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Conteúdo (article):

Access to health services for lesbian women – a literature review

Abstract

This study explores access to health services for lesbians in the light of current literature. A literature search was conducted using various databases and an interpretive synthesis of the findings of the selected articles was produced anchored in the concepts of habitus and symbolic violence developed by Pierre Bourdieu. Two main themes and their respective units of meaning were identified: (a) barriers and difficulties experienced by lesbians in accessing healthcare (issues related to coming out as a lesbian and difficulties experienced by health services and professionals in dealing with lesbian women); and (b) Lesbian women’s experiences in health services (unequal care, invisibility, and feeling uncomfortable). We conclude that, despite advances in policy and care protocols, sexual and gender diversity needs to be widely discussed in social, educational, and health settings.

Keywords: female homosexuality, lesbians, healthcare access.


Introduction
In many countries, access to quality health care is particularly poor among disadvantaged groups. This problem should be understood in a context of political, economic, social, organizational, technical, and symbolic dimensions1.
Specific problems influence access to health services among lesbian women and the quality of care received by this population group. Since feminine sexuality is commonly denied2, some of these problems intersect with those of heterosexual and bisexual women. With regard to the political demands of this population group, the lesbian movement was born out of, and to a certain extent maintains itself at, the intersection between the general homosexual movement and feminist movement, despite seeking its own autonomy and visibility.
A study by Facchini and Barbosa3 showed that, despite the fact that Brazil’s public health system is supposedly designed to ensure universal and equal access to comprehensive healthcare, invisibility and the lack of policies tailored to this group adversely affected the quality of care for lesbians and the performance of healthcare professionals, who, in the absence of specific information, act according to stereotypes.
Another study by Valadão and Gomes4 based on articles and documents published up to 2008 found problems in relation to access to services and the quality of care delivered to lesbian women. Drawing on Bourdieu, they concluded that lesbians were invisible and, in some cases, victims of symbolic violence.
Some policy advances have been made domestically and internationally since Valadão and Gomes’ study, including the creation of the National Lesbian, Gay, Bisexual, Transvestite, and Transgender Health Policy5 in Brazil. It remains to be seen, however, whether these advances will resolve the problems related to access to health services and quality of care for lesbians.
To bring the discussion of this question up to date, it is important to synthesize the findings of the literature on this topic to obtain a better understanding of current knowledge on access to health services for lesbians. Like Valadão and Gomes4, we believe that Bourdieu’s perspective, more specifically the concepts of habitus and symbolic violence, can help in this venture.
Within Bourdieu’s theory (1992, 1998, 2001, and 2002), habitus refers to acquired knowledge, a state of being, capital, indicating ingrained dispositions. It consists of socially and historically constructed matrices, whose enactment is determined by an individual’s social position, allowing him/her to think, see, and act in a wide variety of situations. For Bourdieu, unlike the word habit, which is associated with something concrete, the term habitus involves a creative, active, inventive capacity. From this perspective, the subject receives and reinvents “inheritance” to form habitus6,7,8,9.
Bourdieu frames the concept of symbolic violence within the sphere of domination, observing that there are two ways of dominating someone: outright violence and symbolic violence, where the latter is understood as that which is euphemized, gentle, and invisible10. For Bourdieu, to emphasize symbolic violence does not mean to minimize the role of physical violence or to forget it. It is important that symbolic violence is not understood as the opposite of real violence, a purely ‘spiritual’ violence that has no real effects11. He also maintains that symbolic violence is not exerted in the logic of knowing consciousnesses, but rather in the obscurity of the dispositions of habitus8.
From Bourdieu’s perspective, habitus and symbolic violence are intertwined since heteronormativity is opposed to homosexuality11.
Based on these initial considerations, this study explores the specificities of access to health services for lesbians in the light of current literature.
Method
A qualitative review of articles on the topic was conducted. This method enables the collection of a wide range of information and data dispersed throughout various publications and helps develop a conceptual framework for the phenomenon of concern12.
Literature searches were performed between November 2018 and May 2019 using the following databases: Latin American and Caribbean Health Sciences Literature (LILACS); Base de dados bibliográficas especializada na área de enfermagem (BDENF-Nursing Database); US National Library of Medicine (PubMed); Medical Literature Analysis and Retrieval System Online (MEDLINE); and Scientific Electronic Library Online (SciELO).
