ORIGINAL RESEARCH

BEHAVIOR

Disclosure of Sexual Orientation Among Women Who Have Sex With

Women During Gynecological Care: A Qualitative Study In Brazil
Andréa Cronemberger Rufino, MD, PhD, Alberto Madeiro, MD, PhD, Adriana Silva Trinidad, MD,
Raiza Rodrigues dos Santos, MD, and Isadora Freitas, MD

ABSTRACT

Background: Evidence shows that women who have sex with women (WSW) face disparities in access to health
care when compared to heterosexual women in several countries.
Aim: To investigate the experiences WSW have after disclosure of sexual orientation during gynecological care in Brazil.
Methods: We performed a qualitative study using content analysis. We recorded and transcribed interviews with
34 WSW from the 5 regions in Brazil. Data were analyzed using descriptive content analysis.
Outcomes: The main categories of analysis were decision-making process to disclose and attitude of gynecol-
ogists after disclosure.
Results: WSW disclosed their sexual orientation in an un-favorable environment. Gynecologists rarely asked
about patients’ sexual orientation and used a script for hetero-normative anamnesis. The reactions of gynecol-
ogists were discriminatory, resulting in abbreviated consultations and un-comfortable gynecological exams. They
missed a window of opportunity for prevention, diagnosis, and treatment of various diseases. The experiences
Brazilian WSW had during gynecological care demonstrated the dominant hetero-normativity in the health care
scenario. The attitudes of the gynecologists precarized the existence of WSW in health service.
Clinical Implications: This study suggests that gynecologists missed an opportunity to use WSW’s sexual
orientation disclosure to offer specific care to them.
Strengths & Limitations: This is the first qualitative study about WSW’s experiences during gynecological care
in Brazil. Future studies should be developed from a wider sampling, especially among lower-class WSW.
Conclusion: The results point out the need for a change in medical training and guidelines to assist WSW in the
country. Rufino AC, Madeiro A, Trinidad AS, et al. Disclosure of Sexual Orientation Among Women Who
Have Sex With Women During Gynecological Care: A Qualitative Study In Brazil. J Sex Med
2018;15:966e973.
Copyright
2018, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.
Key Words: Women Who Have Sex With Women; Lesbian; Bisexual Women; Disclosure; Doctor-Patient
Relationship

INTRODUCTION heterosexuality guided the attitude of several professionals during

Several countries show evidence of disparities in health care access
by lesbian and bisexual women compared to heterosexual wom-
en.1e8 Hetero-normativity was identified as the central aspect of the
barriers to accessing health care services.7,9 The presumption of
Received December 2, 2017. Accepted April 30, 2018.
Research and Extension Center for Women’s Health/State University of
Piauí—Teresina, Piauí, Brazil
Copyright ª 2018, International Society for Sexual Medicine. Published by
Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.jsxm.2018.04.648
the treatment of women who have sex with women (WSW).4,5,7
Professional un-preparedness to meet the specific health demands
of these women is associated with events of lesbo-phobia and bi-
phobia, accentuating the vulnerability imposed on them.3e7,10
The inexistence of questions concerning sexual behaviors and
identities and the use of a questionnaire script about contra-
ception are recurrent events.5,6 Lack of knowledge about sexual
behavior among women may result in stereotyped guidelines for
the prevention of sexually transmitted infections (STIs) and
AIDS.5,6 Research conducted in Norway explored the experi-
ences of 121 lesbian women in regard to access to health care.

