Abstract

The bond with healthcare services is a crucial dimension in facilitating the maternal journey of lesbian and bisexual women couples. This study aimed to analyze the culturally constructed meanings regarding the bond with healthcare services and professionals by lesbian and bisexual women who experienced dual motherhood. It is a qualitative investigation grounded in interpretative anthropology. The research corpus was built based on in-depth interviews with 10 lesbian and bisexual women, aged 30 to 39 years. The results indicate that access to parenthood, until its realization, involved a journey permeated by satisfactions and sufferings triggered by failed attempts and gestational losses. Challenges experienced in healthcare provision were also reported due to prejudices, lack of empathy, and unpreparedness of professionals in dealing with prenatal care for lesbian and bisexual women couples. Manifestations of discrimination were more pronounced concerning non-gestational mothers. The findings offer insights into implementing policies that prioritize humanization and planning programs and healthcare services based on culturally sensitive care for lesbian and bisexual women couples as they transition into dual motherhood.

Key words:
Sexual and gender minorities; Woman’s health; Health services; Patient satisfaction

Introduction

We cannot lose sight of the fact that the social, cultural, economic, political, and scientific changes that drive the dynamics of contemporary society have driven profound transformations in the concepts and meanings of practices that regulate family relationships¹1 Vespucci G. Una fórmula deseable: el discurso "somos famílias" como símbolo hegemónico de las reivindicaciones gay-lésbicas. Sex Salud Soc 2014; 17:30-65.. Although a dominant conception still prevails of a monogamous, heterocentric and patriarchal nuclear family, this issue takes on new contours, as this hegemonic model has been challenged in recent decades with the mutations observed in the sociocultural scenario, which have impacted the organization and functioning of contemporary families²2 Gato J, Fontaine AM. Impacto da orientação sexual e do género na parentalidade: uma revisão dos estudos empíricos com famílias homoparentais. Exaequo 2011; 23:83-96.^,33 Lacoste PV, López MEP, Gallegos BP. Discursos conservadores en torno a las familias: entre el orden de género y las falacias naturalistas: el caso del Frente Nacional por la Familia en México (FNF). Cien Soc Relig 2022; 24:e022001.. Values and the symbolic legacy of patriarchy still resist, but they are being put to the test⁴4 Tannuri JGCG, Silva M. Família homoparental: enfrentando a vitalidade do patriarcado. Rev Linhas 2019; 20(43):256-271..

The contemporary era has fostered openings that allow visibility to be given to a variety of family configurations that challenge traditional kinship and filiation relationships⁵5 Meletti AT, Scorsolini-Comin F. Conjugalidade e expectativas em relação à parentalidade em casais homossexuais. Rev Psicol Teor Prat 2015; 17(1):37-49.^,66 Vilhena J, Souza BCA, Uziel PA, Zamora H, Novaes VJ. Que família? Provocações a partir da homoparentalidade. Mal-Estar Subj 2011; 11(4):1639-1658.. One of the most persistent questions calls into question the essentialist notion that there is complementarity between men and women, which would be expressed in the reproductive function and in the idea that only heterosexual unions can provide an ideal environment for the psychological development of children²2 Gato J, Fontaine AM. Impacto da orientação sexual e do género na parentalidade: uma revisão dos estudos empíricos com famílias homoparentais. Exaequo 2011; 23:83-96.^,77 Lira AN, Morais NA, Boris GDJB. Concepções e modos de viver em família: a perspectiva de mulheres lésbicas que têm filhos. Psicol Teor Pesq 2016; 32(4):e324213..

