Abstract

This article aims to study the knowledge of women who have sex with women about Sexually Transmitted Infections and AIDS. Cross-sectional study of 260 women, 81 women who either have sex with women or with men and women (WSW) and 179 women who have sex exclusively with men (WSM). Data were collected in 2019/2020 by means of a form and validated instruments. To study the association between sexual partnership and level of knowledge about Sexually Transmitted Infections and AIDS, multiple Cox regression models were adjusted, producing significant associations of p<0,05. The median percentage of correct answers was lower among WSW when compared to WSM [68% (18-96) vs 75% (14-96); p=0.023]. Having sex with woman [PR=2.36 (1.07-5.21); p=0.033] and less than 11 years of schooling [PR=2.64 (1.12-6.21); p=0.026] were independently associated with low knowledge. WSW had a lower level of knowledge about Sexually Transmitted Infections and AIDS than WSM, and lower education was independently associated with this finding.

Key words:
Knowledge; Sexually Transmitted Infections; AIDS; Female homosexuality

Introduction

In Brazil, women’s reproductive rights started to become recognized from 1984 due to the launch of the Comprehensive Women’s Health Care Program (PAISM)¹1 D'Oliveira AFPL. Saúde e Educação: a discussão das relações de poder na atenção à saúde da mulher. Interface (Botucatu) 1999; 3(4):105-122.. It proposed a comprehensive approach to women that included lifelong health prevention, promotion and recovery actions, breaking with the care model that had been centered on the pregnant-puerperal cycle, thus representing the demands consolidation of social and feminist movements in that historical context²2 Costa AM. Social participation in the achievement of health policies to women in Brazil. Cien Saude Colet 2009; 14(4):1073-1083..

Despite advances in women’s health, some shortcomings were identified and reviewed in 2003 by the National Policy for Integral Attention to Women’s Health (PNAISM), which proposed new actions, such as the inclusion of lesbian women³3 Brasil. Ministério da Saúde (MS). Departamento de Ac¸o~es Programa´ticas Estrate´gicas. Poli´tica nacional de atenc¸a~o integral a` sau´de da mulher: princi´pios e diretrizes. Brasília: Editora MS; 2004.. In 2011, lesbian and bisexual women’s rights were acknowledged by the National Policy for the Integral Health of Lesbians, Gays, Bisexuals, Transvestites and Transsexuals (PNSILGBT)⁴4 Brasil. Ministério da Saúde (MS). Secretaria de Gestão Estratégica Participativa. Departamento de Apoio à Gestão Participativa B. Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais, Travestis e Transexuais. Brasília: MS; 2012..

Although advances in public policies aimed at the lesbian, gay, bisexual, transvestite and transsexual (LGBT) population, both Brazilian⁵5 Roges A, Vasconcelos E, Araújo EC. Needs in the health sector related to the LGBT population (lesbians, gays, bisexuals and transvestites). J Nurs UFPE online 2015; 9(6):1-4.^,66 Marques AM, Oliveira JM, Nogueira C. A população lésbica em estudos da saúde: Contributos para uma reflexão crítica. Cien Saude Colet 2013; 18(7):2037-2047. and international⁷7 Gahagan J, Subirana-Malaret M. Improving pathways to primary health care among LGBTQ populations and health care providers: Key findings from Nova Scotia, Canada. Int J Equity Health 2018; 17(1):76.^,88 Koh CS, Kang M, Usherwood T. "I demand to be treated as the person i am": Experiences of accessing primary health care for Australian adults who identify as gay, lesbian, bisexual, transgender or queer. Sex Health 2014; 11(3):258-264. studies report that health professionals are having difficulties in dealing with this group due to the dominant culture of heteronormativity⁵5 Roges A, Vasconcelos E, Araújo EC. Needs in the health sector related to the LGBT population (lesbians, gays, bisexuals and transvestites). J Nurs UFPE online 2015; 9(6):1-4.^,99 Valadão RC, Gomes R. A homossexualidade feminina no campo da saúde: da invisibilidade à violência. Physis 2011;21(4):1451-1467.. As for women who have sex with women (WSW), difficulties range from accessing health centers to obtaining health care⁹9 Valadão RC, Gomes R. A homossexualidade feminina no campo da saúde: da invisibilidade à violência. Physis 2011;21(4):1451-1467.

10 Facchini R, Barbosa RM. Saúde das mulheres lésbicas - Promoção da Equidade e da Integralidade: Dossiê. Belo Horizonte: Rede Feminista de Saúde; 2006;^-1111 Barbosa RM, Facchini R. Acesso a cuidados relativos à saúde sexual entre mulheres que fazem sexo com mulheres em São Paulo, Brasil. Cad Saude Publica 2009; 25(Supl. 2):S291-S300., as their sexual orientation is still widely ignored.

