Between silence and listening: care narratives of health workers for lesbian and bisexual women in Manaus, AM, Brazil

Abstract

Due to the persistence of inequalities and prejudices that permeate the experiences of lesbian and bisexual women, especially in the field of health, this study analyzed narratives of workers from a Family Health Unit about the care provided to these groups. This qualitative research was grounded in bisexual frameworks and lesbian-feminist epistemologies. Participant observations and semi-structured interviews were conducted with 15 health workers. The narrative analysis allowed for the construction of two core meanings based on (1) perceptions of health needs and demands and (2) technical, ethical, and moral challenges in providing care to these women. It is concluded that the realization of equitable care depends on confronting the heteronormativity that structures institutions and training practices, expanding critical training, and recognizing these workers as protagonists in the transformation of the Brazilian Unified Health System (SUS).

Key words:
Female homosexuality; Female bisexuality; Sexual and gender minorities; Equity in access to health services; Women’s health

Resumo

Em razão da persistência de desigualdades e preconceitos que atravessam as experiências de mulheres lésbicas e bissexuais, especialmente no campo da saúde, este estudo analisou narrativas de trabalhadoras de uma Unidade de Saúde da Família sobre o cuidado voltado a esses grupos, tratando-se de uma pesquisa qualitativa, fundamentada em referenciais bissexuais e epistemologias lésbico-feministas. Foram realizadas observações participantes e entrevistas semiestruturadas com 15 trabalhadoras de saúde. A análise narrativa permitiu construir dois núcleos de sentido baseados nas (1) percepções sobre necessidades e demandas de saúde e (2) desafios técnicos, éticos e morais na prestação de cuidado a essas mulheres; conclui-se que a efetivação de um cuidado equânime depende do enfrentamento da heteronormatividade que estrutura instituições e práticas formativas, da ampliação da formação crítica e do reconhecimento das trabalhadoras como protagonistas na transformação do Sistema Único de Saúde (SUS).

Palavras-chave:
Homossexualidade feminina; Bissexualidade feminina; Minorias sexuais e de gênero; Equidade no acesso aos serviços de saúde; Saúde da mulher

Resumen

Debido a la persistencia de desigualdades y prejuicios que impregnan las experiencias de las mujeres lesbianas y bisexuales, especialmente en el ámbito de la salud, este estudio analizó las narrativas de trabajadoras de una Unidad de Salud Familiar sobre la atención brindada a estos grupos. Esta investigación cualitativa se fundamentó en marcos bisexuales y epistemologías lésbico-feministas. Se realizaron observaciones participantes y entrevistas semiestructuradas con 15 trabajadoras de la salud. El análisis narrativo permitió la construcción de dos significados centrales basados ​​en (1) las percepciones de las necesidades y demandas de salud y (2) los desafíos técnicos, éticos y morales en la atención a estas mujeres. Se concluye que la consecución de una atención equitativa depende de confrontar la heteronormatividad que estructura las instituciones y las prácticas de formación, ampliar la formación crítica y reconocer a estas trabajadoras como protagonistas en la transformación del Sistema Único de Salud (SUS) de Brasil.

Palabras clave:
Homosexualidad femenina; Bisexualidad femenina; Minorías sexuales y de género; Equidade nel acceso a los servicios de salud; Salud de la mujer

Introduction

Since its creation in the 1988 Constitution, which established health as a right of all and a duty of the State, the Unified Health System (SUS) has been consolidated as a civilizational milestone by instituting the principles of universality, comprehensiveness, and equity. However, despite its inclusive vocation, political and structural inequalities persist in shaping access to and the quality of care offered to certain groups, which is revealed above all by the gap between policy formulation and actual practice, as well as by the fragmented care¹.

The experiences of lesbians and bisexual women reveal contradictions between the formulation and implementation of Public Health policies. Despite their inclusion in specific guidelines, such as the National Policy for the Comprehensive Health of Lesbians, Gays, Bisexuals, Transvestites, and Transsexuals (PNSI-LGBT)², the care offered to these women is still marked by practices shaped by heteronormativity, resulting in invisibilization, discrimination, and symbolic exclusion in the daily routine of health services. Such processes reveal a gap that weakens the implementation of the principle of comprehensiveness, perpetuating structural inequalities that affect both access to and the quality of health care^3,4.

