Self-Perceived Discrimination in LGBT Population in Oral Health Services . Medellín , Colombia : A Qualitative Approach

Introduction: We aim to understand the perception about discrimination within the LGBT population when accessing oral health services, from their perspective as well as that of the oral health professional. Methods: A qualitative study from a phenomenological perspective was conducted by means of 37 in-depth interwiews (19 in health service providers and 18 in LGBT members). The script used in the interview included questions related to discrimination in social spaces, quality of life and its relationship with health, access to general and oral health care and proposals and strategies. Verbatim was transcripted and narrative content analysis was carried out for identifying meaning codes and after grouped through emergent categories. Atlas.Ti 6.0 software was used. Results: Five categories within the participants’ discourses were identified: (1) Characteristics of LGBT population: This is a heterogeneous group (physical‚ social and cultural); (2) Quality of life (QOL), health related quality of life (HRQOL) and oral health related quality of life (OHRQOL): QOL is defined as the ability to enjoy opportunities in the human life process under equity conditions; HRQOL is related to an adequate access to health services‚ and OHRQOL as the appropriate state of the structures of the stomatognathic system; (3) Discrimination as a concept and experiences: People conceived discrimination as the act pejorative to someone because of a particular situation. Participants identified some types of discrimination in social spaces; (4) Accessibility to health services: Participants related individual and structural barriers when accessing to public health services; (5) Proposals and strategies: Interviewers suggested some educative strategies and social policies to reduce the endogenous and exogenous discrimination. Conclusions: The LGBT population is vulnerable to perceive experiences of discrimination and this situation causes a negative impact on their quality of life.


Introduction
Discrimination is an important social fact to public health.Several international organizations such as the World Health Organization (WHO) have considered discrimination as a determinant of health that impacts on social inequalities (World Health Organisation (WHO), 2007).This acknowledgement is an important step in this field of research in terms of enquiring about the way that discrimination affects the health of the population.The consequences of discrimination in health conditions are associated with worse levels of self perceived health and chronic diseases (Gee, Spencer, Chen, & Takeuchi, 2007;Larson, Gillies, Howard, & Coffin, 2007;Pascoe & Smart Richman, 2009), mental health problems (Bhui et al., 2005;Gee, Ryan, Laflamme, & Holt, 2006); as well as a factor that has conditioned access and use of primary and specialized health care (Lauderdale, Wen, Jacobs, & Kandula, 2006).Discrimination is a determinant of different aspects of every-day life including social, work, academic and family spheres and it precludes the comprehensive development of the people affected.Social epidemiology, in the last decades, has explored the consequences of discrimination in different social aspects (Krieger, 2001;Krieger, Rowley, Herman, Avery, & Phillips, 1993) , and it is defined as "the process by which a member, or members, of a socially defined group is, or are, treated differently (especially unfairly) because of his/her/their membership of that group" (Krieger, 2001).Most social groups could be categorized as in a special situation of vulnerability depending on their place in the social structure, its position in the hierarchy of power (family, community, social and political), and the characteristics of the social context and culture, among other causes.Literature mainly reflects that most vulnerable groups to suffer discrimination are women (Ronai, Zsembik, & Feagin, 2014), ethnic minorities (Paradies, 2006), the elderly or children (Pachter & Coll, 2009), people with disability (Quinn, Degener, & Bruce, 2002), homosexual and lesbians (Barrientos, Silva, Catalan, Gomez, & Longueira, 2010) , among others.
In that sense, the LGBT population (lesbian, gay, bisexual, transgender) has fought for many years to have the same rights as the heterosexual community.These benefits would allow them to have a better quality of life and access fundamental rights as: marriage, adoption, health services, access to common goods, among others (Keck, 2009;Martel, 2014).In the case of Colombia, the situation has not been different, hence several lawsuits and tutelas (term in Spanish, it refers to legal actions) for the protection of the rights of the citizens have been originated (Quijano & Albarracín, 2009).
LGBT population particularly has been subject of studies related with perceived discrimination and situations of stress, depression, suicide attempts or poor mental health (Burgess, Lee, Tran, & van Ryn, 2008;Mays & Cochran, 2001;Mustanski, Garofalo, & Emerson, 2010).Furthermore, potential barriers to health services access have been identified which involve health professionals and the system itself (Johnson, Mimiaga, & Bradford, 2008;Kass, Faden, Fox, & Dudley, 1992).Although there are studies on general and specialized health services discrimination to LGBT (Kass et al., 1992) , research related with oral health services and the attitude towards these grous is still lacking (Campo, Díaz, & Herazo, 2008).
This research aims at providing information to the scientific community regarding factors that cause feelings of discrimination within the LGBT when accessing oral health services, which ought to generate policies and inclusive strategies for this population as subject of rights and possibilities of human and social development.Furthermore, it aims at bringing professionals closer to this situation hence contributing with more human oral health services provision.In this sense, qualitative research has had great impact on public health and dentistry since it allows the acknowledgement of experiences and percepcions of individuals directly involved, in accordance with their social context.
Accordingly, the objective of this study is to understand the perception about discrimination within the LGBT population when accessing oral health services, from their perspective as well as that of the oral health professional.