966 J Sex Med 2018;15:966e973

Disclosure of Sexual Orientation Among Lesbians
The hetero-normative attitude of health care professionals was
identified by the prescription of contraceptives, medical infor-
mation aimed at heterosexual activities, and pregnancy testing,
even after the disclosure of a lesbian orientation.5
The expectation of a satisfactory doctor-patient relationship
can positively influence WSW’s decision to disclose their same-
sex behavior and sexual identity to health professionals.11
Thus, disclosure of sexual orientation is a decision to be
considered by WSW at each new consultation.5 Disclosure was
considered a delicate moment during medical care. Feelings of
shame, previous experiences of discrimination, and loss of con-
fidence in health professionals negatively influence their decision
to reveal sexual orientation during consultations.1,5,10
The attitudes of health professionals after WSW’s disclosure
proved to be inadequate in different contexts.4e7,10,12,13 The
impact of sexual orientation disclosure to general practitioners on
33 women attracted to women was explored in Australia. About
66% of them revealed their sexual orientation to their general
practitioner. Although the patients preferred to be asked, doctors
were reluctant to ask. The non-welcoming environment for
women to reveal their sexual orientation resulted in a lower
likelihood of disclosure.12
Qualified listening and the provision of adequate guidelines for
their health specificities were minority attitudes.4,5 There were
reports of doctors offering heterosexual-specific guidelines and
treatments for WSW even after the patient revealed having sex
exclusively with women.5,6 Sometimes, gynecological examina-
tions were performed in rude and un-pleasant ways.5 Attitudes of
psychotherapists who pathologized lesbian and bisexual pop-
ulations were also evidenced, compromising the quality of care.5
The current state of gynecological care provided to WSW in
Brazil is un-known. Thus, we decided to investigate the experi-
ences WSW faced after revealing their sexual orientation and
gynecologists’ attitudes after the disclosure. We chose to inves-
tigate these experiences by highlighting sexual behavior di-
mensions and self-reported sexual identity of women.
METHODS
Study Design and Ethical Aspects
We performed a qualitative study with WSW in Brazil using
individual, in-depth interviews between June 2014 and January
2015. In order to participate in the study, participants had to
sign an informed consent form. The study was approved by the
Research Ethics Committee (CAAE 12710513.9.0000.5209),
following the guidelines of Resolution 466/12 of the Brazilian
National Health Council, in compliance with the Declaration
of Helsinki.
Research Participants and Data Collection Settings
This is the first nationwide study conducted in Brazil with
WSW over 18 years of age. They did not know the researcher
J Sex Med 2018;15:966e973
967
Interview questions
Decision-making process for disclosure
1. Did you disclose that you have sex with women or women and men?
2. Was the gynecologist's gender the criterion of choice for you when looking
for a consultation?
3. What was your reasons for the disclosure of your sexual orientation and
identity to the gynecologist?
Gynecologist’s attitude after the disclosure
4. How did the gynecologist react after the disclosure?
5. How was medical care after the disclosure?
Figure 1. Interview questions.
who would interview them and chose bookstores, public places,
and workplaces for the interviews, where only the individual
participant and the researcher were present at the time of the
interview.
Surveys conducted in Brazil estimated the population of
lesbian and bisexual women ranging around 3%.14 However, the
vulnerability conditions related to lesbo-phobia and bi-phobia
make it difficult to have access to these women. A considerable
number of them do not want to be recognized for their practices
and sexual identity. The study was disseminated to women in
cities from the 5 regions in Brazil with the help of intermediaries,
representatives of the lesbian, gay, bisexual (LGB), transvestite,
and transgender (LGBT) community. The invitation to partici-
pate was made by e-mail and through social networks. Frequency
distribution of WSW participating in the study by region in
Brazil was arranged: 7 (20.6%) women in the north region, 5
(14.7%) in the northeast region, 7 (20.6%) in the mid-western
region, 8 (23.5%) in the southeast region and 7 (20.6%) in
the south region.
Women who agreed to be interviewed referred others to
participate in the study, generating a snowball effect. Saturation
occurred at around 30 interviews, and later interviews served to
confirm themes identified earlier. Of the 47 WSW who showed
interest in participating in the study by indicating specific dates
and times for the interviews, 34 followed through and 13
desisted due to un-availability of time.
Research Instrument and Pre-Test
We designed a semi-structured interview script with open-
ended questions, which were organized into 2 topics. The
first topic investigated the decision-making process to disclose
the sexual orientation and identity to the gynecologist. The
second topic questioned the gynecologist’s attitude after the
disclosure (Figure 1).
We developed a pilot project to train the first author for the
interviews, as well as to test and improve the research tool. At
this stage, we analyzed the difficulties to conduct the in-
terviews, the understanding of the questions, and time to
respond to them. The pre-test responses were excluded from
the survey results.
968 Rufino et al

Table 1. Demographics, self-reported sexual orientation and sexual Key issues WSW’s experience
Decision-making: disclosure of Anxiety about disclosing their
behavior of interviewed women who have sex with women
sexual orientation and identity sexual orientation and expectations about
Women who have the attitudes of physicians during health
sex with women care.
Most women disclosed their
Characteristics n % sexual orientation and identity.
Gynecologist's gender WSW reported being seen by
Age
gynecologists of both genders, although
18e29 y 15 44.1 more often by women.
30e49 y 14 41.2 Feeling more comfortable with
>50 y 5 14.7 female gynecologists, combined with the
Education expectation of less unpleasant
Up to 8 y 1 2.9 examination was predominant in the

>8e11 y 9 26.5 WSW report.

