The Brazilian health system presents gaps in the care it provides for lesbian women, especially regarding the particularities of gynecological care, requiring a better incorporation of Health Literacy (HL) in professional health practices, including the performance of HL skills and competencies by users of the health system. Scientific literature has shown that this population faces challenges to receive adequate care, including financial, cultural, and structural issues, in addition to lesbophobia ^(1-3).

All over the world, the traditional structure of these services often creates non-intentional barriers in the care for the LGBT (Lesbians, Gays, Bisexuals, Transvestites, and Transexuals) people, which may cause services to be perceived by these individuals and their families as an inaccessible, hostile, and even unsafe environment⁽⁴⁾.

The Lesbian Women's Health Dossier — Promotion of Equity and Integrality (2006) shows the inequality in the access to health services by lesbian and bisexual women. From a practical standpoint, nearly 40% of lesbian and bisexual women who seek health care do not state their sexual orientation. Among women who do declare their orientation, 28% stated that consultations are faster, and 17% stated that exams that they believe are necessary were no longer requested, increasing their risk and their vulnerability to several health issues^(2,5).

In this context, the ability of lesbian women to understand gynecological self-care involves HL, which, in Brazil, is still rarely explored. The concept of HL, according to the World Health Organization (WHO), is the ability to gather, process, and understand health information to make appropriate decisions for the management of self-care. It emerged as an instrument that could mediate educational activities in health services^(6-7).

According to Parker et al. (1995), this construct describes basic reading, writing, and counting skills as especially important in the health field, as the participation of patients in the therapeutic plan is critical for the success of treatments. Thus, HL can be an important predictor for general health results when compared to sexual orientation, gender identity, ethnicity, age, education, and socioeconomic status^(8-9).

Sorensen⁽¹⁰⁾, by gathering HL definitions, developed an integrated conceptual model that includes the several dimensions of this construct that impact literacy levels and health results. These dimensions were divided into four competences, namely: access (the ability to seek and obtain health information), understanding (the ability to understand the information obtained), evaluation (the ability to interpret, filter, and evaluate health information) and application (the ability to communicate and use information to make decisions to preserve or improve health)⁽¹⁰⁾.

Nevertheless, it was found that there is a gap in health and nursing studies regarding HL from the perspective of the self-care capability of lesbian women, that is, their ability to care for themselves and carry out self-care activities for their own benefit, in order to preserve their life, wellbeing⁽¹¹⁾, and autonomy. Thus, it is essential to gather more knowledge about this topic and explore it further, which is the reason for this study. Part of the health issues presented by individuals, as well as the goals established in interactions between nurse and patient in the context of a therapeutic relationship — such as consultations and educational interventions^(12-13) — are associated with the premises of Health Literacy. Thus, the concept of supported self-care is a useful tool to guide nursing care.

Findings from scientific literature suggest that HL, in isolation, cannot improve self-care nor adherence to therapy, but has been promising as a positive influence to reach better health results⁽¹⁴⁾. Its goal is for people to take on a posture of active self-care, adopting healthy lifestyles, going to consultations, undergoing exams, adhering to damage reduction practices, and taking advantage of their support networks to improve the conditions of their lives⁽¹⁵⁾.

As a result, the guiding question of this research was: How do health literacy skills and competencies contribute for gynecological self-care in lesbian women? Our goal is to analyze how health literacy skills and competencies help improve the gynecological self-care in lesbian women.

METHODS

Study type

This is a qualitative study⁽¹⁶⁾ that followed the guidelines of the Portuguese version of the Consolidated Criteria for Reporting Qualitative Research (COREQ)⁽¹⁷⁾.

Place of Study and Target Audience

Participants included citizens from the municipality of Recife and its metropolitan region (MRR), in the state of Pernambuco, Brazil. They were selected by convenience and according to their availability. The study population included cisgender women who self-declared as lesbians. Inclusion criteria were: cisgender women who self-declared lesbians and were 18 or older. We excluded cisgender women that self-declared as lesbian and did not have devices that would allow them to answer the research during the pandemic (such as computers, cellphones, tablets, Internet, and others). We also excluded those with other gender identities and sexual orientations that were not cisgender and lesbian.

