Nursing actions in Primary Health Care to lesbian and bisexual women

Objective: to investigate the actions of nurses in regard to lesbian and bisexual women in the context of the National Policy for the Integral Health of Lesbians, Gays, Bisexuals, Cross-Dressers and Transgender Persons. Methods: qualitative study involving 25 nurses from the Family Health Strategy, contacted via electronic means. We applied a form containing sociodemographic data and an investigation of actions in primary health care, as well as a thematic content analysis. Results: we found there are professional capacitation activities, embracing of demands, and enhanced interprofessional work. Nonetheless, there were shortcomings in the knowledge regarding health care towards lesbian and bisexual women. Conclusion: there are still prejudices, difficulty to access, and little attendance of les - bian and bisexual women in health services, as well as a deficit in the support to health actions and lack of moni - toring.


Introduction
Women's health is integral, meaning that care should not only be concerned with their reproductive role, but recognize them as diverse citizens with their own particularities. Therefore, we need a health system and a health network that provides visibility to women in different cycles of life and attends to their several demands in health (1) . In this context, despite the advances in public policies regarding women's health, lesbian and bisexual women are a more vulnerable group, as they have to face many obstacles, such as discrimination, prejudice, selective listening, and symbolic barriers in the access to health services (2) . These problems may be related to a double marginalization, involving the invisibility of female sexuality, due to the fact they are biologically female, and the prejudice against their sexual orientation, which deviates from established heteronormative societal standards (3) .
Regarding the physical and psychological health of lesbian and bisexual women, there have been cases of explicit and symbolic violence, since their lives are permeated by a lack of references that validate their place and the way they relate sexually and affectively in society and in family environments (4) . The attention provided to these women often is unrelated to their sexual orientation. As a result, their health specificities remain unnoticed. However, the guidance and care provided should be in accordance with their values and experiences, requiring specific skills in attention (5) .
In 2011, Brazil instituted the National Policy for the Integral Health of Lesbians, Gays, Bisexuals, Cross--Dressers, and Transgender Persons (PNSILGBT), which considers the exclusion and discrimination of these populations as a social health determinant. Among its goals, it seeks to reduce institutional prejudice, ensure qualified and resolutive assistance to health demands, permanently educate health workers and managers, and promote respect and citizenship in services from the Single Health System (SUS) (6) .
In this regard, primary health care is consolida-ted in the Family Health Strategy as an entryway to health services, in order to provide assistance based on health promotion and on the prevention of diseases and other health problems. Nursing workers are deeply inserted in this context, and nurses stand out as essential, as they exercise several roles, from the management of activities to direct care with individuals, family, and community, in such a way as to embrace the users and form user-worker bonds (7) . As a result, this study is necessary due to the health demands of these women. Although there is an operational plan that supports the implementation of the PNSILGBT in all levels of health care, the vulnerability of these populations in the health-disease-care process is well-known, as well as the need to provide them with care compatible with their health specificities, which includes the nurses who work in the Family Health Strategy. Therefore, the study contributes for an investigation directed by the National Policy for the Integral Health of Lesbians, Gays, Bisexuals, Cross--Dressers, and Transgender Persons in professional practice. Therefore, this study attempts to answer the following research question: What are the actions of nurses in the integral care to lesbian and bisexual women in primary care? Therefore, to understand the characteristics of this process in primary health care and provide contributions for quality care, this study aims to investigate the actions of nurses in regard to lesbian and bisexual women in the context of the National Policy for the Integral Health of Lesbians, Gays, Bisexuals, Cross-Dressers and Transgender Persons.

