ORIGINAL ARTICLES

Prevention of sexually transmitted diseases by homosexual and bisexual women: a descriptive study

Patrícia Maria Gomes de Carvalho¹, Bibiana Sidartha Martins Nóbrega², Jayce Lima Rodrigues², Rejane Oliveira Almeida², Fernanda Tavares de Mello Abdalla¹, Lucia Yasuko Izumi Nichiata¹

¹University of São Paulo
²UNINOVAFAPI University Center

ABSTRACT
Aims: To identify the perception of homosexual and bisexual women with regards to healthcare services and how to prevent Sexually Transmitted Diseases (STDs).
Method: This is an exploratory, descriptive and qualitative study, carried out with nine homosexual and bisexual women. Data was collected through semi-structured interviews and treated by thematic analysis.
Results: These women regard the search for assistance and healthcare as fundamental. They are aware about STDs; they are unaware of diseases related to homosexual relationships and; they use inadequate and improvised methods of STD prevention.
Discussion: homosexual and bisexual women are vulnerable to STDs and other preventable diseases.
Conclusion: Health professionals have difficulty listening to and properly accommodating these women. Therefore, we propose a dialogue between health services and these patients to identify their health needs and promote actions for disease prevention and health promotion.
Descriptors: Women's Health; Homosexuality; Homosexuality, Female; Sexually Transmitted Diseases; Delivery of Health Care.

INTRODUCTION

In 1930, public policies addressing women's health in Brazil by means of health-related actions to care for women during pregnancy and childbirth were implemented. At that time, such policies featured a restricted view regarding maternal and child care, based on the biological specificity and social role of women as mothers and housekeepers, responsible for raising, educating and caring for the health of their children and other family members⁽¹⁾.

In 1984, with the creation of the Program for Integral Assistance to Women's Health (PAISM), the country began structuring an expanded reproductive health policy, going beyond the gestation period⁽²⁾. Effectively in 2004, the National Policy for Integral Attention to Women's Health was launched, in order to expand the attention directed to women's health, incorporating issues concerning not only the reproductive health, but also gender relations and sexuality⁽³⁾.

Despite advances in the area of women's health, the responses focused on the needs of homosexual and bisexual individuals are still rarely discussed and incorporated in the scenario of public health policies. As an important initiative, it is worth mentioning the creation of the National Policy for Comprehensive Health of Lesbian, Gay, Bisexual and Transgender (LGBT) in 2010, whose main purpose is to promote greater equity of this population in the Unified Health System (UHS)⁽⁴⁾.

The care focused on the health of lesbian and bisexual women is still invisible or understood as a means of reproduction. This understanding arises in the social function of heterosexual mothers ⁽¹⁾. This invisibility results in the expansion of the contexts of vulnerability of women, because when they seek health care they are not properly oriented for activity of the autonomous, safe and secure sexual practices.

The recognition of the lesbian and bisexual population as being subjects who are entitled to a differentiated health care induces the need to provide assistance that meets the specific needs of these women. At the same time, we may emphasize that improvements in healthcare also have the potential to promote better health conditions and life quality for lesbian and bisexual women⁽⁵⁾. Therefore, a first step in this direction is to make visible their health needs.

The scientific literature in Brazil in relation to the healthcare of homosexual and bisexual women is still scarce, and little is known about the sexual and reproductive health of these women. Given the objective of collaborating with the production of knowledge on the subject, this study aims to: identify the perception of homosexual and bisexual women on healthcare services and ways to prevent Sexually Transmitted Diseases (STDs), as well as to discuss them within the framework of vulnerability, ensuring the right to health and reaffirming the accountability of health professionals regarding their commitment to equity concerning access to healthcare services.

METHOD

This is a descriptive study, in which an exploratory and qualitative approach was used, conducted with women participating in a support group for LGBT. This study, conducted in Teresina, Piauí from January to April 2012, develops recognition actions and struggles to guarantee homosexual rights. The participants were seven lesbian women and two bisexual women, who were selected through random sampling based on convenience and accessibility to participants. The study included lesbians and bisexual women who were aged 18 years and older, who were enrolled in and attended the meetings of the group regularly and who agreed to participate in the study by signing a Letter of Consent.

Data was collected at a place that was pre-established by the participants through semi-structured interviews, which were recorded on digital media devices and they lasted, on average, for 20 minutes.

Thus, a script was previously developed by the authors.