The affirmation of stable romantic relationships between people of the same gender has gained prominence in the public debate both in Brazil and in the Western world⁵5 Meletti AT, Scorsolini-Comin F. Conjugalidade e expectativas em relação à parentalidade em casais homossexuais. Rev Psicol Teor Prat 2015; 17(1):37-49.. Homoparental families have gained prominence in studies on families in recent decades precisely because they promote a development context that does not follow the traditional heterocentric paradigm, as they are made up of affective relationships and parental bonds between people with sexual orientations that differ from the heteronormative standard, such as family groups made up of lesbians, gays, bisexuals and trans or non-binary people⁷7 Lira AN, Morais NA, Boris GDJB. Concepções e modos de viver em família: a perspectiva de mulheres lésbicas que têm filhos. Psicol Teor Pesq 2016; 32(4):e324213.^,88 Santos YGS, Scorsolini-Comin F, Santos MA. Homoparentalidade masculina: revisando a produção científica. Psicol Reflex Crit 2013; 26(3):572-582..

Among the family configurations that are systematically erased and made invisible by the limiting norms of the heteronormative framework, we find the experiences of double motherhood. This construct, which is sometimes referred to in the literature with terms such as lesbian motherhood, refers to the experience of couples of women who maintain an affective-sexual relationship and who experience the project of being mothers⁹9 Azeredo RFD. Maternidade lésbica no Brasil: uma revisão de teses e dissertações nas Ciências Sociais, Humanas e da Saúde [dissertação]. Rio de Janeiro: Universidade do Estado do Rio de Janeiro; 2018.. Such family configurations challenge the stereotypes of heterocisgenderity and question the supposed complementarity between feminine and masculine, binary assumptions that underlie the construction of gendered roles, regulated by scripts to be followed in the parental itinerary.

The literature shows that strategies for accessing parenthood can include different devices - adoption, coparenting, and previous heterosexual relationships, as occurs in stepfamilies, and may or may not involve the use of reproductive technologies¹⁰10 Cecílio MS, Scorsolini-Comin F, Santos MA. Produção científica sobre adoção por casais homossexuais no contexto brasileiro. Estud. Psicol 2013; 18(3):507-516.. The use of different means and resources sometimes reproduces the binary heterosexual model, sometimes deconstructs and denaturalizes it, highlighting original and plural ways to fulfill the desire to build and live in a family⁵5 Meletti AT, Scorsolini-Comin F. Conjugalidade e expectativas em relação à parentalidade em casais homossexuais. Rev Psicol Teor Prat 2015; 17(1):37-49.^,77 Lira AN, Morais NA, Boris GDJB. Concepções e modos de viver em família: a perspectiva de mulheres lésbicas que têm filhos. Psicol Teor Pesq 2016; 32(4):e324213.. From this perspective, it is important to focus, from different perspectives, on the subjective and intersubjective aspects that contribute to the constitution of the homoparental family, without disregarding the socio-historical character of the family institution, whether in its hetero or homoparental configuration⁴4 Tannuri JGCG, Silva M. Família homoparental: enfrentando a vitalidade do patriarcado. Rev Linhas 2019; 20(43):256-271.^,88 Santos YGS, Scorsolini-Comin F, Santos MA. Homoparentalidade masculina: revisando a produção científica. Psicol Reflex Crit 2013; 26(3):572-582..

Public policies, programmatic actions, and social technologies aimed at the LGBTQIAPN+ community (Lesbian, Gay, Bisexual, Transvestite and Transgender, Queer, Intersex, Asexual, Pansexual, Non-binary, and others who fall within the field of sexual and gender dissent) originate in the recognition that the lack of social policies to combat prejudice, discrimination, and exclusion make this part of the population vulnerable¹¹11 Mello L, Brito W, Maroja D. Políticas públicas para a população LGBT no Brasil: notas sobre alcances e possibilidades. Cad Pagu 2012; 39:403-429.. It is enough to remember that, until recently, there was no health promotion policy aimed at the community within the scope of the Ministry of Health.