Brazilian¹²12 Bertolin DC, Ribeiro RCHM, Cesarino CB, Silva DC, Prado DDO, Parro ES. Conhecimento de mulheres que fazem sexo com mulheres sobre o papilomavírus humano. Cogitare Enferm 2010; 15(4):730-735.

13 Rufino AC, Madeiro A, Trinidad A, Santos R, Freitas I. Práticas sexuais e cuidados em saúde de mulheres que fazem sexo com mulheres: 2013-2014. Epidemiol Serv Saude Rev Sist Unico Saude Bras 2018; 27(4):e2017499.^-1414 Oliveira ADS, Nery IS. Mulheres que fazem sexo com mulheres: atitudes e práticas sobre prevenção ao HIV/AIDS. Rev Enferm UFPI 2016; 5(3):10-17. and international¹⁵15 Marrazzo JM, Coffey P, Bingham A. Sexual Practices, Risk Perception and Knowledge of Sexually Transmitted Disease Risk Among Lesbian and Bisexual Women. Perspect Sex Reprod Health 2005; 37(1):6-12.

16 Kowalczyk R, Nowosielski K. Impact of social factors and sexual behaviors on the knowledge of sexually transmitted infections among women who have sex with women/women who have sex with women and men. Int J STD AIDS 2019; 30(2):163-172.^-1717 Paschen-Wolff MM, Reddy V, Matebeni Z, Southey-Swartz I, Sandfort T. HIV and sexually transmitted infection knowledge among women who have sex with women in four Southern African countries. Cult Heal Sex 2020; 22(6):705-721. studies that address knowledge and practices aimed at prevention and factors associated with sexually transmitted infections and AIDS (STI/AIDS) among WSW point to insufficient levels of knowledge, increasing their risk of infection. Although this is not the only determinant, the lack of discussions and access to information on sexual health is associated with that negative outcome, whereas its presence is an important element to adopt safer sexual behavior¹⁸18 Brasil. Ministério da Saúde (MS). Pesquisa de conhecimento, atitudes e práticas na população brasileira. Brasília: MS; 2006..

Evaluating knowledge on STI/AIDS is essential for the development of health interventions and policies and to facilitate future studies on that topic, the present study used the Sexually Transmitted Disease - Knowledge Questionnaire (STD-KQ)¹⁹19 Jaworski BC, Carey MP. Development and psychometric evaluation of a self-administered questionnaire to measure knowledge of sexually transmitted diseases. AIDS Behav 2007; 11(4):557-574., which was validated and adapted to Portuguese to measure knowledge about STI. It is the only questionnaire that analyzes not only the vertical transmission of some infections, but also prevention and protection measures against transmission²⁰20 Teixeira LO, Figueiredo VLM, Mendoza-Sassi RA. Adaptação transcultural do Questionário sobre Conhecimento de Doenças Sexualmente Transmissíveis para o Português Brasileiro. J Bras Psiquiatr 2015; 64(3):247-256..

Considering that WSW are vulnerable to STI²¹21 Andrade J, Ignácio MAO, Freitas APF, Parada CMGL, Duarte MTC. Vulnerabilidade de mulheres que fazem sexo com mulheres às infecções sexualmente transmissíveis. Cien Saude Colet 2020; 25(10):3809-3819. and that literature, especially the Brazilian one, is incomplete on the knowledge of this population about these infections, we propose this research, which aims to study the knowledge of WSW about STI/AIDS.

Method

We performed a cross-sectional study that is part of a broader research on vulnerability of WSW to issues related to mental, sexual and reproductive health and situations of violence in the city of Botucatu, located in the midwestern region of the State of São Paulo.

The target population of the study consisted of women aged 18 years or older and sexually active, excluding those who were not physically and/or mentally able to answer the questions of the data collection instruments.

Data were obtained from May 2019 to November 2020. To obtain our sample, the study was widely shared on social networks (Facebook, email, Instagram, WhatsApp), in bars, various commercial locations and educational and health institutions by means of posters and leaflets/invitation entitled “Taking care Women’s Health - a project aimed at women who have sexual relations with women, with men and with both women and men” and that included the researchers’ contacts and social network pages (@cuidandodamulher19, cuidadondodamulher19@gmail.com, pcsaudedamulher2019). Regarding WSW, dissemination was intensified among LGBT activism groups and participants from previous studies²²22 Ignácio MAO, Andrade J, Freitas APF, Pinto GVS, Silva MG, Duarte MTC. Prevalência de vaginose bacteriana e fatores associados em mulheres que fazem sexo com mulheres. Rev Lat-Am Enferm 2019; 26:e3077.. As a result, women interested in participating in our study contacted us to find out more about our research goals and how to participate.

The sample eventually consisted of 260 women of which 81 had either sex with women or with men and women (WSW) and 179 had sex exclusively with men (WSM).