The following DeCS (Health Sciences Descriptors) were used in Portuguese and English together with the Boolean operator “and”: “female homosexuality” combined with “access to health services” and “comprehensive healthcare”. This search resulted in only a small number of articles from SciELO, BDENF, and LILACS and a larger number from MEDLINE and PubMed. The searches were therefore broadened by adding the following terms: “sexual and gender minorities” and “homosexuality”.
The following article inclusion criteria were applied: full text articles addressing themes related to lesbian women’s health in Portuguese, English, or Spanish published between 2004 and 2018 and with wide circulation in both in the academic and professional world. The year 2004 was chosen because it was the year in which the Brazilian government created the National Women’s Healthcare Policy13, which encompasses lesbians. Editorials, letters to the editor, dissertations, theses, duplicate articles, and articles that took an exclusively clinical/epidemiological approach were excluded.
The searches yielded 273 articles. A total of 204 articles (including 12 duplicate articles) were excluded after reading the titles and abstracts and applying the selection criteria, resulting in 69 publications that were read in their entirety. Thirty-three of these publications were excluded because they did not discuss access to health services for lesbians, their demands, and the specificities of lesbian healthcare, resulting in a final sample of 36 articles.
The articles were analyzed using an adaptation of a thematic analysis technique described by Bardin14. According to this author, a theme is a unit of meaning that breaks away from the text in question and can be translated using a summary, phrase, or word. This technique makes it possible to identify what lies behind the manifest content15. In the present study, the theme is understood to be a wider category that may encompass more than one unit of meaning. The analysis consisted of the following steps: (a) identification of the central ideas expressed in the text of the articles; (b) classification of the underlying meanings of the ideas into themes that summarize the production of knowledge on the study topic; and (c) production of an interpretive synthesis of the findings extracted from the selected articles, using the concepts of habitus and symbolic violence as a theoretical and analytical frame of reference.




Results
Characterization of the Sources
We identified 21 articles published between 2006 and 2014 and 15 published between 2015 and 2018. Twenty-three were in English, 10 in Portuguese, and three in Spanish. Half of the studies were published on MEDLINE and PubMed and half on LILACS, SciELO, and BDENF. The articles were from a variety of countries: the United States (nine), Brazil (nine), Africa (five), Argentina (two), Chile (one), United Kingdom (two), Canada (two), Portugal (two), Germany (one), Norway (one), Sweden (one), and New Zealand (one).
The 36 articles were published in 32 journals, 11 of which were Brazilian, 13 from the US, four English, one Canadian, one Colombian, one Swedish, and one Norwegian.
The academic background of the lead author varied: medicine (20), nursing (three), psychology (four), and sociology (six). The number of authors involved in each publication also varied: three authors (13 articles), two authors (eight articles), one author (five articles), five authors (three articles), four authors (three articles), seven authors (two articles), six authors (one article), and nine authors (one article). Nine articles showed a high level of interaction between different areas of knowledge and interdisciplinary dialogue.
With regard to methodology, 24 articles took a qualitative approach and 12 used quantitative methods. The fact that the majority of studies were qualitative suggests that this is the most appropriate approach for reflecting on and understanding subjective issues. In this respect, qualitative methods address a level of reality that cannot or should not be quantified, since they deal with the world of meanings, motives, aspirations, beliefs, values, and attitudes16. The quantitative studies were predominantly cross-sectional studies involving the LGBT population and lesbian women.
Study participants included lesbian women, lesbians and bisexuals, the LGBT population, and health professionals. Since the initial search limited to articles including only lesbian women resulted in an inadequate number of articles, the descriptors were broadened, resulting in articles encompassing lesbians, lesbians and bisexuals, and the LGBT population.
Most of the studies used snowball sampling to recruit study participants.
Sixteen articles involved lesbians and bisexuals, nine the LGBT population, and 11 exclusively lesbian women.
Box 1 provides a synthesis of the main characteristics of the articles.
Themes
The articles addressed two main themes: (a) barriers and difficulties experienced by lesbians in accessing healthcare; and (b) experiences of lesbians in health services. It is important to stress that – given the nature of the study – the analysis did not compare the epidemiological profiles of diseases related to homosexual, bisexual, and heterosexual women reported by some studies.

Barriers and difficulties experienced by lesbians in accessing healthcare
Two units of meaning stood out in this theme: issues related to coming out as a lesbian and difficulties experienced by health services and professionals in dealing with lesbian women. These meanings are intertwined due to the naturalization of heterosexuality highlighted by some of the articles.