Other documents, such as the 2004 National Policy for Comprehensive Women’s Health Care and the 2014 Report on Comprehensive Health Care for Lesbian and Bisexual Women, had already highlighted the urgency of rethinking care practices and conceptions directed toward women, so as to overcome the heteronormative logic that has historically guided health policies^5,6. Even so, the presumption of heterosexuality and the focus on reproductive issues remain care parameters rooted in the very training process of health workers^7,8, which engages very little with sexual and gender diversity, thereby directly affecting the production of care⁹. In the case of lesbian and bisexual women, this process translates into the denial of their specific sexual and reproductive health needs, the lack of adequate preventive technologies, and the maintenance of symbolic barriers that distance these users from the SUS.

Feminist critique has been fundamental in unveiling the mechanisms that sustain the exclusion and marginalization of dissident bodies. Adrienne Rich¹⁰ problematized compulsory heterosexuality as a political regime that structures relationships and defines the limits of what is recognized as feminine. Monique Wittig¹¹, by questioning the category of “woman” as a social construction produced by heteronormativity, showed that gender is the result of a system of domination rather than a natural essence. In a convergent vein, Gayle Rubin¹², when analyzing the hierarchy of the sex/gender system, highlighted the marginalization of non-reproductive sexual practices, shifting the debate toward the structural dimensions of inequalities manifested in health care practices. These theoretical contributions show that the field of health is not neutral, but rather traversed by power relations and moral norms that determine which bodies ought to be recognized and which are silenced. To this end, Judith Butler¹³ argues that bodies that challenge the supposed linearity of sex-gender and heteronormative logic become socially dehumanized and abject, which directly affects the production of public policies and the implementation of sexual and reproductive rights.

In Primary Care (PC), the main gateway to the SUS, the tensions that permeate care practices directed at lesbian and bisexual women become even more central, since the work developed in this setting should broadly understand the different intersections in the health-illness-care process, prioritizing elements such as bonding, qualified listening, humanization, and territorially grounded work^14,15. Thus, PC becomes a strategic space for materializing practices grounded in the principles of equity and comprehensiveness, especially in the care of historically vulnerable groups. However, recent studies show that services still maintain markedly heteronormative protocols and practices, which limit the implementation of inclusive and sexually diverse-sensitive practices¹⁶.

Given the urgency of these issues, the present study aimed to understand the perceptions and practices of Primary Care workers regarding health care for lesbian and bisexual women in Manaus, Amazonas. Adopting narrative analysis as its methodological approach, the study sought to grasp the ways these workers construct meanings about health needs, the technical, ethical, and moral challenges involved in care, as well as the formative trajectories and sociopolitical experiences that enhance or limit the production of care committed to diversity and equity.

Methods

This qualitative, descriptive, and exploratory study was developed from the perspective of narrative analysis, as guided by Jovchelovitch and Bauer¹⁷ and Schütze¹⁸. This methodological choice is justified because it allows access to the depth of human experiences in social and historical contexts, since discourse-shaped narratives can assign meaning to the experience, approaching personal trajectories and favoring the description and understanding of meanings produced in everyday life.

Fieldwork occurred from August to November 2024, during 30 immersion shifts in a Family Health Unit (USF) located in a peripheral area of Manaus, Amazonas. This is a large unit composed of seven minimum Family Health Strategy (ESF) teams. The starting point for the research was direct contact with the female workers in their work environment, which allowed an approximation to the living labor of Primary Care, marked by doing that carries its own tensions, affections, and displacements, often overflowing the limits of institutional protocols and regulations.

