Sexual orientation and time since last Papanicolaou test in Brazil: the 2019 National Health Survey

Abstract

This cross-sectional study used data from the 2019 National Health Survey to explore the association between sexual orientation and time since last Papanicolaou test in Brazil, by means of Poisson regression with robust variance, to estimate crude and adjusted prevalence ratios (PRs) and respective 95% confidence intervals (95%CI). The participants were 45,307 women, of whom 720 (1.85%) were non-heterosexual, that is, 394 (0.97%) homosexual and 326 (0.88%) bisexual. A negative association was found between sexual orientation and time of less than three years since last Papanicolaou test, among both women aged ≥18 years and those 25-64 years old (the target-population for cervical cancer screening in Brazil), with prevalences of, respectively, 17% (PR=0.83; 95%CI 0.76-0.90) and 14% (PR=0.86; 95%CI 0.78-0.96) lower among non-heterosexuals. That is, in Brazil, homosexual and bisexual women are less likely to have had a Papanicolaou test in the prior three years than heterosexual women, which calls for efforts by health services in Brazil to offer those women this important test.

Key words:
Sexual and gender minorities; Mass screening; Uterine cervical neoplasms; Health surveys; Brazil

Resumo

Este estudo seccional utilizou dados da Pesquisa Nacional de Saúde 2019 para explorar a associação entre orientação sexual e tempo de realização do último exame de Papanicolaou no Brasil por meio de regressão de Poisson com variância robusta, que estimou razões de prevalências (RP) brutas e ajustadas e respectivos intervalos de 95% de confiança (IC95%). Participaram 45.307 mulheres, sendo 720 (1,85%) não heterossexuais, isto é, 394 (0,97%) homo e 326 (0,88%) bissexuais. Uma associação negativa entre orientação sexual e tempo de realização do último exame de Papanicolaou menor que três anos foi evidenciada tanto entre mulheres com idade ≥18 anos quanto entre aquelas de 25-64 anos (população-alvo do rastreamento do câncer do colo do útero no país), com prevalências, respectivamente, 17% (RP=0,83; IC95% 0,76-0,90) e 14% (RP=0,86; IC95% 0,78-0,96) menores entre as não heterossexuais. Portanto, no Brasil, mulheres homo e bissexuais apresentam menor probabilidade de realizar exame de Papanicolaou em tempo menor que três anos quando comparadas às heterossexuais, o que reclama esforços dos serviços de saúde do país para oferecer esse importante exame àquelas mulheres.

Palavras-chave:
Minorias sexuais e de gênero; Programas de rastreamento; Neoplasias do colo do útero; Inquéritos epidemiológicos; Brasil

Resumen

Este estudio transversal utilizó datos de la Encuesta Nacional de Salud 2019 para explorar la asociación entre la orientación sexual y el tiempo transcurrido desde la última prueba de Papanicolaou en Brasil utilizando la regresión de Poisson con varianza robusta, que estimó las razones de prevalencia (RP) cruda y ajustada y sus respectivos intervalos de confianza del 95% (IC95%). Participaron un total de 45.307 mujeres, de las cuales 720 (1,85%) no eran heterosexuales, es decir, 394 (0,97%) homosexuales y 326 (0,88%) bisexuales. Se encontró una asociación negativa entre la orientación sexual y el tiempo transcurrido desde la realización del último examen de Papanicolaou inferior a tres años, tanto entre las mujeres de ≥18 años como entre aquellas de 25-64 años (la población objetivo del tamizaje del cáncer de cuello uterino en el país), con tasas de prevalencia un 17% (RP=0,83; IC95% 0,76-0,90) y un 14% (RP=0,86; IC95% 0,78-0,96) más bajas entre las mujeres no heterosexuales, respectivamente. Por lo tanto, en Brasil, las mujeres homosexuales y bisexuales presentan menos probabilidades de someterse a un examen de Papanicolaou en menos de tres años en comparación con las mujeres heterosexuales, lo que exige esfuerzos por parte de los servicios de salud del país para ofrecer este importante examen a estas mujeres.

Palabras clave:
Minorías sexuales y de género; Tamizaje masivo; Neoplasias del cuello uterino; Encuestas epidemiológicas; Brasil

Introduction

In several developed countries, significant reduction in incidence of cervical cancer and related mortality has been attributed to the introduction of organised screening programmes based on the Papanicolaou (cytopathology) test¹. In Brazil, this is the disease screening method that should be offered to women, or to any person with a cervix, in the 25-64 year age range who has been sexually active, for the purpose of identifying, confirming and treating precursor lesions².

Launched in 1998, the National Plan to Combat Cervical Cancer introduced opportunistically-structured screening measures². Mortality from cervical cancer then trended downwards in Brazil, with annual negative variation of around 2% up to 2014, when the trend became stationary³. This was followed by decentralised implementation of a number of control measures, by way of health education, vaccination and screening in Primary Health Care, particularly since the Family Health Strategy was expanded and strengthened⁴.

Even though potentially preventable by means of early diagnosis of precursor lesions and vaccination against human papillomavirus (HPV)⁵, cervical cancer continues to be a severe public health problem in Brazil. The adjusted rate of new cases estimated for each year from 2023 to 2025 was 13.25 per 100,000 women, making it the third most incident form of cancer among women nationwide and second in the North and Northeast macro-regions (16.77/100,000 and 13.85/100,000, respectively)⁶. Note that, in Brazil, the national health system (Sistema Único de Saúde, SUS) has distributed the quadrivalent HPV vaccine, free of charge, for children and adolescents, since 2014, and the target population has been gradually extended to boys and girls aged nine to 14 years, persons living with HIV, solid organ or bone marrow transplantees and cancer patients aged nine to 45 years, victims of sexual abuse and users of HIV pre-exposure prophylaxis aged 15 to 45 years and those with recurrent respiratory papillomatosis from age two years⁷.