In the wake of the fight for social legitimacy, the National LGBT Comprehensive Health Policy, established in Ordinance No. 2,836, of 2011, is considered an important historical milestone for recognizing the perverse consequences of discrimination and exclusion, and for reaffirming the rights of this population¹²12 Brasil. Ministério da Saúde (MS). Portaria nº 2836, de 1º de dezembro de 2011. Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais, Travestis e Transexuais. Diário Oficial da União; 2011.. The creation and subsequent implementation of this policy stems from a process of maturation of emancipatory struggles and the gradual conquest of spaces by past generations, which need to be continually reaffirmed in everyday life¹³13 Laurentino ACN. Políticas públicas de saúde para a população LGBT: da criação do SUS à implementação da Política Nacional de Saúde Integral de LGBT [dissertação]. Rio de Janeiro: Fundação Oswaldo Cruz; 2015..

The demands that are currently placed in the field of public health contribute to reorganizing social movements and reflect demands from specific groups that feel relegated to the margins, who request understanding from the perspective of differentiated care¹³13 Laurentino ACN. Políticas públicas de saúde para a população LGBT: da criação do SUS à implementação da Política Nacional de Saúde Integral de LGBT [dissertação]. Rio de Janeiro: Fundação Oswaldo Cruz; 2015.. In recent decades, specific actions geared toward the LGBTQIAPN+ population were focused on partial policies to combat HIV and the spread of AIDS. Even in this context, the health of lesbian and bisexual women was largely neglected, reflecting the biases that permeate the relationships between gender and health. For this reason, the need for a plural and multifocal approach to this topic has been increasingly valued, with its implications in the field of women’s sexual and reproductive rights¹⁴14 Corrêa MEC. Duas mães? Mulheres lésbicas e maternidade [tese]. São Paulo: Faculdade de Saúde Pública; 2012..

The issues reported by women involved in creating the couple show the need for specific studies on their needs, including psychosocial support through different modalities of support and care, at different levels of health promotion, prevention, and intervention, especially in the Brazilian reality, which still lacks reliable studies on the issue⁹9 Azeredo RFD. Maternidade lésbica no Brasil: uma revisão de teses e dissertações nas Ciências Sociais, Humanas e da Saúde [dissertação]. Rio de Janeiro: Universidade do Estado do Rio de Janeiro; 2018.. In recent years, this topic has gained increasing space, but double motherhood still faces barriers to impose its agenda and increase its visibility.

Advances in biomedical knowledge have made it possible to use new reproductive technologies to facilitate the maternal project of couples of lesbian/bisexual women, who now have procedures that allow for the pregnancy of one or both partners, using or not their genetic material¹⁴14 Corrêa MEC. Duas mães? Mulheres lésbicas e maternidade [tese]. São Paulo: Faculdade de Saúde Pública; 2012.^,1515 Bos HM, Gartrell NK. Lesbian-mother families formed through donor insemination. In: AE Goldberg AE, Allen KR, editors. LGBTQ-parent families: innovations in research and implications for practice. 2ª ed. Worcester: Springer Publishing; 2020. p. 25-44.. Furthermore, families built through adoption have always been part of - and continue to be part of - the dual motherhood scenario, and the adoption process can be requested by the couple or by one of the partners⁵5 Meletti AT, Scorsolini-Comin F. Conjugalidade e expectativas em relação à parentalidade em casais homossexuais. Rev Psicol Teor Prat 2015; 17(1):37-49..

Considering this panorama, the present study was designed, which aimed to analyze the culturally constructed meanings about the bond with health services and professionals by lesbian and bisexual women who experienced double motherhood.

Method

Methodological design

This study is an investigation based on a qualitative approach and conducted in the field of health anthropology¹⁶16 Alves PC, Rabelo MC, organizadores. Antropologia da saúde: traçando identidade e explorando fronteiras. Rio de Janeiro: Editora Fiocruz, Editora Relume Dumará; 1998.. In international scientific literature, as well as in the Brazilian context, there is a consistent body of research that results in vast bibliographical production with the application of qualitative methods in Collective Health¹⁷17 Minayo MCS. Sampling and saturation in qualitative research: consensuses and controversies. Rev Pesqui Qualit 2017; 5(7):1-12.. The basis of these studies is the interpretation that social actors give to their actions and practices, based on culture, and their resonances in the production of health¹⁶16 Alves PC, Rabelo MC, organizadores. Antropologia da saúde: traçando identidade e explorando fronteiras. Rio de Janeiro: Editora Fiocruz, Editora Relume Dumará; 1998..