The participants were approached through convenience windows, at opportune moments in the unit’s corridors, always respecting availability and avoiding embarrassment. The interviews were conducted individually, using two distinct instruments: a socioprofessional questionnaire and a semistructured guide for producing the workers’ narratives and perspectives on health care for lesbian and bisexual women. The guiding question was: “I would like you to tell me about your understanding of health care for lesbian and bisexual women, and how you believe it occurs in Primary Care, within the Family Health Strategy, taking your own experience as the main parameter for your answer(s).” This question was supplemented by organic inquiries that emerged throughout the conversations.

Fifteen workers participated in the study: five nurses, four community health workers, three doctors, one nursing technician, and two social workers. The inclusion criteria were having been linked to the team for more than six months and having at least one year of experience in Primary Care. Workers who were on vacation, medical leave, or institutional leave during data production were excluded.

The interviews lasted on average between 20 and 40 minutes and were conducted in the participants’ own workspaces, such as offices and dedicated rooms, including the community health workers’ rooms. In all cases, privacy and confidentiality were prioritized as necessary conditions for qualified listening. The audio was recorded on electronic devices and fully transcribed. Data collection ended upon theoretical saturation.

Interview analysis was conducted simultaneously with data production, articulating field impressions recorded in the researcher’s field diary, theoretical reflections, and collective discussions with the research team, which ensured methodological consistency. For the treatment of the material, the narrative analysis technique was used according to Schütze’s guidelines¹⁸, in dialogue with theoretical contributions from bisexuality studies and lesbian-feminist frameworks, especially Adrienne Rich, Monique Wittig, Judith Butler, and Sara Elizabeth Lewis. This approach made identified concepts and discursive codes from the narrated experiences, enabling interpretations of the meanings attributed to health care and the creation of analytical categories.

The study complied with the ethical guidelines set forth in National Health Council Resolutions No. 466/2012 and No. 510/2016 and was approved by the Research Ethics Committee of the Amazonas State University (UEA), under Certificate of Presentation for Ethical Review (CAAE) No. 81437224.6.0000.5016, Opinion No. 077103/2024. All participants were informed about the justification, objectives, and procedures of the study and signed the Informed Consent Form. The study received financial support from the Amazonas State Research Support Foundation (FAPEAM) within the framework of the Amazonas State University (UEA), which facilitated its implementation and development.

Results and discussion

Fifteen workers linked to Primary Care were the subjects of this study. Most participants were cisgender, heterosexual women who self-identified as Brown and Roman Catholic, with a mean age of 45 years and extensive experience in the field of Health. In terms of professional trajectory, the average time of practice exceeded thirteen years, with approximately five and a half years specifically dedicated to Primary Care. Socioprofessional data were obtained through a structured instrument administered in the field, which made it possible to systematize the participants’ information, presented in Chart 1.

Chart 1
Female workers in the Family Health Strategy.

N°	Profession	Age	Sexual orientation and gender identity	Religion	Skin color	Time length in the profession	Time in PHC
1	Nurse	44 years	Cisgender heterosexual woman	Roman Catholic	Brown	20 years	4.5 years
2	Nurse	46 years	Cisgender heterosexual woman	-	Brown	13 years	7 years
3	Nurse	-	Cisgender heterosexual woman	Roman Catholic	White	11 years	11 years
4	Nurse	39 years	Cisgender heterosexual woman	Roman Catholic	Brown	15 years	7 months
5	Nurse	51 years	Cisgender heterosexual woman	Roman Catholic	Brown	25 years	6 years
6	Social worker	67 years	Cisgender heterosexual woman	Roman Catholic	Brown	32 years	13 years
7	Social worker	43 years	Cisgender heterosexual woman	Christian and evangelical	Brown	12 years	1 year
8	Community health worker	53 years	Cisgender heterosexual woman	Roman Catholic	Brown	24 years	6 years
9	Community health worker	36 years	Cisgender heterosexual woman	Roman Catholic	Brown	1 year and 7 months	7 months
10	Community health worker	56 years	Cisgender heterosexual woman	Christian and evangelical	Brown	1 year and 7 months	7 months
11	Community worker	42 years	Cisgender heterosexual woman	Evangelical	Brown	1 year and 9 months	1 year and 9 months
12	Doctor	28 years	Cisgender gay man	Roman Catholic	White	5 years	1 year and 3 months
13	Doctor	38 years	Cisgender heterosexual woman	Roman Catholic	Black	5 years	2 years
14	Doctor	-	Cisgender heterosexual man	Evangelical	Brown	4 years	1 year
15	Nurse technician	-	Cisgender heterosexual woman	Evangelical	White	19 years	19 years

• Source: Authors (2024).