Within the naturalization scenario, the decision to disclose sexual orientation (“come out of the closet”) is one of the main barriers faced by lesbians in seeking health services. In general, the logic behind women\'s health care in health services is based on the heterosexual model, without taking into account – neither implicitly nor explicitly – people who deviate from this hegemonic model, including in this category lesbians35. This has consequences in the form of discriminatory attitudes, meaning that lesbians often fail to access health services because they feel vulnerable50.
The decision to seek health services and disclose sexual orientation may be related to various problems, such as: tension and anxiety52; fear of discrimination, prejudice, and stigmatization19,21,37,45,48,49; lack of assurance of confidentiality31; and shame of being naked in front of a stranger and exposure to intimacy that is often socially devalued22.
Conversely, some lesbian women believe that disclosing their sexual orientation to their doctor does not negatively affect their healthcare28 and that it can even build confidence in the relationship20. Nonetheless, disclosure does not necessarily mean that lesbians will receive treatment that is specific to their needs, contradicting the assumption that “coming out of the closet” is a solution to improve healthcare22. However, the inclusion of sexual orientation in public health systems can help address health inequalities and understand their underlying mechanisms25.
Difficulties in accessing health services are also related to the fact that health professionals do not always know how to deal with lesbian women. One study observed that some health professionals apply the religious belief that heterosexuality pleases god to their professional life46. Other articles suggest that inadequate training means that professionals are ill-prepared for or feel uncomfortable in dealing with the array of sexual orientations40,50,51, meaning that the specific demands and needs of lesbians often go unseen. Other studies attribute the explicit and implicit naturalized heterosexuality found in general practice26 to the attitude of health professionals35,52.
Within this scenario, numerous factors compromise both access to services and the quality of care: failure to address sexuality in general with lesbians38; “erasure” of the homosexual orientation32,47; non-debate about sexually transmitted diseases29,42,44; absence of specific protocols50; indeterminacy of lesbians’ health needs32; and unsafe, fragmented, and non-comprehensive healthcare43.
Lesbian women’s experiences in health services
Three units of meaning synthesize lesbian women’s healthcare experiences: unequal care, invisibility, and feeling uncomfortable.
Some of the studies show that the healthcare experiences of lesbian women differ from those of heterosexual women: lesbian women tend to receive poorer health care17; heterosexual women were more likely to have received a timely Pap test27,33; and lesbian women seeking to build a homoparental family are discriminated during perinatal care41 and receive less guidance and advice27,33.
The literature also associates invisibility with lesbians’ healthcare experiences. This association is based on certain situations: silencing sexuality23; the lack of a welcoming and comfortable environment that promotes listening to patients’ experiences34,36 and bonding39; assumptions of heterosexuality in the forms of verbal and published health care information and education31,35; and the lack of collaborative relationships and relationships of trust40.
Invisibility – whether consciously or unconsciously intended – can compromise lesbians’ healthcare experiences. One of the studies suggests that homosexuality is more visible in the private health system, in which people pay for their own care41.
Two studies report situations that may be perceived as uncomfortable for lesbian women. One showed that lesbians had had past negative experiences with health care21, while another reported that many informants had felt forced to disclose their sexual orientation when questioned about being sexually active and not using contraception24.
Interpretive synthesis
In general, the studies highlight the need to recognize the specific demands and health needs of lesbian women so that they are able to access health services and receive quality care. Policy advances that, to a certain extent, guide this recognition can be observed in some countries. In Brazil, for example, a number of documents may be highlighted: National Policy on Comprehensive LGBTT Healthcare5; Lesbian Women\'s Health Dossier3; Report of the Workshop on Lesbian Women’s and Bisexuals’ Healthcare53; and the booklets “Lesbian and bisexual women: rights, health, and social participation”54 and “If you are a lesbian, the health professional needs to know55.
In contrast, the studies implicitly or explicitly show that the heteronormative habitus found in health practice means that lesbian women tend to be treated as heterosexual. This can lead to both the idea of the naturalization of heterosexuality, which views lesbian existence as deviant, and the non-recognition of multi sexual and gender experiences such as those of lesbians.
At the same time, the articles highlight that, besides the physical and psychological violence generated by the prejudice lesbian women face in public and private places, symbolic violence is present in health services, given that they commonly fail to consider the specific demands and needs of this group, contributing to the erasure of lesbian existence.