Qualitative research seeks to understand the meanings that subjects attribute to their experiences and, to this end, it must be flexible and dynamic¹⁷17 Minayo MCS. Sampling and saturation in qualitative research: consensuses and controversies. Rev Pesqui Qualit 2017; 5(7):1-12.. The methods and aspects related to the study design can be modified as new information is collected. The analysis and interpretation of data also changes over the course of the study as new elements are incorporated and we gain better knowledge of the studied context. In the qualitative approach, the research process is dynamic, flexible, alive, non-linear, non-homogeneous, and non-sequential.

Participants

Ten adult women participated in the study, who self-identified as cisgender lesbian or bisexual women who shared the experience of motherhood with another woman. The following inclusion criteria for the study were established: age over 18 years, self-identification as a lesbian or bisexual woman, who experienced double motherhood. The exclusion criteria were: not having an online access device or internet connection, necessary for data collection; and the impossibility of securing a safe and private place (at home or at work) to participate in an online interview.

Participants were selected using the snowball method. The index person (first to be interviewed) was an active member of an online group on the topic of double motherhood and suggested potential interviewees, including contacting women who were not members of that group, which boosted data collection and ensured the diversity of the set. The first person indicated by the index participant was contacted and, upon confirmation of her availability, data collection continued. This was done successively with the others, until sample saturation was reached, which occurred with eight participants. To ensure this, we carried out two more interviews, which corroborated the recurrence of information, ensuring that saturation was reached. Therefore, the number of interviewees was defined a posteriori using the data saturation criterion¹⁷17 Minayo MCS. Sampling and saturation in qualitative research: consensuses and controversies. Rev Pesqui Qualit 2017; 5(7):1-12. (Chart 1).

Data collection

The precautions recommended by the literature regarding the use of online interviews were observed. The research corpus was constructed based on individual interviews, complemented by the researcher’s notes containing a detailed record of impressions, reflections, and feelings aroused by the participants’ experiences.

The material produced in the interactive context with the interlocutors is based on the perspective of listening and the perspective of a researcher who defines herself as a cisgender lesbian and white woman, researcher in the field of lesbianities. The open, in-depth interview included a guiding question, which asked the participant to talk about her experiences with dual motherhood. The interview was conducted in such a way as to make the interlocutor feel comfortable and free to express herself in relation to the events and thoughts that she considered relevant in her motherhood journey. The use of this specific type of interview is consistent with the objective of the study, as it allows the interlocutors to freely express their experiences, feelings, and meanings attributed to the events they identified as relevant to understanding their experiences with dual motherhood.

Initial contact with the participants was made through messaging applications and digital social networks. For those who accepted the invitation, the Free and Informed Consent Form (FICF) was sent. For those who were contacted via Instagram, the FICF was sent by email or WhatsApp, due to the limitations of the digital platform. Participants were asked to sign the form before carrying out the interview and to ensure that the meetings took place in a private place and under conditions of security and confidentiality. It is important to guarantee a virtual environment free from interference from third parties and that offers comfort and privacy, considering the possibility that sensitive topics related to the interviewees’ privacy could be addressed during the conversation.

The interviews were conducted online, via the Google Meet digital platform, between July and December 2022, lasting between 51 and 92 minutes. The conversations were recorded using the video calling feature provided by the digital platform, with prior consent from the participants. The material was later transcribed in full by the researcher, respecting the literalness of the statements.