The data analysis followed the theoretical and methodological framework of thematic analysis proposed by Minayo⁽⁶⁾, which consisted of several readings of the transcripts, whose goal was to understand the meaning of the discourses of the women participating in this study. The manifest and latent content related to healthcare practices, particularly on the prevention of STDs, was extracted. The collected data was analyzed according to the following phases: pre-analysis (multiple readings of the transcribed speeches), material exploration (general grouping of content, re-reading), treatment (identifying similarities in the content, re-reading and re-classification of topics) and interpretation of results (classification of thematic categories: perception of homosexual and bisexual women regarding assistance in healthcare services and; the perspective of these women on ways for preventing STDs).

We understood vulnerability as a conceptual reference when analyzing the results. The term vulnerability was proposed by the United Nations Program on AIDS (UNAIDS) in the early 90s, and it is employed in this study as something that goes beyond the concept of risk; proposes the overcoming of biological and behavioral approaches and the construction and/or appropriation of tools to identify and intervene in individual and collective dimensions of the health-disease process^{(7, 8)}.

This research meets the requirements of Resolution 196/96 of the National Health Council⁽⁹⁾, which deals with the guidelines for the conduct of research involving humans and was authorized by the Committee for Ethics in Research of the School NOVAFAPI (opinion No. 0385.0.043.000-11). To preserve anonymity, participants were identified by codes represented by the letter I (Interviewee), followed by the sequential number of the interview: I1 up to I9.

RESULTS

Interviews were conducted with nine women between 25 and 40 years of age. All of them have a university degree and were in the labor market at the time of the interview. Two women were lawyers; four were elementary and/or high school biology teachers; one was a biologist; one was a company administrator and; one was a social worker. Seven of them identified themselves as lesbians and two as bisexuals. Five of them used the Unified Health System (UHS) exclusively.

The perception of homosexual and bisexual women on healthcare services

Regarding the perceived care in healthcare services, six of the interviewees consider that the demand for healthcare services is due to the need for preventing diseases, usually associated with the realization of women’s routinely preventive health examinations, such as pap smears and preventive exams for breast cancer. Some interviewees considered that these tests should be performed annually; three of them carry them out every six months and one of them three times a year.

As for the perception of the participants, there is embarrassment and discomfort in having a gynecological examination among those who had not had the experience of penetration in their sexual relationships. One of the interviewees associated the procedure of introducing the speculum to the penetration of the penis into the vagina:
We have to do this test, but it is as if I had sex with a man. I really don't like going to the gynecologist because I have to do these women exams, and introduce that piece of metal during the exam. I'm afraid of it. (I3)

Another interviewee reported that when her partner had had a bad experience, she did not realize other examinations, thus compromising her care:
She was afraid to tell the doctor she was a lesbian, so she ended up doing the preventive examination without ever having had sexual intercourse and that generated a trauma and she never sought health services again. (I4)

Although expressing fear and discontent with the conduct of examinations, they understand their importance in disease prevention:
I do the preventive exams, although I do not like it. I do the gynecological exams to prevent future diseases, and this is indeed the greatest care I have. I always keep the prevention exams updated; I always do the preventive exams. (I9)

In another speech, we observed a preference for seeking a general practitioner, for she would not feel comfortable with a specialist:
I don't really like going to gynecologists, because I feel embarrassed. (I1)

The interviewees consider that, both in the private and public healthcare service, care is aimed at heterosexual women. The professional that meets them, in most cases, does not ask them about their sexual orientation and when he realizes that he is treating a homosexual woman, he tries to do so without directly addressing the issue. As for the service in the public healthcare system, they said that the assistance is limited and that they do not feel welcomed:

I think the service is poor, because the staff of the UHS is not prepared to welcome us and we also do not feel comfortable to talk to them. (I2)

The women participating in this study assessed that there is a lack of preparation of health professionals regarding care for lesbian and bisexual women and that the gynecologist in particular, regardless of being male or female, shows little or no sensitivity for dealing with the health needs of this population:

I evaluate it in a bad way. Health professionals are not ready to meet any LGBT individuals. There is no awareness among gynecologists and other health services staff. Sometimes they are look at us and judge us. They treat us with prejudice. (I7)

For the interviewees, it is often difficult to reveal intimate details regarding their sexual orientation. According to their beliefs, the fear of judgment and exposure to prejudice and discrimination by health professionals justify their secrecy regarding their sexual orientation. By omitting this information, women can receive meaningless guidance:

In the consultation with the gynecologist, he always treats me as if I were straight. He recommended me to use condoms and pills; I then leave his office with a sentiment of mistrust. (I5)

According to one interviewee, the health professional must be sensitive to a woman’s sexuality. On the other hand, the health professional should not assume the sexual orientation of an individual according to her personal characteristics.

