A atenção básica e a saúde de mulheres lésbicas

RESUMO

Objetivo: conhecer as concepções de enfermeiras/os da atenção básica sobre a saúde das mulheres lésbicas. Método: estudo exploratório, de abordagem qualitativa, realizado no contexto da Atenção Básica do município de Belém, desenvolvido no período de outubro de 2018 a janeiro de 2019. Realizadas entrevistas semiestruturadas individuais, acompanhadas de questionário sociodemográfico, com 13 enfermeiros. Resultados: por meio dos discursos, revelou-se a presunção da heterossexualidade das usuárias e uma concepção estereotipada de gênero impostos à lesbianidade. Conclusão: o conhecimento sobre saúde das lésbicas por profissionais de saúde foi observado nesta pesquisa que identificou a presunção da heteronormatividade como uma das maiores fragilidades encontradas, ocasionada quando um profissional de saúde oferece um cuidado equivocado, englobando todas as mulheres como heterossexuais. Outro ponto observado é o desafio de desconstrução do estereótipo de gênero, citado em alguns discursos dos enfermeiros, quando tentavam caracterizar seus pacientes pelo seu tipo de comportamento ou vestimenta.
DESCRITORES: Atenção Primária à Saúde; Lésbica. Enfermagem; Discurso; Saúde da Mulher.

 

ABSTRACT
Objective: to know the conceptions of primary care nurses about the health of lesbian women. Method: exploratory study, with a qualitative approach, carried out in the context of Primary Care in the city of Belém, developed from October 2018 to January 2019. Individual semi-structured interviews were carried out, accompanied by a sociodemographic questionnaire, with 13 nurses. Results: through the speeches, the presumption of the heterosexuality of the users and a stereotyped conception of gender imposed on lesbians were revealed. Conclusion: knowledge about lesbian health by health professionals was observed in this research, which identified the presumption of heteronormativity as one of the greatest weaknesses found, caused when a health professional offers the wrong care, encompassing all women as heterosexuals. Another point observed is the challenge of deconstructing the gender stereotype, mentioned in some of the nurses' speeches, when they tried to characterize their patients by their type of behavior or clothing.
DESCRIPTORS: Primary Health Care; Lesbian. Nursing; Speech; Women's Health.

 

RESUMEN
Objetivo: conocer las concepciones de enfermeras de atención primaria sobre la salud de mujeres lesbianas. Método: estudio exploratorio, con abordaje cualitativo, realizado en el contexto de la Atención Primaria de la ciudad de Belém, desarrollado de octubre de 2018 a enero de 2019. Se realizaron entrevistas individuales semiestructuradas, acompañadas de un cuestionario sociodemográfico, con 13 enfermeros . Resultados: a través de los discursos se reveló la presunción de la heterosexualidad de las usuarias y una concepción estereotipada de género impuesta a las lesbianas. Conclusión: se observó en esta investigación el conocimiento sobre la salud lésbica por parte de los profesionales de la salud, que identificó la presunción de heteronormatividad como una de las mayores debilidades encontradas, provocada cuando un profesional de la salud ofrece una atención equivocada, englobando a todas las mujeres como heterosexuales. Otro punto observado es el desafío de deconstruir el estereotipo de género, mencionado en algunos discursos de las enfermeras, cuando trataban de caracterizar a sus pacientes por su tipo de comportamiento o vestimenta.
DESCRIPTORES: Atención Primaria de Salud; lesbiana Enfermería; Discurso; La salud de la mujer.

 

INTRODUCTION
One of the primary attributions of Primary Care is to be close to users, and it appears as the preferential gateway to care. The National Primary Care Policy (PNAB) points out that actions and services involve health promotion and disease prevention, emphasizing that these cannot promote exclusion due to age, gender, ethnicity, race, social condition, sexual orientation, among others. ⁽¹⁾

Thus, knowledge of these conceptual aspects of the Unified Health System (SUS) is important in the discussion of the rights of all people, showing that claims for the applicability of these rights are not a matter of favoring a group, but a duty of the State.

