ABSTRACT

This study aims to understand the perception of healthcare professionals regarding the care of lesbian and bisexual women. This qualitative research project involves 12 professionals from several fields and Belford Roxo, Rio de Janeiro, healthcare facilities. Regarding the results, we underscore two main themes with their respective core meanings: 1) Care provided to Lesbians and Bisexuals in Healthcare Facilities; 2) Facilitators and barriers for Lesbians and Bisexuals to accessing services. Despite the recognition that diversity in women’s healthcare is part of the daily routine of the interviewed professionals, the health needs and specificities of lesbian and bisexual women are still undervalued in care practices, preserving heteronormative protocols. Dialogue on female diversity, knowledge, and the materialized LGBT policy is essential for professionals and managers, enabling changes in this setting and minimizing access difficulties. Finally, we should discuss how LGBTQIA+ health policy is being addressed in curricula and is on municipal management commitments’ agenda to guarantee this population’s rights in health services.

KEYWORDS
Sexual and gender minorities; Health services accessibility; Women’s health; Homosexuality, female

Introduction

Although the 1988¹1 Brasil. Constituição (1988). Constituição da República Federativa do Brasil. Brasília, DF: Senado Federal; 1988. Constitution guarantees the right to health, some population groups struggle to access health services when they seek care. Lesbian and bisexual women have been reporting that their demands and specificities are made invisible by health professionals, influenced by compulsory heterosexuality, which contributes to ‘erasing’ these women - and when they do gain access, they are exposed to discrimination and prejudice.

Concerning lesbian and bisexual women, specificities and singularities emerge and are crossed by the issue of gender, sexual orientation, and gender identity, and can even derive from an ethnic-racial and class perspective²2 Araújo LM, Penna LHG. A relação entre sexo, identidades sexual e de gênero no campo da saúde da mulher. Rev. Enferm UERJ. 2014; 22(1):134-138..

Given the existence of these social markers, these women’s invisibility, promoted consciously or unconsciously, can compromise the experience of lesbian women during care by health services³3 Brasil. Ministério da Saúde. Atenção Integral à Saúde de Mulheres Lésbicas e Bissexuais: Relatório da Oficina Atenção à Saúde de Mulheres Lésbicas e Bissexuais. Brasília, DF: MS; 2014., leading to lower demand for gynecological appointments than heterosexual women and vulnerability, illness, deteriorated health condition, or even death.

Despite the advances and achievements resulting from the fight for guaranteed health rights by feminist and lesbian movements, the specificities and demands of Lesbians, Gays, Bisexuals, Transvestites, Transsexuals and Transgenders, Queer, Intersex, Asexual, and others (LGBTQIA+) have not yet been duly recognized⁴4 Silva AN. Políticas públicas de saúde voltadas as lésbicas: analisando o contexto de produção dos textos e das práticas de cuidados. [tese]. Rio de Janeiro: Instituto Nacional de Saúde da Mulher e da Criança Fernandes Figueiras; 2021.. Complaints of rights violations and exclusion in health services have escalated since the publication of the National Policy for Comprehensive Health for Lesbians, Gays, Bisexuals, Transvestites, and Transsexuals (PNSI-LGBT)⁵5 Brasil. Ministério da Saúde. Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais, Travestis e Transexuais. Brasília, DF: MS; 2013., a milestone in recognizing the demands of this population group⁶6 Lionço T. Que direito à saúde para a população GLBT? Considerando direitos humanos, sexuais e reprodutivos em busca da integralidade e da equidade. Saúde Soc. 2008; 17(2):11-21..

We underscore situations such as disrespect during the visit or screening in light of the sexual practices of lesbian and bisexual women, compromising the establishment of bonds and individualized care. This moment should be one of listening, reception, and focused on comprehensive and humanized care. As a result, lesbian and bisexual women have been moving away from health services due to the barriers and difficulties that contribute to deteriorated health conditions. Based on these considerations, this study aims to understand health professionals’ perceptions of the care of lesbian and bisexual women in Belford Roxo, Rio de Janeiro.

