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Conteúdo (article):

Política nacional de saúde integral de Lésbicas, Gays, Bissexuais, Travestis e Transexuais: análise de imagem
National policy for Comprehensive Health of Lesbians, Gays, Bisexuals, Transvestites and Transgender: image analysis

João Cruz Neto 1
Joseph Dimas de Oliveira 2
Glauberto da Silva Quirino 3
Renata de Moura Bubadué 4
1 Universidade da Integração Internacional da Lusofonia Afro-Brasileira. E-mail: enfjcncruz@gmail.com ORCID: https://orcid.org/0000-0002-0972-2988
2 Universidade Regional do Cariri. E-mail: joseph.oliveira@urca.br ORCID: https://orcid.org/0000-0001-8105-4286
3 Universidade Regional do Cariri. E-mail: glauberto.quirino@urca.br ORCID: https://orcid.org/0000-0001-5488-7071
4 Faculdade de Ciências e Educação Sena Aires. E-mail: renatabubadue@gmail.com ORCID: https://orcid.org/0000-0001-8121-1069

Resumo: O artigo analisa a comunicação da imagem da capa da Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais, Travestis e Transexuais. Trata-se de estudo qualitativo-descritivo com análise de imagem conduzida à luz dos conceitos de Judith Butler. O corpus textual tinha 13 textos, seis figuras e o plano de fundo. As principais cores utilizadas foram o preto e o azul. As figuras humanas que performaram o gênero masculino se sobrepõe àquelas do gênero feminino. Os textos apenas situam o teor do documento enquanto política pública. O princípio do conhecimento difundido foi identidade de gênero, sendo este termo identificado com maior frequência. A capa do documento reforça estereótipos ao representar performances de gênero tradicionais de forma fixa e desconsiderar o uso político das cores do movimento a que se propõe representar.
Palavras-chaves: Gênero e saúde; análise do gênero; identidade de gênero; política de saúde; sexualidade.

Abstract: This article analyzes the communication of the cover image of the National Policy for Comprehensive Health of Lesbians, Gays, Bisexuals, Transvestites, and Transgender. This is a qualitative-descriptive study with image analysis conducted in the light of Judith Butler\'s concepts. The textual corpus included 13 texts, six pictures, and the background. The main colors used were black and blue. The human figures that perform the male gender are superimposed upon those of the female gender. The texts only situate the content of the document as public policy. The principle of knowledge disseminated was gender identity, and this term was identified more frequently. The cover of the document reinforces stereotypes by representing traditional gender performances in a fixed way and disregarding the political use of the colors of the movement it purports to represent.
Keywords: gender and health; gender analysis; gender identity; health policy; sexuality