Data collection

For data collection, we used semi-structured individual interviews. This technique allows the manifestation of individual perceptions and opinions, while making it possible to interact with the participant by enabling them to express different points of view, which can have an impact on the data collected and, consequently, on the achievement of effective results.

During this process, we considered the previous experience of the authors involving the topic at hand, as well as their experience conducting this type of interview. The tools used to conduct the session included a virtual room, which was created in the platform Google Meet®. A script with semistructured interview questions was also elaborated, including the following questions: 1. Tell me what you understand as self-care. 2. Tell me how to carry out your gynecological self-care. 3. Tell me how health workers help your gynecological self-care.

Participants were invited individually through the WhatsApp® messaging app. There, they were informed about the specificities of the development of the present study and asked for consent. After they gave their consent to participate, a virtual group was created in WhatsApp®, in which the participants were included to streamline communication. The access link to the on-line Google Meet® room was made available in the group, and the day for each interview was scheduled in advance.

During the conversation in the messaging group, we discussed all details related to the development of the interviews. Most preferred participating at 8 pm, after work hours. We recommended participants to go to a private and silent location, which is a necessary precaution to avoid external interference during data collection. Before starting the interview, we applied an objective on-line questionnaire via Google Forms®, requesting sociodemographic information to characterize the participants.

Sessions were carried out in September 2023 and lasted approximately 60 minutes each. Participants were informed about the goals of the interviews through an Informed Consent, made available on-line via Google Forms®, in accordance with Resolution No. 466/2012, which establishes norms for research with human beings. The confidentiality and privacy of their information obtained was respected.

The narratives were recorded in video, to which participants consented. They were also asked to keep their cameras on, and the main researcher carefully observed pauses and intonation in their discourse, as well as facial expressions, gestures, and other forms of body language, which were subtly recorded in the form of a "field note", carefully following all steps needed to ensure the reliability of a qualitative research⁽¹⁸⁾. To preserve the identity of participants, their names were replaced using an alphanumeric system, based on the letter "E". Their statements were transcribed in full, and the data produced was processed using the software Interface de R pour les Analyse Multidimensionnelles de Textes et de Questionnaires (IRAMUTEQ)⁽¹⁹⁾.

The ethical principles of justice, beneficence, and non-maleficence were respected, and the study was approved by the Research Ethics Committee of the Health Sciences Center of the Universidade Federal de Pernambuco under opinion No. 4.862.503 and CAAE No. 47777421.0.0000.5208.

Data analysis

The processing module Descending Hierarchical Classification (DHC) was used to analyze the data collected. In this process, the vocabulary in the text corpus is identified and quantified regarding its frequency and placement in the text, that is, it is submitted to statistical calculations for later interpretation. This analysis aims to divide the text into segment classes which share a similar vocabulary, but have a different one from that in other classes⁽²⁰⁾.

After data processing, the classes indicated by IRAMUTEQ were analyzed, and Elementary Context Units (ECU) grouped in each class were closely read, so they could be understood and named⁽²⁰⁾. The findings were analyzed and interpreted inductively using a theoretical-conceptual framework formed by the Health Literacy Model proposed by Sorensen⁽¹⁰⁾, after the content derived from the empirical data was obtained.

RESULTS

The participants were aged from 25 to 29 years old and lived in the Metropolitan Region of Recife (PE). They were single, with no children, complete higher education, family income between three and five minimum wages, and periodic medical consultations. They stated that they do take preventive measures for breast and vaginal diseases and do disclose their sexual orientation during health care.

The general corpus included four texts, divided in 81 text segments (TS), of which 72 were used (88.89%). There were 2,841 occurrences (words or forms), with 978 unique words and 582 that appeared only once. The corpus analyzed was divided into seven classes, distributed as follows: class 1, with 12 TS (16.7%); class 2, with nine TS (12.5%); class 3, with ten TS (13.9%); class 4, with 11 TS (11.1%); class 5, with eight TS (15.3%); class 6, with 12 TS (16.7%) and class 7, with ten TS (13.9%).

