Affirmative care for the sexual orientation of adult and elderly gay men: technology prospection protocol

Vinícius de Oliveira Muniz¹, Edielson Mello dos Santos Júnior², Cléton Salbego³, Priscila Oliveira de Araújo⁴, Aderson Reis de Sousa⁵

^1,2,5Federal University of Bahia. Salvador (BA), Brazil.

³Federal University of Santa Maria. Santa Maria (RS), Brazil.

⁴State University of Feira de Santana. Feira de Santana (BA), Brazil.

Introduction

With the advance of knowledge, new ways of conceiving health practices have been discussed to better help professionals interpret the phenomena of a constantly evolving society. Affirmative care is seen in this context as strategies to be developed in order to combat the inequality that exists between different minority groups (the poor, blacks, sexual minorities, quota holders, descendants of other ethnic groups, among others), also involving measures that act to prevent discrimination or compensate for disadvantages arising from existing structures, behaviors and attitudes.¹

In this context, adult and elderly gay men suffer a double burden of stress, made up of ageism² and homophobia;³ therefore, they are eligible for affirmative care. One perspective is that this public suffers from declaring and expressing their sexual orientation, and they omit this information during health care,^4,5 giving rise to the opportunity to the affirmative practice, with a view to promoting a healthy transition in the context of ageing (from adulthood to old age).

This declaration/expression of sexual orientation can be complicated due to perceived discrimination throughout life, to disrespect on the part of health professionals, to heterosexism, to the risks of assuming/declaring one's sexual orientation to family and society, and to socio-historical stigmas, making associations with emotional upheavals and psychological signs and symptoms emerge.⁶

A Brazilian study carried out with the sexual minority population of over 50 years of age⁷ concluded that there was worse access to traditional health services, a fact that is in line with an international study,⁸ which also showed worse access by the target public in countries such as Argentina, South Korea and Canada. This can be explained by the lack of demand for health care due to fear of prejudice about sexual orientation, as well as the invisibility of individuals and of their specific health issues.⁴

In this sense, if access to health services is excluding for adult and elderly gay men, there is a need to investigate other forms of access and reception that facilitate care for health needs contribute to healthy and safe ageing for the public under investigation.

With the advent of the COVID-19 pandemic, new ways of accessing healthcare have been devised to help the population's care process, considering the accelerated technological advances, initiatives such as telehealth and telenursing were considered of great importance in the pandemic scenario, allowing access to communication with the population.⁹ Applications (apps) or other Digital Technologies (DT), such as podcasts, have gained prominence in the self-care of elderly people, as those are easy to access, have clear language, improve patient engagement and contribute to co-responsibility in the health-disease process, resulting in improved adherence.^10,11

Considering the object of this research, centered on the access to affirmative care by adult and elderly men who declare themselves gay and suffer from claiming their sexual orientation in each socio-cultural context, technology prospection studies are recommended so that researchers can map existing technologies in a variety of data sources, a methodological strategy still not widely disseminated in nursing, is a way of mapping and creating technological resources that meet the emerging demands of nurses' practice in multiple care scenarios.¹²  

Going beyond traditional health models and guaranteeing equal, inclusive, equitable and universal access to adult and elderly gay men contribute to strengthening public health and social protection policies and helping to expand population coverage by the Unified Health System (SUS – Sistema Único de Saúde).  

Based on the results, it will be possible to suggest the use of these technological resources so that the target population is better served by health services as recommended in the booklet “Gay and Bisexual Men: Rights, Health and Social Participation”,¹³ through greater visibility and an adequate welcome that encouraging digital inclusion for everyone (managers, care professionals and patients), thus contributing greatly to sustainability.

A preliminary search was carried out using the descriptors "Sexual and Gender Minorities", "Health of the Elderly" and "Digital Technology" in mobile app stores and intellectual property databases, with several digital technologies on men's and gay people's health and health care having been found separately, making it possible the on-screen study. On the Open Science Frameworks (OSF) platform, by using the terms “Technology Prospection” and “Innovation and Technology in Health” there are not record of protocols aimed on affirmative care to the health of gay people.