To change this situation, actions need to extend beyond the field of health and shake up institutions in order to confront the habitus that disregards lesbians and other sexual orientations that contest heteronormative hegemony. These actions should give special prominence to social movements, particularly the gay and lesbian movement. According to Bourdieu11, this movement cannot draw the line at symbolic breaks even though they may be effective. He maintains that the gay and lesbian movement “must perform and impose a durable transformation of the internalized categories (schemes of thought) which, through upbringing and education, confer the status of self-evident [...] on the social categories that they produce” (p. 146). However, he warns that achieving recognition of the particularity (moving from invisibility to visibility) can imply its annulment. Hence, as in the case of other movements born out of dominated and stigmatized groups, the gay and lesbian movement lives in a pendular structural contradiction between “invisibilization and exhibition, between the suppression and celebration of difference. As a consequence [...] they adopt one or the other strategy according to the circumstances...” (p. 146)11.
Final considerations
The literature shows that inequalities in access and barriers to healthcare faced by lesbian women who disclose their sexual orientation are directly related to normative gender presumptions, which in turn influence whether to come out or not to health professionals. Despite advances in policy and care protocols, sexual and gender diversity needs to be widely discussed in social, educational, and health settings to ensure health equity and more comprehensive care.
Public health policy formulation and the creation of protocols and interventions from a heteronormative perspective hampers bonding and care, resulting in fragmented care and thus contributing to exclusion and symbolic violence.
According to Bourdieu’s theoretical framework, one way to change this habitus is to intensify the discussion of this theme in spaces of dialogue between the lesbian movement, government, and academia in order to improve policy-making and protocols and promote research on lesbian health. It is also important to incorporate this theme into technical courses, undergraduate degree programs, and residencies and develop specialist training courses to develop the necessary skills to help make patients feel comfortable and welcome and promote a better understanding of the specific demands and health needs of lesbian women.
Health professionals should develop skills and competencies that enable them to understand and value the real needs of this population group and create a welcoming environment that fosters bonding, an open patient-care provider relationship, and inclusive, comprehensive, and humanized care. This requires a break with institutional abuse in healthcare settings marked by stigma, discrimination, and fear, respect for the singularity of the other, and the deconstruction of all forms of violence and discrimination against lesbians.

References
1. Assis MMA, Jesus WLA. Acesso aos serviços de saúde: abordagens, conceitos, políticas e modelo de análise. Ciên & Saúde Colet 2012; 17(11):2865-2875.
2. Portella AP. Direitos Sexuais e Necessidades de Saúde de Lésbicas e Mulheres Bissexuais na Percepção de Profissionais de Saúde e Usuárias do SUS. In: Ministério da Saúde (MS). Atenção integral à saúde de mulheres lésbicas e bissexuais. Brasília: MS; 2014. p. 23-30.
3. Facchini R, Barbosa RM. Dossiê saúde das mulheres lésbicas: promoção da equidade e da integralidade. Belo Horizonte: Rede Saúde; 2006.
4. Valadão RC, Gomes R. A homossexualidade feminina no campo da saúde: da invisibilidade à violência. Physis: Revista de Saúde Coletiva 2011; 21(4):1451-1467.
5. Ministério da Saúde (MS). Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais, Travestis e Transexuais. Brasília: MS; 2013.
6. Bourdieu P. A Economia das Trocas Simbólicas. São Paulo: Perspectiva; 1992.
7. Bourdieu P. O Poder Simbólico. Rio de Janeiro: Editora Bertrand Russel; 1998.
8. Bourdieu P. Meditações pascalianas. Rio de Janeiro: Bertrand Brasil; 2001.
9. Bourdieu, P. Esboço de uma teoria da prática. Oiras [Portugal]: Celta Editora, 2002.
10. Bourdieu P. O senso prático. Petrópolis: Vozes; 2009.
11. Bourdieu P. A dominação masculina. Rio de Janeiro: Bertrand Brasil;1999.
12. Lima TCS, Mioto RCT. Procedimentos metodológicos na construção do conhecimento científico: a pesquisa bibliográfica. Rev Katálysis [periódico na Internet]. 2007 [acessado 2019 Nov 05];10(n. spe): 37-45. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1414-49802007000300004
13. Brasil. Ministério da saúde (MS).Secretaria de Atenção à Saúde. Departamento de ações Programáticas estratégicas. Política nacional de atenção integral à saúde da mulher: princípios e diretrizes. Brasília: MS; 2004.