However, the Ministry of Health indicates that many Primary Care professionals do not feel comfortable or qualified to deal with the issue of sexuality or the sexual health of service users. ⁽²⁾ A survey, carried out in Basic Health Units in Piauí, found that the lack of reception in health services is one of the main barriers to effective care for lesbian women.⁽³⁾  

Another survey carried out in Cajazeiras, Paraíba, showed that lesbians, gays, bisexuals, transvestites and transsexuals (LGBTT) experienced embarrassment in the assistance provided by health professionals, that is, there were barriers in accessing services for people with a sexual orientation other than heterosexual, and for people with a non-hegemonic gender identity. ⁽⁴⁾

Care practices for women are still focused on the heteronormative pattern, focusing on the pregnancy-puerperal model. ⁽⁵⁾ However, despite health policies punctuating the reproductive health of lesbians, access to family planning is a practice that does not cover all families in their diversities. Among the diseases that affect lesbians, the development of cervical cancer and the risk of HPV infection can be aggravated for this public. ⁽⁶⁾

Discrimination in society and the vulnerability of women to different pathologies often cause more illnesses and deaths than the various pathogens or etiological agents,

that is, social, cultural and historical factors can influence the illness, which is why they are considered social determinants in health, as is the case of lesbophobia. ⁽²⁾

Health professionals have a relevant role in this context, especially nurses, as it plays a significant role in the care process and must seek to improve its practices, taking into account human dignity and the social determinants of health. ⁽⁷⁾

Therefore, this article aims to understand the conceptions of Primary Care nurses about the health of lesbian women, since knowing such discourses is an important way to promote reflections aimed at transforming and breaking paradigms in relation to health care involving this population.

 

METHOD

Therefore, this article aims to understand the conceptions of Primary Care nurses about the health of lesbian women, since knowing such discourses is an important way to promote reflections aimed at transforming and breaking paradigms in relation to health care involving this population. ⁽⁸⁾ It had a qualitative approach that makes use of interpretive structures to demonstrate the phenomenon, in order to know it from the meanings that people and groups have about the daily situations of a problem and/or reality. ⁽⁹⁾

The research was carried out in the municipality of Belém do Pará, within the scope of Primary Care, linked to the eight (8) Administrative Districts of the city: Mosqueiro (DAMOS), Outeiro (DAOUT), Icoaraci (DAICO), (DABEN), Entroncamento (DAENT), Sacramenta (DASAC), Belém (DABEL) and Guamá (DAGUA). ⁽¹⁰⁾ (Belém City Hall, 2017). For each district, a Basic Health Unit (UBS) was listed.

Nurses who work in Basic Health Units (UBS) and who develop actions aimed at women's health care in the context of health policies and programs for this population group were invited to participate in this research, being presented the objectives and justifications of the research. The invitation was carried out in person, after the consent of the health services manager and the presentation of the servers in exercise of the function.

Among the 23 nursing professionals consulted, 10 nurses who only work in other health programs were excluded. Thus, 13 nurses constituted the group of participants in this research.

 Data collection was carried out individually by the main researcher from October 2018 to January 2019, being carried out in the practice scenarios of the research participants, through the application of a sociodemographic questionnaire, followed by a semi-structured interview script, dealing with the following topics: service routines at the UBS, health and sexual and reproductive rights, in addition to health care for lesbian women. The interviews were audio-recorded and later transcribed in Microsoft Word®.

The content analysis proposed by Laurence Bardin ⁽¹¹⁾ was used, fulfilling the stages of pre-analysis, material exploration, treatment of results, inference and interpretation. During these stages, the highlight phrases were listed and, later, the categories to carry out the discussion of the data found.

The research was submitted to the Ethics Committee in Research with Human Beings of the Federal University of Pará (UFPA), approved by opinion number CAAE 90860018.3.0000.0018, respecting the resolution of the National Health Council (CNS) nº 466 of December 12th, 2012.

The participants signed the Free and Informed Consent Form (TCLE), in which the researchers assumed responsibility for the information received or obtained from voice recordings and other means, related to the research subjects.

The results were presented preserving the nurses' identity, using alphanumeric coding for each participant (E1, E2, E3, ...), in order to guarantee the minimum of risks, both individual and collective, as well as to ensure that damages to services and workers were created.

RESULTS

Of the UBS linked to the eight (8) Administrative Districts, only 07 of them were included, leaving out DABEL as it is the only district that does not have a UBS. Among the 13 participants, 84.6% are women, 15.4% are men and all participants present themselves as heterosexual. Regarding religious aspects, 38.5% are Catholics, 23% of nurses said they had no religion, 15.4% reported being Adventists, 15.4% Evangelicals and 7.7% Spiritualists.

When asked about care for lesbian women, participants mentioned the idea of normality by offering the same type of action, demonstrating that they do not differentiate people by sexual orientation. In this speech on behavior patterns, some speeches addressed this pattern of normality, observing the influence of heteronormativity that encompass the thoughts of some health professionals in relation to assistance, as highlighted below:

[...]. Here we already have nursing care aimed at all the people who need us, so she would normally be attended to at our house, like a normal patient (E12)

However, paradoxically, when trying to show that they are normal, they name normal as the others, and not lesbianism as something normal:

[...] I don't ask the normal person, only if they come and tell me, get it? (E12)

Added to the idea of normality, the conception linked to a process of pathologizing sexuality, comparing it with the care of people living with tuberculosis or syphilis, for example:

[...] So she would be attended normally by our house, like a normal patient, even as a TB patient (tuberculosis), as a leprosy patient, like all other cases (E02)

In the case of prenatal care, it signals the naturalization that care is provided only to heterosexual women, not taking into account that lesbian women can get pregnant and have other pathologies.