>11 y 24 70.6 Reasons for disclosure Their participation in militant

LGBT groups made it easier for them to
Sexual identity
assume a lesbian sexual and political
Lesbian 30 88.2 identity and, consequently, to disclose
Bisexual 4 11.8 their orientation to the gynecologist.
Sexual behavior* Professional attitude: gynecologist’s Most gynecologists of both
Exclusively same-sex experiences 21 61.8 reaction after disclosure genders demonstrated negative reactions:

With both men and women 13 38.2 use of a standardized script of questions
directed at heterosexual women, dodging
Total 34 100
attitudes and silence, moral judgment,
*Sexual behavior throughout life. didn’t know how to act, short
consultation, discriminatory situations,
refusal to provide care.
Exceptional positive reactions:
Interview and Data Analysis Receptive attitudes and professional
A female researcher experienced in qualitative methods and knowledge about the health specificities
LGBT health care explained the reasons that motivated the of WSW.

research to WSW, and conducted the interviews. After the The institutional context of the
consultations didn’t affect the attitude of
consent of the women, the interviews were audio recorded,
the Brazilian gynecologists, which
transcribed verbatim, and the recordings were later erased. The remained unsatisfactory.
interviews lasted from 30 minutes to 1 hour, with an average of Medical care after disclosure: Painful and inadequate
42 minutes. The interviewer took field notes and no interviews health examinations and advice received gynecological exams.

were repeated. The transcripts were not corrected by the Cytology sample collection for
cervical cancer prevention were not
participating women.
performed.
2 Independent researchers performed a comparative and Professional training Expectation of having their health
descriptive content analysis by extracting similarly codes, and needs met during gynecological
consultations.
identifying recurring issues and differences in the narratives.
Unpreparedness of physicians and the
Both researchers discussed the main themes they had recog-
importance of professional training
nized and discrepancies were mutually resolved. Representative for their consultations.
quotes are described to illustrate key aspects of each theme.
Figure 2. Key issues regarding women who have sex with women
Finally, we debated the results with some of the women
(WSW) experiences of disclosure. LGBT ¼ lesbian, gay, bisexual,
participating in the survey. transvestite, and transgender.

RESULTS Decision-Making: Disclosure of Sexual Orientation

Most of the women belonged to the 18- to 49-year age group
and declared more than 11 years of schooling. Most of them
reported exclusive same-sex partners and self-reported a lesbian
sexual orientation identity (Table 1). 6 Main themes were
identified: decision-making: disclosure of sexual orientation and
identity; gynecologist’s gender; reasons for disclosure; profes-
sional attitude: gynecologist’s reaction after disclosure; medical
care: health examinations and advice received; and professional
training (Figure 2).
and Identity
WSW reported anxiety about disclosing their sexual orientation
and expectation about the attitude of physicians during health care.
According to WSW’s reports from all regions of the country, a
minority of gynecologists asked about their sexual orientation or
sexual practices, whether with a man, a woman, or both. A lesbian
student (participant P6) described a typical consultation with basic
questions: “Do you have sexual relations? Do you use any contra-
ceptive method? No? So, you want to get pregnant, right?”