Introduction
The inclusion of the lesbian, gay, bissexual, travestite, and transexual (LGBT) population in policies and programs, in any sector and in all realms of management, is based on the search for equal rights, the diminishing of vulnerabilities/discrimination, and the potential for health promotion. In this sense, what must be debated are the services provided for the notification of violence until scientific evidence can be provided in such a way as to diminish iniquities1-2.
The progress in Brazilian public policies in the 21st century first began with the implementation in the constitutional recognition of health as a civil right for all and a duty of the State. For this purpose, studies have been developed to give visibility to the needs of the LGBT population3-4.
In this scope, the National Policy for the Comprehensive Health of the LGBT population, set forth under Decree No. 2.836/2011, resulted from social movements seeking to strengthen their ethical commitment. However, there is a challenge in the implementation and realization of the LGBT policy concerning the comprehension of a social and historical phenomens, and not merely a biological5-6.
The LGBT movement communicates socially through written texts and images in the sense of making a political use of the word and the image to inform, transform, and construct counter-narratives when faced with heteronormativity and control of sexuality, of bodies, and of genders. Heteronormativity is referent to the functionalism between the binarity of genders, that is, to frame all relationships, even homosexual relationships in the model of a heterosexual couple, for the purpose of reproductive practices7. The image text communicates, creates, and reinforces narratives and new forms of social representation that begin to integrate the collective unconscious8-9.
Historically, different images associated with the LGBT movement can be identified, such as: flags (LGBT, bisexual, transgender, pansexual, intersexual, bears, and lumberjack pride), clothing accessories (bandanas, pieces from the bondage universe: discipline, domination, submissions, sadism, and masochism), and symbols (lesbian triangle, Nazi black triangle). Some of these have positive connotations, while others do not8. There are, therefore, a wide range of image texts that legitimate the movement and have social value8.
The image most commonly linked to the LGBT population is certainly the LGBT Pride flag, with its colors of rose, red, orange, yellow, green, turquoise, indigo, and violet in horizontal lines placed one over the other, from top to bottom, representing sexuality, life, health, the sun, nature, art, serenity, and the spirit, respectively. Thus, each color of this image text communicates a concept, making it informative from both symbolic and political points of view8.
The image text educates, informs, communicates, and legitimates existences. However, the image text is polysemic and is thus commonly linked to the written text, which gives its message content and firm grounding. As an educational element, the image text is thus a pre-text that, when associated with the written text, creates a context9.
The written and image texts allow for the signs to gain meaning, applying the language of the most diverse media and their respective processes of communication, from their orality to the space for printed and virtual media. The visualization, in this sense, offers something explicit through the realization of ideas and the guidance of thought illustrated in the relations between contradiction or superimposition.
Considering the dimensions of governmental public policies geared toward the Brazilian LGBT population and the image text associated with it, one can inquire: what communicates the image texts and the written texts present on the cover of the document, “National Policy for Comprehensive Health of the LGBT population”? As this is the main LGBT publication related to a health policy, the image on the cover thus contains the essential attributes to communicate the signs, languages, and messages of the sender to the receiver of the text/image.
In this sense, the analysis of the cover of the document that establishes the public policy geared toward the LGBT population can help people understand how the governmental sphere dialogues with this social group and what messages are communicated through the images. It is important to highlight that, in a bibliographic review, no studies concerning the analysis of the image of this governmental material were found.
Therefore, this study aimed to analyze the communication of the image on the cover of the National Policy for Comprehensive Health of the LGBT population.

Method
This work is a qualitative study and image analysis. Image analysis includes the selection and analysis of written and image texts whose objective is to investigate the elements of meaning and, with this, identify the particularities that compose them, linking them with the sociocultural context9.
The data source included the cover of the National Policy for Comprehensive Health of the LGBT population from 20136, published on the official platform of the federal government. For data collection, a form with all of the stages relative to the image analysis was used. The data collection and analysis occurred between August and September 2020.
The analyzed variables were the image and written texts. The image texts were classified in human figures (children, men, women, elderly) and non-human figures (animals, objects, buildings, cars, for example). Each image was located on one part of the cover. For this, the cover was divided into four quadrants: right upper quadrant, left upper quadrant, right lower quadrant, and left lower quadrant. This division enabled an easy identification of the localization.
The image analysis was made up of five stages: selection of the textual corpus, denotative stage, connotative stage, theme analysis, and identification of the principle of knowledge. In the first stage, the selection of the textual corpus was performed. In the present study, this stage included the initial selection of the cover of the document, entitled: “National policy for Comprehensive Health of Lesbians, Gays, Bisexuals, Transvestites and Transgender” and, subsequently, the identification of the image texts and the written texts of interest.
Initially, 26 texts were selected, including 13 image texts and 13 written texts. Of the 13 image texts, nine were of human figures and four of non-human figures (one plant with four branches, two undefined objects, and the background). Of these 13 image texts, six were excluded: three human figures and three non-human figures (a plant and the two undefined objects, as they were considered to be merely decorative images). Thus, seven image texts remained (six human figures and the background). Of the seven written texts, one text had no communicative function (“VENDA PROIBIDA”) and was excluded, leaving six written texts. Hence, the textual corpus under analysis was comprised of 13 texts, including seven image texts and six written texts.
In the denotative stage, the type of image was identified: be they photographs, illustrations, drawings, or sketches, for example; much like the colors used in the image4. In the connotative stage, the elements present in the image were selected (be they human figures, objects, animals, or plants, for example) and the linguistic signs (words, acronyms, phrases, and hashtags, for example). In the fourth stage, the presented themes were recognized. In the present study, the themes were identified in the light of the concepts of gender identity, performance, and gender performativity.
Finally, the fifth stage highlighted the principle of knowledge disseminated and/or the myth that substantiates the sociocultural construction of the image9, which, in the present study, was also based on the gender theory set forth by feminist author Judith Butler11. The data collected were organized in a table, according to the elements contained in the phrases of the image analysis. In the case of this study, analytical categories were created from the themes identified in the final stage of the analysis9. The data were analyzed in the light of the concepts of gender identify, performance and gender performativity11.