The adoption of the WSW nomenclature is justified if we consider the diversity of sexual practices among women, regardless of their sexual orientation and identity, which requires that STI/AIDS prevention actions in this population prioritize their sexual history. Therefore, research on STI and WSW¹¹11 Barbosa RM, Facchini R. Acesso a cuidados relativos à saúde sexual entre mulheres que fazem sexo com mulheres em São Paulo, Brasil. Cad Saude Publica 2009; 25(Supl. 2):S291-S300.

12 Bertolin DC, Ribeiro RCHM, Cesarino CB, Silva DC, Prado DDO, Parro ES. Conhecimento de mulheres que fazem sexo com mulheres sobre o papilomavírus humano. Cogitare Enferm 2010; 15(4):730-735.

13 Rufino AC, Madeiro A, Trinidad A, Santos R, Freitas I. Práticas sexuais e cuidados em saúde de mulheres que fazem sexo com mulheres: 2013-2014. Epidemiol Serv Saude Rev Sist Unico Saude Bras 2018; 27(4):e2017499.^-1414 Oliveira ADS, Nery IS. Mulheres que fazem sexo com mulheres: atitudes e práticas sobre prevenção ao HIV/AIDS. Rev Enferm UFPI 2016; 5(3):10-17.^,1616 Kowalczyk R, Nowosielski K. Impact of social factors and sexual behaviors on the knowledge of sexually transmitted infections among women who have sex with women/women who have sex with women and men. Int J STD AIDS 2019; 30(2):163-172.^,1717 Paschen-Wolff MM, Reddy V, Matebeni Z, Southey-Swartz I, Sandfort T. HIV and sexually transmitted infection knowledge among women who have sex with women in four Southern African countries. Cult Heal Sex 2020; 22(6):705-721. has used this term to compare studies over time without neglecting the historical struggle of lesbian and bisexual women for their rights and inclusion in public and identity policies.

To collect data, we used a form of questions related to sociodemographic variables, substance consumption, sexual and protective behavior/practices, clinical conditions, and access to health centers. We also applied the following validated instruments: the Sexually Transmitted Diseases - Knowledge Questionnaire (STD-KQ)¹⁹19 Jaworski BC, Carey MP. Development and psychometric evaluation of a self-administered questionnaire to measure knowledge of sexually transmitted diseases. AIDS Behav 2007; 11(4):557-574., the Alcohol Use Disorder Identification Test (AUDIT)²³23 Babor T, Higgins-Biddle JC, Saunders JB, Monteiro MG. The Alcohol Use Disorders Identification Test: Guidelines for use in primary care. Geneva: WHO; 2001. and the Self-Reporting Questionnaire (SRQ-20)²⁴24 Harding TW, Climent CE, De Arango MV, Baltazar J, Ibrahim HHA, Ladrido-Ignacio L, Murthy RS, Wig NN. Mental disorders in primary health care: A study of their frequency and diagnosis in four developing countries. Psychol Med 1980; 10(2):231-241..

The form was developed for the main research and contains open and closed questions. It was submitted to experts in women’s and mental health who analyzed its clarity and contents, including one woman who has sex with woman. It was tested with women who were not part of the sample, and no changes were deemed necessary.

STD-KQ¹⁹19 Jaworski BC, Carey MP. Development and psychometric evaluation of a self-administered questionnaire to measure knowledge of sexually transmitted diseases. AIDS Behav 2007; 11(4):557-574. is a validated instrument that was developed in the U.S.A. by Jaworski and Carey in 2007 to assess knowledge about STIs and HIV/AIDS. The original version contains 27 items related to knowledge about HIV/AIDS, hepatitis B, human papillomavirus (HPV), genital herpes, chlamydia and gonorrhea and was adapted to Brazilian Portuguese in 2015²⁰20 Teixeira LO, Figueiredo VLM, Mendoza-Sassi RA. Adaptação transcultural do Questionário sobre Conhecimento de Doenças Sexualmente Transmissíveis para o Português Brasileiro. J Bras Psiquiatr 2015; 64(3):247-256.. One question about the use of lambskin condoms was removed and two questions about syphilis, a highly prevalent disease in Brazil, were included. The questionnaire can be self-administered and consists of 28 items that need be categorized as either “true”, “false” or “I don’t know”. The result is calculated by adding the correct answers, each of which counts one point, resulting in a maximum score of 28 points.

AUDIT²³23 Babor T, Higgins-Biddle JC, Saunders JB, Monteiro MG. The Alcohol Use Disorders Identification Test: Guidelines for use in primary care. Geneva: WHO; 2001. identifies reliable and standardized information on problematic alcohol consumption. It contains 10 questions about alcohol consumption in the 12 last months regarding quantity and frequency, dependence and consequences, its top score is 40 points. In our study, risk consumption was defined by a score equal to or greater than eight points.

