Vulnerability of lesbian and bisexual women to HIV: a qualitative meta-synthesis

INTRODUCTION

The concept of vulnerability in the field of health is understood as the possibility of exposing a person to illness, considering individual and collective factors contextualized around a disease. According to the exposition, three dimensions of vulnerability are individual, social, and programmatic¹.

The configuration of literary productions on the vulnerability and/or sexual practices of women who have sex with women is still less present in studies on sexuality and sexual health²,³.

The AIDS epidemic strengthened the LGBT movement by enabling the social debate on sexuality and homosexuality, enabling public health policies that contemplated the specificities of this population⁴,⁵. Sexual practices among women who have sex with women (a universe that includes both lesbians and bisexuals) were made invisible in the context of HIV infection due to the initial idea of contagion, in which it was thought that the spread of the virus occurred only through the sharing of body fluids².

HIV/AIDS is a topic widely studied in scientific research. However, these studies related to the field of sexuality still present a panorama predominantly focused on male sexual practices in relation to female sexual practices, either in the context of heterosexuality or still relatively incipient when focused on female homosexuality. Given the above, it is essential to identify and analyze the production of knowledge in the health literature on vulnerabilities to HIV in the context of lesbians and bisexual women. This study aimed to analyze scientific evidence on the vulnerability of lesbian and bisexual women to HIV, compared to heterosexual women.

METHODS

The methodology of systematic review (SR) of the meta-synthesis type was adopted⁶. Initially, in the elaboration of the guiding question, the PICo strategy was used, proposed by the Joana Briggs Institute for qualitative SR, where P corresponds to the participants=lesbians and bisexual women; I corresponds to the phenomenon of interest=vulnerability to HIV/AIDS; and Co corresponds to the context of the study=HIV vulnerability of lesbians and/or bisexuals.

The review protocol was submitted to the International Prospective Registry of Systematic Reviews, with registration number CRD42021274780. The searches were carried out in February 2021 in the databases (CINAHL), SciELO, and National Library of Medicine (PubMed/Medline). Controlled descriptors and keywords in English were used: Female Homosexuality, Lesbian, Sexual and Gender Minorities, Gay, Health Vulnerability, Vulnerability, and HIV; and their correlates in Portuguese and Spanish according to the classification of Health Sciences Descriptors (DeCS) and Titles of Medical Subjects (MeSH/PubMed) crossed with the Boolean operators AND, OR, and NOT.

Inclusion criteria are as follows: only primary studies that addressed vulnerability related to HIV in lesbian and/or bisexual women, available in full, in Portuguese, English, and Spanish (because they are the most predominant languages in the databases used). Furthermore, exclusion criteria include publications of the editorial type, letters to the editor, books and/or book chapters, monographs, dissertations, theses, experience reports, systematic and/or integrative reviews, gray literature, and predatory publications.

The period of publication was limited to the years 2010–2020 due to the publication of scientific evidence in 2009 of the first confirmed case of exclusive HIV infection among women⁸. The selection was performed using the Rayyan Application with two independent reviewers, and, when necessary, a third reviewer was requested in articles where there was disagreement. After this careful evaluation, a final sample of 16 studies was obtained. The level of evidence of the articles was evaluated based on the proposal by Melnyk and Fineout-Overholt⁷. The Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) instrument was used to search and select the articles described in Figure 1. The analysis of the results was based on a thematic analysis⁹.

Figure 1
Flowchart of study selection process.

RESULTS

Among the 16 selected articles, which were predominantly published in English, as for the methodology used, there were 9 articles with a quantitative approach¹⁰–¹³,¹⁷,¹⁹,²⁰,²³–²⁵ and 7 articles with a qualitative approach¹⁰,¹⁴–¹⁶,²¹,²². Table  1 summarizes the information on the articles included in the final sample.

Table 1
Distribution of articles regarding methodological design, authors, and level of evidence.

Authors/Year	Methodological design	Evidence level
Batista and Zambenedetti10 (2017)	Intervention research, following the analytical-institutional framework	LE=VI
Lyons et al.11 (2014)	Prospective cohort study and bivariate and multivariate logistic regressions	LE=IV
Poteat et al. (2013)	Cross-sectional cohort study, with mixed method	LE=IV
Logie et al. (2019)	Multicenter, nonrandomized pilot study	LE=IV
Mora and Monteiro14 (2010)	Qualitative research with ethnographic observations and in-depth interviews	LE=VI
Daly et al.15 (2016)	Qualitative analysis of health policies	LE=VI
Sandfort et al.16 (2013)	Qualitative field research	LE=VI
Herrick et al.17 (2010)	Cross-sectional descriptive study	LE=VI
Muzny C.A. et al.18 (2013)	Qualitative study through focus groups	LE=VI
Andrade et al. (2019)	Cross-sectional descriptive study	LE=VI
Paschen-wolff et al. (2019)	Prospective cohort study and multivariate logistic regression	LE=IV
Muzny A. et al.21 (2013)	Qualitative study	LE=VI
Poteat et al. (2017)	Exploratory study, through spoken narrative	LE=VI
Palma et al. (2015)	Cross-sectional mixed method study	LE=VI
Zaidi et al. (2012)	Cross-sectional descriptive study	LE=VI
Wang et al.25 (2012)	Cross-sectional descriptive study	LE=VI

DISCUSSION

Vulnerability in women who have sex with women is revealed in the contexts of vulnerability that permeate the social and pragmatics, in addition to the contexts of individual invisibility and identity invisibility expressed in the situations identified in the research that composed the sample of this review.