Results
In the first plane of the textual corpus, there are three human figures performing the male gender, while in the second plane, there are three human figures performing the female gender. The human figures that perform the male gender are superimposed upon the human figures of the female gender. Of the three human figures that perform the male gender, two presented clothing understood as the corresponding gender and one with no chothing. The same occurs with the figures that perform the female gender.
In relation to the denotative stage, five illustrations of human figureds and one illustration as a background were identified. The colors used in the human figures were: black (5); blue (4); white, yellow, and red (3); purple and pink (2); and orange, brown, green, and gray (1). Therefore, 11 colors were used, with an average of 1.5 colors per image, where at least one color per image was identified (the text from image 2 has two tones of the same color) and at maximum six colors (in the case of the texts that are in images 4 and 7). In the background, two colors were used: dark blue on the border and light blue in the center of the image.
From the analysis of the textual corpus and the characterization of the human figures in the image on the cover, six human images were found, as set out in Figure 1.

Figure 1

Regarding the connotative stage, six human figures and seven written texts were identified, of which two were located in the upper quadrants in capital letters: “Ministry of Health” and “National Policy for Comprehensive Health of Lesbians, Gays, Bisexuals, Transvestites and Transgender” and five written texts in the lower quadrant: three in capital letters, “1st edition”, “1st reprint”, and “Brasília-DF”; and the year “2013”.
The themes present in the corpus and that preceded the principle of disseminated knowledge were: the performance of female and male genders. The theme of “gender performance” appears six times, while the theme of “gender identity” appears seven times, since the human figures present in the image texts portrayed gender patterns relative to the male and female genders.
In the identified textual corpus, two gender performances were pointed out, based on key elements, such as the clothing and the layout of the human figures in the image, which appear with a clear differentiation and localization in the text where each gender occupies its own defined and fixed space: the human figures of the male gender in front and the human figures of the female gender behind.
These themes precede and substantiate the principle of a broader disseminated knowledge that is the gender identity, as it is a larger category and which includes different gender performances identified in the previous stage of the image analysis.