Considering the HL construct and its four dimensions, according to the guidance in Table 1, we were able to group classes in such a way as to make clear how they apply to the results found during the semi-structured interview.

Table 1 - HL skills and competencies proposed by the Integrated Conceptual Model of Sorensen et al. (2012) and their association with the presentation of the thematic classes in this study.

Skills/ competencies:	Theoretical-conceptual definition:	Theoretical framework of the findings:
Access	The capacity to find and obtain health information (classes 1 and 6).	The gynecological self-care of lesbian women depends on the search for information and individual initiative to be effective.
Understanding	This refers to the understanding of the information found during the exercise of health care (classes 2 and 3).	For lesbian women to carry out gynecological self-care, their understanding must be facilitated, and health workers must welcome them into the services. The same is valid for therapeutic possibilities to be used, considering lesbian specificities.
Evaluation	This is the ability to interpret, filter, and evaluate a certain piece of health information (class 4).	Lesbian women self-care in health also depends on their access to the information provided by health workers to improve HL.
Application	This is the skill of applying the knowledge acquired, using information to make decisions to preserve and/or improve one's health (classes 5 and 7).	The knowledge is applied by associating the guidance received and one’s life experience in regard to health care. The ability of self-care in lesbian women is insufficient, especially when it comes to gynecological care.

Class 1: “Searching information for self-care” found that, to promote their self-care, these women obtained information by consulting several sources that were “considered safe”. These sources were used to corroborate the guidance provided by health workers, and included the application of traditional and cultural knowledge in self-care:

[...] I can carry out my own research (after a consultation) and see whether it makes sense or not and, even if I couldn't, having higher education makes this possible... marginalized women are very unlikely to have this possibility available to them. E2

[...] before searching for a physician I usually use natural treatments, which I learn from my mother and grandmother. E4

Class 2: "Guidance and welcoming of health workers" guidance for self-care provided by health workers was highlighted, as they reproduced prejudiced practices and were found to be restrictive, exclusive, non-interactive, and insufficient for the needs of a lesbian woman:

[...] they have another (prejudiced) attitude... it's the same as hurting me, I feel harmed. E1

[...] my friends don't feel that they have to confront their physician regarding the medicine they are given, the procedures they think are necessary... I say that because I feel I'm in this place and I ask them to give me an explanation. E2

Class 3:"Possibilities in self-care for lesbian women" it was found that they have trouble accessing information and applying individual self-care strategies, making it clear that they do not understand well the topics of gynecological self-care:

[...] self-care is quite absent in health, in general. When I was single and trying to meet other women, I didn't know which methods I could use to protect myself. E2

[...] self-care should become a naturalized behavior; we should see the need and really have to change gynecological health. The obstacles and invisibility are so great that we cannot conceive of the possibility of using the same condom used for penetrative sex for sex between women. Our health is that limited. E3

Class 4: "The information provided by the health worker" by interpreting the information provided to change their health care practices, the participants described feeling that professionals are distance due to their prejudice, value judgment, and lack of data that could lead to a change in behavior. This pushes lesbian women from health services, and the alternatives they have left are special services in which care is provided with no dogmatism that could interfere in the acquisition of information for self-care:

[...] I always mentioned my sexual orientation when going to gynecologists, no one ever asked, but I always mentioned it. Some of them tried to be funny, saying that in that case I didn't need to worry about contraception... only when things are really bad I'll go to a physician. I also went to gynecologists. I've been told I don't need a preventive exam. E4

[...] I disagree, I express my disagreement, and I really wish it would change. The same happens during gynecological follow-up, when people ask if I want to get pregnant, if I want to be a mother by adopting, if I am fulfilled as a person due to my sexual orientation, if there's nothing missing in my relationship. E1

[...] I searched for the LGBT outpatient clinic when it started because there I felt at ease to really talk about my sexual orientation and my specificities, something I wouldn't do in other physicians. I felt really isolated, I have heard some bad things from gynecologists. E3