Data analysis

The research development process included careful analysis of the collected material, which included the researcher’s reflective and observational field notes, describing in detail facts, acts, and feelings awakened from her observation of the field. Exhaustive readings of the material were carried out based on an analysis procedure, which made it possible to identify units of meaning that gave rise to the thematic axes, providing support for the interpretation of data and the construction of results¹⁷17 Minayo MCS. Sampling and saturation in qualitative research: consensuses and controversies. Rev Pesqui Qualit 2017; 5(7):1-12..

The collected data were successively organized and refined into themes and the analysis consisted of the constant comparison of elements that emerged from the different observations, seeking to capture common/convergent elements and possible differences/divergences in the records. At this stage of the analysis, it was possible to establish the recurrences and singularities observed in the situations and contexts reported by the interviewees, taking care to separate and differentiate the convergences of singularities (unique marks)¹⁷17 Minayo MCS. Sampling and saturation in qualitative research: consensuses and controversies. Rev Pesqui Qualit 2017; 5(7):1-12..

Geertz’s Interpretative Theory of Culture was used as a theoretical framework for data interpretation¹⁸18 Geertz C. A interpretação das culturas. São Paulo: Livros Técnicos e Científicos; 1989.. This framework emphasizes the importance of cultural diversity as a multifaceted and innovative resource, used to broaden the view of the complexity of the meanings of human actions, drawing inspiration from values such as divergence, respect, and sharing of ideas and experiences of the mothers interviewed in the construction of their experiences and social practices related to double motherhood.

In this epistemological conception, anthropological knowledge arises from symbolic practices and discourses fueled by differences and their borders. In interpretative anthropology, the search for knowledge takes place through the effort to get closer to others, understood as a way to embrace otherness and legitimize what is different. In the path outlined to understand reality, it is admitted that uncertainties, paradoxes, and ambiguities are an inherent part of the process. The valorization of such elements replaces the search for causal, regular, cyclical relationships, as it privileges a range of attempts at understanding produced in local and particular contexts, in which it is expected that unforeseen events and previously unknown challenges will appear during the research itinerary¹⁸18 Geertz C. A interpretação das culturas. São Paulo: Livros Técnicos e Científicos; 1989..

The affirmation of double motherhood offers a catalytic context for the destabilization of certainties and established beliefs in relation to the family and raising children, introducing unpredictability into a field scrutinized by hegemonic and standardizing discourses, at the same time that the production of local knowledge is valued¹⁸18 Geertz C. A interpretação das culturas. São Paulo: Livros Técnicos e Científicos; 1989..

The results of the analyses were systematized and interpreted based on studies in the area of dual motherhood, guided by the theoretical framework of interpretative anthropology, which made it possible to unveil the dimensions of the living experience revealed from the viewpoint of its protagonists.

This study obtained prior approval from the institution’s Research Ethics Committee (CAAE No. 58782922.5.0000.5407) and followed the recommendations recommended by Resolution No. 510/2016, safeguarding the right to privacy of participants and their families.

Results and discussion

Regarding the sociodemographic characteristics of the participants, the age range varied between 30 and 39 years (average age 34.5 years). Regarding the level of education, three had completed higher education (Samantha, Camila, and Vivan), two had incomplete higher education (Débora and Maria), two had completed postgraduate studies (Talita and Tarsila), two had incomplete postgraduate studies (Alice and Coral) and Renata had completed high school. In relation to work activity/occupation, eight participants were active in the exercise of their professions. Camila was a micro-entrepreneur (innkeeper), Vivan was a stylist, Tarsila was a doctor, Débora was a municipal public servant, Alice was an advertiser, Coral was a public health consultant, and Maria was an administrator and proofreader. Samantha declared that she works as a freelancer. Talita and Renata were not engaged in paid work at the time of the interview and reported having left the job market after having children.

Nine participants declared themselves married (Talita, Vivan, Tarsila, and Débora for three years; Alice and Renata four years; Camila and Coral seven years; and Maria eight years), and one was recently separated (Samantha). All the women had regularized their relationships, some even before stable unions were equated with marriage between people of the same sex, as a way of guaranteeing social and legal rights.

