Phase one: Identification of commissions, keyword search and data extraction.

The Commission reports were identified from the Lancet website, which hosts the entire archive (www.thelancet.com/commissions). All commissions published in Lancet journals from conception through November 25^th, 2023 (n = 102) were extracted [41]. Four authors (MB, SWG, MM, WER) identified and coded key terms in all published reports. The coding team identified 32 key terms by consulting the literature and discussing the relevance of each term to discourse around LGBTQIA+ social justice issues. Key search terms can be found in Table 1. Two coders (MB, WER) then individually searched the text of each Commission for the terms. The coders created an entry in an Excel database for every mention of a key term in a Commission. Each entry included the page number of the Commission where the key term appeared and a reproduction of the paragraph where the key term was mentioned. Coders also indicated whether the key terms appeared in the “Key Messages,” “Executive Summary,” or “Recommendations” sections of the Commission. The total number of references to each key term in each Commission was tallied. A third coder (MM) conducted a confirmatory check of a randomly selected 10% of excluded Commissions (with no key term mentions) to ensure no references to LGBTQIA+ communities had been missed.

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Table 1. Search terms and descriptive statistics.

https://doi.org/10.1371/journal.pone.0311506.t001

Phase two: Critical discourse analysis.

The Commission reports were analyzed using the Fairclough approach to CDA [38], which draws on discourse analysis techniques to examine lexical items within a dataset across different levels. This commenced with a textual (micro) level analysis, considering the item itself and the words collocated around or proximally located to it. In the context of this analysis, the items analyzed at the micro level were each usage of the ‘key terms’ within every Commission. The analysis then progressed to the contextual (meso) level, exploring the visibility and placement of the references within the Commission and how LGBTQIA+ communities were addressed alongside other groups. Finally, the analysis moved to a societal (macro) level to consider the broader implications of the reference for the genre (a form of discourse with socially agreed upon conventions⁵—in this context, peer-reviewed scientific journals) and society.

The analysis included consideration of intertextuality, which examines how and where the document references other sources of knowledge (in this case, citations), and interdiscursivity, which explores the discourses drawn upon in the document. Intertextuality was considered through a systematic and iterative process of ‘zooming in and out’ and moving backward and forward through the dataset (i.e., each Commission and the collection as a whole) to examine explicit and latent constructions of LGBTQIA+ inclusion or exclusion. We also considered notable absences where references to the terms were expected but not found, such as in reports examining sexual health.

Application.

The analysis (conducted August-November 2023) was led by KB (a sociolinguist), who trained a subset of authors (the CDA team: DB, NM, SWG) in the methods. Analysis was conducted in three phases: 1) exploratory phase, 2) description and interpretation and 3) explanatory phase.

Exploratory phase. The analysis methods were trialed using three sample Commissions, which were analyzed independently by each member of the CDA team. The analysis involved: (1) consideration of which specific lexical terms were used to reference LGBTQIA+ communities (e.g., ‘LGBT,’ ‘gay,’ ‘men who have sex with men,’ ‘transgender,’ etc.); (2) examination of how each reference might contribute to broader discourses that construct or shape characterizations, values, norms, or assumptions that may lead to the inclusion, exclusion, marginalization, or discrimination of LGBTQIA+ people (interdiscursivity); and (3) consideration of the citations provided as evidence for statements made regarding LGBTQIA+ communities (intertextuality). After completing this initial analysis, the team met to discuss their findings. A second phase of exploratory analysis was conducted using three different Commissions with varying subject matters and number of references to LGBTQIA+ communities. The team reconvened to discuss the analysis, refine analytical processes, and ensure consistency among the team members. At this stage, the team began considering potential broader themes, interpretations, and implications emerging from the initial findings.