In the contexts of vulnerability category, it was found that although there are policies that affirm the importance of promoting sexual rights and the promotion and prevention of HIV, women who have sex with women, lesbians, and bisexual women, in addition to sex workers in a particular way, remain with their rights unexplored. In terms of epidemiology and structural factors of social and pragmatic vulnerabilities, this may mean the need for more targeted approaches to the demands from different policy approaches aimed at the LGBTQI public identified in the deficiency in the service of this population¹⁴.

Historically, individuals who experience practices that differ from the heterosexual norm with different expressions of sexual orientation, that is, desire or effective attraction to the same sex or both, have been positioned in a restricted place. Very less is known about lesbian and their past experiences, as well as the patterns of seeking health care, leading them to avoid and be reluctant to seek help and medical advice²⁶–²⁸.

Understanding how to provide appropriate and comprehensive counseling for lesbian and bisexual women is essential in preventing and controlling the transmission of the virus to their female sexual partners. In addition, reporting their sexualities and sexual practices with same-sex partners should not impede trained health professionals in addressing the potential sexual risks for these women¹⁶.

Perspectives on issues of social and pragmatic vulnerability are consistent with social networks and the training of health professionals involved in assisting this group¹⁹. Particularly in parts of the world where HIV prevalence is high, women who have sex with women and other sexual minorities face various forms of homophobic violence. All these women must receive adequate information about sexually transmitted infection (STI) prevention and HIV²⁰.

When analyzing the different contexts of vulnerability, different perspectives are opened which allow judgments and understanding of individual and collective differences and how everyone faces the health-disease process²⁹. Moreover, this will be effective only if the heterogeneity in the population of lesbians and bisexual women is recognized, with health programs adapted to meet the needs of these women in an integral and targeted way²⁵.

Thus, for these women, the perception of the vulnerabilities in which they are inserted occurs through their relationships with society, often surrounded by taboos and prejudices rooted in historical contexts established from heteronormative standards. For health professionals and services, these women are recognized only during the provision of care that has already been instituted and guided as subjects framed in the pattern of sexual practices positioned in heteronormative issues, seen as the central axis of care, displacing their sexual practices between women by a context of subordination to the dominant model, because men and women assume that they are different in the exercise of their sexuality, especially for men, sexuality is linked to power²⁹.

In the Invisibility Processes category, although there is an understanding of the aspects that make women who have sex with women vulnerable to STIs, there is still no consideration that the methods and means of prevention made available to this public are unfeasible, because they consider these methods out of context, with the perception that the methods are linked to the reduction of their sexual pleasure. In addition to having this idea of prevention, the biomedical and prescriptive nature of the interventions always follows the heteronormative bias, where the information given do not match the context and demands of these women, prioritizing what would be more or less important, which ends up accentuating the dimension of programmatic vulnerability¹⁰–¹⁴.

This idea is also present when they point out that the risks for these women are even more intensified because their peculiar characteristics are neglected by many health professionals, who are still outdated and prejudiced, which can influence their search patterns for health care²⁵,¹².

Throughout the history, HIV infection has been unique in that its modes of transmission are primarily related to human behavior with drug use and unprotected sex⁸, which ends up making women who have sex with women even more vulnerable, as gender relations and relations that generate social constructions end up bringing severe repercussions to the health of these women involved³⁰.

Another perceived point is the relationship of influence in trust between social and sexual interaction on the risk of HIV, the bonds with their sexual partners and social networks among women end up transmitting confidence, minimizing the perception of the risks of HIV contamination among them. Women denote the forms and meanings attributed to their sexual and prevention practices between partnerships as a result of a historical production centered on heterosexual practices¹⁸. Thus, socially and economically disadvantaged populations experience greater capacity and risk of acquiring HIV, as the burden of disease and prevention innovations are not evenly distributed among populations²⁷–²⁹.

CONCLUSION

It was noted that the existing belief about sexual practices between women, which is still widely understood as illegal or out of the ordinary, has as its reference the heteronormative standards of society, which ends up resulting in contexts of discrimination and stigma, thus bringing negative consequences for women.

The contexts of vulnerability found in the articles point to the contexts of stigma generated by the lack of empowerment and low social support of these women.

Their relationships enhance these vulnerabilities, especially with regard to reception and care, in addition to illness and exposure to various diseases.

STUDY LIMITATION

The probable limitations in this study are the limitations of time and language, which may have reduced the scope of findings in the sample. The definition of not having included the term “bisexuality” in the crossings in the databases may have also limited the research, but it was decided not to use it due to the possibility of including studies that addressed male bisexuality. This bias was controlled with the use of “NOT GAY” in the crossings performed with the other DESC and MESH.

• Funding: none.

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Publication Dates

• Publication in this collection
  14 Apr 2023
• Date of issue
  2023

History

• Received
  15 Jan 2023
• Accepted
  21 Jan 2023