In the definition of sexual health published by the World Health Organization (WHO) in 2001, it was already established that it requires “a positive and respectful approach to sexuality and sexual relations, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence” [1].

That same year, the European Parliament passed Resolution 2001/2128 on sexual and reproductive health, making a set of recommendations to the governments of the European Union (EU) Member States. This resolution emphasizes that “sexual education should be considered in a positive and holistic way that pays attention to psycho-social as well as bio-medical aspects and based on mutual respect and responsibility”. Although reproductive health policies are the responsibility of the Member States, the EU can contribute to their improvement [2]. In Spain, to adapt the regulatory framework to the European consensus, the Organic Law 2/2010, of 3 March 2010, on sexual and reproductive health and the voluntary interruption of pregnancy was passed. In its Article 9, this law contemplates the incorporation of “sexual and reproductive health education in the educational system, as part of the integral development of education on personality and values, including a comprehensive approach”. This legislation advocates the recognition and acceptance of sexual diversity and the harmonious development of sexuality in accordance with the characteristics of young people [3].

In order to fulfill the objectives set forth in this Law, in 2011, the Spanish Government, in cooperation with the regional governments of each of the Autonomous Communities (CC.AA.) in Spain, approved the Sexual and Reproductive Health Strategy, drawn up with the collaboration of scientific and professional societies and social organizations. As a general objective in the area of sex education, this Strategy aims to “to promote quality care with accessible sexual health services, contributing to improve the experience of sexuality in an integral, autonomous, diverse, egalitarian, pleasurable, responsible, healthy and respectful manner throughout life, where the sexual and reproductive rights of women and men, regardless of their sexual options and orientations and gender identities, are guaranteed” [4]. The Strategy is based on the results of the 2009 National Survey on Sexual and Reproductive Health, according to which heterosexuality continues to be the dominant norm and latent homophobia and biphobia persist in society [5]. During the development of the Strategy, a wide variability in sexual health care between regions was noted [4].

Hate crimes have been shown to cause death, injury, illness, psychological and emotional sequelae, behavioral changes, and suicide in its victims. Respect for all options and orientations also prevents the occurrence of this type of interpersonal violence against lesbian, gay, bisexual, trans and intersex (LGTBI) persons ^[6][7][6,7].

In 2011, the United Nations High Commissioner for Human Rights published the report on discriminatory laws and practices and acts of violence against individuals based on their sexual orientation and gender identity. Among other practices, the following recommendation is issued “enact comprehensive anti-discrimination legislation that includes discrimination on grounds of sexual orientation and gender identity” and “investigate promptly all reported killings and other serious incidents of violence perpetrated against individuals because of their actual or perceived sexual orientation or gender identity” [8].

Evidence collected by the European Union Agency for Fundamental Rights points to concerning rates of non-reported, bias-motivated violence and harassment against minorities. The guiding principles on encouraging reporting of hate crime set out actions such as “address the invisibility of hate crime and actively communicate and disseminate hate crime data” [9].

A hate crime is defined in the Spanish Penal Code as “hostility, discrimination or violence against a group, a part of a group or against a specific person because of their membership, on racist, anti-Semitic or other grounds related to ideology, religion or beliefs, family situation, membership of an ethnic group, race or nation, national origin, sex, sexual orientation or identity, gender, illness or disability”. Hate crimes are regulated by Article 510 of the Penal Code [10]. The reform of the Organic Law 1/2015, of 30 March 2015, modified this concept [11]. The new regulation differentiates between actions of incitement to hatred or violence against groups or individuals and acts of humiliation or contempt against them and the glorification or justification of crimes committed against them or their members with a discriminatory motivation. It increases the penalties and punishes those who commit such crimes through the Internet or other social media.

The relationship between LGTBI rights legislation and related hate crimes is not sufficiently covered, mainly because hate crimes are difficult to accurately count ^[9][12][9,12]. Nevertheless, several international studies have shown how legislation against discrimination of LGTBI people has an overall positive impact on the reduction in hate crimes although they yield contradictory results. Thus, legislation against employment non-discrimination reduces hate crime, however, partnership recognition increases them. In addition, there are other mediating variables between LGTBI rights legislation and hate crimes as these researcheuthors argue that violence against LGTBI people is an extreme manifestation of social stigmatization and cultural norms fostered by social institutions [12].