Most participants had complementary graduate-level training, especially in Family Health, evidencing continuous investment in qualifying care practices, even in the face of demanding and exhausting routines. As observed in the table, although two participants in the study identified as cisgender men, this text uses the term “female workers” in recognition of the overwhelming presence of women on the team, considering the historical and political dimension of the feminization of care in the SUS.

From the empirical material produced, two analytical categories were delineated and structured the presentation of results and discussion: (1) perceptions of the health needs of lesbian and bisexual women, showing how these understandings are articulated with broader social representations; and (2) technical, ethical, and moral challenges emerging in care practice, which place strain on the daily work of health care. Given the nature of the study, we should underscore that the analysis of these dimensions does not seek universal generalizations, but rather the identification of disputed meanings, normative crossings, and affects that shape the workers’ performance. Therefore, one recognizes that health work is permeated by contradictions, silences, and potentials, constituting a field marked by tensions between institutional norms, individual experiences, and social demands.

Each topic is introduced below through a polyphonic narrative, also known as a network narrative, constructed through a patchwork quilt carved out of collective experiences¹⁹. Notably, the use of polyphonic narratives served solely as an aesthetic way of compiling and presenting the interviews’ discourses, especially considering the possibilities that emerge from the creative and sensitive process of qualitative research.

Fragments of care under construction: perceptions about the health needs of lesbian and bisexual women

Care happens normally. I don’t make distinctions. I never treat a woman differently because of her sexual orientation; everybody is treated the same. I try to receive her in a way that she doesn’t feel... violated, or the target of prejudice. That’s even more important during exams, like cytology, the Pap smear. In many of those moments, I notice they get scared, as they’ve already been through traumatic experiences. However, they can rest assured: we always perform the exam. I never leave anyone without care. Every woman who sits down with me is advised to get all the exams. Of course, the approach has to be a little different. I also know that many of them need more information and health education. Most of them say they don’t use barrier methods because they believe they don’t need to. Many appointments end up being quick, too quick. Even because... we don’t even have an appropriate space. There isn’t a private room where we can talk calmly, with privacy. That’s also something we’re missing. (Polyphonic narrative, Family Health Strategy)

The narratives revealed that the workers’ understanding of the health needs of lesbian and bisexual women did not occur in a linear or systematized way, but was crossed by normative, affective, and moral repertoires that structure the everyday routine of Primary Care. Despite the expanded concept of health embedded in the SUS principles and guidelines-considering that the category of “health needs” refers not only to biological lacks but also to dignity, autonomy, ways of life, and social constructions-the recognition of these dimensions is not always incorporated into the workers’ practice^20,21. We perceived that the care offered remained, to a great extent, anchored in a universalist logic, in which the reference subject is marked by presumed heterosexuality and reproductive conjugality²².

Two paradoxical conceptions marked this analysis and showed that the workers’ understanding of what is or is not a “need” is directly linked to the way they recognize (or fail to recognize) these women as legitimate subjects of comprehensive care: the discourse of neutrality, expressed by the phrase “it’s all the same,” and the recognition of difference, represented by the surprise of “I had never thought about that.”

The first aspect shows that there is an erasure of specificities under the pretext of equality, sustained by care protocols and flows that reinforce the image of a universal subject of care, erasing individual and sociocultural differences. In this context, neutral and depoliticized discourse aligns and articulates itself with the logic of non-difference, often functioning as a “shield” of justice and equality in the workers’ narratives^14,23,24. Silva and Gomes²⁴, in their study on lesbianity and health policies, show that this approach disregards the specific needs of lesbian women, reproducing structural inequalities and compromising care comprehensiveness.