Description and interpretation. Following the initial exploratory phase, the team developed an extraction table in Excel to collate example quotations across emergent themes. The entire corpus of 36 Commissions, including those used in the exploratory phase, was divided between the four members of the CDA team and analyzed independently at the micro and meso levels, as described above. The CDA team met two more times to consider the macro analytic level and identify and synthesize key findings and interpretations. During these meetings, four additional key terms were identified (‘nonbinary,’ ‘same-sex,’ ‘same-gender,’ and ‘sexuality,’ the latter pertaining to sexual orientation, not intimacy), which had not been included in the initial extraction phase, bringing the total number of key terms to n = 36. All Commissions were then re-searched by the phase one analysis team for the use of these terms to ensure completeness (see Table 2 for the complete list of key terms).

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Table 2. Mentions and descriptive statistics by commission report.

https://doi.org/10.1371/journal.pone.0311506.t002

Explanatory phase. The CDA team developed a shared working document to construct an initial narrative of the findings, supported by examples from the data, and to expand upon the potential implications of this work for the genre and at a societal (macro) level. The authors’ intention was to identify examples of best practices and delineate ways to improve communication with, for, and about minoritized groups at a policy level. As such, a list of recommendations for practice and policy derived from the data was also developed at this stage. Finally, the CDA team met with the entire study team (all authors) to present the findings and discuss the description and interpretation, after which the analysis was refined and finalized.

Micro-level findings.

Terminology. The lexicon used to refer to LGBTQIA+ communities varied across Commissions (Table 1). Terminology included commonly used descriptors of sexual orientation (e.g., ‘lesbian,’ ‘gay,’ ‘bisexual,’ ‘asexual’), as well as more outdated terms (e.g., ‘homosexual’). Additionally, common descriptors of gender identity (e.g., ‘transgender,’ ‘intersex’) and rare instances of outdated and stigmatizing terms (e.g., ‘transsexual,’ ‘transgendered’) were identified, along with a variety of abbreviations (e.g., ‘LGBT,’ ‘LGBTQ,’ ‘LGBTI,’ ‘SOGIESC’). Further descriptors used to refer to LGBTQIA+ communities were associated with behaviors (e.g., ‘men who have sex with men,’ ‘MSM,’ ‘same-sex’ relationships, etc.).

Descriptors were also employed to position LGBTQIA+ individuals in terms of risk (e.g., ‘key populations,’ ‘high-risk populations,’ ‘at-risk populations’) and to differentiate them from other (dominant groups of) people, as evident in the use of terms like ‘sexual minorities’ or ‘gender minorities.’ Some examples used language that was othering and implied an assumed norm (e.g., ‘sexual or gender non-conforming,’ ‘gender-atypical,’ and ‘not heterosexual’). The most extreme examples used stigmatizing and archaic terminology (e.g., ‘sexual deviancy’).

Some more uncommon descriptors were also identified incidentally during the analysis which were used to discuss LGBTQIA+ women, such as ‘female partnerships’ and ‘female couples’. These desexualized descriptors were particularly noteworthy when used within a Commission focusing on sexual and reproductive health and rights and contrast with the most common term found across Commissions: ‘men who have sex with men (MSM).’ Moreover, there was occasional inconsistency between and conflation of gender identity and sexual orientation, as seen, for example, in a reference to ‘gender orientation’.

In instances where abbreviations were employed it was rare for Commissions to recognize the sub-identities and varying risk profiles within and beyond the abbreviation. There were also examples where an abbreviation was used interchangeably with another non-synonymous term (e.g., ‘LGBTI’ and ‘sexual minorities’). Finally, on rare occasions, abbreviations were presented in a less common format (e.g., ‘LGBQT,’ ‘SOGIESC’) without an explanation of the choice.

The terminology used throughout the Commissions varied in frequency and lexical choice. However, the decisions behind these choices were rarely made explicit. For example, authors tended not to state their positionality in relation to the lexicon used or the socio-political context behind their choice of language despite accepted guidelines from professional organizations (e.g., the American Psychological Association’s ‘Inclusive Language Guide’) [43]. An explicit and exemplary approach was evident in the Commission on ‘Women, Power, and Cancer’ [44], which delineated sex and gender and clarified the approach adopted (i.e., intersectional feminist).

Meso-level findings.

