The second phase was undertaken between 2001 and 2002, with the participation of Humanus, EROS and, once again, ATRAS and GAIH, among others. The aim of the Project was to strengthen and promote the diffusion of LGBT groups in the areas where they operated4,9.
Around 2000, the Grupo Gay da Bahia was looking for social movements in municipalities in the state of Bahia with gays who had come out who could take part in training offered by the Group in Salvador with a view to creating a movement in their hometown (E - 15).

The formulation. Marcelo Cerqueira and Luiz Mott gave us a load of model projects. That’s how we learned to write projects. Based on the reality in Salvador, we took the problem tree, which in this case was the problem in our city, and adapted the idea. Sometimes we removed one thing and added another and it ended up working out well. And through this engagement, we ended up strengthening our practice and today writing projects is a doddle (E – 19).
Actions were also proposed within bureaucratic and scientific spaces: by the Bahia State Department of Health (SESAB) – activities developed by the former regional health board (DIRES) focusing on the provision of broader and more comprehensive health care in inland areas of the state; and by universities and agents with high levels of scientific capital, including the promotion of educational events during the weeks leading up to the annual gay pride parade.
And an interesting thing that’s worth highlighting from that time is that when we started to send forms to municipal governments asking about the actions developed with the LGBT community [we received] a unanimous chorus [of replies saying]: “we have a Testing and Counseling Center, we distribute condoms and gel, do the test, STD treatments”. There were already LGBT health actions, reinforcing that initial problem that I mentioned: the association between LGBT health care and HIV (E - 01).
We took it from the Department of Human Sciences and Philosophy to the Dean’s office and received support. So we started doing events in the university the week before the gay pride parade. It started with the public from the university, then the audience grew, because we started the... Today it’s really crazy... (E - 11)


3. Publication of the Brazil without Homophobia program by the federal government and local and state conferences preceding the 1st National LGBT Conference
The most prominent discussion for the formulation proposals for health actions began with the publication of the Brazil without Homophobia program in 2004, later reinforced by local and state LGBT conferences in 2008 in the run up to the 1st National LGBT Conference31.
Brazil was the first country to hold a representative and institutional national conference addressing this theme32. The federal government initiative drew the attention of a number of legislators, the Public Prosecutor’s Office and, particularly, LGBT activists. The conference was widely attended by the public and included activities to celebrate the 60th anniversary of the Universal Declaration of Human Rights32,33.
It is important to emphasize that the local conferences held before the national conference raised the specific concerns and identified the peculiarities of each municipality and each different segment of the LGBT community.
The GLBT movement – that was 2005. It wasn’t LGBT. It was GLBT. Support for future calls for a national [debate], for a conference on public policy. At that moment the GLBT movement was already aware that the policy had to come from Brasília. I couldn’t, here in my municipality in inland Bahia, the south of Bahia, more specifically Itabuna, keep on yelling, trying to do something, just because I needed to... Then, in 2008, the First National Conference on Public Policies for the GLBT Community was convened. A lot came from the proposals we made at the 2005 meeting. We revisited those agendas – all the groups – we took the proposals decided at the local and state conferences to the national conference (E - 16).
Most of the debates we had were precisely [during] the municipal conferences. Representatives of organized gay, lesbian and trans groups from the municipalities began to attend the municipal conferences bringing them inside. And this was really important because today you have representatives of the LGBT community even on the National Health Council (E – 01).
After the 1st National LGBT Conference in 2008, the broader debate about LGBT health was further consolidated by criticism levelled by the movement at health actions. Groups adopted successive positions to press the government to include specific issues on the agenda of the health social space.