The second aspect shows that, even within the context of standardized and heteronormative protocols and the invisibilization of differences, contact with lesbian and bisexual users can promote shifts and generate new meanings of care, even if only subtly. This encounter with difference leads workers to question previously naturalized practices, revealing, through interaction, other specific needs and dimensions of care that often had remained unconsidered.

The alleged neutrality, presented as an expression of justice and non-discrimination, ends up reinforcing invisibilities, since it does not problematize the contexts of symbolic and structural violence that shape these women’s experience in seeking health care²⁴. In this sense, “not differentiating” does not guarantee equity; rather, it tends to perpetuate veiled forms of exclusion. Even when workers recognize the need for a form of care that avoids violence, reception often remains restricted to the prevention of immediate harm, without necessarily favoring active inclusion or the development of practices sensitive to this population’s specificities.

The cervical cytology exam emerged as a central point in this logic because it is when lesbian and bisexual identities seem to become more visible, albeit as exceptions and deviations from the norm. The discourses of Nurses 3 and 5 illustrate this perspective: [...] many of them even reveal themselves because of having the speculum inserted. (Nurse 3). [...] During some cytology exam, the Pap smear, they get, like, really scared. It seems like they’ve been through some trauma. And I’ve noticed that here in about three cases. (Nurse 5).

We observed that the presumption of heterosexuality led to interpreting discomfort or refusal of the exam as a manifestation of individual resistance, rather than as the expression of institutional violence that insists on normalizing bodies and practices^10,13. Araújo et al. ²⁵ reinforces that policies, instruments, technologies, and health resources are mostly directed toward heterosexual family, sexual, gynecological, and reproductive health needs, which makes health workers remain daily waiting for only straight women to enter their offices^4,26.

By describing female users as “scared” or “traumatized” regarding gynecological examinations, workers end up reproducing asymmetrical relations in which lesbian and bisexual women are perceived as problematic figures within the care logic. In this context, the preventive exam appears as the central focus of the appointment, regardless of the pain or discomfort reported, evidencing a hierarchy in which the protocol overrides the patient’s autonomy. Although some female workers show openness to recognizing differences, their narratives still swing between uncertainty and imposed universalist practices, revealing the limits and breaches for transforming this care²⁴.

This reading of fear or trauma also reveals a distress medicalization process, in which legitimate feelings in the face of prejudice and exclusion are transformed into clinical or pathological signs. This framing shifts to the individual body experiences that are socially produced, transferring responsibility for structural violence to biomedical, heteronormative, and gendered diagnoses and protocols. In light of Foucault²⁷, this movement can be understood as an expression of the disciplinary power of Medicine, which defines what is normal and what must be treated, turning experiences of anguish and insecurity into objects of clinical intervention. This model reinforces an ethics oriented toward productivity and obedience to flows, to the detriment of care ethics based on bonding, listening, and attention to the users’ specificities.

Names left unsaid, presences felt: technical-care-related, moral, and ethical difficulties in care delivery

Some of them tend to be very discreet. I could never easily identify them among other women. I remember once when I made some comment alluding to that topic, and the woman answered me: “Oh, no. She’s my friend,” and changed the subject. Sometimes they do say it. I just don’t know how to proceed. I don’t ask directly if a woman is a lesbian. Actually, in some cases, you don’t even need to ask. Some I know are lesbians because they walk around like men. Sometimes they show up with their wife. Even then, I don’t feel comfortable asking: “Are you two a couple?” That’s not how it works. The truth is, generally, we don’t even ask that question that’s in the form, about sexual orientation. It feels invasive. When I realize it or suspect it, I keep asking myself: now what? What do I do differently? The truth is, I wouldn’t really know how to advise them properly either. (Polyphonic narrative, Family Health Strategy)

The concept of “technical-care-related difficulties” covers here the scarce resources and physical infrastructure, as well as the modes of recognition of users, the normality references activated by workers, and the training gaps that sustain heteronormative care practices. In short, this concept refers to the obstacles and challenges faced in the provision of health care, both in individual care and in the functioning of the system as a whole²⁸. To this end, one of the first obstacles observed was the dependence on gender stereotypes as a strategy for identifying users, to the detriment of direct questions about sexual orientation. This dynamic was sustained by the reinforcement of stigmatizing representations, synthesized in the figures of the “caricatured lesbian” and the “promiscuous bisexual”^10,11.