14. Bardin L. Análise de conteúdo. Lisboa: Edições 70; 1979.
15. Gomes R. A análise de dados em pesquisa qualitativa. In: Minayo MCS, organizadora. Pesquisa social: teoria, método e criatividade. Petrópolis: Editora Vozes; 2002. p. 67-80.
16. Minayo MCS.Ciência, técnica e arte: o desafio da pesquisa social. In: Minayo MCS, organizadora. Pesquisa social: teoria, método e criatividade. Petrópolis: Editora Vozes; 2002. p. 21-22.
17. Kerker BD, Mostashari F, Thorpe L. Health care access and utilization among women who have sex with women: sexual behavior and identity. J Urban Health 2006; 83(5): 970-979.
18. Araújo MAL, Galvão MTG, Saraiva MMM, Albuquerque AD. Relação usuária-profissional de saúde: experiência de uma mulher homossexual em uma unidade de saúde de referência de Fortaleza. Esc Anna Nery 2006;10(2):323-327.
19. Heck JE, Sell RL, Gorin SS. Health care access among individuals involved in same-sex relationships. Am J Public Health 2006; 96(6):1111-1118.
20. Mravcak SA. Primary care for lesbians and bisexual women. Am Fam Physician 2006; 74(2):279-286.
21. Tjepkema M. Health care use among gay, lesbian and bisexual Canadians. Health Rep 2008;19(1):53-64.
22. 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(Supl.2):s291-s300.
23. Matebeni Z, Camargo TMCR, Camargo Júnior KR, Dias LF. All sexed up: a resposta de mulheres lésbicas negras jovens ao sexo (mais) seguro em Johannesburg, África do Sul. Physis: Revista de Saúde Coletiva 2009; 19(2):333-348.
24. Bjorkman M, Malterud K. Lesbian women’s experiences with health care: a qualitative study. Scand J Prim Health Care 2009; 27(4):238-243.
25. Dilley JA, Simmons KW, Boysun MJ, Pizacani BA, Stark MJ. Demonstrating the importance and feasibility of including sexual orientation in public health surveys: health disparities in the Pacific Northwest. Am J Public Health 2010; 100(3):460-467.
26. Fish J, Bewley S. Using human rights-based approaches to conceptualise lesbian and bisexual women’s health inequalities. Health Soc Care Community 2010;18(4):355-362.
27. Austin EL, Irwin JA. Health behaviors and health care utilization of southern lesbians. Womens Health Issues 2010; 20(3):178-184.
28. Formby E. Lesbian and bisexual women\'s human rights, sexual rights and sexual citizenship: negotiating sexual health in England. Cult Health Sex 2011; 13(10):1165-1179.
29. Charlton BM, Corliss HL, Missmer SA, Frazier AL, Rosario M, Kahn JA, Austin SB. Reproductive Health Screening Disparities and Sexual Orientation in a Cohort Study of U.S. Adolescent and Young Adult Females. J Adolesc Health 2011; 49(5):505-510.
30. Marques AM, Oliveira JM, Nogueira C. A população lésbica em estudos da saúde: contributos para uma reflexão crítica. Cien Saúde Colet 2013; 18(7):2037-2047.
31. Corbett SL, Frecker HM, Shapiro HM, Yudin MH. Access to fertility services for lesbian women in Canada. Fertil Steril 2013; 100(4):1077-1080.
32. Carvalho CS, Calderaro F, Souza SJ. O dispositivo "saúde de mulheres lésbicas": (in)visibilidade e direitos. Rev Psicol Polit 2013;13(26):111-127.
33. Nóbrega BSM, Oliveira JL, Almeida RO, Abdalla FTM, Nichiata LYI, Carvalho PMG. Prevention of sexually transmitted diseases by homosexual and bisexual women: a descriptive study. Online Braz J Nurs 2013; 12(4):931-941.
34. Mosack KE, Brouwer AM, Petroll AE. Sexual identity, identity disclosure, and health care experiences: is there evidence for differential homophobia in primary care practice? Womens Health Issues 2013; 23(6):e341-e346.
35. 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.
36. Brown JL, Pecheny M, Tamburrino MC, Conde LL, Perrotta GV, Capriati A, Andia AM, Mario S, Ibarlucia I. Atención ginecológica de lesbianas y bisexuales: notas sobre el estado de situación en Argentina. Atención ginecológica de lesbianas y bisexuales: notas sobre el estado de situación en Argentina. Interface (Botucatu) 2014; 18(1):673-684.