[...] Here it is very basic, here we only assist pregnant women and Hiperdia, only, so about contact with this type of people, until today I have not had it, you know? (E7)

[...] prenatal care is based on that relationship that you think is a hetero relationship, “if you want” (no) we ask if the partner is of the same sex or not (E6)

 

Nurses express the ways in which they perceive and identify lesbianism, crossed by the identification of behaviors and roles considered as masculine:

[...] The very way of acting, also in some cases, but sometimes they are very discreet that you can't see it visually, in a way of the characteristics of the person's conduct, we know when it is (E1 ).

 

Finally, the linear association between gender and sexuality is evident when linking a lesbian sexual orientation to the construction of gender identity:

[...] we know that some lesbians today have that somewhat stereotyped pattern already tending towards the masculine (E4)

[...] One of the girls I attended looks like a man, if I look at her at night she is a boy, her work is metallurgical (E12)

 

According to the research participants' speeches, the stereotype used to identify lesbians in services was noted, placing them as those who try to insert themselves into socially accepted male behavior. This standard brings to the discussion the conceptions of what it means to be a man or a woman in society. Subordination behaviors are attributed to women through the imposition of stereotypes of what it means to be a woman, which are historically influenced by the patriarchal society.

The result, through the speeches, revealed a misconception of what it is to be a lesbian and what the health needs of these women are, reinforced by the pathologization of lesbian sexual orientation, as well as by the presumption of heterosexuality and the gender stereotypes imposed on lesbianism.

 

DISCUSSION
            The expression of “normality” in nursing care and the pathologization of lesbian women's sexual orientation

The first conception evidenced by the nurses is about the issue of normality, of treating the other as 'normal'. By nominating the other as 'normal', lesbianism occupies the space of abnormality in the nurses' conception. People who do not fit socially established standards are stereotyped as abnormal and may be excluded and marginalized. ⁽¹²⁾

Due to this theory, it is observed that those who break with this pattern are considered a danger to the conservation of the social order. Now, the standard of normality came to be defined according to bourgeois and capitalist values, through the device of sexuality, which defined standards that aimed at the division between man and woman, and legitimized only heterosexual sexual practices. ⁽¹²⁾

Due to prejudice and discrimination in relation to non-normative sexual orientations, lesbians and bisexual women move away from health services, considering the lack of humanized assistance and the lack of training of health professionals. ⁽¹³⁾ When health professionals do not respect and/or are not interested in a person's sexual orientation, for example, they are being negligent and do not fulfill their role from an ethical point of view.⁽¹⁴⁾

With regard to the concepts that pathologize the lesbian sexual orientation, Foucault helps in the reflection by describing, in detail, the universalization of sexual deviation and the entry of sexuality into the domain of psychiatry. ⁽¹⁵⁾ Identify, distribute and pathologize the sexualities considered deviant from the norm to the extreme of naming them as abnormal. Also according to Foucault, from the mid-nineteenth century onwards, psychiatry abandoned what had constituted the essential justification for mental medicine: illness. What it assumes now is the behavior, its deviations, its anomalies from an already instituted normative development. Since then, sexual experiences other than heterosexuality have been pathologized or, at the very least, stereotyped.

In spite of hierarchical relations, since the 17th century, homosexuality and women's sexuality are seen as sexual perversions, with this discourse linked to normative practices and techniques of power that influence the behavior of these groups. ⁽¹²⁾

From this perspective, the constant gender violence that affects lesbians also occurs because they do not follow the heteronormative standard imposed by society, proliferating offenses and threats that occur in their daily lives as one of its mitigating factors. ⁽¹⁶⁾ What is considered normal within health services or in society is problematized. So, the question is: where did this standard of normality come from, which is also reproduced in health care practices?