Class 5:"Applying the guidance received to self-care" this category showed how participants use the knowledge obtained in their health experiences, showing their ability to self-care considering conversations and questions about sexual practices that emerge among their peers, as well as developing gynecological self-care actions:

[...] self-care can be multiplied and socialized when you take the initiative... you share... we are in that network, a micro-network, everyone here has been with everyone, knows everyone... we need to naturalize this. E2

[...] I'm used to always ask when I have sex with someone, I tell them I take precautions, that I have no discharge, did my quick tests, and everything is alright! I think we should at least treat that as a natural thing, talking about it. E3

Class 6:"Personal initiatives for self-care" it was found that personal initiative in the search for care in health services was primarily guided by specialized services for the LGBT population. When a lesbian woman does not use these services, she carries out her gynecological self-care in routine exams, such as mammographies and exams to prevent cervical cancer:

[...] I donate blood, and whenever I do, every 4 months, I get results from all exams. I always do exams, every year, cytologic ones. E1

[...] regarding gynecological health I always try to go to consultations in the LGBT clinic in the women's hospital, this year it hasn't happened yet because when it was about to start the pandemic began and this type of care was interrupted, but I'm always mindful of that. E3

[...] in the public service we get folders and educational materials that I send to my friends because they don't always have access to the same health services that I do, and sometimes they have gynecological problems, so I always try to pass them forward. E4

Class 7:"Insufficient methods for gynecological self-care" the applicability of self-care actions is impaired by the fact that few methods are provided that consider the specificities of lesbian women health, which reflects the cisheteronormativity in the production of knowledge in health:

[...] plastic film, male condom, female condom. Male condoms weren't made with women in mind, they were made for the penis! The female condom wasn't created for the vaginal canal, it doesn't cover the vulva, and a lesbian woman uses more than just the vaginal canal. E2

[...] we think of protective methods for lesbian sex, but they're really insufficient. About the barrier method, you won't stop what you're doing to go grab plastic film and wrap that present, if you do that all the excitement is gone. E3

[...] even today, the physician is trying to convince me to do a transvaginal ultrasound and I won't do it! I won't let him penetrate that thing in me. I decided I won't do it! Let him do a pelvic ultrasound. E3

DISCUSSION

Through data analysis, we could ascertain, using the integrated conceptual model proposed by Sorensen ⁽¹⁰⁾, how HL abilities developed by the lesbian women in this study contribute for gynecological self-care⁽²¹⁾. The classes that emerged from the analysis of the text corpus showed which characteristics of lesbians have a direct association with the dimensions of HL, allowing them to reflect on the self-care practices carried out, as well as on the relationships between lesbian women and the health system and its workers.

It was found that participants access information on gynecological self-care autonomously, by sharing experiences among themselves and using different sources of information, or during consultations in health services. Additionally, they face difficulties when trying to access health care units due to the invisibility of their specificities, and even as a result of cases of prejudice and discrimination from health workers⁽³⁾.

A study showed that, in relationships between two women, there was trouble in the use of the condom and in the welcoming of users in health services; it also showed independent search for knowledge about protection as a care strategy, especially when it comes to sex-related information, which was gathered using the Internet and the help of other lesbians⁽¹⁾. Tactics such as those, which can often be refuted, are still an act of defiance to attempts to destroy non-heterosexual sexualities.

In this context, lesbian women tend to seek health units less often and have more trouble accessing gynecological care when compared to heterosexual women, especially among those who never had penetrative intercourse with males, those whose body grammar is socially perceived as "masculinized", and those who belong to lower socioeconomic segments. Data also shows that the access of lesbian women to the Pap test has decreased, even among those with higher income and educational level, which makes them more vulnerable to cervical cancer diagnoses⁽²²⁾.

Regarding their understanding of information, the context of the statements of lesbian women showed that the guidance provided by health professionals was restricted, not very interactive, and exclusionary, directly interfering in their understanding about gynecological self-care. It stands out that gynecological evaluations are extremely delicate moments, both for professionals and users. They can involve a series of communication issues, especially in this group, since, often, the practice of care can involve the stigma that affects lesbian sexual practices in our society⁽²³⁾.