It is noted that all interviewees used assisted reproductive technologies and none had children from previous relationships. A common element in the reported experiences was the loss of babies and successive failed pregnancy attempts during the in vitro fertilization process.

Regarding family composition, eight interviewees (Talita, Camila, Vivan, Tarsila, Débora, Alice, Coral, and Renata) reported having a nuclear family, one participant reported having a single-parent family at the time of the interview (Samantha, in the process of recent separation) and another classified her family as extended (Maria, who lives with her wife, son, and mother-in-law).

Family income ranged from R$ 1,000.00 to R$ 40,000.00. Regarding religious affiliation, six participants declared no affiliation (Samantha, Talita, Camila, Tarsila, Débora and Coral) or were atheist (Samantha). Vivan claimed to be a “practicing pagan”, attending her religious practices monthly. Alice declared to be a spiritualist, but stated that, after the birth of her son, she became lax in her religious practices, which were weekly in the period before the transition to motherhood. Maria claimed to be Catholic, with weekly religious practices. Renata also declared herself Catholic but stated that she has not practiced it recently.

With the support of interpretative anthropology, we seek to understand the ways in which the women interviewed express and interpret their experiences of gratification and suffering within the scope of reproductive health services to enable motherhood. The theme was created: “Building links with health services and professionals”. The statements were coded as follows: MG: pregnant mother; MN: non-pregnant mother.

The results show that the desire to be a mother was inscribed early in the participants’ history:

The pregnancy-puerperal process was experienced as a sensitive experience that establishes the foundations of mother-child bonding, along with the desire and, at the same time, fear of what it would be like to care for a child. To make pregnancy viable, women resorted to in vitro fertilization techniques. Reproductive technologies currently allow, through the Reception of Eggs from the Partner (ROPA) method, for one of the women in the couple to have children with the implanted egg of the other. It is also possible to use donated semen, whether from known men or an unknown donor⁹9 Azeredo RFD. Maternidade lésbica no Brasil: uma revisão de teses e dissertações nas Ciências Sociais, Humanas e da Saúde [dissertação]. Rio de Janeiro: Universidade do Estado do Rio de Janeiro; 2018.^,1515 Bos HM, Gartrell NK. Lesbian-mother families formed through donor insemination. In: AE Goldberg AE, Allen KR, editors. LGBTQ-parent families: innovations in research and implications for practice. 2ª ed. Worcester: Springer Publishing; 2020. p. 25-44.. The experience with medical treatment was assessed as “terrible” by one of the interlocutors:

Concerns about the pregnancy-puerperal process, which sometimes accompany experiences of transition to motherhood, need to find a welcoming environment in the health sector. However, the majority of participants reported some critical incident during meetings with health service professionals:

Most interlocutors accessed specialized services from the private network. Camila highlighted the good experience she had with the service provided by SUS (“they are more receptive than in private”). All couples initially chose to use reproductive technologies based on the understanding that the biological route would be the fullest way to experience motherhood. When couples made the use of technology their first choice, they experienced setbacks and disruptive experiences, such as interrupted pregnancies. In most couples, the resulting suffering was mitigated thanks to the relief provided by the successful outcome after several unsuccessful attempts:

There were those who ended up choosing the path of adoption, as they were unable to complete the process after several failed pregnancy attempts. Mishaps experienced during health care were also reported regarding the quality of the bond established with professionals. The most striking manifestations of lesbophofia were directed at non-pregnant mothers:

To protect themselves from possible exposure to prejudice and discrimination in healthcare settings, some anticipated and took some precautions:

From the perspective of the interlocutors, health professionals often ratify the prescriptions of heteronormativity:

There was a bit of this burden, like: “Ah, so [wife’s name] is the mother who is carrying the baby, and you are the mother who goes to work”. So, like: “You’re a man” [makes sign of quotation marks with your hands] (Coral, 39, MN).