The SRQ-20²⁴24 Harding TW, Climent CE, De Arango MV, Baltazar J, Ibrahim HHA, Ladrido-Ignacio L, Murthy RS, Wig NN. Mental disorders in primary health care: A study of their frequency and diagnosis in four developing countries. Psychol Med 1980; 10(2):231-241. is a screening questionnaire for Common Mental Disorders (CMD) used to assess general mental health conditions, such as anxiety, insomnia, and other symptoms of psychological distress. It consists of 20 questions of binary-type answers (yes/no, scoring 1 and 0, respectively). Women who scored 8 or more points are considered having some kind of CMD.

The data collection team consisted of three postgraduate nurses, including the first author, who were properly trained to apply the data collection instruments. Data collection took place at the Auxiliary Unit of the School of Medicine of Botucatu with 225 subjects until March 2020. It was interrupted due to the COVID-19 Pandemic and the remaining 35 subjects were interviewed between October and November 2020, as we were allowed to resume our research by complying with all health protection measures aimed at participants. Data collection lasted approximately 30 minutes per subject.

The outcome studied was the low level of knowledge about STI/AIDS (yes/no), which was the case when the correct percentage of the STD-KQ¹⁹19 Jaworski BC, Carey MP. Development and psychometric evaluation of a self-administered questionnaire to measure knowledge of sexually transmitted diseases. AIDS Behav 2007; 11(4):557-574. was below 50%.

The independent variable was the type of sexual partner (either WSW or WSM).

The following covariates were examined: age in years (18-21, 22-29, ≥30); self-reported skin color (white, non-white); full years of schooling (≤11 years and ≥12 years); marital status (together, not together); religion (yes/no); per capita family income in Brazilian Reais (BRL); paid professional activity (yes/no); tobacco use (yes/no); illicit drug use (yes/no); alcohol abuse (AUDIT²³23 Babor T, Higgins-Biddle JC, Saunders JB, Monteiro MG. The Alcohol Use Disorders Identification Test: Guidelines for use in primary care. Geneva: WHO; 2001.≥8 points, <8 points); number of sexual partners in the last three months (0, 1, ≥2); use of sex accessories (yes/no), consistent use of condoms in penetrative practices (in all vaginal and/or anal intercourses) (yes/no); use of hormonal contraceptives (yes/no); common mental disorder (SRQ-20²⁴24 Harding TW, Climent CE, De Arango MV, Baltazar J, Ibrahim HHA, Ladrido-Ignacio L, Murthy RS, Wig NN. Mental disorders in primary health care: A study of their frequency and diagnosis in four developing countries. Psychol Med 1980; 10(2):231-241.≥8 points, <8 points); opportunity to ask questions about STI/AIDS at health centers (yes/no); has received information on STI/AIDS prevention at a health center (yes/no); knows the female condom (yes/no); where they obtain information about STI/AIDS (media/formal education/family, friends, work/health center), had a gynecological visit in the 12 months prior to data collection (yes/no), obtained free condoms at health centers or at other locations (yes/no).

Data were coded and typed twice in a MS Excel® spreadsheet. Inconsistencies forced us to revise the instrument and to make the required corrections in the database. Data were made available after that.

The descriptive study of the categorical variables was based on the frequency distribution and the quantitative numerical variables, on measures of position and dispersion and, in the comparison of the groups, on the Chi -square and Fisher’s Exact tests. Multiple Cox regression models were adjusted to define the association between the type of sexual partner and the low level of knowledge about STI/AIDS, by including in the deterministic component of the models the most strongly associated variables (p<0.20), which were identified by means of a bivariate analysis. In the final model, associations were considered statistically significant if p<0.05. Analyzes were performed using the Statistical Package for the Social Sciences (SPSS 21) software program.

The research project was submitted and approved by the Research Ethics Committee of the School of Medicine of Botucatu, Universidade Estadual Paulista “Júlio de Mesquita Filho” and received a favorable verdict (No. 3.320.951). All participants were duly informed about the goals and ways of participation and the subjects who agreed to participate signed the Free and Informed Consent Term. After data collection, we provided guidance to women who lacked information or had questions about STI/AIDS.

Results

Women were 26 years old (18-50) on average and their per capita family income BRL 1,666.66 (BRL 223.30-BRL 15,000.00), respectively (data not shown in tables).

Most women were aged between 22 and 29 (43.5%), declared to be white (77.3%), had 12 or more full years of schooling (86.5%), were not in a relationship (77.3%), were religious (65.8%), had a gainful occupation (62.7%), had had a gynecological consultation in the 12 months prior to data collection (63.5%), clarified questions (56.5%) and received information about STI/AIDS at a health center (54.6%). 35.0% had used tobacco, 40.8% had used one or more illicit drugs, 42.3% had used alcohol abusively, and 16.9% used condoms consistently in penetrative practices (Table 1).