37. Marques AM, Nogueira C, Oliveira JM. Lesbians on medical encounters: tales of heteronormativity, deception, and expectations. Health Care Women Int 2015; 36(9):988-1006.
38. Poteat TC, Logie CH, Adams D, Mothopeng T, Lebona J, Letsie P, Baral S. Stigma, sexual health, and human rights among women who have sex with women in Lesotho. Reprod Health Matters 2015; 23(46):107-116.
39. Rubin R. Minimizing Health Disparities Among LGBT Patients. JAMA 2015; 313(1):15-17.
40. Hirsch O, Löltgen K, Becker A. Lesbian womens\' access to healthcare, experiences with and expectations towards GPs in German primary care. BMC Fam Pract [periódico na Internet]. 2016 Nov [acessado 2019 Jul. 21]; 17(1):162. Disponível em: DOI 10.1186/s12875-016-0562-4.
41. Videla CF, Muñoz AV. Experiences of lesbian users about the process of perinatal care in the metropolitan region of Chile in 2016. Interface(Botucatu) 2018; 22(66):777-778.
42. Daly F, Neil S, Samantha W. Sexual rights but not the right to health? Lesbian and bisexual women in South Africa’s National Strategic Plans on HIV and STIs. Reprod Health Matters 2016; 24(47):185-194.
43. Munson S, Cook C. Lesbian and bisexual women’s sexual healthcare experiences. J Clin Nurs 2016; 25(23-24):3497-3510.
44. Silberman P, Buedo PE, Burgos LM. Barreras en la atención de la salud sexual en Argentina: percepción de las mujeres que tienen sexo con mujeres. Rev Salud Pública 2016; 18(1):1-12.
45. Bränström R, Hatzenbuehler ML, Pachankis JE. Sexual orientation disparities in physical health age and gender effects in a population-based study. Soc Psychiatry Psychiatr Epidemiol [periódico na Internet]. 2016 Feb [acessado 2019 Set. 20];51(2):289-301. Disponível em: http://dx.doi.org/10.1007/s00127-015-1116-0.
46. Vitiritti, B, Andrade, SMO, Peres, JEC. Diversidade sexual e relações profissionais: concepções de médicos e enfermeiros. Temas Psicol 2016; 24(4):1389-1405.
47. Moscheta MS, Febole DS, Anzolin B. Visibilidade seletiva: a influência da heterossexualidade compulsória nos cuidados em saúde de homens gays e mulheres lésbicas e bissexuais. Saude & Transf 2016;7(3):71-83.
48. Alpert AB, CichoskiKelly EE, Fox AD. What lesbian, gay, bisexual, transgender, queer, and intersex patients say doctors should know and do: a qualitative study. J Homosex 2017; 64(3):1368-1389.
49. Müller A. Scrambling for access: availability, accessibility, acceptability and quality of healthcare for lesbian, gay, bisexual and transgender people in South Africa. BMC Int Health Hum Rights 2017; 17(1):16.
50. Müller A. Health for all? sexual orientation, gender identity, and the implementation of the right to access to health care in south Africa. Health Hum Rights 2016; 18(2):195-208.
51. Rufino AC, Madeiro A, Trinidad AS, Rodrigues dos Santos R, Freitas I. Disclosure of sexual orientation among women who have sex with women during gynecological care: a qualitative study in Brazil. J Sex Med 2018; 15(7):966-973.
52. Rufino A C, 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 Saúde
[periódico na Internet]. 2018 Abr. [acessado 2018 Nov. 12];27(4). Disponível em: http://www.scielo.br/pdf/ress/v27n4/en_2237-9622-ress-27-04-e2017499.pdf
53. Brasil. Ministério da Saúde (MS). Secretaria de Políticas para as Mulheres. Atenção Integral à Saúde de Mulheres Lésbicas e Bissexuais. Relatório da Oficina Atenção à Saúde de Mulheres Lésbicas e Bissexuais: Brasília: MS; 2014.
54. Brasil. Ministério da Saúde (MS). Secretaria de Gestão Estratégica e Participativa. Departamento de Apoio à Gestão Participativa. Mulheres lésbicas e bissexuais: direitos, saúde e participação social. Brasília: MS; 2013.
55. Lemos AM, Manoela Alves dos Santos, Rafaela Barbosa, organizadoras. Cartilha Se você é lésbica a/o profissional de saúde precisa saber. Pernambuco: Coletivo de Lésbicas e Mulheres Bissexuais de Pernambuco (COMLESBI); 2016.