Discussion
On the Latin American continent, the Southern Common Market (MERCOSUR), founded through the Treaty of Assunción in 1991, fostered debates on public policies, focused primarily on human rights. Brazil is the pioneer with its National Plan for the Promotion of LGBT Citizenship and Human Rights from 200412-13.
The title of the document brings the terminology “Lesbians, Gays, Bisexuals, Transvestites, and Transexual (LGBT)”. Over the years, the acronym of the LGBT community has undergone some changes, and with them, there have also been changes in the graphic representation of the images disclosed socially in an attempt to include the different sexual and gender identities14-15.
The institution of identity politics entails a plural struggle of the subordinated and minority social groups. This movement seeks to make other ways of life visible, to feel and speak for themselves and about themselves. This refers to the inherent toppling of the universal representations through the multiplicity of positions, which make it impossible to think in binary or fixed terms16. Thus, any attempt to create a plural categorization seems to be incoherent and futile.
The sexual orientations and gender identities are discursive-corporeal aspects, not linked to the genitalia, and are thus subjective and relative dimensions. In the sociocultural context governed by heteronormativity, one way to make sexual orientations and gender identities visible and impacting is actually through clothing, behavior, and attitudes17. Therefore, there is an attempt to define something that is, in itself, volatile, since it is not restricted to materiality, but rather to the subjective relations between body and mind.
Concerning the elements identified in the denotative stage, it was observed that the cover in question used human figures. It is important to note that human beings create an identification more easily with images that are similar to themselves. In this sense, photographs and illustrations of human figures can be more useful in printed materials that treat questions related to human beings than might figures of animals, plants, or objects, for example18.
Brazil is made up of three main ethnicities: blacks (black and brown), whites, and Indians19. Hence, it can be observed that, on the cover of the policy in question, only two of the three main Brazilian ethnicities seems to be represented, thus revealing an invisibility of the Indian ethnicity, indicating not only an exclusion of gender identities, but also of racial identity.
The question of gender has a direct relation with the ethnic question in the Brazilian context, since the society is based on racism, discrimination, and different forms of violence toward minority ethnicities20. In official documents, the invisibility of minority groups is also a form of violence.
Distinct violence applied to a specific group is standardized through the desire to eliminate a class, and this is linked to a sole criterion, that of selectivity, which excludes the individuals for being who they are on the premise that the assailants are merely superior to the attacked/dead11.
However, it is important to highlight, in the case of the first image, that black was used to color the face, while the neck and part of the collar were painted white, creating a similar effect that, in humans, can be characterized as a phenomenon called blackface. In this case, a white individual paints his/her face black with the intention of looking like a black person, generally in a theatrical or whimsical context. This performative act has been heavily criticized by activists of the black movement, which characterizes this as racism. In Brazil, the color black is overloaded with gender, racial, and sexual stereotypes21.
From this point of view regarding sex, performativity, and culture, it is interesting to note that the elements that constitute the cover of the Brazilian health policy are human figures. The use of human figures in educational, publicity, or governmental materials seek to lead the reader to an immediate identification. Today, there are important debates on representativity, especially that related to minority groups22.
The transgender flag itself uses three colors: two blue stripes, two pink stripes, and one central white stripe, which, although they have been used on the cover of the LGBT policy, do not maintain a deeper relation, since they were used in an unequal manner: blue was used six times, white three times, and pink only once. Therefore, the colors most commonly linked to LGBT flags were not explored in a political manner on the cover in question.
However, blue has a strong relationship with the highly set and conservative gender patterns, which are associated with masculinity – to the contrary of pink, which is associated with femininity. Another problem has been the disregard for the more emblematic color palette of the LGBT community in the confection of the first version of the national health policy for this population, which disregards the imagery of the group and the political use that is made with some colors, internationally recognized and associated with the group8,23.
The policy and representation are controversial. If on the one hand the representation is understood as the identification of a visibility, on the other, the policy is a criterion of the education of individuals, for this reason, the gender has not always been constructed in a coherent manner and the performativities attributed to it have been rejected and disregarded11.
The image texts used were illustrations of human figures. The illustrations are characterized by the use of colors – to the contrary of less sophisticated drawings that used black and white – and, with this, became more attractive and can more easily create an identification. However, they can be less effective in this aspect than the photographs where there is already an immediate identification18.
The cover of other Brazilian health policies brings photographs such as, in this case, the National Policy of Comprehensive Children’s Health Care, with children with and without disabilities in movement; the National Policy of Comprehensive Women’s Health Care, which brings some photographs (bag, pregnant woman’s belly, eyes and eyebrows, female face, curly hair and formal clothes, flower and earring), reinforcing the idea of femininity that segregates the genders; and the National Health Policy for People with Disabilities, which brings photographs mixed with a water mark, for example24-26.
The illustrations can be concrete or abstract, where the former have a greater connection with reality, while the latter does not. The use of photographs of human figures joins important aspects for the field of health such as the humanization of health care. What is being analyzed here is that, as the project of communication, the photograph communicates more than the illustration from the human point of view. The dehumanization is, in fact, an important social question and that, if reproduced in the context of health care, makes the vulnerable populations even more vulnerable and, therefore, dehumanizes them27.