There is a socially constructed space for non-pregnant mothers: a discredited and invisible place. It’s as if there were a constant validation of the popular adage that states: “there is only one mother”. The difference culturally attributed to whoever bears and carries the baby is evident even in the (im)possibility of expressing one’s own suffering in the face of painful experiences of pregnancy loss:

There are situations in which the couple themselves seem to reproduce the heteronormative and gendered division of parental roles:

The perception of parenthood among female couples is influenced by controversies fueled by family and naturalistic ideologies, which are currently sharpened by the conservative offensive³3 Lacoste PV, López MEP, Gallegos BP. Discursos conservadores en torno a las familias: entre el orden de género y las falacias naturalistas: el caso del Frente Nacional por la Familia en México (FNF). Cien Soc Relig 2022; 24:e022001.. The lesbian/bisexual couple who share the motherhood project contest the supposed “naturalness” of the essentialist system based on sexual difference and gender norms. This system reproduces the nuclear family model inherited from the patriarchal system and, in so doing, reaffirms a certain hierarchy of prestige and valuation. For this reason, by asserting themselves as mothers, the couple of lesbian and bisexual women subvert the dominant relationships of alliance, affiliation, and sexuality, turning them upside down¹⁹19 Tombolato MA, Maia ACB, Santos MA. A trajetória de adoção de uma criança por um casal de lésbicas. Psicol Teor Pesq 2019; 35:e3546.^,2020 Tombolato MA, Maia ACB, Uziel AP, Santos MA. Prejudice and discrimination in the everyday life of same-sex couples raising children. Estud Psicol 2018; 35:e3546..

Health professionals may feel uncomfortable addressing these relationships, which contributes to their invisibility and silencing in the field of reproductive health. Furthermore, due to the normative prescriptions of patriarchy, women are inferior in various social spheres in which men enjoy privileges and power⁴4 Tannuri JGCG, Silva M. Família homoparental: enfrentando a vitalidade do patriarcado. Rev Linhas 2019; 20(43):256-271.. Therefore, it is important to expand the domains and spaces of speaking and listening where words can be clearly articulated and audibly loud and clear, without subterfuge and without subtle prejudices disguised as tolerance.

Special attention should be paid to the place of the non-pregnant mother in healthcare. It is necessary to deconstruct the naturalization of the primacy of the biological bond, as an element of the collective imagination that gives legitimacy to kinship relationships and that is reproduced in health²¹21 Ben-Ari A, Livni T. Motherhood is not a given thing: experiences and constructed meanings of biological and nonbiological lesbian mothers. Sex Roles 2006; 54(7):521-531.. The literature states that this socially naturalized conception is an untouchable belief that constitutes a persistent challenge for couples that contradict heteronormativity²²22 Biblarz TJ, Savci E. Lesbian, gay, bisexual, and transgender families. J Marr Fam 2010; 72(3):480-497.. Added to this is the tendency towards objectification and biological reduction that permeates biomedical discourse: “At no point were we considered a couple, [...] there we were uteruses” (Vivan, 35, MN).

What is frequently seen is that, in the eyes of health professionals, the mother responsible for the child’s biological pregnancy seems to enjoy more rights and responsibilities over the child⁷7 Lira AN, Morais NA, Boris GDJB. Concepções e modos de viver em família: a perspectiva de mulheres lésbicas que têm filhos. Psicol Teor Pesq 2016; 32(4):e324213.^,1414 Corrêa MEC. Duas mães? Mulheres lésbicas e maternidade [tese]. São Paulo: Faculdade de Saúde Pública; 2012.. The non-pregnant mother does not have her voice heard and legitimized, which suggests that there is the production of different meanings for the lesbian/bisexual woman’s motherhood, depending on the perception of its biological implication in the child’s pregnancy²¹21 Ben-Ari A, Livni T. Motherhood is not a given thing: experiences and constructed meanings of biological and nonbiological lesbian mothers. Sex Roles 2006; 54(7):521-531.. The non-pregnant mother hardly has her participation in the pregnancy-puerperal process recognized, respected, or endorsed. To deal with these vicissitudes, women can access reproductive technology strategies, in which one of them creates a child with the other’s egg or one becomes pregnant with the semen of one of her partner’s relatives, in order to ensure the child’s biological bond. with both mothers, or they can even resort to registering the names of both mothers on the birth certificate¹⁴14 Corrêa MEC. Duas mães? Mulheres lésbicas e maternidade [tese]. São Paulo: Faculdade de Saúde Pública; 2012..