In addition to the gaps pointed out, the need for this study is justified on the basis of one of the objectives of the National Policy for the Comprehensive Health of Lesbians, Gays, Bisexuals, Transvestites and Transsexuals,¹⁴ which is to carry out studies and research related to the development of services and technologies aimed at the health needs of this population, besides complying with the thematic axes of sexual/reproductive health and the prevention of violence/accidents belonging to the National Policy for the Comprehensive Health of Men (PNAISH - Política Nacional de Saúde Integral à Saúde do Homem).¹⁵ One alarming highlight lies in the National Health Policy for the Elderly, which does not address the field of sexuality in its guidelines.¹⁶

The purpose of the technological development is anchored in the possibility of implementing affirmative care focused on physical and mental well-being, on citizenship, on quality of life, and on respect for different human expressions through an inclusive resource of highly innovative content based on unprecedented knowledge that contributes to reducing inequalities and to improving the quality of life of older gay people by clinically managing the pathological upheavals caused by internalized homophobia and other types of violence and discrimination.¹⁷

In this sense, the objective was to map digital technologies aimed at affirmative care as support for the expression of sexual orientation of adult and elderly gay men.

Method

This is a technology prospection protocol from the Forecasting group, with a qualitative exploratory approach, registered on the Open Science Framework (OSF) platform (https://osf.io/cve75/). 

Technology prospection is a systematic method that supports the need to develop new technologies for collective improvement by investigating scientific and technological advances in order to meet the demands and emerging problems of a given population. This type of study maps out the possibilities for future scientific and technological developments based on an analysis of the present and the past, using documentary research as a method for explaining primary documents; specifically, the understanding of technologies.¹²

Prospections in the Forecasting group consist of making projections based on historical information and trend modeling, a connotation of predictability that involves trying to estimate future conditions based on the present, a partially definitive probabilistic indication of the future supported by assessments of possibilities and alternatives.¹² In order to carry out the technology prospection, nine steps will be taken:¹⁸

1. Guiding question for the technological prospection and objectives:

The prospection question was developed using the PCC mnemonic: Population (adult and elderly gay men), Concept (affirmative care) and Context (digital technologies), namely: which digital technologies on affirmative care are used to support the expression of sexual orientation by adult and older gay men? The objective is to map digital technologies about affirmative care as a support for the expression of sexual orientation of adult and older gay men.

2. Inclusion criteria/Participants:

The technology prospection will include DT, such as apps for mobile devices, websites and podcasts, aimed at affirmative care for the adult and elderly cgay male public. According to the Brazilian Institute of Geography and Statistics, adults are those between the ages of 20 and 59; individuals over the age of 60 are considered elderly.¹⁶

Sexual orientation refers to the way of relating to others, arousing deep affective-amorous and sexual attraction to individuals of a different gender, of the same gender, or both, as well as having intimate and sexual relations with these people.¹

A gay man (an expression of English origin) is someone who feels an affective, emotional and sexual attraction to be in a loving relationship with people of the same sex/gender, going beyond sexual orientation, involve the way of being a man, being a gay man. For further clarification, cisgender men are individuals who have a gender identity that coincides and identifies with their biological sex at birth and when are gay, relate with other cisgender men.^19,13

This protocol did not or will not involve human beings; the data will come from virtual databases that house DT and will not need to be approved by the Research Ethics Committee, following all the legal rigor regarding the protective use of the data under investigation.

Concept:

Affirmative care is related to the propositions of Affirmative Action, regarded as any program, public or private, linked to the policies of the Welfare State that aims to grant special resources or rights to members of a disadvantaged social group, a broad concept that encompasses any condition of life that is the object of systematic discrimination and undergoes social differentiation. They include improving access to health services, strengthening social safety networks, fighting stigmatization^, and investigating any kind of practice that recognizes a disadvantageous position for a given community.²⁰ This political reference will help on the conceptual characterization of affirmative care.   

Context:

Digital technologies are connections in a network that comprise the group of Digital Communication and Information Technologies (DCITs), such as videos, software, applications, smartphones, images, consoles, virtual games, which come together to make up new technologies, referring to any electronic equipment connected to the Internet, expanding the possibilities of communication for its users.²¹ Podcasts are also part of this group of DCITs.¹¹

App are considered software specifically designed for smartphones and tablets. They process data and reduce the time required for users to complete tasks. They can also be installed on MP3 players.²² These apps are composed of various functions, libraries, and modules, which together create a functional program at the end of the development process.²³

A podcast is an audio resource used for the health education of the population, organized into episodes of varying lengths, usually hosted on a streaming platform with an interface that can be accessed through app stores.¹¹

Exclusion criteria:

DT that do not produce affirmative care for adult and elderly gay men, podcast that do not have the participation of such social actors as guests/reporters of life experiences, and that are not functioning normally.