3. 2009-2011: Social construction of proposals
The findings show that the agents from the different fields (scientific, bureaucratic, and militant) put forward distinct yet often overlapping propositions (Box 3). However, the creation of the LGBT Health Technical Area (ATS-LGBT) within SESAB in January 2013 led a convergence of proposals in tandem with the health equity movement, which encompasses different vulnerable populations, including LGBT people34.
[inserir box 3]
The ATS-LGBT came into being because a SESAB staff member embraced the LGBT agenda. An agent from the bureaucratic field whose trajectory included working with sexual minorities, human rights, and LGBT health, she was willing to take on the debate about the health of this population in the social space of the SESAB.
So the matter was very much the responsibility of the person from the coordination. Since the matter has to do with the way of being in the world, I always identified with the LGBT agenda. I was already working in SESAB, in the adolescent health technical area (E – 25).
As part of this movement, various agents from the state of Bahia got together to discuss the creation and implementation of LGBT policies, focusing on health. From their capital and trajectories, it is possible to observe which position each agent adopted and which place they occupied in the social space that was beginning to take shape. In this respect, the findings show that the strong presence of agents from the LGBT movement with a high level of militant and symbolic capital made a significant contribution to the consolidation of the network of relations and convergence of proposals.
Another important milestone was the creation of the State Committee for the Promotion of LGBT Citizenship and Human Rights in the Bahia State Department of Justice and Human Rights (SJDH), in 2010, in response to calls from the social movement.
These articulations can be seen in the sociogram in Figure 1, which shows the connections between agents and the groups and/or subgroups present in the space in which the emergence and genesis of the PNSI-LGBT took place. Figure 1 synthesizes the nodes and links overlaid on the territorial map of Bahia, showing the regional distribution of the groups, influenced by the agents and formation of social movements, particularly by the GGB and SOMOS project.
The GGB is represented by a single node in the center of the sociogram and has various lines linking it to groups in the municipalities included in this study. The primary articulation of the GBB and other groups gave rise to secondary articulations through other groups in their respective areas, strengthening the LGBT movement. The sociogram also highlights management institutions, including SESAB, municipal health departments, and municipal councils.
[inserir Figure 01]

4. 2011-2014: Recognition of the problem and formulation of actions and propositions
The need for a comprehensive LGBT health policy in the state of Bahia was identified in the meetings promoted by the State Committee on LGBT Policy, made up of representatives of different state government departments: health, education, social development, promotion of equality, among others. The creation of the Committee resulted in the institutionalization of the demands of the LGBT population in Bahia35,36.
Committee meetings promoted by the SJDH were attended by agents from various segments of the LGBT community, health bureaucrats representing primary care and the STI and AIDS program, and the SESAB staff member who embraced the LGBT agenda. Despite the participation of agents from a range of fields with differing viewpoints, there were no objections to the proposal to create a technical area within SESAB. From this social space, a network of relations comprising agents from the militant, bureaucratic, and scientific fields was built that would culminate in the emergence of the LGBT health technical area social space.
So it was interesting because we faced major difficulties forming a network. So in this process of pushing the agenda regularly in meetings, having a space, a secretary who brought together other partners, helped draw attention to other needs and reinforce the need for a health policy. (E – 25)
The State Committee on LGBT Health was initially made up of representatives of SESAB’s Care Management Directorate and LGBT technical area (Antônio Purificação and Guida França), representatives of CUS, a LGBT student group from the Federal University of Bahia (for example Leandro Colling), a representative of gay members of the Fórum Baiano LGBT (Wesley Francisco), a representative of the transvestite community (Keyla Sympson), and representatives of the Superintendency for Health Surveillance and Protection (SUVISA) and Epidemiological Surveillance Directorate (DIVEP), among others.
The Committee meetings gave rise to the creation of the Bahia without Homophobia plan in 2011, inspired by the Brazil without Homophobia program, which, according to one of the interviewees, was the embryo for the genesis of LGBT health policy in Bahia.
At a second moment, social movements were on the rise and the LGBT movement couldn’t be left out of this broader articulation of all the movements... so the technical area started to emerge from that, together with the rise of the movements; naturally the social movements were pushing health issues as well (E – 25).
And that’s when the LGBT health policy started to be discussed, because it was only in 2009, I\'m talking ten years ago, that we started ten years ago, that we started to think that we needed a specific policy across the three levels of management to think about comprehensiveness in this population, which was distant from the unified health system, because it really was distant (E – 07).
While symbolically demarcated with someone who was prepared to take on the LGBT agenda, the LGBT health technical area had yet to be formalized. It was only in 2013, two years after the creation of the PNSI-LGBT, that the agent formally became responsible for the technical area.
So I developed closer ties with the movement and so on... My director came up to me and said: “look, you have an identity; we need someone to take on this specific agenda here. We have a group, it’s not ideal, but you have a team of at least four and I have a place that I need someone for. So I’d like you to consider the possibility of you taking on the LGBT agenda (E – 25).
There is no evidence suggesting that scientific capital alone was a decisive factor in assigning agents a prominent position in the bureaucratic field. However, the combination of scientific capital with other types of capital enabled agents to reach higher positions, as was the case with the coordinator of the Gender Identity Clinic, Ailton Santos. The proposal for the clinic was born from his PhD thesis in 2014 after returning from Rio de Janeiro.
However, despite the creation of networks of relations, the process of formulating state policy proposals made slow progress, since it was bound to the SJDH.
We didn’t manage to make any progress when it came to writing the state LGBT health policy. Especially since, as we discussed, the policy was under the responsibility of another department (at the time the department of justice and human rights). SESAB was only a partner. There was no way of taking the lead (E – 25).
Despite the absence of a formal policy on SESAB’s website, various legal and institutional apparatus, including the State Committee on LGBT Health, the Gender Identity Clinic, and SESAB’s LGBT technical area, constituted potential spaces for promoting the inclusion of LGBT people’s right to health34.
If we had approved the policy, it would have been another management tool we could have used to require municipal managers who were resistant to this approach to implement LGBT policy. However, I believe that a public policy does not necessarily have to be formalized to happen in people’s lives. So much so that, despite not having written the state policy, Bahia was a reference for health care delivery to this segment [of the population] in Vitória da Conquista, Feira de Santana and, to a certain extent, Ilhéus. Because we had well-qualified municipal managers who embraced the policy and an active battle-hardened LGBT movement that was a partner in its implementation (E – 25).
Finally, it was possible to gain important insights into alliances between social groups with common interests, negotiations of and adjustments to LGBT health policies, and the dynamics of the social game, characterized by the clashes between the groups of agents interested in implementing the policy.
It is worth highlighting that the elements presented here provide important insights into the recent emergence and genesis of LGBT health policy in Bahia, which is still in the early stages of implementation and development, and indicate some new directions for future research.