It is evident that, in the 21st century, ideas about what constitutes a family are becoming more inclusive, which reinforces bonds of belonging. Based on her personal experience as a lesbian mother with her wife, Meisner²³23 Meisner N. Double pregnant: two lesbians make a family. Canadian: Fernwood Publishing; 2014. mobilizes the “natural” category to question the “nature” of what is considered “normal” within each culture at a local level, showing that double motherhood challenges the meaning of family today. Traditional notions of gender and gender roles are easily deconstructed when looking at families comprised of people of the same gender.

The care provided in health services constitutes a fundamental part of the support network to strengthen care actions for women and their homoparental families in the various areas of health. For this reason, the concepts of health professionals, often saturated with prejudices, clichés, and stereotypes about family and marital ties, must be continually questioned and stressed.

Final considerations

The results showed that the mothers’ first choice was the desire to conceive a child from their own womb or from their partner. Once this decision had been made, our interlocutors began to think about the method of conception, as well as study the means of making pregnancy viable. Access to health services and reproductive technologies was favored by the good social condition of the majority of participants. Few used the public health system. However, couples encountered several setbacks in their health journeys, including manifestations of discrimination and a lack of empathy, which were more striking in relation to the non-pregnant mother.

It is necessary to expand the body of knowledge about the relationship between users and professionals who work in the field of collective health, training them so that they can build references and implement guidelines to improve access to diversity-sensitive care for non-heterosexual women in the reproductive age. The expansion of knowledge production is necessary to provide subsidies that allow for the guidance of inclusive policies in various care centers and community resources, such as the Family Health Strategy, which incorporates the basic principles of the SUS, such as universalization and comprehensiveness, in addition to valuing active community participation. As part of the fight against stigmatization and invisibilization, it is necessary to integrate homoparental families, expanding their sense of belonging to the territory. Between erasures and resistance, the problems listed by this study call for the visibility and appreciation of new ways of thinking about collective health, capable of contemplating the plurality of modes of existence.

There is a certain perplexity with the persistence of prejudiced postures and attitudes in services. The results of this study indicate that the reproduction of lesbophobia in healthcare settings has repercussions on the quality of the bond established between professionals and couples who experience double motherhood. This contributes to restricting the differentiated care to which this population is entitled, which goes against the shared values of human dignity in the production of health care. Another controversial factor is the relationship between biomedical knowledge and the naturalization of motherhood in confluence with heteronormativity. The dichotomy induced by the biomedical care model fuels persistent tensions between the needs of lesbian and bisexual women who wish to have children and the knowledge produced by biomedical rationality and the hegemonic models that prevail in health services. This phenomenon unfolds at different levels of health care, increasing the challenges of professional performance in women’s health care, particularly in the care of those who experience the spectrum of sexual dissent.

This study’s limitation is the participant recruitment strategy, since the technique used may restrict the diversity of informants. Studies that focus on the organization of the maternal and child health care network and the indicators for monitoring the performance of care offered to users who experience dual motherhood can contribute to improving the quality of the bond. The implementation of the National Comprehensive Health Policy, defined by Ordinance No. 2,836, requires the qualification of professionals and managers, as well as the organization of the care network in search of coordinated intra- and intersectoral action, which makes it possible to destabilize naturalized notions about family and deconstruct prejudices about homoparenting. One potential of this study is that the data analyzed comes from dense descriptions obtained through in-depth interviews carried out with the interlocutors.

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