Corroborating this finding, researchers have shown that lesbian and bisexual women must face challenges during nursing consultations, including issues during reception, prejudice, and nonspecific information about disease prevention, in addition to reports that they were not well received, cared for, or assisted regarding their health needs and specificities⁽³⁾.

On the one hand, users have doubts about whether they must state what their sexual orientation is or what sexual practices they engage in, and they know that, if they choose to provide such information, they may hear lesbophobic discourse that could interfere in the conduct of the professional and cause discomfort. On the other hand, professionals often have to face their own prejudice when it comes to female homosexuality and how to provide care based on the information brought forth by the user, in order to provide them with less traumatic care⁽²⁴⁾.

In this context, it must be understood that lesbian sexual practices are multiple, and may involve hands, sexual toys, or other forms to provoke pleasure. They may get into contact with the vaginal mucus or menstruation, take part in oral or anal sex, and use sexual accessories without a condom, activities that can lead to the transmission of Sexually Transmitted Infections (STIs). Thus, it is necessary to discuss methods and strategies of combined prevention that can address lesbian relationships; this information must be considered during health care⁽²⁵⁾.

The discourse of participants also showed a high level of autonomy and self-care in health, even when dealing with prejudiced discourse from health workers and non-inclusive practices. As a result, health literacy skills and self-perception are important health indicators, as they are strategic in the dimensions of thought and individual health care, while being related to the wellbeing of an individual and their satisfaction with life⁽²⁶⁾.

Thus, participants interpret and evaluate information received from health workers in a negative fashion as they felt it is restricted by their prejudice, judgment, and lack of information about gynecological self-care. Health workers must understand lesbian women’s sexual orientation and sexual practices in order to guide them in a consultation, adapting their orientations to the specificities of this group and promoting comprehensive care. Non-interactive health workers are one of the obstacles for them to carry out self-care, as the participants reported⁽³⁾.

Exclusionary, prejudiced, and superficial medical discourse about lesbian health, as reported, reflects the process of pathologization of sexual identities and any sexual practice that disagrees with social cisheteronormative practices, which legitimate and reproduce discriminatory processes. In Brazil, in order to provide assistance to lesbian women, professionals must develop care actions that overcome the stigmatizing approach reproduced by the medical-scientific discourse⁽⁴⁾.

Participants use information to promote their gynecological self-care, but the information and methods are insufficient to ensure their support, due to the prejudice or unpreparedness of health workers. In most reports, it becomes clear that the practical application of the information gathered was based on the exchange of experiences among lesbian women, or on autonomous searches for information in websites or scientific articles about the topic, in order to find more data about certain pathologies⁽²⁷⁾.

Since there is a remarkable lack of information about their situation, some participants use strategies to prevent STIs such as smelling and/or looking at a partner’s genitals, or excluding certain partners that report, in the first contact, a history of "discharge" or any significant alteration in their gynecological system, a decision associated with "risk behavior"⁽²³⁾. These findings corroborate the definition of HL provided by the WHO, reiterating the need to increase the level of knowledge, personal abilities, and confidence to make decisions that can improve one's personal and community health, changing styles and life conditions⁽¹⁾.

The HL abilities discussed here directly interfere in the promotion of gynecological self-care among lesbian women, reflecting on the three domains of health: health care, disease prevention, and health promotion. Thus, the use of HL skills can increase the autonomy of these women to overcome personal, structural, social, and economic barriers to health, improving health results and mitigating the effects of structural lesbophobia^(26-27).