Notably, these expressions are used here illustratively, not as analytical categories or as descriptions of these women’s concrete experiences, but as discursive formulations that condense socially (re)produced stereotypes. The first alludes to the stigmatized representation of the lesbian woman associated with masculinization, while the second refers to the moralizing construction of female bisexuality as synonymous with promiscuity, risk, and affective-sexual instability.

Adopting appearance and gender performance as criteria for recognition not only simplifies complex identities but also renders invisible those who do not fit such representations. In this process, we observed that, in order to avoid directly asking about sexuality, workers seek a pattern of expression that allows them to recognize the woman without her needing to name herself, as in the case of lesbians whose expression or performance is perceived as masculine^13,29. Consequently, lesbians and bisexual women who do not perform masculinity, or who move through contexts said to be heterosexual, remain erased from care routines, having their experiences assimilated to heteronormative molds and interpreted as straight women²⁴.

Heteronormativity was also expressed in the way lesbian and bisexual families were understood by health workers. Same-sex/bi-affective relationships and reconstituted families are interpreted through the logic of the “husband and wife” couple, evidencing the difficulty of recognizing family arrangements that escape the binary model^13,29,30. This effort at “translation” into normative categories of gender and parenthood not only limits the intelligibility of experiences, but also weakens the reception and legitimation of rights. The female workers referred to these families when reporting “how and with whom” the lesbian and bisexual women in the territory served by the health unit lived.

When considered, sexuality appeared as a thorny topic, frequently silenced in care encounters. The lack of questioning about sexual orientation and gender identity is seemingly tied to some technical consequences, as well as moral and ethical constructs. Despite the presence of these questions in the e-SUS system, the female workers reported choosing not to fill them in, justifying this by the lack of practical relevance or by fear of embarrassing the users and invading their privacy. This discourse appeared in the perspectives of Community Health Workers 2 and 3: “Generally, we don’t ask that question that comes in the form [...] that part of the form is very invasive” (ACS 3), “We don’t ask about sexuality... I don’t ask because some people don’t like it, so I think it’s embarrassing” (ACS 2).

This invisibility, however, does not erase the marks of stigma. Bisexual women were frequently associated with HIV and STIs, being remembered by workers almost always through the logic of risk. This framing reduces care to the offering of rapid testing and specific counseling, neglecting other social and health dimensions. The association between bisexuality and STI risk reveals the stigma of promiscuity and hypersexualization historically imposed on bisexualities, which also unveils a fragmented care specifically directed to these women³¹, while also revealing that female workers’ discourses still operate under a regime that, at times, privileges moral issues over clinical aspects.

On the other hand, women who identify as lesbians often have prevention treated as nonexistent or irrelevant, the opposite problem from that observed in bisexuality, which also reinforces care practices that fail these women³¹. The lack of specific technologies for STI prevention in sex between women reinforces the idea that such practices do not constitute “legitimate sex” for the biomedical field. When they are recognized, improvised solutions appear, such as the use of plastic wrap or cut external condoms, which reveal institutional neglect more than an effective preventive response. This gap reinforces the marginalization of sex between women, reducing it to invisibility or to makeshift solutions. As for internal condoms, although technically available, they are often considered uncomfortable or inadequate, which illustrates the distance between health policies and concrete reality^32,33.

Another central axis is the lack of technical and pedagogical preparation. Most female workers acknowledged that they had never discussed sexual diversity in undergraduate education nor participated in specific training in their work settings. This blank space in training feeds insecurity in addressing singular demands, reinforcing practices based on improvisation and the reproduction of prejudice and stigma. Health training, marked by curricular and institutional silences, maintains heterosexuality as an implicit parameter, rendering invisible practices that move beyond heteronormative models. In this setting, the training and sensitization of these female workers emerges as one of the main factors crossing care for sexual and gender diversity^14,24,34.