In Spain, the CrimiPenal Code punishes hate crimes based on sexual orientation or identity. Moreover, and since the Organic Law 2/2010 of 3 March 2010, also punishes behaviours which violate those related to sexual and reproductive rightshealth [11]. The governments LGTBI of the different regions of the country have alsosince passed laws that protect the rights of LGTBI people.

2. Current Studies

Figure 1 shows the classification of the different regions according to the aspects legislated.

Figure 1. Regional laws passed regulating healthcare and the rights of LGTBI people. Spain (2011–2021).

In the first group are those regions that have regulated their own healthcare services for trans persons: Andalusia, Murcia, Navarre, the Basque Country and Valencia.

In a second group are the regions in which regulations focus on equality and comprehensive protection against discrimination based on sexual orientation, gender expression and gender identity: Asturias, Galicia, Castilla-La Mancha and Castilla-León (these two are at the drafting stage).

In a third group are the regions that have regulated both issues: Aragon, Balearic Islands, Canary Islands, Cantabria, Catalonia, Extremadura and Madrid.

Finally, in La Rioja, no legal text has been developed to date, neither on health care nor on the rights of LGTBI persons.

Table 1 summarizes the results regarding the legislation developed in the different Spanish regions that regulate the health care and rights of LGTBI persons.

Table 1. Autonomous Community legislation on sexual health care in each Autonomous Community during the period from 2011–2021. Chronological order.

SAC *	LGTBI ** Rights	Aspects That Are Legislated
	Annual Rate per 100,000 Inhabitants
	2015	2016	2017	2018	2019	2020	Average Annual Percentage of Change
Basque Country	2012: Law 14/2012 of 28 June [13]	2012: Law 14/2012 of 28 June [15]	Regulates the health care and rights of transgender minors.
0.00	0.60	−25.1%	Galicia	2014: Law 2/2014 of 14 April [14]	2014: Law 2/2014 of 14 April [16]	Regulates equal treatment and non-discrimination of lesbian, gay, transsexual, bisexual and intersex persons.
Galicia	0.37	0.40	0.22	0.37	0.44	0.19	−1.2%	Catalonia	2014: Law 11/2014 of 10 October [15]	2014: Law 11/2014 of 10 October [17]	Regulates health care and the rights of lesbian, gay, bisexual, transgender, and intersex persons; and for the eradication of homophobia, biphobia and transphobia.
La Rioja	0.00	0.00	0.00	0.32	0.00	0.00	0.0%	Extremadura
Ceuta	2015: Law 12/2015 of 8 April [16].	2015: Law 12/2015 of 8 April [18].	Regulates health care and comprehensive care for transsexual persons (including genital reconstruction) and public policies against discrimination based on sexual orientation and gender identity.
0.00	0.00	0.00	0.00	0.00	0.00	0.0%	Madrid	2016: Ley 2/2016, of 29 March [17]	2016: Ley 2/2016, of 29 March [19]	Regulates the protection of the right to physical, mental, sexual, and reproductive health and health care.
C. La Mancha	0.24	0.24	0.34	0.35	0.25	0.29	6.5%	Murcia	2016: Law 8/2016 of 27 May [18]	2016: Law 8/2016 of 27 May [20]	Regulates the health care and rights of transsexual minors: hormone blocking at the onset of puberty and cross-hormonal treatment at the appropriate time of puberty to encourage their body development to correspond to that of persons of their age.
Balearic Islands	2016: Law 8/2016, of 30 May [19]	2016: Law 8/2016, of 30 May [21]	Regulates health care and rights of lesbian, gay, trans, bisexual and intersex persons and to eradicate LGTBI* phobia.
Valencia	2017: Law 8/2017 of 7 April [20]	2017: Law 8/2017 of 7 April [22]	Regulates the health care and rights of transsexual minors: consent, hormone blocking at the onset of puberty and cross-hormonal treatment at the appropriate time of puberty to encourage their body development to match that of persons of their age.
0.21	0.67	0.33	35.5%
Catalonia	0.84	1.02	2.94	1.37	1.32	1.22	28.9%	[24]	2018: Law 18/2018, of 20 December [26]	On equality and comprehensive protection against discrimination based on sexual orientation, gender expression and gender identity.
Cantabria	2020: Law 8/2020, of 11 November [25]	2020: Law 8/2020, of 11 November [27]	Regulates health care for trans and intersex persons, trans and intersex minors, social equality and non-discrimination based on sexual orientation and gender.
Asturias	2021: Decree 3/2021, of 29 January [26].	2021: Decree 3/2021, of 29 January [28].	Regulates the organization and functioning of the Asturian Observatory against LGTBI * phobia.
	Preliminary draft law of the Principality of Asturias [27]	Preliminary draft law of the Principality of Asturias [29]	On the guarantee of the right to free expression of sexual and/or gender identity.
Cantabria	0.34	0.52	0.00	0.17	0.17	0.17	10.1%
Murcia	0,27	0.14	0.34	0.34	0.20	0.26	18.0%
Valencia	0.34	0.26	0.63	0.24	0.32	0.34	Navarra	2017: Foral Law 8/2017 of 19 June [21]	2017: Foral Law 8/2017 of 19 June [23]	It regulates the health care and rights of transsexual minors: consent, hormone blocking at the onset of puberty and cross-hormonal treatment at the appropriate time of puberty to encourage their body development to match that of people their age.
18.4%
Madrid	0.30	0.65	0.60	0.64	0.60	0.62	23.2%	Andalusia	2017: Law 8/2017 of 28 December [22]
Castilla-León	2017: Law 8/2017 of 28 December [24]	Regulates health care and rights of transsexual minors: hormonal blockage at the onset of puberty and cross-hormonal treatment at the appropriate time of puberty to encourage their body development to correspond to that of persons of their age, in order to promote the development of desired secondary sexual characteristics.
0.28	0.16	0.29	Aragón	2018: Law 4/2018, of 19 April [23]	2018: Law 4/2018, of 19 April [25]	Regulates health care for trans persons, informed consent and shared decision making for trans minors.
	2018: Law 18/2018, of 20 December
Aragón	0.30	0.38	0.23	0.46	0.08	0.23	40.0%
Andalusia	0.17	0.39	0.21	0.49	0.50	0.41	40.6%	Canary Islands	2021: Law 2/2021 of 7 June [
Asturias	0.10	0.10	0.19	0.68	0.59	0.10	51.5%
Canary Islands	0.29	0.14	0.76	0.23	0.65	0.69	99.1%	28]	2021: Law 2/2021 of 7 June [30]
Extremadura	Regulates health care for trans and intersex persons, trans and intersex minors, social equality and non-discrimination based on gender identity, gender expression and sexual characteristics.
0.00	0.28	0.46	0.19	0.47	1.60	100.1%	Castilla-La Mancha	Preliminary Draft Law [29]	Preliminary Draft Law [31]	On sexual diversity and LGTBI rights.
Basque Country	0.87	2.42	2.14	2.41	0.54	2.75	101.6%	Castilla y León	Preliminary Draft Bill [30]	Preliminary Draft Bill [32]	Regulates the principle of equal treatment and non-discrimination based on sexual orientation and gender identity.
La Rioja	Not developed