I don't talk to everyone about my sexual orientation. It is very obvious; I don't need to say it, he should perceive it and treat me differently from the other women. (I6)

The perspective of homosexual and bisexual women about prevention methods related to STDs

Specifically regarding STDs, we found that the respondents know what they are. They report knowing syphilis, gonorrhea, hepatitis, genital herpes and AIDS. Other diseases, such as trichomoniasis, candidiasis and condylomata acuminata (Human Papilloma Virus/HPV), were cited in accordance with signs and symptoms:

There are several diseases that cause vaginal discharge, a bad smell and itching and there are some that occur because of wounds. (I8)

It was found that, in fact, intercourse is recognized by all interviewees as the main route of disease infection:
They are transmitted through sexual intercourse, some through contact with saliva. (I3)

Regarding ways to prevent them, basic hygiene in general was cited:

I brushed my teeth an hour before [having a sexual relationship] to prevent myself from contracting any disease; we also wash our hands and keep our nails cut. (I2)

The wearing of a condom was remembered by all of them, especially in situations where there is sexual intercourse with men. According to what was extracted from the interviews, the use of condoms in homosexual relations is not common practice, especially in relations between regular female partners. This fact is also common in heterosexual relations⁽¹⁰⁾. It is imagined that the fact of getting to know the partner eliminates the risk of acquiring an STD:

Nowadays, I've been having more relationships with women, but when I had relations with men, I often wore condoms. You have to be more careful with men and you also have to know the person, you cannot just hang with anyone. (I5)

In sexual relations between women, condom use is improvised:

During the relationship I usually make a small barrier, I mean, I cut a square out of a condom and put it on the genitals –. I believe that it protects us a bit, because it reduces the contact. (I7)

I know there is a kit called a prevention kit, which includes a pair of scissors, a condom that you cut to use; I think there is also a condom for the tongue. That’s basically it. (I8)

DISCUSSION

The results brought by this study show that homosexual and bisexual women experience situations in which their rights of access to quality healthcare services are violated or neglected.

Regarding the perception of homosexual and bisexual women concerning healthcare services, it was found that it is a routine that is present in their lives. However, this demand is directed toward medical care aimed at the prevention of diseases, generally associated with routine examinations.

The realization of the gynecological exam was associated with a situation of embarrassment and discomfort by the women subjects in this study, but it is worth remembering that the gynecological exam is an intimate and invasive procedure that is not necessarily well accepted by women in general, regardless of their sexual orientation; therefore it does not seem to be a peculiarity of homosexual women ⁽¹¹⁾.

In a study that addressed the knowledge of women in general about the Pap smear test, several justifications were identified as barriers to their taking it, such as shame, discomfort in performing it and lack of guidance by the physician performing the exam ⁽¹²⁾.

The interviewees expressed difficulties in talking about their sexuality and assessed that health professionals, who present themselves with little or no sensitivity to cope with their health needs, especially with regard to sexuality, are unprepared.

The lack of a favorable environment and staff prepared to deal with the exposure of the health needs of homosexual and bisexual women may cause a neglected response to them by both the professional and the users themselves, since they do not feel comfortable in declaring their sexuality and talking about their experiences⁽¹³⁾. The difficulty in revealing the individual's sexual orientation in health services was also observed in another study that found that this applied to about 40% of women⁽¹⁴⁾.

The fear of not being understood by health professionals, of being stigmatized or discriminated against, excludes homosexual or bisexual women from health services, contributing to the neglect of their own body and a low adherence to self-care practices, both key points in preventing STDs⁽¹⁵⁾.

This is a complex issue, because the women in this study pointed out that when their sexual orientation is an issue in the search for health services, there is the occurrence of unequal access to these services. A study that addresses this issue showed that, among the women who identify themselves as lesbian, 28% noted a reduced time in healthcare services, with little attention by the doctor, and 17% said that the medical professional failed to order tests considered necessary by them⁽¹⁴⁾.

There are differences in the provision of health services with regard to the preventive test for uterine cervical cancer. This situation indicates discrimination and inequity. Among heterosexual women, the coverage for this exam is on average 89.7%, falling to 66.7% among lesbian and bisexual women, even if they are considered to be of a higher education and income⁽¹⁴⁾. Thus, homosexual and bisexual women are more vulnerable to diseases that could be identified early, such as cancer of the cervix and breast, as well as being more vulnerable to STDs.