Methods
This is a quantitative study that used the Consolidated Criteria for Reporting Qualitative Research (COREQ) as a guideline to elaborate and write a 32item verification list. The research was carried out from March to April 2021 and distributed in 21 teams in the urban area and 11 in the rural area of a municipality in Ceará, Brazil.
The population included nurses from the 32 Primary Care Units. Inclusion criteria considered: nurses who worked in the Primary Care Units for at least six months, which would enable the formation of a bond with the community. Were excluded nurses who were not working at the time of research due to leaves or vacations, and those who did not answer the guiding questions within an acceptable time frame. The sampling was by convenience and the final sample included 25 participants, as some refused to participate.
Initially, the nurses were contacted by the researcher via e-mail and/or WhatsApp ® , which had been procured and made available by the Primary Care Coordination from the Municipal Health Secretariat. The research was presented and explained to them, and they were invited to participate, which was confirmed through the sending of the Free and Informed Consent Form, which was filled in via Google Forms ® . It stands out that the researcher had no professional association with the Primary Health Care Units or with the interviewees.
Data collection took place in a virtual environment, due to the COVID-19 pandemic. The instrument used for collection was a form validated (8) and adapted for this research, in order to investigate the knowledge of nurses regarding the PNSILGBT. The instrument is formed by two sections. The first is aimed at collecting general data from the profile of the participants, including age, sex, year of graduation, post-graduation, time working in the city, and time working in primary health care.
The second sections investigated routine actions experienced by these professionals as they provided care to lesbian and bisexual women. It included two subjective questions, which were: In your opinion, what was the goal of application of the National Policy for the Integral Health of Lesbians, Gays, Bisexuals, Cross-Dressers and Transgender Persons? And how do you, as a Primary Care nurse, develop actions targeted at the needs of lesbian and bisexual women?
Data were systematized and treated after a full transcription, being categorized and analyzed using thematic content categories (9) , a type of analysis that is divided in the stages of pre-analysis, exploration of the material or coding, and treatment of the results found. The interpretation of the content allowed for the definition of the central axis "Knowledge applied to actions targeted at lesbian and bisexual women," seeking central meanings to extract the categories. Considering the regularity of the discourses, the interviewees were coded as Nurse 1, Nurse 2, Nurse 3, and so on, guaranteeing their anonymity.
The research was approved by the Research Ethics Committee for research with human beings at Universidade Regional do Cariri, under opinion 4,435,109/2020 and Certificate of Submission to Ethical Appreciation 39809320.4.0000.5055.

Results
Considering the sociodemographic aspects of the nurse participants, most were female (21 -84%), from 23 to 56 years old, with a mean of 36.88 years (standard deviation of ± 8.753). 12 (48%) nurses finished graduation from 2010 to 2019 and, regarding post-graduation, 24 (96%) of them had specializations, and 1 had a master's degree. Regarding time working in primary care, it varied from 1 to 26 years, with a mean of 11 years of work.
The analysis of the responses led to the emergence of two thematic categories: The importance of the National Policy for the Integral Health of Lesbians, Gays, Bisexuals, Cross-Dressers and Transgender Persons; and Actions regarding the health needs of lesbian and bisexual women.

The importance of the National Policy for the Integral Health of Lesbians, Gays, Bisexuals, Cross-Dressers and Transgender Persons
The nurses considered the implementation of the PNSILGBT as a way to consolidate the basic principles of SUS -universal, integral, and egalitarian health, as the content below shows: Consolidation of the basic principles of the SUS (Nurse 25). It proposes integral quality health with specific approaches for genders, with a broader look based on the laws of SUS (Nurse 1). The construction of more equality in SUS (Nurse 5).
Nurses interviewed recognized the vulnerability of this population in the health-disease process. There are also situations permeated by erasure, prejudice, and discrimination, especially experienced in the health services, as the statements show: We have to fight against inequality, discrimination and prejudice, and we attend to everyone integrally, promoting health in all LGBT groups (Nurse 4).
Help receiving these women, avoid discriminating and excluding them (Nurse 9). Promote universal and integral care to this public, who has always been at the margins of politics and health services (Nurse 18).
As the interviewees mentioned, we observed that the National Policy for the Integral Health of Lesbians, Gays, Bisexuals, Cross-Dressers and Transgender Persons contributes to guide health care better in regard to this public, while also providing nursing care to the specific health needs of each individual, family, and community: It reduces differences, prejudice, gives guidance on how to act best and not to exclude them from society, it guides the workers so they can know the best way to attend them and guides the family at home (Nurse 21). Inclusion and better preparation of the professionals regarding this public (Nurse 5).

Actions regarding the health needs of lesbian and bisexual women
Regarding health education actions, nurses reported there being no educational actions about the needs of lesbian and bisexual women, despite understanding them as a constructive and essential moment in the promotion and maintenance of health: I, as a nur-