FINAL CONSIDERATIONS
Based on the synthesized evidence, this analysis of the sociogenesis of LGBT health policy in Bahia shows how organized social movements and institutions/agents in the state came together and how their articulation led to the proposal of actions to promote comprehensive health care for this segment of the population, despite the policy not being available on a website in the public domain. The failure to provide a transparent explanation of the official document illustrates Bourdieu’s claim that as history moves forward, the space of possibilities closes as decisions and choices are forgotten by the agents through the process of objectification of proposals and counterproposals that circulate during the policy formulation process13.
It is worth reiterating that the study of policy genesis has the potential to reveal a diverse range of propositions, including those that did not prevail until the end of the process. In addition, the theoretical framework allowed us to elucidate the motivations and historical conditions of possibility underlying the creation of the LGBT Health Technical Area, representing the state government’s response to the need to enhance actions geared towards LGBT health.
Possible study limitations include the fact that it was not possible to conduct some interviews with suggested agents, which may have resulted in the absence of some details of the historical facts analyzed by the study. However, the fact we collated the data with information from other sources minimized potential information gaps.

ACKNOWLEDGEMENTS
We are grateful to the Ministry of Health, DIAHV, Department of Health Surveillance, and National Council for Scientific and Technological Development for the funding awarded via the joint call for proposals CNPq/MS-DIAHV Nº 11/2018 – Core area 3 - Service Management Analysis (grant reference number 404011/2018-7). This study was also conducted with the support of the Coordination for the Improvement of Higher Education Personnel (CAPES – funding code 001). A.M Santos is grateful to the CNPq for awarding a research output grant and senior postdoctoral fellowship (grant Nº 102139/2022-9). Finally, we would like to thank the study participants for their willingness to take part in the study and extreme helpfulness, and the members of the Bahia Health Care Networks Observatory (OBRAS) for their support in executing the study.
Authors’ contributions: Stud conception: Camila Amaral Moreno Freitas, Nília Maria de Brito Lima Prado, Adriano Maia dos Santos; Data curation: Camila Amaral Moreno Freitas, Vinicius Nunes Carvalho; Project administration: Adriano Maia dos Santos; Fundraising: Adriano Maia dos Santos; Analysis, investigation, methodology, software, supervision, validation, visualization, drafting of the manuscript and final version of the article, revision and editing: Camila Amaral Moreno Freitas, Nilia Maria de Brito Lima Prado, Vinicius Nunes Carvalho, Clavdia Nicolaevna Kochergin and Adriano Maia dos Santos.

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