3. Defining the search strategy:

In order to devise the strategy, the guiding question for the prospection, its eligibility criteria, the particularities of each store and platform, and the strings closest to the object of study were observed.²⁴ In technology prospection studies, the use of the term string is common to indicate terms, descriptors or keywords; it is a sequence or matrix of characters in quotation marks, namely: “Men's Health”; “Gay”; “Elderly”; “Health Education”; “Sexuality”, “LGBTQ People”, all registered in DeCS/MESH, except for the term “Elderly Gay”, which has been applied in an app store and in a streaming channel, in Portuguese, English and Spanish.

4. Search in databases and online stores:

Three intellectual property databases will be included: the World Intellectual Property Organization (WIPO), the National Institute of Industrial Property (INPI - Instituto Nacional da Propriedade Industrial), and SimilarWeb; two virtual application stores: Android (Google Play®) and iOS (Apple Store®); two streaming platforms: Spotify® and Deezer®. The combination of strings or terms for each platform may include the Boolean operators AND and OR (Chart 1).

Chart 1 - Search strategy. Salvador (BA), Brazil, 2023.

Digital platforms	Combination of strings and terms	Initial results
World Intellectual Property Organization (WIPO)	“Elderly” AND “Gay”	(n=10)
National Institute of Industrial Property (INPI)	Elderly	(n=414)
	Gay	(n=584)
Apple Store®	“Gay” and “Elderly”	(n=18)
	“Sexuality”	(n=10)
Google Play®	Health Education and Elderly Gay	(n=249)
	Men's Health	(n=150)
Streaming	Spotify®	(n= 206)
	Elderly Gay
	Deezer®	(n=298)
	Gay
SimilarWeb	LGBTQ people	(n=2.338)

5. Selection of digital technologies

The filtering and selection of mobile app, websites and podcast will be guided by the quality parameters of the PRISMA-ScR phases,²⁵ adapted to their uniqueness.

In phase one (identification), an initial search will be carried out in the databases and stores through the strings to identify the apps that have the selected terms in their titles or descriptions, a pre-selection that will comprise the initial results of the study, as well as their adaptations for each platform. It is worth noting that the initial search model was validated internally by researchers with expertise in technological studies.

In phase two (selection), this initial search model will be applied to all selected databases and stores with the inclusion of terms from the apps that were not included in phase one. Each selected database and store has a justification, namely:

World Intellectual Property Organization (WIPO): a database of global brands.

National Institute of Industrial Property (INPI): a legally organized national database for registering intellectual properties such as trademarks and patents, which can be used for apps. 

SimilarWeb: an electronic address for searching websites using specific terms, which filters the results related to the search of interest.

Google Play® and Apple Store®: both are virtual stores that host mobile apps from around the world.

Spotify® and Deezer®: streaming platforms (a technology for transferring audio and video without the need to download it), which host podcasts, resources that narrate life experiences and care measures on a particular issue.

In phase three (inclusion), the DT retrieved by the terms will be included, focusing on their similarity to the object of the research. If the app has no information about its purpose and functions, the developers may be contacted. 

In phase 4 (eligibility), eligible the final sample and the scientific and/or gray literature will be searched to supplement the information.

6. Categorization:

The information on the selected DT will be collected by means of an instrument based on the model available in the Joanna Briggs Institute (JBI) manual,¹⁸ adapted to the standards of technology prospection studies (Chart 2), organized with the aid of the Microsoft Excel® program and categorized according to the extraction of the obtained data. 

Chart 2 - Instrument for data extraction, Salvador (BA), Brazil, 2023. 

Identification of digital technologies
Name	Launch year	Country of development	Operational system	Downloads
Update	Developer	Store/Language	Area	Acquisition
Main results
Objective	Description	Public evaluation	Comments

Acquisition refers to whether the resource is made available for free or paid for. Public evaluation is available on the download platforms, conducted by individual users and based on the proportional number of evaluations, ranging from one to five stars depending on the current quality of the technology.

7. Data organization, processing and analysis:

The data will be organized using the Microsoft Excel® program and the notepad, and the content will be submitted to a Categorical Thematic Analysis in three phases: 1) pre-selection of the DT to be analyzed; 2) analytical, interpretative, systematic and individual reading of these technologies; and 3) reflective analysis of the information from the mobile apps, websites and podcasts; summary of the results; formation of thematic categories; and comparison of the results with the scientific literature.²⁶

8. Presentation of results, and conclusion and observation on the implications of the findings:

The summary of the results will be presented in descriptive and explanatory texts, in the form of narrative discussions, pictograms, graphs showing the time evolution of the studies and charts showing the main findings, leading to clarifications of the proposed objectives and answers to the research questions. The charts will be organized according to the elements of the data extraction instrument.

9. Conclusion and observations on the implications of the findings:

The content of this section will be developed based on the final structuring of the results, which will be analyzed, discussed, and published in the future in the original format of the technological prospecting.