Among the 28 questions of the STD-KQ¹⁹19 Jaworski BC, Carey MP. Development and psychometric evaluation of a self-administered questionnaire to measure knowledge of sexually transmitted diseases. AIDS Behav 2007; 11(4):557-574., none of them was answered correctly by 100.0% of the women and no woman answered all the 28 questions of the instrument correctly. Questions whose percentage of correct answers was below 50% included: Frequent urinary infections are caused by Chlamydia (20.0%); Having anal sex increases a person’s risk of getting Hepatitis (35.8%); It is easier to catch HIV if a person also has some other kind of STD (39.2%); A woman can tell by the way she feels her body if she has an STD (45.0%); A woman can look at her body and tell if she has Gonorrhea (45.8%); A person with Genital Herpes must have open wounds to pass on the infection to their sexual partner (48.1%) (Table 2).

The correct median percentage of the STD-KQ¹⁹19 Jaworski BC, Carey MP. Development and psychometric evaluation of a self-administered questionnaire to measure knowledge of sexually transmitted diseases. AIDS Behav 2007; 11(4):557-574. questions of WSW was lower than that of WSM [68% (18%-96%) vs 75% (14%-96%); p=0.032]. WSW also had a higher percentage of poor knowledge level in relation to WSM (18.5% vs 7.8%, p=0.038) (data not shown in tables).

We observed that WSW had a lower percentage of correct answers than WSM regarding the following questions: HPV can lead to cancer in women (81.5% vs 92.7%, p=0.007); If a person has had Gonorrhea in the past, they are immune (protected) and cannot get infected again (67.9% vs 79.3%, p=0.046); Men can avoid getting Genital Warts by washing their genitals after sex (65.4% vs 79.3%, p=0.017); and Even if your partner has no lesions on their penis, anus or vagina, they may still infect you with syphilis (79.0% vs 92.2%, p=0.002) (Table 2).

The main sources of information on STI/AIDS cited by women were: mass media (74.2%), formal education (55.8%), health centers (54.5%) as well as family, friends and work (42.7%). It is noteworthy that a lower percentage of WSW received information from health centers compared to WSM (40.7% vs 60.9%, p=0.003) (Figure 1).

According to the bivariate analysis, variables most associated with poor knowledge about STI/AIDS (p<0.20) were non-white skin color [PR=1.79 (0.83-3.86); p=0.135]; less than 11 years of schooling [PR=3.92 (1.85-8.31); p≤0.001]; per capita family income [PR=1.00 (1.00-1.00); p=0.148]; illicit drug use [PR=0.55 (0.25-1.25); p=0.154]; use of hormonal contraceptives [PR=0.53 (0.22-1.23); p=0.139], clarified questions about STI/AIDS at health centers [PR=6.24 (2.38-16.37); p=0.000]; received information about STI/AIDS at health centers [PR=5.78 (2.20-15.14); p=0.000]; source of information on STI/AIDS by means of formal education and mass media [PR=2.80 (1.28-6.15); p=0.010], [RP=1.76 (0.83-3.73); p=0.139], respectively; and sexual partnership with women [PR=2.37 (1.14-4.91); p=0.020] (Table 3).

Table 4 presents the results of the Multiple Cox regression that investigated the variables that were associated with a low level of knowledge about STI/AIDS. The type of sexual partnership was independently associated with poor knowledge about STI/AIDS, where WSW showed a more than twofold increase in the prevalence of this outcome compared to WSM [PR=2.36 (1.07-5.21); p=0.033]. It was also observed that education was independently associated with a low level of knowledge about STI/AIDS: women having 11 years of schooling or less showed a two-and-a-half times higher prevalence of this outcome than those having 12 or more years of schooling [PR=2.64 (1.12-6.21); p=0.026] (Table 4).

Discussion

The present study identified an independent association between the type of sexual partner and a low level of knowledge about STI/AIDS, in which WSW showed worse results than WSM. The lowest level of education, less than 11 years of study, was also associated with the result of our analysis. The study made it further possible to identify specific topics on STI/AIDS in which WSW showed greater lack of knowledge and the main sources from which they obtain information, as they had received less information in health centers than WSM.