In the literature, studies with an image analysis of contexts related to health are still scarce, especially those that analyze the covers of public policies. Nevertheless, it is important to highlight the use of the illustrations to support the profound medical learning, especially concerning emerging diseases and the identification of faces when associating infections in social media, as in the case of HIV, demonstrating distortions of knowledge, an increase of disparities, and the marginalization of bodies28-29.
In a national study, the evaluation of official campaign images against HIV/AIDS during Carnaval observed a publication of photographs with a verticalized language and words in the imperative tense24. Another study identified a discrepancy between the image text and the associated term in the logo of the family health strategy, reinforcing a traditional language, based on gender and a limiting context30.
The abstract illustrations distance themselves from the reality and delegitimate the LGBT population, shedding light on the idea of dehumanization. The power devices have been used in the perspective of ranking social groups; in this sense, there has been a great reprisal of the dominant classes over the marginalized7. Dehumanization is part of this exclusion; in the images, this is expressed in the planes of the images, in which there is a difference between the male and female performances, with the male being highlighted. In the colors, the option for calm scenes, free of struggle, and with no relation to the LGBT flag is one divisive way to choose not to represent that which is theirs, or that which represents that population.
Another type of attitude that perpetuates the dehumanization can be found in the image of the “blackface”. This would certainly represent an attempt to contribute to the de-characterization of the black LGBT population, which, in fact, have not been represented on the cover. The disuse of photographs, preferring images, has compromised the representativity and expressiveness of the images31. In the images of the cover, one can still observe the undue use of colors in gender performances, as they do not identify or represent the public in question.
Hence, the exclusion of ethnicities is also a failure of the policy, as the representativeness should be extended to all. In the fields of health, this inequality also emerges in the access and realization of the public policies, in the construction of bridges of knowledge, and in the universalization of the services, which is dismantled by some professionals in such a way as to produce prejudice and oppression22.
The performance is that which comes after the identity itself, a cause and consequence relationship, where the final work is the very existence of the subject. In this sense, they are compared to that represented by drag queens32.
The gender is changeable, and for this reason, it is created in its cultural construction. This construction, therefore, is the result of the different interactions with the environment. In this sense, a space is opened to contemplate the multifaceted structures of gender, not as a universal entity, but rather one that is multiple and mobile, replete with characteristics, functions, and distinct performativities11,33.
Therefore, this is not about the construction of a sexualized being, but rather about the regulation of the different facets linked to it. The sex is part of the construction and deconstruction of the gender, which is inserted into the principle of the naturalization of the bodies and not a truth predisposed to identity11,33.
The construction of the sex is related to a cultural and material operation of the bodies, in which the internalized stigma differs from an appealing feeling; it is configured concretely as a repulsion or shame that is the result of the structural formation of that which the gender should perform11,34.
In the fields of health, this difference is in the attention given to the LGBT community in the public services, where there is still a distinction between the genders and inequality governed by heteronormativity and homophobias, which emasculates the principles of equality, universality, and comprehensiveness, an inequality based on binarism, which does not occur in the flow in which health activities should be provided, but rather according to the “standards” that are identified35.
The principle of identified disseminated knowledge was gender identity, which can be understood as a phenomenon linked to the norms that allow for its easy and quick identification, with no questioning within a given cultural context11,36. In the textual corpus of the present study, the gender identities are marked especially by clothing, which obeys the norms established by the cultural context.
In the case of Brazil, the predominant cultural clothing standard complies with a Western logic related to a strictness of gender, given that there are clothes made only for men and others made only for women. In recent decades, some male clothing items have been incorporated into women’s apparel, but the reverse did not happen with the male gender11,36.
Finally, the construction of knowledge is an integral part of the history of gender, which is, in turnm important to the formulation of public policies. It is for this reason that the implementation of human rights confirms the equality among people and carries out the necessary action for each reality with transversal and intersectoral actions that benefit the LGBT population; in the image, these themes appear within the idea of performativity11,29,37.
One can cite the following limitations to this study: the lack of studies that analyze images on the themes that can support the discussion. At the same time, one of the potentials of this study is to present a research method that is able to analyze other official materials on public health policies ( and other areas) as well as to indicate the approximations and distancing between what is proposed in the written text and that which is presented in the image text, thus providing support for future studies.

Final Considerations
The analysis of the images found on the cover of the National Policy for Comprehensive Health of the LGBT population showed human illustrations with light complexions, with no indigenous representation, and subjects with a blackface. The disconnection of color and race with the policy can be considered a gap in knowledge, whose investigation has the potential to avoid the use of representations that reproduce prejudice and promote ethnic-racial diversity linked to the LGBT population.
It is pointed out that in the use of colors on the cover, there is no political exploitation of the colors of the LGBT movement’s flag and an unequal use of the palette of colors from the Transgender flag. It is thus recommended that future studies explore research questions that involve the association of the colors and the icons representative of the health movement, since, historically, these populations tend to be located in the margins of society.
The themes treated on the cover of the policy spoke about the male and female gender performances, with a predominance of the female gender. The main disseminated knowledge focused on gender identity. In this sense, there was a perpetuation of hegemonic and exclusionary ideologies, with the need for theoretical and scientific investment in research on the (de)construction of the image formation linked to gender in this population, as well as the inclusion of the those that do not identify with the binary model focused on men and women.

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