J Sex Med 2018;15:966e973

Disclosure of Sexual Orientation Among Lesbians
Gynecologist’s Gender
WSW chose gynecologists using criteria such as gender,
competence and professional approach to address their health.
They reported being seen by gynecologists of both genders,
although more often by women. A lesbian lawyer (P9) said: “We
do research to find a professional who is more open and does not
practice any violence, how to say that we must see the psychia-
trist or ignore our condition as lesbian or bisexual.” They said
feeling more comfortable with female gynecologists, combined
with the expectation of a less un-pleasant examination was pre-
dominant in the WSW report. A journalism lesbian student
(P23) reported: “I prefer a female doctor because I only feel
comfortable with them. I don’t like male doctors.” A lesbian
biology student (P29) also reported preferring female gynecolo-
gists: “Because I feel more at ease to expose myself.”
Reasons for Disclosure
In turn, most women disclosed their exclusive sexual practices
with a woman or with both a woman and a man to their
gynecologists. Their participation in militant LGBT groups
made it easier for them to assume a lesbian sexual and political
identity and, consequently, to disclose their orientation to the
gynecologist. A bisexual woman (P8) said: “We had already
learned, in this milieu of militancy, how important it was to tell
the professional, to never conceal. So, talking was a political and
pro-health position as well.”
Professional Attitude: Gynecologist’s Reaction
After Disclosure
Women from all regions of the country reported that in most
gynecological consultations physicians of both genders adopted a
standardized script of questions directed at heterosexual women.
A lesbian woman’s (P20) report highlighted the ordinary ques-
tions: “Do you have an active sex life? So, do you use condoms?
Do you use any contraceptive method? Which contraceptive
method do you use?” A lesbian woman (P2) said, “They sound
like they’re a little mechanical, like hetero-normatives.”
For the interviewed women, the disclosure about their sexual
practices triggered negative reactions characterized by dodging
attitudes and silence from most gynecologists. A bisexual student
(P1) said: “I noticed a certain distance, a coldness from the
moment I spoke.” A lesbian woman (P13) said: “The doctor did
not raise her head at all. She would just write what I said. No, she
hardly looked me in the eye.”
Gynecologists’ attitudes of moral judgment regarding homo-
sexuality were also frequent. The gynecologist told P6, “Well, I
don’t know if you know, but I don’t do artificial insemination for
dykes.” That was when she replied: “But I did not even come here
looking for artificial insemination.” So, the physician responded:
“No? That’s the only reason dykes look for a gynecologist.” A
gynecologist told a lesbian college student (P16) after learning
about her same-sex orientation: “Tell me about your first sexual
relationship.” The woman talked about her first sexual experience
J Sex Med 2018;15:966e973
969
with a boy and she said to the woman’s surprise: “Oh, so it was
traumatic!” The woman replied, “No, it was not traumatic!”
Some women noticed that the gynecologist showed that they
didn’t know how to act and shortened the end of the consulta-
tion due to the surprise of the disclosure. A lesbian lawyer (P21)
reported that the consultation almost ended after her disclosure:
“The physician was very embarrassed, you know? Things began
to fall, and she got quite clumsy. It affected me, but I had already
anticipated that possibility.”
The majority of the WSW interviewed showed dissatisfaction
with the gynecological consultations already performed. Women
in different cities described discriminatory situations. P25 (a
physician) reported that she was a lesbian during a gynecological
consultation. At this point, the gynecologist “wrote with big
letters: homosexual, using about 5 lines, in bold letters, taking up
all the space of the page. While I was talking, she would highlight
the letters to make it noticeable in the medical record.”
Other WSWs reported refusal to provide care. A lesbian
teacher (P18) sought care with a report of urinary tract infection
and was discharged from treatment without an indication of
appropriate treatment. “The physician focused on the medical
record. Everything was a reason to spend less time with me, as if
it bothered her. She asked me to leave and wait there at the front
desk. And it was clear that she did not want to treat me anymore.
Then, no one else came to talk to me.”
Receptive attitudes and professional knowledge about the
health specificities of WSW were an exception. A lesbian
librarian (P7) commented on a gynecologist’s discourse: “Look,
sorry, but I have never studied anything about it. And I don’t feel
comfortable providing care for you now and continuing to see
you without a minimum of knowledge. Come back later and
we’ll talk about everything you need to know.” P6 went back the
following week and was surprised by the physician’s behavior: “I
think she had devoured 837 books because I came back and she
knew everything.”
Medical Care: Health Examinations and Advice
Received
WSW from all regions of the country reported painful and
inadequate gynecological exams. A lesbian woman (P15) said:
“Some physicians were a bit more aggressive even though I said I
was not used to vaginal examinations.” P31 reported the gyne-
cologist’s un-timely attitude: “He came to introduce with this
real lack of sensitivity! He knew because I had spoken. That
device caused me a lot of pain.” A lesbian trainer (P33) also
reported: “He hurt me with that speculum. Just because I told
him I lived with a woman, you know?”
Some examinations were not performed, such as cytology
sample collection for cervical cancer prevention. A lesbian
woman (P10) said: “After I said I was a lesbian, she never used
the little gadget, just a cotton swab. I feel the consultation is
incomplete, right? I have sex, I have intercourse. So, she has to
970
treat me the same way she treats her heterosexual patients.” P25
received the justification that she would not be examined even
after she said she had sex with a woman. The gynecologist said,
“I’m not going to give you pelvic exam because you’re a lesbian
after all.” She replied, “But that does not mean I do not have
intercourse, right?”
Medical care occurred in private and public institutional
contexts with differences considering the regions of the country.
Women interviewed in the northern region reported using
mainly public service, while those in the mid-western region used
private health insurance. Women in the northeast, southeast, and
south regions used equally public and private health insurance
services. WSW who used public and private services reported
better quality of health care in private service, although the
hetero-normative questionnaire script was the same in both
services. P16 was the only woman who reported care in a uni-
versity hospital. She reported human papillomavirus (HPV)e
related health problems that required consultations every 3
months. At each return, the script of questions about contra-
ception and use of male condoms was repeated, despite her
reporting that she was a lesbian. She said, “I asked them to write
on my chart that I was a lesbian to end those questions.” She also
noted: “I was never asked to get permission for so many students
to enter the examination room. I felt like a guinea pig. I never got
any advice about HPV risk to my partner.”
Professional Training
Many WSW spoke of the expectation of having their health
needs met during gynecological consultations. For a lesbian
public worker (P9), the disclosure of her same-sex sexual
behavior is an opportunity that the gynecologist has to instruct
her. A lesbian woman (P3) stated, “And after they knew I was
homosexual, they wouldn’t talk about avoiding AIDS, using
condoms, that kind of thing, you know? Even if they talk about
sexual practices, they dodge talking, educating, and instructing.”
Other WSW highlighted the un-preparedness of physicians and
the importance of professional training for their consultations. A
lesbian coach (P19) reported regarding one physician’s discourse:
“We are not prepared for these things, nor for lesbian issues, nor
for gay or nothing.”
DISCUSSION
This article offers a current study of Brazilian WSW’s experi-
ences during gynecological care. The women participating in this
study were predominantly young and highly educated with a
distribution in the 5 regions of the country. They were reached
through regional and national LGBT groups, which may have led
to a politicized bias in the sample. However, considering the great
extent of the country and regional cultural differences, this is the
first qualitative study of national coverage of which we are aware.
Our findings highlighted an un-favorable scenario of gyne-
cological care for WSW in all regions of Brazil, similar to
Rufino et al
international reports.1e9 The dissatisfaction with the attitude of
gynecologists of both genders dominated the report of the
interviewed WSW. A systematic review of qualitative studies on
the experiences of the lesbian, gay, and bisexual population
during health care revealed communication difficulties in a
hetero-normative care setting.15
The decision-making process of the interviewed WSW to
disclose their sexual orientation was marked by the anxiety
caused by the expectation regarding the attitude of the physician.
WSW chose to be seen preferentially by female gynecologists
with the expectation to facilitate the disclosure. WSW reported
that gynecologists of both genders should ask about sexual
orientation, but only a few did so. Most gynecologists followed a
script of questions about contraception, creating an un-familiar
environment that made the disclosure difficult. The presump-
tion of women’s compulsory heterosexuality leads to a systematic
question about the use of contraceptive methods.5,6
There is evidence that the decision and timing to disclose
sexual orientation are complex and challenging for sexual mi-
norities.11,16,17 In qualitative research with Norwegian lesbian
women, disclosure was considered risky and capable of causing
vulnerability, although clinically important when gynecological
and reproductive symptoms are involved.16 Canadian lesbian,
gay, bisexual, and queer individuals have shown that the clinical
setting of the consultations did not remove the difficulties
regarding the disclosure of sexual identity.17
Despite this scenario, almost all interviewed WSW disclosed
their sexual orientation. Most of them did not wait to be ques-