Literature points out that the mere fact of being informed about STI/AIDS may not necessarily lead to applying preventive practices. However, lack of knowledge does increase vulnerability to these infections¹³13 Rufino AC, Madeiro A, Trinidad A, Santos R, Freitas I. Práticas sexuais e cuidados em saúde de mulheres que fazem sexo com mulheres: 2013-2014. Epidemiol Serv Saude Rev Sist Unico Saude Bras 2018; 27(4):e2017499.^,1818 Brasil. Ministério da Saúde (MS). Pesquisa de conhecimento, atitudes e práticas na população brasileira. Brasília: MS; 2006.^,2525 Aragão JS, França ISX, Coura AS, Medeiros CCM, Enders BC. Vulnerability associated with sexually transmitted infections in physically disabled people. Cien Saude Colet 2016; 21(10):3143-3152.^,2626 Carey C, O'Donnell K, Davoren M, Quinlan M, Igoe D, Barrett P. Factors associated with lower knowledge of HIV and STI transmission, testing and treatment among MSM in Ireland: Findings from the MSM Internet Survey Ireland (MISI) 2015. Sex Transm Infect 2021; 97(5):351-356.. As shown in these studies, lower education may influence access and understanding of information and consequent exposure to risk situations. Despite the fact that our sample was made up of women with a high educational level, findings show a three-times higher risk of poor knowledge about STI/AIDS among women with less than 11 years of schooling.

Lower education level associated with poor knowledge about STI/AIDS was also found in national²⁷27 Miranda AE, Ribeiro D, Rezende EF, Pereira GFM, Pinto VM, Saraceni V. Associação de conhecimento sobre DST e grau de escolaridade entre conscritos em alistamento ao Exército Brasileiro, Brasil, 2007. Cien Saude Colet 2013; 18(2):489-497.

28 Carvalho FF, Takeda E, Chagas EFB, Pinheiro OL. Knowledge of the prison population about sexually transmitted infections. Rev Gauch Enferm 2020; 41:e20190268.^-2929 Rodrigues VCC, Lopes GF, Silveira GEL, Sousa IB, Sena MM, Lopes TSS, Aquino PS. Fatores associados ao conhecimento e atitude de adolescentes quanto ao uso de preservativo masculino. Rev Bras Enferm 2021; 74(Supl. 4):e20190452. and international³⁰30 Keizur EM, Bristow CC, Baik Y, Klausner JD. Knowledge and testing preferences for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis infections among female undergraduate students. J Am Coll Heal 2020; 68(7):754-761.^,3131 Yaya S, Bishwajit G, Danhoundo G, Shah V, Ekholuenetale M. Trends and determinants of HIV/AIDS knowledge among women in Bangladesh. BMC Public Health 2016; 16(1):812. studies that evaluated the general population, adolescents and a population deprived of freedom. Our study shows that more than twice as many WSW had a low level of knowledge about STI when compared with WSM and that having sex with a woman was independently associated with this finding.

In a recent study performed in Southern Africa¹⁷17 Paschen-Wolff MM, Reddy V, Matebeni Z, Southey-Swartz I, Sandfort T. HIV and sexually transmitted infection knowledge among women who have sex with women in four Southern African countries. Cult Heal Sex 2020; 22(6):705-721. with a sample of 591 WSW, 60.7% had never received any kind of information about STI/AIDS. Among those who had access to that kind of information, 70.6% had received it from LGBT organizations, 50.9% from pamphlets and flyers, 39.9% from friends, 31.6% from family members and the Internet. These data contrast with those obtained by our study in which the media, including the Internet, provided WSW with most information about STI/AIDS (74.1%), followed by formal education (51.9%), family/friends/work (42.0%) and health care professionals (40.7%). These data highlight the important role of discussions on sexual and reproductive health issues for the LGBT population, with a special focus on WSW, including training of health professionals and health centers to reduce health inequities.

The STD-KQ¹⁹19 Jaworski BC, Carey MP. Development and psychometric evaluation of a self-administered questionnaire to measure knowledge of sexually transmitted diseases. AIDS Behav 2007; 11(4):557-574. is a validated questionnaire that has been used in several countries and with different populations³²32 Pereira H. Sexually Transmitted Diseases: Knowledge and Perceived Prevalence of Symptoms in University Students. Int STD Res Rev 2014; 2(1):1-11.

33 Logie CH, Daniel C, Newman PA, Weaver J, Loutfy MR. Psycho-educational HIV/STI prevention intervention for internally displaced women in leogane, haiti: Results from a non-randomized cohort pilot study. PLoS One 2014; 9(2):e89836.

34 Saad A, Rampal L, Sabitu K, AbdulRahman H, Awaisu A, AbuSamah B, Ibrahim A. Impact of a customized peer-facilitators training program related to sexual health intervention. Int Health 2012; 4(4):277-282.^-3535 Pourmarzi D, Sharami S. Midwives' educational needs and knowledge about sexually transmittable infections in the Islamic Republic of Iran. East Mediterr Heal J 2017; 23(9):611-618.. It was used for the first time by our study to assess knowledge of WSW, which is an opportunity to compare studies on similar topics in the future. Previous studies that used other knowledge measurement methods showed that WSW had insufficient levels of knowledge about STI/AIDS¹²12 Bertolin DC, Ribeiro RCHM, Cesarino CB, Silva DC, Prado DDO, Parro ES. Conhecimento de mulheres que fazem sexo com mulheres sobre o papilomavírus humano. Cogitare Enferm 2010; 15(4):730-735.^,1515 Marrazzo JM, Coffey P, Bingham A. Sexual Practices, Risk Perception and Knowledge of Sexually Transmitted Disease Risk Among Lesbian and Bisexual Women. Perspect Sex Reprod Health 2005; 37(1):6-12.