Considering the dates of publication and therefore the enforcement of the laws of each region, the Basque Country was the first community to legislate after the national law, publishing its regulation in 2012. The years between 2014 and 2018 were the years with the most legislation; however, even today there are regions that are still in the preliminary draft phase (Castilla-La Mancha and Castilla-León) or that lack their own regulations (Murcia).

The results represented by the number of victimizations for hate crimes based on sexual identity or orientation during the study period are shown in Table 2. The first year in which there are records of victimizations in Spain is the year 2015, when the lowest rate was recorded, whereas the highest rate was recorded in 2017; thus, an average annual percentage of change of 15.4% is observed, pointing to an upward trend.

Table 2. Hate crimes based on sexual identity or orientation at the national level and in each autonomous community: annual victimization rates per 100,000 inhabitants and average annual percentage of change. (Ascending order.)

Navarra	2.50	2.50	1.24	0.31
Melilla
0.00
3.49
1.16
2.32
1.16
8.04
115.6%
Balearic Islands	0.27	0.36	0.09	0.53	0.09	0.60	190.8%
Total Spain	0.41	0.60	0.90	0.67	0.59	0.69	15.4%

In analyzing what occurs in the most populated regions (Andalusia, Catalonia, Madrid and Valencia), it is evident that all these regions show high rates of annual victimizations with an average annual percentage upward trend. Catalonia stands out for presenting a 49.3% average annual percentage change and the highest annual rate with 2.94 cases of victimizations per 100,000 inhabitants in 2017.

In general, an upward trend was observed in all regions, with the Balearic Islands, the autonomous city of Melilla, the Basque Country and Extremadura showing the highest annual percentage change. A downward trend was only observed in Navarra (−25.1% average annual percentage change) and Galicia (−1.2%). In La Rioja (the least populated region) and the autonomous city of Ceuta, no change was observed.