Visibility. References to LGBTQIA+ communities were most prevalent in Commissions related to HIV/AIDS and sexual and reproductive health and rights (>60 references per Commission report). They were also frequently identified in those related to childhood and adolescence, intimate partner violence, migration, and women’s health (18–43 references per report). Few, if any, references to LGBTQIA+ people were included in Commissions related to public health agendas, chronic non-malignant conditions, and cancer care (except for two Commissions on women and cancer, which included 27 [45] and 45 [44] references, respectively) regardless of the increased prevalence of these conditions for LGBTQIA+ people. For example, despite the growing evidence to suggest an increased prevalence of cardiovascular disease among LGBTQIA+ populations [46,47], the Commission on ‘Women and Cardiovascular Disease’ did not mention LGBTQIA+ people [48]. In contrast, other minoritized groups, including along axes such as ethnicity and socioeconomic status, were discussed in detail in the Commission, further bringing into relief the exclusion of LGBTQIA+ people. Table 3 provides the top five commissions ranked by the number of key term mentions.

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Table 3. Ranking of top five commissions by number of key term mentions.

https://doi.org/10.1371/journal.pone.0311506.t003

Within the Commissions that did mention LGBTQIA+ people, not all sub-communities were discussed, and some garnered much more focus than others. For example, when an LGBTQIA+ community was discussed in greater depth, the focus was often on ‘men who have sex with men (MSM)’ in the context of infectious diseases, especially sexually transmitted infections. The bisexual community was rarely considered independently but more often mentioned alongside the lesbian or gay communities. In some cases, examples of bisexual erasure were evident; this was notable in the context of Commissions on women’s health [44], with comparisons of statistics between lesbian and heterosexual people making no mention of bisexual women, who are at especially high risk of experiencing outcomes common to women, such as intimate partner violence [49–51].

It is important here to distinguish visibility (as a proxy for inclusion) and meaningful engagement with the needs of LGBTQIA+ people. Many Commissions (65%) did not refer to LGBTQIA+ people within the report, or they displayed an active decision to exclude certain groups—for example, excluding trans women from a report ‘owing to the current paucity and quality of data’ despite evidence to the contrary [48]. Many additional Commissions were unclear in their positionality, for example, failing to clarify whether they included trans individuals in discussions of ‘men’ and ‘women.’

However, other Commissions made vague references to LGBTQIA+ communities, for example, mentioning sexual orientation only in passing and without discussion of its relevance. In one notable example, found in a Commission that had one of the highest numbers of total references (n = 106) to LGBTQIA+ people and which claimed a focus on gender equality [52], sexual orientation and gender identity were conflated throughout the report. There were descriptions of “women and sexual and gender minorities.” The Commission also failed to discuss the needs of LGBTQIA+ people, apart from in one location where a panel was used to highlight a specific geographical example.

Placement. Concerning the placement of references to LGBTQIA+ communities, they were seldom mentioned in the “Executive Summaries” of the Commissions. Where LGBTQIA+ people were mentioned in the “Executive Summary,” it was either as part of Commissions focused on sexual or reproductive health and rights or within a list of other minoritized groups without an explanation as to why they had been grouped together.

It was also rare for LGBTQIA+ people to be mentioned in the “Key Messages” or “Recommendations” sections of Commissions (25%). This was often the case even when the needs of LGBTQIA+ communities had been addressed in reasonable depth elsewhere in the Commission (e.g., in the context of viral hepatitis or HIV/AIDS Commissions). Outside of the context of Commissions concentrating on HIV/AIDS, references to LGBTQIA+ communities tended to be limited to sections on inequities, discrimination, or sexual and reproductive health and rights. In several instances, all mentions of LGBTQIA+ communities in a Commission were within a single sentence, paragraph, or panel.

Grouping. LGBTQIA+ communities were often included as part of lists with other minoritized or marginalized groups or communities. While such grouping could yield a positive impact in terms of visibility, it also risks contributing to the collectivization of minoritized and marginalized groups, ignoring the unique needs of each and the intersectional needs of those belonging to multiple such groups and identities.