16 Kowalczyk R, Nowosielski K. Impact of social factors and sexual behaviors on the knowledge of sexually transmitted infections among women who have sex with women/women who have sex with women and men. Int J STD AIDS 2019; 30(2):163-172.^-1717 Paschen-Wolff MM, Reddy V, Matebeni Z, Southey-Swartz I, Sandfort T. HIV and sexually transmitted infection knowledge among women who have sex with women in four Southern African countries. Cult Heal Sex 2020; 22(6):705-721., which corroborates the findings of our study.

On the other hand, a Brazilian study that evaluated the knowledge of WSW about HIV/AIDS¹⁴14 Oliveira ADS, Nery IS. Mulheres que fazem sexo com mulheres: atitudes e práticas sobre prevenção ao HIV/AIDS. Rev Enferm UFPI 2016; 5(3):10-17. by means of an evaluative survey concluded that WSW had regular knowledge about that disease. However, use of protective measures was erratic, which is confirmed by our study, according to which 96.0% of WSW were not using condoms on a regular basis.

Our study detected some gaps in terms of knowledge about STIs, especially about forms of contamination and transmission of HPV, Gonorrhea and Syphilis. Knowledge about these infections is essential as it impacts the sexual and reproductive health of this population. Studies show a high prevalence of STIs, especially in WSW²¹21 Andrade J, Ignácio MAO, Freitas APF, Parada CMGL, Duarte MTC. Vulnerabilidade de mulheres que fazem sexo com mulheres às infecções sexualmente transmissíveis. Cien Saude Colet 2020; 25(10):3809-3819.^,3636 Pinto VM, Tancredi MV, Tancredi Neto A, Buchalla CM. Sexually transmitted disease/HIV risk behaviour among women who have sex with women. AIDS 2005; 19(Supl. 4):S64-S69.. Educational practices aimed at that group should therefore emphasize that kind of information, especially when larger gaps are detected.

It is noteworthy that in our study, only a small number of health professionals provided information on STI/AIDS and even less to WSW when compared to WSM. The same situation was found by an international study¹⁷17 Paschen-Wolff MM, Reddy V, Matebeni Z, Southey-Swartz I, Sandfort T. HIV and sexually transmitted infection knowledge among women who have sex with women in four Southern African countries. Cult Heal Sex 2020; 22(6):705-721., which might be due to their lack of preparation and difficulties in assisting women whose sexual practice depart from heteronormativity²¹21 Andrade J, Ignácio MAO, Freitas APF, Parada CMGL, Duarte MTC. Vulnerabilidade de mulheres que fazem sexo com mulheres às infecções sexualmente transmissíveis. Cien Saude Colet 2020; 25(10):3809-3819.^,3737 Cardoso HM, Moretti-Pires RO, Campos DA. Gênero, sexualidade e saúde: mapeamento das exclusões de pessoas LGBT em situação de rua frente nos serviços de saúde no município de Florianópolis, SC. Brazilian J Dev 2020; 6(8):54255-54266.^,3838 Hafeez H, Zeshan M, Tahir MA, Jahan N, Naveed S. Health Care Disparities Among Lesbian, Gay, Bisexual, and Transgender Youth: A Literature Review. Cureus 2017; 9(4):e1184..