It is important to highlight that, both for the performance of nursing in health services, and for society in general, it is agreed that, at this moment, the focus is less on understanding what causes heterosexuality (unquestionable until then because it is natural) and homosexuality (until then deviant and abnormal), but to understand “the problem of why and how our culture privileges one and marginalizes – when not discriminating – the other”, which highlights the cultural, social and political character of sexuality. ⁽¹⁷⁾

Compulsory heterosexuality and the stereotypes imposed on lesbianism

Another idea that emerges in the speech of the participants is the naturalization of sexuality, associated with the presumption of heterosexuality. It signals that people are only considered normal when they are heterosexual; therefore, those who break with these standards are considered unnatural. ⁽¹⁸⁾

Heteronormative social norms validate socially imposed standards in relation to gender, body and cultural issues, which determine the ways of assistance within institutions. ⁽¹⁹⁾ Another aspect of this dimension is that there are lesbians who are resistant to heteronormative culture, especially when the “rejection of a compulsory way of life” occurs, practiced by resistance as a rejection of patriarchy. ⁽²⁰⁾

Another aspect of this dimension is that there are lesbians who are resistant to heteronormative culture, especially when the “rejection of a compulsory way of life” occurs, practiced by resistance as a rejection of patriarchy. ⁽²¹⁾

When the understanding of care for lesbian women is expressed from a perspective, dissociating the concept of integrality of care, one can perceive the existence of a stereotyped process about lesbianity. As a use of the expression “this type of person” referring to the lesbian, stating that he does not attend to her, as he only provides care to people with hypertension. Another nurse stated that he also does not assist lesbian women because he only does prenatal care. These thoughts are stereotyped and wrong, as they claim that lesbian women cannot have high blood pressure or become pregnant.

For fear of prejudice, many lesbians do not reveal their sexual orientation in health services, which reinforces the importance of permanent training processes, that will allow the health professional to understand more precisely that, in the care relationship, they should use empathic embracement, thus providing a bond of trust between professional and service user. ⁽²²⁾

For fear of prejudice, many lesbians do not reveal their sexual orientation in health services, which reinforces the importance of permanent training processes, that will allow the health professional to understand more precisely that, in the care relationship, they should use empathic embracement, thus providing a bond of trust between professional and service user.

The existence of a preconceived image to identify lesbians in health services is perceived, building a stereotype that places them as women who try to insert themselves in the context of socially accepted male behavior. A social posture that leads us to reflections on what it is to be a man or a woman in society, where women are attributed subordination behaviors historically imposed by patriarchal society. In practice, these standards of conduct become more profound when directed at non-heterosexual women.⁽²³⁾

Added to this is the idea that nurses know, without questioning, when people have a non-heterosexual orientation, highlighting the misconception of believing that expressions of gender and sexuality should be made explicit by the body. This also implies a compulsory correspondence between sex, gender and sexuality.

In this way, it is necessary to break with conceptions that define a single pattern of behavior for men and women, as this causes suffering for many people, such as lesbians, for example. It was clear that many of them are perceived as men, as they go against the socially imposed standard of what it means to be a woman. It should be noted that a haircut, clothes, colors and shoes have no gender.

Thus, it is agreed that there are paths towards health care that promotes the realization of the rights of lesbian women. This care can take the form of cultural humility, associated with cultural competence. Cultural humility is a term that a priori was used to address the issue of refugees, focusing on multiculturalism, being “defined as a process of being aware of how culture can affect health-related behaviors”. ^(24:1,2)

 Cultural competence is fundamental to conduct effective health care, provided that the health professional is trained to act in accordance with the cultural context of the health service user. Both terminologies should lead the professional to reflect on the cultural differences of society. ⁽²⁴⁾

In these terms, when a professional acquires a foundation on sexual diversity, understands the vocabulary, reviews his personal beliefs and his role as a professional, he creates an inclusive environment during care. ⁽²⁵⁾

CONCLUSION

Health professionals' knowledge about lesbian health was observed in this research, which identified the presumption of heteronormativity as one of the greatest weaknesses found, caused when a health professional offers the wrong care, encompassing all women as heterosexuals. To overcome these misconceptions, education and the development of skills are recommended that allow professionals to understand that health care must be carried out in an equitable manner.

Another point to be considered for health practices is the challenge of deconstructing the gender stereotype, mentioned in some of the nurses' speeches, when they tried to characterize their patients by their type of behavior or clothing.

The appropriation of this stereotype brought reflection on the necessary, urgent and permanent training and awareness that needs to occur, so that they can positively influence the profile of this professional, since someone's sexual orientation is only accessed when the person himself reveals it.

It is also necessary to think about approaching this theme in undergraduate nursing courses, contributing to the training of professionals sensitive to the ways of being and living of the multiplicity of people, in order to guarantee the realization of the right to health, which involves access free of prejudice, strictly ethical and offered in the assumptions of comprehensive care.

During the journey through the health services, the nurses' interest in the subject of the study was observed, although the fragility in conceptual aspects and in the practice of these professionals was shown in the results of the research in question.

It is noteworthy that, from the beginning, this research did not have the interest of revealing villains or culprits, much less had the intention of accusing professionals about their speeches, insofar as, during the crossing, it was pointed out in the discussions that many actions that are in the imagination of each one were historically and culturally constructed, but that are subject to deconstruction.

 

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