Material and methods

This qualitative, descriptive, exploratory study adopted the interpretation of meanings to understand the meanings attributed by health professionals during care for lesbian and bisexual women⁷7 Gomes R. Análise e intepretação de dados de pesquisa qualitativa. In: Minayo MCS, Deslandes SF, Gomes R, organizadores. Pesquisa social: teoria, método e criatividade. Petrópolis: Vozes; 2016. p. 72-95.. The study settings were health units in Belford Roxo, Rio de Janeiro. Twelve professionals selected by gender criteria from different areas and health units voluntarily agreed to participate in the research. We excluded male professionals, those who were away on leave, special leave, or sick leave during the period of interviews.

Data were produced using the narrative interview technique⁸8 Gomes R, Mendonça EA. A representação e a experiência da doença: princípios para a pesquisa qualitativa em saúde. In: Minayo MCS, Deslandes SF, organizadores. Caminhos do pensamento: epistemologia e método. Rio de Janeiro: Fiocruz; 2002. p. 109-132., using a semi-structured roadmap, with the interview conducted at the participants’ place of work in May 2022. There was also a sociodemographic questionnaire and information about the training process and work seniority. The narratives of the health professionals were recorded and later transcribed.

The steps for interpreting the narratives were: a) Comprehensive reading of the material; b) Identification and problematization of explicit and implicit ideas in the materials; c) Search for meanings related to the statements and actions of the research subjects; and d) Preparation of an interpretative synthesis, seeking to articulate the study’s objective, the theoretical basis adopted, and empirical data⁸8 Gomes R, Mendonça EA. A representação e a experiência da doença: princípios para a pesquisa qualitativa em saúde. In: Minayo MCS, Deslandes SF, organizadores. Caminhos do pensamento: epistemologia e método. Rio de Janeiro: Fiocruz; 2002. p. 109-132..

The research followed the ethical and legal recommendations and guidelines necessary for good research practice under Resolutions Nº 466/2012 and Nº 510/20161 of the National Health Council. It was approved by the Research Ethics Committee of the Sergio Arouca National School of Public Health of the Oswaldo Cruz Foundation - ENSP/FIOCRUZ (Certificate of Presentation for Ethical Assessment - CAAE 57021522.1.0000.5240, Opinion Nº 5.434.546). All participants signed the Informed Consent Form, and each was assigned a code S1 to S12 to preserve their anonymity. We should underscore that the research was self-funded by the authors.

Pierre Bourdieu’s theoretical framework was used for data analysis, namely habitus, field, and symbolic violence⁹9 Bourdieu P. A Economia das Trocas Simbólicas. São Paulo: Perspectiva; 1992.,¹⁰10 Bourdieu P. O Poder Simbólico. Rio de Janeiro: Editora Bertrand Russel; 1998. since these concepts are fundamental to understanding how inequalities are perpetuated in the field and how these professionals build their care since they are responsible for legitimizing the health needs of the population in the field.

Results and discussion

Three categories of analysis appear in the dataset analyzed: 1) Knowing Belford Roxo’s health professionals; 2) Care provided to lesbian and bisexual women in the health unit; and 3) Facilitators and hindrances to lesbian and bisexual women’s access to services.

Knowing Belford Roxo’s health professionals

All 12 female health professionals interviewed were cis women. Most defined themselves as heterosexual (66.7%). The predominant religion was Roman Catholic (33.3%), and most women were in the 50-56 age group (41.7%).

The participants had healthcare experience and worked in the field for over seven years. Most participants had some kind of lato sensu specialization but with a predominance of specialization in mental health (33.3%), followed by specialization in violence (16.6%). One participant reported lato sensu specialization in social psychology and another in clinical nutrition.

Care provided to lesbian and bisexual women in the health unit

Two concepts can be highlighted in this category: approach during care for lesbian and bisexual women and women’s demands. When the professionals were asked how these services occur, the answers were similar among the respondents regarding the fact that the search for care is not necessarily related to health issues, which can be observed in the narratives:

In this sense, seeking health services is related to other problems, such as family conflicts and a lack of knowledge about having served this population. Another fact that appears in the statement of one respondent refers to the feminine symbolism:

There is a need to refine the approach to the issue of access to gynecological care among lesbian and bisexual women, considering these women’s diversity, their experiences and bodies’ different representations, the risk of illness, and the role of seeking gynecological care, in order to produce more effective actions to reduce access hardships¹¹11 Barbosa RM, Facchini R. Acesso a cuidados relativos à saúde sexual entre mulheres que fazem sexo com mulheres em São Paulo, Brasil. Cad. Saúde Pública. 2009; 25(supl2):s291-s300..