Discussion

The digital technologies already found in preliminary research offer inclusive access to affirmative health care, capable of meeting the particularities of sexual minorities in the context of a transition to healthy ageing. Innovative and specific models for adult and elderly gay men need to be created and implemented for the clinical management and monitoring of the negative and pathological impacts of stressors such as ageism and homophobia suffered throughout life.^27,2

Evidence from the field of psychology and mental health points to reports from middle-aged and older adults about perceived discrimination throughout life, heterosexism and the risks of coming out as gay to family and society, associated with deficits in a number of aspects of physical and emotional health.²⁸

Such innovative care models, therefore, can develop interdisciplinary interventions, especially nursing care, through unique therapeutic projects structured around domains of well-being, such as health promotion, stress coping/tolerance, and self-perception, contributing to the quality of life of ageing individuals, to preserved psychosocial health with benefits for collective health as well, going beyond the countless barriers to access to a "gay-friendly" welcome that distances the non-heterosexual public from health services.⁴

Data from a survey in South Africa reveal that the majority of people in the sexual minority group have poor communication with health professionals and a lack of discussions about sexual health, including sexual orientation and behavior, with breaches of confidentiality and inappropriate comments about sexual orientation, as well as a lack of research into inclusive health models, such as Inclusive Primary Care,²⁹ for example.

National studies have concluded that the unpreparedness and unethical practices by health professionals lead to intimidation, exclusion, helplessness, omission, indifference and embarrassment of the gay public in the face of gaps in communication related to counseling on sexual behavior and in the expanded listening of Family Health Strategy nurses when caring for the public in question.^30,4

A cross-cultural adaptation of the Minority Stress Model, which proposes that prejudice against sexual diversity generates stress and can lead to serious mental health consequences, analyzes three stressors: 1) imposed stigma; 2) internalized homonegativity; and 3) concealment of sexual identity. This is a North-American model validated in Brazil, with recommendations for future research into mental health and its relationship with the resilience of gay men, as it has adequate internal consistency indices and a satisfactory factor structure in line with its three-dimensional proposal.²⁷

Brazilian anthropological references, also from multidisciplinary fields present in studies on gay adults and elderly people, confirm a heteronormative scenario on ageing and old age, alerting professionals to the new social actors.³¹

Nevertheless, in order to create a technology capable of operating educational content on affirmative health, it is necessary to have a guiding thread, a line of thought that establishes a dialog between the theoretical and methodological frameworks.³² For this reason, the post-prospection technology study tends towards the field of Gay Gerontology Analysis,³³ whose constructs are the verification and reaffirmation of negative stereotypes about gay ageing, their critique and deconstruction, and the rise of a positive gay model in the literature, reflected in political, theoretical and analytical projects with a diverse empirical background, with the possibility of elucidating general trends in the analyses, usually linked to certain positive or negative social representations.

These perspectives may contribute to the transfer of knowledge becoming effective as it goes off the paper and is implemented in practice, with the intention of improving the capacity to carry out activities and increase the quality of the care provided.¹⁷

The limitations relate to the lack of technological development anchored in a theoretical framework on the subject under investigation, which justifies the descriptive format of the presentation of the state-of-the-art of the phenomenon of gay male aging, with insights into the production of care presupposed by a new field of action, that of Affirmative Nursing, a concept that requires further clarification.

At the moment, reading is taking place to better define the theoretical framework itself, but the hypotheses that are emerging about growing old as a gay man are related to deviations in psychological health and the lack of demand for health services, assumptions that may point to a framework that will better unravel this phenomenon.

Authors Contributions

Study design: Vinícius de Oliveira Muniz, Edielson Mello dos Santos Júnior, Cléton Salbego, Pricila Oliveira de Araújo, Anderson Reis de Souza. Manuscript writing: Vinícius de Oliveira Muniz, Edielson Mello dos Santos Júnior, Cléton Salbego, Pricila Oliveira de Araújo, Anderson Reis de Souza. Critical review of the manuscript: Vinícius de Oliveira Muniz, Edielson Mello dos Santos Júnior, Anderson Reis de Souza. Approval of the final version of the text: Vinícius de Oliveira Muniz, Edielson Mello dos Santos Júnior, Cléton Salbego, Pricila Oliveira de Araújo, Anderson Reis de Souza.

Conflicts of interest

There are no conflicts of interests.

Funding

Bahia State Research Support Foundation (FAPESB), grant number 0626/2023.

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Corresponding Author:

Vinícius de Oliveira Muniz

E-mail: viniciusomuniz22@gmail.com

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