Macro-level findings.

Framing. Legal frame. One example was the placement of LGBTQIA+ communities within a legal frame (see Table 4, Quotation 1). In these cases, sexual orientation was mentioned alongside, for example, ethnicity, disability, religion, family or marital status, or other legally protected characteristics (Quotation 2), such as those protected by the UK Equality Act, 2010 [53,54].

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Table 4. Macro-level framings of LGBTQIA+ communities with exemplar quotations from Lancet commission reports.

https://doi.org/10.1371/journal.pone.0311506.t004

Vulnerability frame.

Another common grouping concerned perceived ‘vulnerability,’ ‘marginalization,’ or ‘disadvantage’ (Quotation 3). In these instances, LGBTQIA+ people were listed, for example, alongside migrants, people with low socioeconomic status, victims of violence and war, and others vulnerable to deprivation of their human rights or criminalization (Quotation 4). However, it was scarce to find any explanation as to why these communities had been grouped (Quotation 5). Commissions largely omitted any indicators of shared experiences among these groups and did not provide an in-depth explanation of why they might have similar specific needs. The analysis was generally limited to acknowledging that these groups may have unmet needs (Quotation 6).

Risk frame.

A further frequent grouping was about ‘risk’ and suggested ‘high-risk’ or ‘risky’ behaviors (Quotation 7). Here, LGBTQIA+ people were repeatedly listed alongside people who inject drugs, sex workers, and people in juvenile detention centers or prisons, especially in the context of being at risk of contracting or transmitting infectious diseases, particularly HIV/AIDS and/or viral hepatitis. Again, it was uncommon for there to be any explanation as to why these groups were listed together, beyond all being conceived of as ‘high-risk’ or ‘key populations’ for the transmission of certain infectious diseases (Quotation 8). Nevertheless, a few Commissions provided more nuanced analyses for the reasons behind ‘concentrated epidemics’ or ‘hot spots’ and potentially higher infectious disease transmission rates in communities such as MSM, including by considering the roles of structural factors (Quotation 9). Commissions that did address structural factors as drivers of infectious disease transmission were primarily those focused on HIV/AIDS.

Characterization. How LGBTQIA+ communities were referenced and grouped with other communities played a role in how they were characterized.

As victims.

It was common for LGBTQIA+ people to be characterized as victims, for example, as being the targets of ‘discrimination,’ ‘abuse,’ ‘stigma,’ and/or ‘marginalization’ (Quotation 10). However, there was seldom mention of any structural, social, or individual agents in relation to these phenomena, such as homophobia, transphobia, etc. Such phenomena were most often mentioned in Commissions on HIV/AIDS, where the structural determinants of discrimination and stigma were occasionally addressed more comprehensively.

Another example of the victim frame concerned violence, with a few Commissions linking being LGBTQIA+ with attracting violence. While higher levels of violence must be discussed and prioritized within Commissions, on occasions Commissions directed the blame for these actions toward the individuals themselves based on their personal circumstances and characteristics. Indeed, it was rare for the potential structural causes of violence against LGBTQIA+ people, to be indicated by Commissions (Quotation 11).

There were also notable absences related to violence and discrimination toward LGBTQIA+ people. One Commission specifically addressing gender-based discrimination and violence failed to mention or acknowledge violence directed toward gender expansive people, such as trans and nonbinary people, despite widespread reports of increasing levels of violence experienced by these groups [55–57]. Elsewhere in the Commission, despite referring to ‘women and gender minorities,’ and recognizing misogyny as a structural cause of violence, there was a failure to mention transphobia as a cause (Quotation 12).

As blameworthy.

Another common framing was that of blame (Quotation 13). This was often, though not exclusively, linked to sexual behaviors and underscored by a subtext of moral judgment (Quotation 14). For example, LGBTQIA+ people were referred to as facing inequities ‘because of’ their ‘non-conforming’ sexual orientation or gender identity. This may appear to imply that inequities are an inherent and unavoidable consequence of being LGBTQIA+ rather than rooted in societal or cultural patterns of discrimination, evident in phraseology such as ‘sexual orientation is a source of discrimination’ [45].