The lack of technical and educational preparation is also reflected in the difficulty of recognizing and naming one’s own limitations. Many female workers acknowledge that they do not know how to properly advise lesbian and bisexual users regarding STI prevention or appropriate gynecological care, especially in contexts of sex between women. Rather than motivating a search for training, this insecurity is often converted into silence or into protocol-based referrals that are poorly connected to these women’s reality. On the other side, users’ silence about their sexuality tends to be interpreted as a lack of interest or omission, when in fact it constitutes a strategy of resistance in the face of hostile environments. This “not saying” protects against explicit violence and microaggressions, but it also reinforces the cycle of invisibility. Such silence cannot be understood as neutrality, but as a manifestation of structural lesbophobia and biphobia conditioning these women’s access to and circulation through health services^24,34.

The difficulties reported reveal tensions between the principles of universality and equity in the SUS. The discourse of “equality” often serves as a justification for non-differentiation, but in practice, it ends up homogenizing distinct demands and legitimizing exclusion. By relying on universalist protocols, workers tend to reproduce a care logic centered on heterosexuality, rendering invisible the specific differences and needs of lesbian and bisexual women^14,32.

Final considerations

The results, therefore, show that the implementation of comprehensive care for lesbian and bisexual women requires compliance with technical protocols-and certainly not with supposedly “neutral” biomedical ones-and observance of the protocols and guidelines established in reference documents such as the PNSI-LGBT and the Report on Comprehensive Health Care for Lesbian and Bisexual Women, which constitute specific foundations and evidence regarding this population and must be effectively implemented.

Nevertheless, reflective practices, the problematization of institutional norms, and the articulation between training, sensitization, and accountability must also form part of the praxis of work, placing strain not only on the everyday routine of health units but also on public policy itself. The construction of care sensitive to diversity depends on overcoming institutional silences, incorporating specific public policies into the care routine, and recognizing the workers’ life experiences and sociopolitical trajectories as instruments of ethical and clinical training.

On the horizon of these reflections, it becomes evident that the issue is not restricted to the inclusion of lesbian and bisexual women in the SUS, but involves the need to problematize the heteronormative structure as a whole that organizes health care in Brazil. In this process, medical and nursing pedagogies, clinical protocols, and the ethical and moral limits that continue to cross and condition care practices become objects of analysis.

In short, the study shows that, although there are specific advances and spaces for transformation, health care for lesbian and bisexual women remains fragmented and permeated by historical and structural inequalities. Advancing in this field requires coordination between policies, training, and institutional practices that promote inclusion, recognition, and equity, thereby consolidating comprehensiveness as an active SUS principle.

We hope that the reflections developed here will call upon the scientific community, training institutions, lesbian and bisexual women’s movements, and health services to broaden the debate, not merely to correct gaps, but to (re)think and (re)build the very foundations of care. If the SUS was historically built as a project of social justice, the implementation of comprehensiveness and equity depends on recognizing that those who escape the norm are not exceptions, but rather a legitimate and constitutive part of the field of Health.

Acknowledgments

The authors express their gratitude to the Municipal Health Secretariat of Manaus (SEMSA/Manaus), especially to the workers in the family health strategies, for their technical support, data provision, and partnership that made this research possible.

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• Funding
  The study was made possible with financial support from the Fundação de Amparo à Pesquisa do Estado do Amazonas (FAPEAM), within the scope of the Universidade do Estado do Amazonas (UEA), which enabled its execution and development.
• Data availability statement
  The data sources adopted in the research are indicated in the article’s body.

• Chief editors:
  Maria Cecília de Souza Minayo, Romeu Gomes, Antônio Augusto Moura da Silva, Vania de Matos Fonseca

Data availability

The data sources adopted in the research are indicated in the article’s body.

Publication Dates

• Publication in this collection
  17 Aug 2026
• Date of issue
  Aug 2026

History

• Received
  22 Apr 2026
• Accepted
  27 Apr 2026
• Published
  29 Apr 2026