Therefore, the fact that homosexual and bisexual women do not reveal their sexual orientation may contribute to the invisibility of the real health needs they have. On the other hand, revealing their sexual orientation brings complications regarding the quality of the services offered to them. In both situations, we can identify the vulnerability in ensuring the rights of these women to healthcare.

In fact, there is no specific professional training in healthcare services to deal with the LGBT population. A study addressing this issue concluded that lesbian and bisexual women do not receive any encouragement from health professionals to verbalize their sexual orientation when seeking assistance, therefore, a disqualified care occurs⁽¹⁵⁾.

A study that addresses access to care related to healthcare among women who have sex with other women found that, during the service, health professionals do not ask for the sexual orientation of women, assuming that all of them are heterosexual and, furthermore, some professionals do not believe that this is a relevant information for treatment, and that it should be addressed only if the user feels comfortable to do so, justifying that sexual orientation is part of their intimacy⁽¹⁶⁾.

Regarding the attitude of health professionals towards the treatment of women, we emphasize that these professionals should be prepared to welcome all women when they seek healthcare services, as well as deal with the difficulties that arise at this point, regardless of their sexual orientation.

Recognizing the right of the sexuality of lesbian and bisexual women requires change, which is not an easy task in a society where the heterosexual pattern is hegemonic and directly influences the professional conduct for a practice that can lead to prejudice and discrimination in some situations.

Respect towards sexuality is an issue that should be discussed in undergraduate healthcare courses. Health professionals should have content in their curricula related to coping with prejudice associated to sexual orientation and gender identity, so they are not considered unnatural⁽¹⁷⁾. We must remember that the exercise of diversity tolerance, respect for rights and humanization should be permanent, extending along the career path of health workers, in view of ongoing in-service education.

To consider women as subjects of law, regardless of their sexual orientation, can be the key to open up a clear, frank dialogue redeeming the genuine sense of care between professionals and users. It is up to the health professional to foster an atmosphere for this dialogue to occur. When health professionals assume their responsibility in relation to equal access of lesbians and homosexuals to healthcare services, they take responsibility for the care of others in its clearest sense, which is the sense of promoting autonomy, citizenship, dignity, promoting their health, reproductive and sexual rights^(13,15).

In this study, the perspectives of homosexual and bisexual women about prevention methods related to STDs did not indicate interventions that can make prevention strategies appropriate to STDs, such as the use of disposable gloves and topical antimicrobial gel solutions, which enable decreased transmission by vaginal discharge and guidance that women who use vaginal sex toys should use male condoms⁽¹⁸⁾.

It was found that, in women’s minds, men are still more vulnerable to STD infections, therefore they, the women, end up taking care of themselves on a daily basis when they have relationships with men.

As for HIV/AIDS, until the 1990s, the possibility of HIV infection on the part of lesbians has been much less considered in Brazil. This invisibility also had a close relation with the way the spread of the virus was conceived, based on the idea that the lack of penetration and contact with bodily fluids would make lesbian women less vulnerable to HIV infection, unlike homosexual men at the beginning of the epidemic⁽¹³⁾.

The trajectory of the HIV/AIDS epidemic shows that men are more affected by the virus than women, but this proportion has been falling over the years⁽¹⁹⁾. In this study, we identified that women feel less vulnerable to STDs in homosexual relationships. Therefore, conducting educational activities particularly aimed at homosexual women is essential to combating STDs and HIV/AIDS.
Sex between women presents a higher risk for developing vaginosis, trichomoniasis, genital herpes and HPV lesions. Such a fact is due to the exchange of vaginal secretions during masturbation alternation, using and sharing sex toys and with tribadism (a vagina touching the other vagina)⁽¹⁸⁾.

Regarding ways to prevent STDs in the health system, it is emphasized that there is no specific condom for oral sex, especially for use in sex between women.

As a strategy for the prevention of STDs during sex between women, we may highlight the guidelines on the use of a prevention kit proposed by the Ministry of Health (MOH), which contains a small pair of scissors, gloves and a nail clipper. The use of pellicles for oral sex, which can be adapted from condoms, pellicles with protective plastic or gloves are also suggested as effective strategies for prevention⁽²⁰⁾. It is noteworthy that such actions are important to minimize the risk of STDs, but they do not meet the needs of these women, since the early handling of these materials may denounce the intention of sexual relations and mechanize the meeting.