Design and Setting
A qualitative study from a phenomenological perspective was developed in Medellín and its Metropolitan Area.In-depth interviews was the source of information.This approach allowed the acknowledgement of individual experiences and perceptions about a specific phenomenon by trascending the description of the social context (Cohen et al., 1994).Also, this research assumes the concept of perception from an anthropological perspective which involves a process of symbolic elaboration from the experiences that allow the attribution of characteristics of a social fact, considering culture and ideology, by means of which the individual gives different meanings to its reality (Melgarejo, 1994).

Participants
Participants in this study were, on the one hand, members of LGBT population, selected by theoretical sampling and contacted through Non-Governmental Organizations (NGOs) and using the snowball method, allowing the participation of volunteers.On the other hand, oral health service providers from the public and private sectors also participated.Also, a psychologist and an nurse from an NGO took part to broaden the perspective of the discourse.Tables 1 and 2 describe in detail the sociodemographic characteristics of the participants.

Data Collection Techniques
Data was collected from July 2013 and August 2014.The research group used a semi-structured interview technique using several topics and questions according to the objectives of the study and the type of participants (Table 3).These topics allowed the emergence of new categories of analysis.Interviews lasted between 20 and 90 minutes, recorded and typed for later analysis.The final number of interviews was 37, defined by the saturation of the categories of analysis defined by the study.Fieldwork was complemented using observation notes describing the main characteristics found during the interviews.• Definition of discrimination • Experiences of discrimination in social groups.
• Discrimination against LGBT in

Data Analysis
A manual analysis of the interviews was initially done in order to review initial and emerging categories.Subsequently, data were segmented using the Atlas.Ti software allowing to identifying significant text fragments from the study script used.

Ethics
This study complied with ethical requirements at national (República de Colombia.Ministerio de Salud y Protección Social, 1993) and international levels (World Medical Association General Assembly, 2004).It is considered a minimal risk research.Oral and written informed consent was guaranteed, as was anonymity and volunteer participation.The Faculty of Dentistry at the University of Antioquia, as an academic exercise, approved this study.

Results
As shown in Figure 1, five speech categories within the participants were identified.These categories of analysis permeate between them and they are interrelated to discrimination as a social fact.Results are presented differentiating LGBT and providers, and later to show a comparative analysis.Table 4 summarizes the main characteristics found in the interviews in terms of similarities and differences in the perception of the social phenomenon.LGBT identified endogenous discrimination within the group Quality of life (QOL), Health related Quality of life (HRQOL), Oral health related Quality of life related with oral health (OHRQOL).
QOL was identified as Access to goods and services that allow the enjoyment of life.HRQOL was defined as an adequate access to health services OHRQOL was adopted as the adequate provision of health services LGBT mentioned that QOL is related also with respect for the human being.
OHRQOL is determined to a good extent by self care Discrimination as a concept Both groups agreed on that discrimination relates to a degrading treatment against a person or group with specific characteristics No differences found

Access of LGBT to health services
Structural flaws in the health system which negatively impact on its provision (funding, type of insurance, cost of services) While providers identified discriminatory attitudes by the staff which interferes with an adequate service, LGBT did not perceive them.

Proposals and strategies
Proposals and strategies based on education.
While providers addressed educational strategies to staff, LGBT mentioned they should benefit the whole of the population from an early age to reduce discrimination.