On the other hand, they believe that the visibility of ‘masculine’ lesbian women would facilitate care. The heteronormative habitus in health practices leads professionals to provide heterosexuality-focused care, which can contribute to the naturalization of heterosexuality and the failure to recognize plural sexual and gender experiences¹²12 Silva AN, Gomes R. Acesso de mulheres lésbicas aos serviços de saúde à luz da literatura. Ciênc. saúde coletiva. 2021; 26(supl3):5351-5360..

Another critical point was the lack of recognition of lesbian and bisexual women’s actual demands. When professionals were asked about their knowledge of the main demands and the lack of connection with services and teams, the answers were troubling:

The respondents’ perception indicates that the experiences of lesbian and bisexual women when they receive care contribute to their not returning. Considering this reality, it is necessary to keep a close eye on the inclusions, exclusions, possibilities, and limits that they set on the daily process of bringing a given political subject, with their demands, to the public space. This view allows us to consider the subjects enunciated by the movement as always open to inclusion, receiving new and different demands, and questioning hierarchical arrangements¹¹11 Barbosa RM, Facchini R. Acesso a cuidados relativos à saúde sexual entre mulheres que fazem sexo com mulheres em São Paulo, Brasil. Cad. Saúde Pública. 2009; 25(supl2):s291-s300..

Regarding the organization of services to meet the demands of lesbian and bisexual women, the narratives showed that there is a lack of support that allows their experiences to be heard. Moreover, the service protocols keep a format for serving heterosexual women, which is shown in the narratives:

Corroborating these narratives, other studies indicate that one of the challenges faced by lesbian and bisexual women in accessing health services is humanized care, with a focus on the specificities of lesbian and bisexual patients, which requires professionals to be prepared and qualified to recognize the needs of this population, which implies redefining skills and competencies during the training process of health professionals to recognize the actual demands of the population under their care, promoting a receptive space, and creating bonds that respect singularities and deconstruct any form of institutionalized violence¹²12 Silva AN, Gomes R. Acesso de mulheres lésbicas aos serviços de saúde à luz da literatura. Ciênc. saúde coletiva. 2021; 26(supl3):5351-5360..

Furthermore, not including the PNSI-LGBT in the training of professionals, the use of protocols and interventions from a heteronormative perspective has hindered building bonds and providing care, thus producing fragmented care, which leads to exclusion and symbolic violence, hampering these women’s access and permanence in health services¹²12 Silva AN, Gomes R. Acesso de mulheres lésbicas aos serviços de saúde à luz da literatura. Ciênc. saúde coletiva. 2021; 26(supl3):5351-5360.,¹³13 Santana ADS, Lima MS, Moura JWS, et al. Dificuldades no acesso aos serviços de saúde por lésbicas, gays, bissexuais e transgêneros. Rev. enferm UFPE. 2020; 13:e243211..

The invisible demands and specificities of lesbian and bisexual women in healthcare are linked to the heteronormative habitus⁹9 Bourdieu P. A Economia das Trocas Simbólicas. São Paulo: Perspectiva; 1992.,¹⁰10 Bourdieu P. O Poder Simbólico. Rio de Janeiro: Editora Bertrand Russel; 1998. in health practices and the training process of health professionals who direct their care to heterosexual women¹²12 Silva AN, Gomes R. Acesso de mulheres lésbicas aos serviços de saúde à luz da literatura. Ciênc. saúde coletiva. 2021; 26(supl3):5351-5360.. This naturalization has facilitated symbolic violence and fragmented comprehensive care.

Facilitators and hindrances to lesbian and bisexual women’s access to services

When asked about the facilities for providing care to lesbians and bisexual women in health services, we observed that the presence of lesbian and bisexual professionals on the team facilitates the care experiences:

Also, on the subject of access and service facilitators, when asked about which facilities they believe are necessary to conduct these services, the professionals stated that:

However, we observed that facilitators depend exclusively on the perspective of each professional. Furthermore, it is necessary to establish bonds and recognize and respect lesbian and bisexual women’s uniqueness for their comprehensive care, deconstructing all forms of violence, stigma, and discrimination⁴4 Silva AN. Políticas públicas de saúde voltadas as lésbicas: analisando o contexto de produção dos textos e das práticas de cuidados. [tese]. Rio de Janeiro: Instituto Nacional de Saúde da Mulher e da Criança Fernandes Figueiras; 2021.,¹²12 Silva AN, Gomes R. Acesso de mulheres lésbicas aos serviços de saúde à luz da literatura. Ciênc. saúde coletiva. 2021; 26(supl3):5351-5360.. This initiative influences the construction of spaces that can receive these women and health professionals who, on the one hand, have not been aware of their real needs and, on the other, when affected by prejudice and discrimination, contribute to fragmented care.