Health care environments are expected to welcome and offer care to everyone, to accept their singularities and pluralities and to be free from prejudices and stigmas. However, even today, people in homosexual relationships are often invisible and their specific care needs are often ignored³⁹39 Paulino DB, Rasera EF, Teixeira FDB. Discourses on the healthcare of lesbian, gay, bisexual, and transgender (LGBT) people adopted by doctors working in brazil's family health strategy. Interface (Botucatu) 2019; 23:e180279.^,4040 Santos AR, Santos RMM, Souza ML, Boery RNSO, Sena ELS, Yarid SD. Implicações bioéticas no atendimento de saúde ao público LGBTT. Rev Bioet 2015; 23(2):400-408.. Studies have shown that the LGBT population has had less access to health centers⁴⁰40 Santos AR, Santos RMM, Souza ML, Boery RNSO, Sena ELS, Yarid SD. Implicações bioéticas no atendimento de saúde ao público LGBTT. Rev Bioet 2015; 23(2):400-408.^,4141 Alencar AG, Lima GC, Silva QG, Alves MJH, Belém JM, Santos FFW, Paiva LS, Nascimento VB, Maciel ÉS, Valenti VE, Abreu LC, Adami F. Access to health services by lesbian, gay, bisexual, and transgender persons: systematic literature review. BMC Int Health Hum Rights 2016; 16:2. and that most health professionals ignore their specific needs, perpetuating the wrong perception that there is a low transmission risk of STI/AIDS among WSW⁴²42 Muzny CA, Sunesara IR, Martin DH, Mena LA. Sexually transmitted infections and risk behaviors among African American women who have sex with women: Does sex with men make a difference? Sex Transm Dis 2011; 38(12):1118-1125.. It has been shown by previous studies that an important factor associated with WSW’s vulnerability to STI/AIDS is the low perception of risk, which increases the chance of contracting infections²¹21 Andrade J, Ignácio MAO, Freitas APF, Parada CMGL, Duarte MTC. Vulnerabilidade de mulheres que fazem sexo com mulheres às infecções sexualmente transmissíveis. Cien Saude Colet 2020; 25(10):3809-3819.^,4242 Muzny CA, Sunesara IR, Martin DH, Mena LA. Sexually transmitted infections and risk behaviors among African American women who have sex with women: Does sex with men make a difference? Sex Transm Dis 2011; 38(12):1118-1125.. However, those studies mention that these infections are exclusively related to sexual relations with male partners, which corroborates studies that showed that WSW undergo fewer gynecological consultations, fewer routine tests for cervical cancer screening and fewer serological tests¹³13 Rufino AC, Madeiro A, Trinidad A, Santos R, Freitas I. Práticas sexuais e cuidados em saúde de mulheres que fazem sexo com mulheres: 2013-2014. Epidemiol Serv Saude Rev Sist Unico Saude Bras 2018; 27(4):e2017499.^,4343 Curmi C, Peters K, Salamonson Y. Barriers to cervical cancer screening experienced by lesbian women: a qualitative study. J Clin Nurs 2016; 25(23-24):3643-3651.

44 Ramos LG, Medeiros BM. Saúde sexual de mulheres que fazem sexo com mulheres: Prevenção de infecções sexualmente transmissíveis. Rev Context Saude 2021; 21(43):214-224.^-4545 Rodrigues JL, Falcão MTC. Vivências de atendimentos ginecológicos por mulheres lésbicas e bissexuais: (in)visibilidades e barreiras para o exercício do direito à saúde. Saude Soc 2021; 30(1):e181062..

Our research data show that health centers should increasingly use mass media and promote a closer contact between formal education equipment and workspaces for the dissemination of clear and specific information about the STI/AIDS aimed at WSW, especially considering the knowledge gaps our study highlights. It also suggests that professionals should be better prepared for health education and multidisciplinary actions aimed at WSW, including better planning of educational actions and an emphasis on the role of nurses, given their specific training in this area⁴⁶46 Rosa DF, Carvalho MVF, Pereira NR, Rocha NT, Neves VR, Rosa AS. Nursing Care for the transgender population: genders from the perspective of professional practice. Rev Bras Enferm 2019; 72(Supl. 1):299-306.

47 Nietsche EA, Tassinari TT, Ramos TK, Beltrame G, Salbego C, Cassenote LG. Nursing training for care to the homosexual and bisexual population: Students' perception. Rev Baiana Enferm 2018; 32:e25174.^-4848 Kawata LS, Mishima SM, Chirelli MQ, Pereira MJ, Matumoto S, Fortuna CM. Attributes mobilized by nurses in Family Health: Reaching performances when developing managerial competence. Rev Esc Enferm USP 2011; 45(2):349-355..

Our study further suggests investing in health education aimed at WSW, especially in inclusion strategies and discussions on this topic in digital media and as content of formal education subjects and courses on health. Since these sources of information on STI/AIDS are the least often mentioned by this group, it is essential that this topic be included in continuous education of health professionals.

One of the drawbacks of our study is the fact that it was developed at a regional level, preventing us from creating comparison groups between women who have sex exclusively with women and those who have sex with both men and women. This is due to the difficulty of creating a representative sample and to the fact that subjects are mostly white and have a high level of education. However, our research remains relevant insofar as it addresses a population group that is considered difficult to access, the lack of studies on that topic and due to its originality, which results from having used a highly reliable instrument that allows to reduce the knowledge gap in this area and thus subsidize actions aimed at the sexual and reproductive health of this population group.

Conclusion

The WSW investigated in the present study had poor knowledge about STI/AIDS compared to WSM and the fact that they were less educated was independently associated with this outcome.

There is an emerging need to put into practice public policies aimed at WSW, as well as a need to invest in health education aimed at this group, especially considering strategies aimed at mass media, formal education, opportunities in health centers. In addition, we suggest that this topic should be discussed to a greater extent in undergraduate courses and continuing education of health professionals to improve the current situation.

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