In cases related to infectious diseases, such as HIV/AIDS, LGBTQIA+ people were frequently described as voluntarily engaging in risk behaviors and, by implication, as worthy of blame. They were portrayed as transmitters of infection, as choosing not to use condoms (Quotation 15), and as causing increased rates of ‘preventable deaths’ (Quotation 16). The blame-framed presentation tended to occur when Commissions had a broader health agenda but included a subsection on sexual and reproductive health and rights. Notably, in Commissions specifically focused on HIV/AIDS or sexually transmitted infections, this presentation was less common, with increased recognition of the structural causes contributing to observations of increased prevalence.

As a problem.

Linked to the blame frame was a problematizing one employed more subtly throughout the Commissions. This framing tended to position LGBTQIA+ people as a challenge or problematic in some way, with their health concerns described as being a ‘problem’ or ‘issue.’ Communities were also sometimes characterized as lacking responsibility or being complacent, for example, in the context of increasing rates of HIV infection. (Quotation 17).

At a micro level, the use of terms that assume a societal norm contribute to this framing (e.g., ‘non-conforming gender identities or sexual orientations,’ ‘when not heterosexual,’ ‘if they do not conform to social norms regarding sexual orientation and gender identity,’ etc.). On rare occasions, Commissions also employed a discourse of biological imperative, which reinforces this problematizing frame with respect to LGBTQIA+ communities. Notably, a Commission on ‘Women and Health’ included the statement, ‘Nulliparity and reduced contraceptive pill use increase their [sexual minority women’s] risk of breast cancer and uterine cancer’ [45], problematizing and presupposing LGBTQIA+ women’s bodily choices and experiences.

At a meso level, the problematizing frame was also attended to through broad statements about a lack of evidence concerning LGBTQIA+ communities. This contributed to the perception that clear avenues for improving policies and practices for LGBTQIA+ populations may be difficult or impossible to achieve. Commissions variously described the ‘paucity and quality of data’ [48], a lack of ‘data disaggregated by age and sex or data on high-risk populations’ [58], or how ‘some stratifications might be sensitive to collect in certain contexts, such as for race, ethnicity, religion, or sexual orientation’ [59]. Some Commissions recognized the contribution of stigma and discrimination to LGBTQIA+ people’s experiences. However, many Commissions’ focused on ‘under-reporting’ and individuals’ purported lack of willingness to disclose LGBTQIA+ identities—without any presentation of potential solutions. This shifts the locus of responsibility more toward LGBTQIA+ people to disclose their identities and provide these data, despite the risks that may entail, or risk inhibiting their access to care.

This problematizing frame and the frequent shifting of responsibility toward LGBTQIA+ people were also utilized in ways that undermined or minimized the needs and experiences of LGBTQIA+ individuals. For example, in the context of HIV/AIDS, one Commission discussed an increased incidence of HIV in gay men ‘despite an increasingly open and tolerant attitude toward homosexuality’ [58], contributing to both the problematizing and blame narratives, wherein LGBTQIA+ communities themselves are designated as the source of the problem and as worthy of blame. This problematizing frame was extended with reference to the financial burden to society of ‘key populations’ (e.g., ‘If the political will to spend so much public money on injecting drug users, MSM, and sex workers exists, the bulk of these countries should have the fiscal capacity to pay for their national HIV programs’) [58].

In addition, such minimizing and undermining were also evident in other contexts where the validity of LGBTQIA+ experiences was questioned. For example, one Commission discussed the ‘perceived obstacles’ [60] that LGBTQIA+ people may experience in accessing mental health services, and another appeared to use the paucity of evidence argument to undermine the differences in risks and outcomes that LGBTQIA+ people experience and their causes (Quotation 18).

Finally, many Commissions exhibited limited utilization of citations to substantiate statements related to LGBTQIA+ communities when they were considered.