In addition to preventive care in terms of the use of barrier methods in female sex, whether homosexual, bisexual or heterosexual, it is considered important to rescue broader aspects involving practices for preventing STD/HIV, such as prevention practices and health promotion that are guided in the actions of health education. The exposure to STDs and HIV is not the exclusive result of the willingness of women and the degree of their clarification, since their behaviors are the result of a set of structural and contextual conditions, which, in the first instance, expose them to the greater or lesser vulnerability to these aggravations.

From this perspective, interventions to prevent STDs and HIV/AIDS should cover more powerful responses, mainly involving the development of emancipatory processes for these women, taking their autonomy as a key concept⁽⁷⁾.

Analyzing the preventive and educational practices aimed at coping with diseases like STDs and HIV/AIDS, we highlight the inefficiency of practices that induce fear and practices that detach people from the problem⁽⁸⁾.

Being aware of the risks is another important activity, but this should be seen in a limited way. That is, the risks involved in HIV transmission among homosexual and bisexual women are clear and measurable, described in epidemiological studies; however, they are not sufficient to identify subjective aspects and meaning involved in the relationships, not just sexual relations⁽⁸⁾.

Educational practices appear as valuable strategies for the prevention of STDs and HIV/AIDS, but you must be careful to value the knowledge people already have regarding the problem. The professional must understand that no one teaches anyone anything, but everybody learns together, and that the patterns of unidirectional and authoritarian communication of the transmission of information are not effective in education⁽⁸⁾. The professional should leave the position of knowledge keeper to the knowledge mediator, in order to share and build knowledge. You cannot just expect that to inform or convey knowledge about prevention to women, whether homosexual or bisexual, will redirect their behavior toward prevention.

The preventive practices for STDs and HIV/AIDS should not be limited to information, but a dialogue that should be present in the relationships between subjects. The subject is not the individual subject, but rather an individual who participates in the entire construction of identities.

Prevention strategies in terms of lesbian and bisexual women should be directed to the identification of the subjectivity that makes up their life contexts. One of the challenges is precisely to define the intersubjective contexts that are generators of vulnerability to STDs, and, pivotally, define these favorable contexts to the reduction of vulnerabilities, contributing to prevention.

CONCLUSION

There is the perception that the Pap smear test is essential for the early diagnosis of cervical cancer, and this is a reflection of years of public policy actions in the area of prevention in women's health. However, assistance in healthcare services is still weak and insufficient. A major challenge for healthcare remains the fight against discrimination and prejudice in all its different forms.

There is not a concrete approximation to the reality of homosexual and bisexual women in the relationship between them and health professionals. This fact hinders the answers to their health needs.

Homosexual and bisexual women are vulnerable and invisible to health services. There are still difficulties to be overcome in trying to improve the relationship, both by professionals and women. It is essential to expand these discussions in the curricula of healthcare courses, since professionals need to be open to sexual diversity and know and respect the sexual practices and characteristics of each individual.

Condom use is not identified as essential in sex between women and prevention methods are not appropriate, contributing to an increased vulnerability to STDs.

Actions in the area of prevention against STD/AIDS for lesbian and bisexual women should be broadened, in order to allow access to quality information and have adequate supplies for prevention.

The limited knowledge of these women about prevention and the practice of safe sex is a result of individual and social vulnerability, introduced by prejudice and by the heterosexual model installed. The absence of a specific and effective public policy, disseminated to all healthcare services, strengthens the vulnerability in the program framework.

It is necessary to integrate health professionals with groups of homosexual and bisexual women, in order to establish a dialogue in an attempt to identify the health needs of these women. Health services should promote actions aimed at this population, both in issues of health education, as well as in the practices of disease prevention and health promotion.

By highlighting the perspective of the subjects and their intersubjectivity contexts, it was possible to identify some conditions of vulnerability in the attempt to ensure the rights of lesbian and bisexual women, having as their horizon the transformation of healthcare. The study sought to give visibility to the issue from the perspective that the full exercise of citizenship of this group is guaranteed.

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Authors:
Patrícia Maria Gomes de Carvalho: Research conception, literature review, data analysis, final report of the research and adequacy of the article to the standards of the journal.
Bibiana Sidartha Martins Nóbrega: Research conception, literature review, data collection and data analysis.
Jayce Lima Rodrigues: Research conception, literature review, data collection and data analysis.
Rejane Oliveira Almeida: Research conception, literature review, data collection and data analysis.
Fernanda Tavares de Mello Abdalla:     Critical revision of the article, adequacy of the article to the standards of the journal.
Lucia Yasuko Izumi Nichiata: literature review, data analysis and critical revision of the article.

Received: 05/02/2013
Revised: 25/11/2013
Approved: 02/12/2013