Considering HL in the care to lesbian women implies in changing the context of providing them with care, assuming a perspective that leaves behind a type of health care based on lesbophobia, racism, and misogyny, one that is exclusionary and little interactive and does not recognize the specificities of women in this group. This is necessary to manage topics that are sensitive and necessary for health, such as discussing preventive strategies for women who have sex with women⁽²⁸⁾. The discourse, technology, and self-care information are restricted, which prevents one from reflecting about practices and knowledge to adopt new measures. As a result, lesbian women become marginalized and vulnerable, resorting to empirical gynecological care and optimizing the interconnection between Health Literacy and Social Determinants of Health⁽²⁹⁾. This was also found by a study carried out with men, in which generational and age determinants have revealed specificities about the level of literacy of the individuals surveyed⁽³⁰⁾.

Although HL was present in the development of many health policies around the world, it is still challenging to incorporate its principles into professional practice between segments that are vulnerable. It is important to rethink the context of care provided to lesbian women in health services, especially when it comes to developing educational health practices that are the base of HL and, when incorporated into the thought process of professionals and their practice, may be able to modify the realities presented here.

This study was limited by its small number of participants, since data collection was carried out via Google Meet®, which limits our ability to reflect on the reality experienced by the participants. Further interaction with participants and a deeper connection with the topic would be necessary to reach more comprehensive conclusions about the reality of these women. Furthermore, we faced challenges when including participants in the study, since some of them did not respond to the contact attempts of the main researcher, or did not show interest in participating in the research, due to the context of socioeconomic vulnerability that affects many of them.

Therefore, further research should be conducted to serve as the basis for the formulation of public actions and policies targeted at this segment, focusing on health literacy to promote gynecological self-care. It is essential to overcome the cisheteronormative logic of care and health training, allowing for an egalitarian nursing practice of health that recognizes the specificities of lesbian women.

FINAL CONSIDERATIONS

It was found that participants access information on gynecological self-care autonomously, by sharing experiences among themselves and using different sources of information, or during consultations in health services. Regarding their understanding of the information gathered, the guidance provided by health professionals was restricted, not very interactive, and exclusionary, directly interfering in their understanding about gynecological self-care. Lesbians interpret and evaluate the information received from health workers in a negative fashion, as they felt restricted by prejudice and discrimination and there was scarce information in regard to their specific reality. Consequently, they seldom apply the orientation received in their daily lives.

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Funding and Acknowledgements:

Our thanks to the Pernambuco Science and Technology Support Foundation (FACEPE).

Authorship criteria (authors’ contributions)

Danilo Martins Roque Pereira. 1. contributed substantially to the conception and/or planning of the study; 2. in obtaining, analyzing, and/or interpreting the data; 3. as well as in the writing and/or critical review and final approval of the published version.

Laís Magalhães Lima. 1. contributed substantially to the conception and/or planning of the study; 2. in obtaining, analyzing, and/or interpreting the data; 3. as well as in the writing and/or critical review and final approval of the published version.

Ednaldo Cavalcante de Araújo. 1. contributed substantially to the conception and/or planning of the study; 2. in obtaining, analyzing, and/or interpreting the data; 3. as well as in the writing and/or critical review and final approval of the published version.

Anderson Reis de Sousa. 1. contributed substantially to the design and/or planning of the study; 2. in obtaining, analyzing and/or interpreting the data; 3. as well as in the writing and/or critical review and final approval of the published version.

Adrian Thaís Cardoso Santos Gomes da Silva Araújo. 1. contributed substantially to the design and/or planning of the study; 2. in obtaining, analyzing and/or interpreting the data; 3. as well as in the writing and/or critical review and final approval of the published version.

Karyne Kirley Negromonte Gonçalves. 1. contributed substantially to the design and/or planning of the study; 2. in obtaining, analyzing and/or interpreting the data; 3. as well as in the writing and/or critical review and final approval of the published version.

Vânia Pinheiro Ramos. 1. contributed substantially to the design and/or planning of the study; 2. in obtaining, analyzing and/or interpreting the data; 3. as well as in the writing and/or critical review and final approval of the published version.

Declaration of conflict of interests

Nothing to declare.

Scientific Editor: Ítalo Arão Pereira Ribeiro. Orcid: https://orcid.org/0000-0003-0778-1447

Rev Enferm Atual In Derme 2025;99(Ed.Esp): e025015

Atribuição CCBY