Characteristics of LGBT Population
When requesting a characterization of LGBT in the opinion of health service providers a homogeneous construct was identified.They expressed not finding a difference as compared with heterosexuals in terms of demographic, social or cultural characteristics.There are LGBT in all social, racial or professional groups.The difference relates mainly to sexual orientation.It is important to highlight that they comment on being aware of the political and social situation faced when promoting equal rights.Providers conceptualized QOL as the right to access goods and services to ensure a good style and way of life, meeting needs such as housing, food, education, and recreation.
"…I think there has to be some basic issues or minimum compliance of welfare in society which refer to quality of life such as health, education, and access to various goods and services of social protection.That means quality of life" [Interview 21, Dentist (woman)] When relating HRQOL, participants identified basic elements present in good health services (accessibility, universality, integrality, efficiency, efficacy and opportunity) in the human vital process and are qualified as "vital" for normal human development.

"Good quality of life in health?
To have easy access to basic health services, having the right answer at the time of a pain or illness of any kind, to have access to information useful to improve some situation that is affecting me at some point in my normal life" [Interview 6, Dentist (man)] Now, OHRQOL was defined as the access to oral health services in all levels from the onset of life accordingly to each individual's and community's needs.
"…Having access to prevention from the onset of life, right.Having all basic tools for oral health care and accessing different levels of attention in dentistry, depending on the person's needs" [Interview 7, Specialist Dentist (woman)]

Discrimination as a Concept and Experiences
Providers understand discrimination as differentiated and derogatory treatment against someone in a specific condition or with particular characteristics, and outside conventional behavior in society.This affects directly the quality of life and personal and social growth.Participants identified different types of discrimination based on the person it affects: women, children, elderly, LGBT, among others; and its form: verbal, physical, behavioral, psychological.
Discrimination against providers was not identified.However, they do relate discriminatory behaviors against LGBT, in particular transgressions against transsexuals in public places.
" "I have witnessed molestation against people here and on the street.People on the street, travesty, eh! Transsexual who are physically attacked on the street because of their sexual orientation or by taxi drivers.This is a macho society, very traditional, little progressive in many aspects of social life.There have been important steps taken in the world that are yet to happen here.In those scenarios I have seen physical and psychological abuse" [Interview 1, Dentist (man)]

LGBT Population Access to Health Services
When interviewing health service providers regarding access by LGBT population, they identified barriers as: rush attention, excessive biosafety measures, whisper, indirect mocking and service denial.It is important to highlight that these acts impact directly on the adequate service as well as the quality of life also in health and oral health of LGBT population.These actions occur mostly in public hospitals and to transsexual people whose appearance is most impressive to staff.

"I noticed people are too aware to LGBT only if there is a possibility of HIV or STD, and then people take extra protective measures if a homosexual person comes to consult" [Interview 8, Dentist (women)]
"I did get to see a gay person with HIV in the emergency room.I know protection is very important but they overreacted then.I even think the patient felt uncomfortable because he was not terminal to be treated in that manner: 20 gloves, 3 masks, covered the chair, and the instrumental was sterilized like 20 times… they overreacted.I considered it was enough to wash it and sterilize it but the instruments were isolated for a long time just because" [Interview 18, Dental assistant (woman)]

Proposals and Strategies
Health service providers made proposals and strategies to reduce discrimination against LGBT, based on education of staff and the vulnerable population.It would take place in governmental entities, and technical and higher education institutions, and cover topics as diversity, human gender and comprehensive attention and care of the patient as a person.

"I mean, educating on being human beings and the possibilities of finding people of different race or sexual orientation or religion, is a matter of tolerance" [Interview 2, Dentist (man)]
"…to me it has to be something more at government level where it is stated that they have the same attention rights, I mean, as everyone else.Being homosexual does not mean that attention will be different or everyone get the same attention" [Interview 13, Nurse (woman)]

Characteristics of LGBT Population
LGBT participants mentioned that their population is diverse.There are people with different sexual orientation in all scenarios: social, political, economic and cultural.In the same manner, health service providers mentioned that the only difference between them and heterosexuals is sexual orientation.It is important to highlight that LGBT identifies discrimination and the sociopolitical process undergone to counteract it.They also identified that between younger LGBT there is greater endogenous discrimination accentuated by differences in their socioeconomic levels, gender identity and personal or collective tastes.
"…Well, there are too many.LGBT defined QOL as the valuation and respect from society towards oneself, guaranteeing the development of the individual.Furthermore, they agree with providers in that QOL is linked to the guarantee of access and enjoyment of basic goods and services.
" The concept of HRQOL was described by providers as the provision of a human health service: timely, effectively, efficiently and comprehensively.
"…that I am seen on time.That I am treated nicely, not rushing.There are many doctors that check you without taking their time or looking at you.They should be nice, check you and care for the patients" [Interview 33, gay man] When interviewing LGBT on OHRQOL, they expressed it is the health of the mouth and the image projected to others.
"…in one simple word: being clean.Not having oral diseases as cavities.That teeth look good…, as mentioned before, to me it is a state of wellbeing.If I don't feel comfortable with someone else because of my teeth, then I won't have oral quality of life" [Interview 28, gay man]