Discussion
The nurses that participated in the study are mostly female. Regarding continued education, all of them have some kind of degree after graduation, showing they seek specific knowledge, consolidating thematic fields and research lines.
Continued education is a strategy for professio-nal qualification, but goes beyond that; in addition to technical improvement, it can change paradigms and reiterate values in many contexts (10) . Therefore, they seek the development of professionals together with the multidisciplinary health team, so they can receive autonomous, safe, and integral care. Culturally, health is associated with the absence of disease. However, the World Health Organization determined, since 1946, that health is the complete physical, psychic, and social wellbeing. Therefore, the need to analyze body, mind, and the social context of an individual becomes clear, and PNSILGBT recognizes sexual orientation and gender identity as social determinants of health (4) .
The sexual orientation of lesbians and bisexual women is central in their lives, and strongly affects their social and affective environments. As a result, they experience abandonment and violence, such as bullying in schools, violence within the family, and abandonment from relatives or expulsion from home. It should also be mentioned that they face a difficult professional trajectory, with interruptions at work, study, and in their social circles (6)(7)(8) .
In this study, it was found that nurses recognized the importance of the National Policy for the Integral Health of Lesbians, Gays, Bisexuals, Cross-Dressers and Transgender Persons and its applications, due to the existence of prejudice, discrimination, and lack of abilities to deal with the specificities of this population, especially in the case of lesbians and bisexual women. The inequality in the access of this group to the services are well-known, especially when it comes to the existence of obstructions associated with the universality principle, which are enmeshed in symbolic difficulties to access the service, such as stigma, prejudice, and intolerance, which leads to the denial of care and to arbitrary treatment (11) .
In addition, the policy mentioned is recognized by the nurses as something essential, although their use of the term "sexual preference" shows that they lack knowledge in the field. Nonetheless, 48% of the nurses interviewed concluded graduation from 2010 to 2019, a period of significant change concerning actions targeted at this public. Corroborating our findings, it can be noted that, in the formation of the nurse, there is little to no discussion of sexual education, indicating the need for them to receive training about the basics of the sexuality process in the different stages of the life cycle (12) .
In agreement with these results, a study that interviewed students from the field of health showed that 57% of them did not know about the health policy for this population. When asked whether there was any subject in graduation that addressed the topic, 71% answered that there was none in their syllabi (13) .
In the same vein, a study carried out with 348 students from the field of health stands out, as it found that only 39.70% of students received complete or partial training in their academic education to provide integral care to this population (14) . Additionally, a study with students from the nursing course showed that only 3% consider themselves capable of providing adequate care to this population. The same is true regarding the presence of this topic in the subjects. 45% believe that the institution must implement changes (5) .
Sexuality, during academic education, is often addressed only in regard to its biological aspects, with a bias towards pathologies. A superficial perspective, eventual and informal, when it takes place during academic education, can lead to feelings of insecurity, embarrassment, and anguish in nursing care, as well as to negative reactions in regard to the lack of preparation in assistance regarding sexuality, especially if not in accordance with heteronormative standards (15) . Therefore, it is essential to consider the fundamentals of the National Curricular Directives for academic formation, as they guide the syllabi of courses and establish essential criteria that must be addressed within their content, while also indicating the need for a generalist, humanist formation, with critical-reflective thought. Therefore, interpreting the population and its plurality during graduation leads one to find the extreme validity of understanding social determinants and, later, to offer egalitarian health care (15) .
In accordance with these findings, international literature also highlights the lack of preparation of undergraduate nursing students in providing egalitarian and integral care to LGBT people, pointing at negative attitudes from the students and high levels of homophobia. Furthermore, male participants are more likely to manifest negative attitudes against sexual minorities, negatively affecting their care management, the quality of the service provided, and nursing itself (16)(17) .
Most nurses who participated, when asked whether they perform actions targeted at the needs of lesbian and bisexual women, reported that they do not. They also state that they do carry out consultations and/or educational activities with women, but do not address sexual orientation.
Sexuality is still superficially addressed, and often, not debated at all, due to the current social culture, education, and family conduct in regard to sexuality. This directly causes difficulties for both women and health workers to address this topic during consultations (18) . Therefore, the assistance provided has shortcomings regarding the sexual and reproductive health of lesbian and bisexual women. This shows that health workers lack knowledge about their health needs, the way to provide guidance during consultations, and their own heteronormative behaviors (19) .
Breast and cervix cancer are more likely to take place in lesbians and bisexual women; however, these women undergo less gynecological consultations and preventive examinations, such as tests for sexually transmitted infections and pap smears (20) . This shows a lack in the screening, due to an antiquated denial of risk, both on the part of health workers and women. Therefore, the guidance provided regarding the use of condoms and other preventive methods, and about how often preventive exams should be conducted, is often inadequate (4,21) .
Regarding the use of condoms in the sexual practice of women who have sex with women, it was found that more than 80% of the women interviewed have oral and manual sex with no condom, had vaginal contact during intercourse, and had no single partner. Therefore, they are more vulnerable to sexually transmitted infections (22) . Lesbians, gays, bisexuals, cross-dressers, and transgender persons show little attendance to activities carried out in primary health care and in the services from the Family Health Strategy. This is related to their fear of being treated with prejudice and discrimination, both by the users of the services and by health workers (15) .
Some statements showed an opening for these women to search for the health services, but no actions targeted at them. Therefore, in nursing consultations for women, the health worker often cannot recognize LGBT people, and does not ask about the sexual orientation of the users. As a result, fearing prejudice and discrimination, many women feel uncomfortable revealing their sexual orientation or talking openly about it, especially when no bond has been established (20,23) .
In this study, it was found that nurses had worked in the city for as long as they had worked in the same health unit, showing that most of them always worked in primary health care and, therefore, had professional experience in this field. The time working in the same city contributes to forming bonds with the community and to knowing the characteristics of the population in the area.
The bond with the community in the setting of primary care is considered to be a strategy to organize work, produce care, and to improve access to health care and its quality (18) . This leads to a horizontal relationship between the nurse and the health service user, based on embracement, dialogue, sensible listening, and a holistic approach, promoting opportunities to value the uniqueness of each user (24) .
The therapeutic relationship of care depends on the quality of the dialogue between the worker and the woman, since, in a space open for dialogue, we can understand the context of life of the patients, the social determinants and the aspects of their health. Therefore, educational methods must be created and developed, reflecting on the health demands presented and enabling the construction of proposals for effective solutions (21) .
A nurse is also an education professional. This allows them to carry out educational activities to provide moments where knowledge can be created and self-care can be promoted (1) . Educational actions targeted at LGBT groups enable guiding them about their rights and duties in the health care system, reiterating the importance of carrying out preventive exams against cervix and prostate cancer, in addition to providing sexual and mental health (6) . These actions guarantee there will be an approximation between patients and health workers, as well as damage control and prevention against health issues in this population (18) .
On the other hand, health education activities is impaired by the lack of resources, no support from managers, infrequent actions, lack of participation from different social segments in the planning of strategies, and, especially, by the overload of activities focused on the primary care nurse (15) .
We can see that most nurses have a positive attitude towards the importance of confronting health inequality; nevertheless, they show to be disassociated from the execution of permanent education activities involving the professionals in the services and health education for lesbian and bisexual women. It became clear that these activities do not take place, showing that knowledge is associated with action in professional practice.
In addition to the professional practice, we must also consider the organization of the service, which often does not favor the professional to work in different ways and carry out diverse activities. While population demands change, it becomes essential to organize the service and adapt managers to these new demands; this issue, as a result, goes beyond the training of direct assistance workers (2,19) .
Nurses must know the health demands of this group to identify the countless factors that lead to shortcomings in assistance. Since these topics are not adequately addressed during graduation, these women become invisible and vulnerable individually and socially, showing how important it is for managers to know the health and demands of their population. Therefore, it is urgent to raise the awareness of health workers and managers through educational activities about the specificities of the LGBT population, especially in the case of lesbian and bisexual women, so they can get closer to their health demands and learn better about the public policies, allowing the axes of the policy to extend from the theoretical-organizational plane, being incorporated and perceptible in practice.