tioned and made the disclosure in response to the script of
hetero-normative questions. A U.S. study investigated the impact
of sexual orientation disclosure on health disparities of 420
WSW of different sexual identities using a secure collection box
technique. About 49% of WSW reported that they had disclosed
their sexual orientation without being asked by the physician.13
Our data showed that assuming a lesbian or bisexual identity
was considered a decisive factor for sexual orientation disclosure.
The participation of the interviewed WSW in LGBT militant
groups empowered them to assume their sexual identity and to
disclose to gynecologists without being questioned. Research
conducted in Norway interviewed lesbian women about coping
strategies adopted in situations regarding sexual orientation. The
successful strategy was identified as an attitude of positive self-
esteem toward lesbian identity, indicating that being a lesbian
is respectable and dignified.18 A U.S. survey investigated the
patterns of sexual orientation disclosure of 396 LGB individuals.
Lesbian and bisexual women more likely to disclose their sexual
orientation to health care providers were those who reported
stronger feelings of lesbian and bisexual identity, lower rates of
internalized homo-phobia, and increased connection to the
LGBT community.19
In the perception of the interviewed Brazilian WSW, most
gynecologists demonstrated negative attitudes after sexual
J Sex Med 2018;15:966e973
Disclosure of Sexual Orientation Among Lesbians
orientation disclosure. According to the women’s report, pro-
fessional attitude after the disclosure was not influenced by the
gynecologist’s gender. Gynecologists’ attitudes (of both genders)
varied among silence, curiosity, moral judgment, discrimination,
and not knowing how to act after the disclosure. There was an
isolated report of satisfactory gynecological care and receptivity
based on the health specificities of WSW. The attitude of the
Brazilian gynecologists was not affected by the institutional
context of the consultations but makes WSW feel invisible
during care, which makes their health needs go un-noticed.4,5,7
Our findings pointed to the vulnerability of WSW during
consultation and gynecological examination, despite the
disclosure of their sexual orientation. There were reports of
discrimination, abbreviated consultations, painful gynecological
examinations, and avoidance in the treatment of acute illness. In
a survey carried out in the United Kingdom, there were reports
of discriminatory notes in the medical record and the use of a
script of hetero-normative anamnesis, although the patient had
previously informed her sexual identity.4 Experiences of good
communication and provision of guidelines adequate to the
health specificities of Brazilian WSW were a minority, similar to
what was found in the United Kingdom4 and Norway.5
Brazilian WSW reports showed the lack of preparation of
gynecologists from all regions of the country to provide them
with appropriate health services. Sexual orientation disclosure
was the majority attitude of WSW during care. Guidelines on
strategies aimed at health professionals to facilitate the dissemi-
nation of sexual orientation and to improve the care of lesbian
and bisexual women have been published.11,20 Recent Australian
research emphasized that responsibility for disclosure should be
shared between WSW and their physicians. However, the
greatest burden of responsibility must be assumed by physicians
in creating conditions for the disclosure.11
The physician’s sensitive attitude to recognize that the LGBT
population is marginalized by hetero-normativity is central to
health care.17 It is incumbent on them to provide an inclusive
environment, communication strategies, and language conducive
to disclosure.11,17,21 A systematic literature review was conducted
in 2010 to investigate global guidelines on LGB population
health care.21 The adoption of changes in communication styles
by physicians and the use of adequate language are strategies that
would facilitate the reception of LGB individuals during care.21
In our sample, gynecologists missed the moment WSW dis-
closed their sexual orientation as an opportunity to offer specific
care to them. According to the women’s report, there was
absence of examination or inadequate cytology sample collection
for cervical cancer screening and the loss of a window of
opportunity to guide STI prevention. Other studies showed
prevalence of STI and AIDS in women who have sex with
women only, although the percentages are lower than among
those who have sex with men.22e25 Research that investigated
the epidemiological aspects of STI in a sample of 145 Brazilian
WSW showed their vulnerability by combining several risk
J Sex Med 2018;15:966e973
971
factors.22 A U.S. study investigated the coverage of the cytology
examination for the prevention of cervical cancer and found that
the test was less frequently performed on lesbian women
(44e57%) compared to heterosexual women (75e84%).23 The
lack of medical health knowledge about specificities and dispar-
ities in access to health among WSW imposes vulnerabilities on
this population.8,26,27
The model of medical training remains based on hetero-
normativity, reinforcing the attitudes of professionals that all