Respect for the right to health was identified in the narratives of the respondents and was seen as a hindrance in the care of lesbian and bisexual women. However, we noted a difficulty due to religious issues and conservative attitudes:

There is concern about the need for a change in the outlook of professionals with conservative positions. Corroborating a document from the Ministry of Health, conservatives believe that this is not a problem to be debated in the Unified Health System (SUS) and that this debate is seen as an agenda not addressed in services, except in specialized services for care for Sexually Transmitted Diseases (STD)/AIDS³3 Brasil. Ministério da Saúde. Atenção Integral à Saúde de Mulheres Lésbicas e Bissexuais: Relatório da Oficina Atenção à Saúde de Mulheres Lésbicas e Bissexuais. Brasília, DF: MS; 2014..

Another relevant aspect of the interviews concerns the embarrassment of lesbian and bisexual women in revealing or not their sexual orientation due to having endured negative experiences during care when pressured to reveal their sexual orientation¹²12 Silva AN, Gomes R. Acesso de mulheres lésbicas aos serviços de saúde à luz da literatura. Ciênc. saúde coletiva. 2021; 26(supl3):5351-5360..

We should highlight that appointments should be permeated by bond construction, leading these women to freely reveal their sexual orientation, when they have the right to reveal it to professionals or not, which implies considering the many possibilities of prevention and existing conducts for each sexual practice reported¹⁴14 Milanez LS, Nabero APP, Silva AN, et al. Saúde de lésbicas: experiências do cuidado das enfermeiras da atenção básica. Ciênc. saúde coletiva. 2022; 27(10):3891-3900. during care. The lack of support spaces for lesbian and bisexual women is a reality they face daily. It appears as a hindrance in the professionals’ reports:

The professionals expressed discomfort due to the lack of spaces to serve lesbian and bisexual women. This feeling can be understood by the lack of this dialogue in educational spaces and the understanding that the SUS is universal, equitable, and comprehensive. However, the lack of visibility and representation of these women perpetuates the stigma, discrimination, and symbolic violence⁹9 Bourdieu P. A Economia das Trocas Simbólicas. São Paulo: Perspectiva; 1992.,¹⁰10 Bourdieu P. O Poder Simbólico. Rio de Janeiro: Editora Bertrand Russel; 1998. that they face. Therefore, lesbian and bisexual women should share their experiences with health professionals³3 Brasil. Ministério da Saúde. Atenção Integral à Saúde de Mulheres Lésbicas e Bissexuais: Relatório da Oficina Atenção à Saúde de Mulheres Lésbicas e Bissexuais. Brasília, DF: MS; 2014..

Conclusions

Despite the recognition that diversity in women’s health care is part of the daily lives of professionals, the demands and health specificities of lesbian and bisexual women are still undervalued in care practices, preserving heteronormative protocols, thus devaluing their sexual trajectories and practices.

In Belford Roxo, health units are not prepared to meet the demands of these women, i.e., having programs that cover gender and sexual orientation issues. Although the respondents showed empathy for this social group, this is knowingly not enough to improve the quality of care in general, as these are specific and not structural actions. In this sense, there is a need to reflect on the care process from the perspective of gender and sexuality. Moreover, we emphasize the need for professional training and continuing education that encompasses comprehensive health care, which implies dialogue on LGBTQIA+ public policies and the approach and recognition of the demands and specificities of this population. This action enables greater acceptance and belonging when this population seeks health units for care, a path to deconstructing the perpetuation of the heteronormative habitus in care practices and symbolic violence.

Finally, dialogue on female diversity, knowledge, and implementation of the PNSI-LGBT is essential for professionals and managers to promote changes in this setting, minimizing hardships of lesbian and bisexual women in accessing health services in which their experiences are valued. Furthermore, we should stress knowledge about the extent to which the health policy for the LGBTQIA+ population has been addressed in the curricula and is on the agenda of commitments of the municipal administration in order to guarantee the rights of this population in health services.

References

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