Study limitations
This study only counted on virtual data collection. It was not possible to meet participants physically, which prevented the extrapolation into other perspectives. The number of nurses interviewed was also below expectations.

Contributions to practice
The social, professional, and scientific importance of this study stands out, as it considers the need of providing more humane care to lesbian and bisexual women. It can, thus, give support to the work of other researchers and nursing professionals. We also expect this study to call attention to a holistic and integral care to these women in primary care, being useful as an element of comparative studies.

Conclusion
There is a concerning lack of health care actions on the part of nurses. We found there are professional capacitation activities, embracing demands, and enhanced interprofessional work. Nevertheless, it became clear that there is prejudice, difficulties of access, and little attendance of lesbian and bisexual women in the health services. Workers were also found to lack knowledge about the National Policy for the Integral Health of Lesbians, Gays, Bisexuals, Cross--Dressers and Transgender Persons due to gaps in the syllabus of nursing courses, lack of interest on the topic, lack of participation from managers, and lack of support to the development of health care actions, in addition to the lack of monitoring.

Authors' contribution
Concept and design or analysis and data interpretation: Mender SC, Silva JWM. Writing of the manuscript or relevant critical review of the intellectual content: Mendes SC, Silva JWM, Teixeira MMS, Lopes MSV. Final approval for the version to be published: Mendes SC, Teixeira MMS, Lopes MSV. Responsible for all aspects of the text, to guarantee that the manuscript in its entirety and all its isolated parts are accurate and have integrity: Mendes SC, Teixeira MMS, Lopes MSV.