women are heterosexual.8,28e31 In several countries, professionals
had difficulties in collecting a sexual history, which results in the
difficulty to address sexual practices, identities, and trajectories
and reinforcing the insensitive and discriminatory attitudes.6,7
The discomfort in dealing with sexual issues may be related to
lack of adequate training. Sexuality education in medical training
courses is considered critical to ensuring the comprehensive care
and sexual rights of the population.32,33 In South African med-
ical school, only 9% of professors addressed LGBT themes.
Knowledge and ability to talk about the health needs of the
LGBT population were not provided.31
In 2014 a Brazilian survey was conducted to better under-
stand sexuality medical training in undergraduate courses.28
Sexual orientation was mainly addressed with themes related
to heterosexuality (67.5%) compared to homosexuality
(47.1%) and bisexuality (36.1%).28 The lack of medical
training may be responsible for the fact that Brazilian WSW are
at an especially high risk of being harshly treated and even
discriminated against by their gynecologists. However, profes-
sional knowledge about the LGBT health specificities can be
improved by change in the provision of sexuality medical
training. In our findings, a physician’s personal interest in
knowing about WSW health resulted in receptive attitudes and
better medical care.
This study presents some limitations to be considered. The
young profile of participants with a high level of education and
who are connected to the LGBT community may have biased
the findings on the disclosure of sexual orientation to gynecol-
ogists. Another limitation of this study was investigating nuances
involved in WSW’s decision and their view regarding gyneco-
logical care only. We did not investigate physicians’ view and
attitudes about sexuality and sexual issues in general. The
absence of interviews with the gynecologists did not allow un-
derstanding about their subjective experiences in the care offered
to the population under study. In this sense, we need to consider
tensions between WSW’s perception and physician’s view of the
consultation.34 However, the scenario of consultation with lack
of questions about WSW sexual practices may suggest difficulties
for gynecologists to address sexual issues. Their conduct during
consultations also suggests discomfort to deal with issues related
to non-heterosexual sexualities. The WSW’s perception of
medical care could be a resource for balancing the complex
physician-patient interaction and facilitating the disclosure of
sexual orientation.35
972
CONCLUSION
The present investigation about the experiences of Brazilian
WSW during gynecological care evidenced an un-favorable sce-
nario. A few WSW reported being questioned about their sexual
orientation, whether by the extent of their sexual practices or by
their sexual identity. The lack of medical training may have
resulted in the adoption of a script of questions inappropriate to
the specific health needs of WSW.
Most WSW revealed their sexual orientation, despite the non-
welcoming environment offered by gynecologists. In our find-
ings, responsibility for disclosure of sexual orientation was not
shared between WSW and gynecologists. The patients alone
took responsibility for this decision, despite the un-favorable
scenario for disclosure. The attitude of most gynecologists has
made it difficult for WSW to disclose their sexual orientation.
The gynecological care received by them exposes their invisibility
and the precariousness of services in Brazilian health centers.
Given this scenario, it is imperative to change the gynecological
care health professionals provide to Brazilian WSW. Our find-
ings provoke the debate about medical education in Brazil and
highlight the need for guidelines for WSW health care in the
country.
Corresponding Author: Andréa Cronemberger Rufino, MD,
PhD, Research and Extension Center for Women’s Health/State
University of Piauí—Teresina, Avenida Coronel Costa Araújo,
3033 Teresina, Piauí, Brazil 64049-460. Tel: 5586994522797;
Fax: 558632213170; E-mail: andreacrufino@gmail.com
Conflict of Interest: The authors report no conflicts of interest.
Funding: This research was supported by the Brazilian National
Council of Scientific and Technological Development under
process no. 472995/2013-8.
STATEMENT OF AUTHORSHIP
Category 1
(a) Conception and Design
Andréa Cronemberger Rufino; Alberto Madeiro; Adriana Silva
Trinidad; Raiza Rodrigues dos Santos; Isadora Freitas
(b) Acquisition of Data
Andréa Cronemberger Rufino; Alberto Madeiro; Adriana Silva
Trinidad; Raiza Rodrigues dos Santos; Isadora Freitas
(c) Analysis and Interpretation of Data
Andréa Cronemberger Rufino; Alberto Madeiro; Adriana Silva
Trinidad; Raiza Rodrigues dos Santos; Isadora Freitas
Category 2
(a) Drafting the Article
Andréa Cronemberger Rufino; Alberto Madeiro
(b) Revising It for Intellectual Content
Andréa Cronemberger Rufino; Alberto Madeiro; Adriana
Silva Trinidad; Raiza Rodrigues dos Santos; Isadora Freitas
Rufino et al
Category 3
(a) Final Approval of the Completed Article
Andréa Cronemberger Rufino; Alberto Madeiro; Adriana Silva
Trinidad; Raiza Rodrigues dos Santos; Isadora Freitas
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