Discrimination as a Concept and Experiences
LGBT population explains discrimination as the act of being treated differently because of a specific condition.It feels identified with the discrimination process because of their different sexual orientation.Some groups as transsexual and transgender express having lived discriminative experiences in public spaces in the city.
"To me discrimination is being treated as a different entity, I mean, as a freak... "

[Interview 28, homosexual man]
"…because of the way you walk, dress, speak, the more delicate manners.It is most seen at school but people always look at you weird when you go out" [Interview 35, transgender woman]

LGBT Population Access to Health Services
LGBT population expresses being comfortable with public and private health services.They do not correlate perceiving discriminating attitudes given their sexual orientation or gender identity.However, they do identify structural flows in the public system, as the limitation of appointment time, lack of insurance benefits in dental procedures and dehumanization of health.

Discussion
It was found that some LGBT groups have experienced experiences of discrimination in health services and other social scenarios.This has a negative impact on their quality of life hampering fundamental human rights.Such events are more common for transsexuals whose physical appearance causes greater visual impact on other citizens.The health providers perceived discriminatory behaviors by their counterparts and this situation is more common in public health centers than private dental offices.Notwithstanding, some LGBT do not notice discriminatory behavior at the dentist from the medical staff.
Studies aimed at making a characterization of LGBT make an important collectivity because of social movements and political developments (Martel, 2014;Prado, Mountian, Machado, & Santos, 2010).In Colombia, particularly, the socio political configuration of this group began in the 40s from anonymity, while becoming a strong movement in the 80s and evolving until recently (Maduro Santamaría, 2009).Generally speaking, it is constituted as a diverse group in regards to social and educational levels, political position, and ethnic background and believes (Barrientos-Delgado, Cárdenas-Castro, & Gómez-Ojeda, 2014).The results of the research considered a category that describes the main characteristics of the group, from their own perceptions, how they see themselves and their social group, as well as how professionals perceive the LGBT population.
In regards to discriminatory experiences and their concepts and perceptions of this social phenomenon, results match other studies that describe different moments of discrimination in social and work environments (Barrientos, Silva, Catalan, Gomez, & Longueira, 2010;Kass, Faden, Fox, & Dudley, 1992).This study showed that the conceptual construction regarding discrimination developed by service providers as well as LGBT agrees with social epidemiology approaches by Krieger (1999Krieger ( , 2001)), even with some differences from the analysis of those involved.
LGBT is described as a group that lives a sociocultural process of exogenous discrimination (non homosexuals) as well as endogenous (people with the same sexual orientation).
Even though research on discrimination against LGBT in oral health services is scarce, some studies show how providers and the group can perceive discrimination in health (Kass et al., 1992).In California, for example, a study reported that 18.7% of doctors felt uncomfortable when providing services to homosexuals, particularly those with HIV (Smith & Mathews, 2007).In regards to access of transsexual population in Spain, in a study by Esteva de Antonio et al. (2012), the main results are the fact that there is not a homogeneous provision in the Autonomous Communities, or direct support from governmental entities.Even if not a generalization, some discourses refers certain resistance and opposition to attention of transsexuals, mainly due to ideology.Campo Díaz y Herazo (2008), showed a bibliographic review of homophobia in dentistry students and hygienist.It concluded that the levels of homophobia are low.This research found behaviors towards LGBT identified by the health personnel though not perceived by LGBT patients, which interfere with a comprehensive health service and were accentuated by visual impact caused and in the public system.These can be attributed to personal beliefs and the structure of the public system, acting as barriers to access, as found by other studies (Kass et al., 1992).
Quality of life has been studied by different disciplines and for diverse social groups, by applying both quantitative and qualitative methodologies.However, research relates that QOL, HRQOL and OHRQOL in LGBT population are less frequent.Barrientos y Cárdenas (2013) analyzed the effects of prejudice in the quality of life of gay and lesbians, finding that having homophobic experiences can generate negative effects on QOL of sexual minorities.It is also mentioned that LGBT has an elevated tendency to be victims of violence due to sexual orientation and are more prone to suffering psychiatric disorders as depression and alcoholism than heterosexuals.As expressed by the participants, those conditions have a negative impact on the quality of life in the light of the subjective perception of wellbeing by psychologically, socially and economically affecting the LGBT individual.These do not allow them to develop their potential by hindering the access to goods, services and opportunities in equal terms.
An important finding has to do with policies and strategies to prevent and diminish discrimination as expressed by participants.The anti-discrimination lay is implicit in the Universal Declaration of Human Rights (United Nations, 1948) which has been followed by different law initiatives in different countries to promote equity and equality of rights of all people.This requires the creation of policies and strategies to diminish discrimination levels, including discrimination due to sexual orientation (Lerner, 2003;Martel, 2014).In Colombia, particularly, Law 1482 of 30th November of 2011, which modifies the criminal code, in its article 1 declares as an objective to guarantee the protection of rights of a person, a group of people, a community or town, as they be violated through acts of racism and discrimination (Colombia. Congreso de la República, 2011).This is considered advancement within Colombian jurisprudence to guarantee the free exercise of human rights.It is implicit that the Law, together with international treaties on human rights, permeates all areas of social development, including the health sector where attention, diagnosis, treatment and counseling to every person are guaranteed without possibility of discrimination.
As strength of this research it is important to mention the qualitative perspective which allows approaching social realities from the actors and their different perspectives.Also, it is important to highlight the innovative nature of the study, even internationally, allowing a broader approach.In contrast, the narrow view of oral health service providers regarding discrimination is a real limitation, therefore it is important to include different providers in like studies.According to the discourses of participants and the type of phenomenological analysis conducted it is very difficult to distinguish what is related to the LGBT fact and what is not.For example, the overreaction to an HIV patient (hygiene measures, etc.) is linked to the disease, not to the patient's sexual preference but interviewed participants expressed ideas of discrimination in several spaces and they attributed some procedures as discriminatory.Similarly, qualitative research acknowledges a changing and dynamic social reality allowing new research to complete the participant's discourses through demographic studies that allow the characterization of the phenomenon in public and private institutions in Medellín, with the support of organizations for sexual diversity.Participative research should allow the generation of new strategies for social inclusion.

Conclusion
LGBT population is vulnerable to perceive some experiences of discrimination of health services and in other social scenes, having a negative impact on their quality of life.Political actions and strategies could contribute to diminish inequality and inequity situations in LGBT groups from a public health perspective.

Figure 1 .
Figure 1.Conceptual categories used in the analysis of the interviews, Medellín, Colombia (n=37)

Table 3 .
Content of the semi-structured script used in interviews with participants, Medellín, Colombia (n=37)* • Definition of discrimination Feelings: vulnerability, dependency, insecurity, loneliness, self-steem, role change, use of free time.
Strategies and policies *This is a general script but during the interview new questions could have arisen from participants' experiences • Definition of discrimination • Experiences of discrimination by dentists• Experiences of discrimination

Table 4 .
Commonalities and differences in the answers of the LGBT population and health providers Discriminating is like isolating people, picking them out.You, not you, you can't you are not capable, and taking them out" [Interview 16, Dental Hygienist (woman)] There are teachers at this university, city managers, congressmen in this country that are surely LGBT, as well as recyclers and homeless" [Interview 22 gay man] "Socioculturally, the LGBT community is broadly accepted though there is still discrimination within them.Currently the youngest are split in family-like structures and use the same last name, using it to exclude or fight" It is leading a healthy life, a full life, a life filled with obstacles so I feel good before anyone, before society.It is to be respected in regards to gender: feminine, masculine, and independent" "…I consider that quality of life is having health first and foremost, having the tools to adequately live with my needs.Regardless if you are rich, poor or have enough to have a comfortable life, but having enough"[Interview 37, gay man] Proposals and StrategiesProposals and strategies to reduce discrimination based on sexual diversity brought forward by LGBT groups is based on education from early stages focusing on values as respect, tolerance, solidarity and coexistence."…startingfromsocial education, I mean, people first have to understand the LGBT community and what are its particularities, in order to accept it.Hence, the first step would be to socially educate people"[Interview 23,  bisexual woman] "Some dentists don't care.For rushing they do not prescribe as needed.I think that as dentists they should concern themselves with oral wellbeing.Sometimes you feel the dentist just looked at the teeth and says: you are ok, or there is nothing wrong, or floss more, or just leave… Not being seen on time is a structural norm in the system" [Interview 27, gay man] 3.2.5