Although evidence has been shown that, in Brazil, the percentage of women, regardless of age, who have taken a Papanicolaou test in the past three years has increased and the percentage who never had one has decreased⁸, it is also known that among those from 25 to 64 years of age, prevalences of testing in the past three years are higher among those whose race/colour is white, who have more schooling and family income, private health insurance and reside in the South and Southeast macro-regions, particularly in state capitals and urban areas⁸. Meanwhile, among the target population, the highest prevalences of never having had a Papanicolaou test are found among those whose race/colour is black or mixed, who have less schooling and family income, high parity, no private health insurance and reside in the North and Northeast macro-regions, particularly outside state capitals⁸.

In that light, the authors stress that the role of sexual orientation in determining Papanicolaou testing in Brazil is unknown. That is because, not only was a national policy for lesbian, gay, bisexual, transvestite and transsexual health not introduced until 2011⁹, but nationally representative surveys never collected data on sexual orientation, until the second national health survey (Pesquisa Nacional de Saúde, PNS) in 2019¹⁰. Specific aim 12 of the National Comprehensive LGBT Health Policy is to prevent new cases of cervical cancer among lesbians and bisexual women⁹, warranting research studies on the subject which can collaborate towards understanding the vulnerabilities of this population group and improve related screening measures in Brazil.

Accordingly, this study explored the association between sexual orientation and time since last Papanicolaou test in Brazil.

Methods

This cross-sectional study used data from the 2019 PNS, a representative population-based survey by the Ministry of Health, in partnership with the official bureau of statistics, of individuals 15 years old or more residing in private households in Brazil. On the basis of a complex sampling strategy, the 2019 PNS used a three-stage cluster plan, in which the primary units were census tracts, the secondary units, households and the tertiary units, residents aged 15 years or more¹¹.

Data were collected, from March 2019 to March 2020, by appropriately trained interviewers using mobile devices. Residents (N=88,531) selected randomly in each household answered questions on work and health after signing a declaration of free and informed consent, after execution of the 2019 PNS was duly approved by the National Research Ethics Committee (Opinion No. 3.529.376, of 23 August 2019)¹¹.

The study reported here included women who responded ‘heterosexual’, ‘homosexual’ or ‘bisexual’ to the question ‘What is your sexual orientation?’, addressed only to interviewees ≥18 years old, who responded directly onto the mobile data collection device, so as to ensure privacy¹¹. Excluded were those for whom no information was given on the variables colour/race (n=3) and monthly per capita household income (n=18).

In Brazil, a woman is defined as being heterosexual, homosexual or bisexual, respectively, as: a person of female gender identity who has relations with persons of male gender identity; a (lesbian) woman who has affective and sexual relations with other women, regardless of gender identity; and a person of female gender identity who has affective and sexual relations with persons of both sexes, regardless of gender identity¹².

The exposure variable (sexual orientation) was transformed into only two categories: heterosexual and non-heterosexual, the latter comprising self-declared homosexuals and bisexuals. The outcome variable (time since last Papanicolaou test) was obtained by the question ‘When was the last time you had a cervical cancer prevention test?’ and was also transformed for the same purpose: those who responded ‘Less than a year ago’, ‘From one year to less than two years ago’ and ‘From two years to less than three years ago’ formed the ‘Less than three years’ category, while those who responded ‘Three years or more ago’ and ‘Never had one’ formed the ‘Three years or more’ category. The covariables used to control for confounders in the association of interest were age (in years), race/colour (white and non-white), schooling (none, incomplete lower secondary, complete lower secondary, incomplete upper secondary, complete upper secondary, incomplete higher and complete higher), monthly per capita household income (in minimum wages: up to ¼, from ¼ to ½, from ½ to 1, from 1 to 2, from 3 to 5 and 5 or more) and macro-region of residence (South, Southeast, Mid-west, Northeast and North).

All statistical analyses were performed on Stata 15.0 software, using procedures with the svyset command to contemplate the complex sampling of the 2019 PNS. First, the outcome was explored, in percentage terms, by sexual orientation and age ranges (18-24, 25-64 and ≥65 years), and the covariables, by sexual orientation. The association between sexual orientation and time since last Papanicolaou test was explored by Poisson regression with robust variance, which estimated prevalence ratios (PRs) and 95% confidence intervals (95%CIs). From that crude model, others were tested with adjustment for the covariables, which were introduced, one by one, in the following order: age, race/colour, schooling, monthly per capita household income and macro-region of residence. Covariables which then returned a p-value > 0.05 were excluded from the above sequence. The association of interest was explored in the whole study population (women aged ≥18 years) and in the 25-64 year age range, which is the target-population for cervical cancer screening in Brazil².

Results

The study participants were 45,307 women: 44,587 (98.15%) of them heterosexual and 720 (1.85%) non-heterosexual; of the latter, 394 (0.97%) were homosexual and 326 (0.88%) bisexual. Most were in the 25-64 year age range (71.01%), non-white (55.91%), had complete upper secondary schooling (30.11%), monthly per capita household income from ½ to 1 minimum wage (29.54%) and resided in Southeast Brazil (43.70%). Table 1 shows the proportional distribution of these covariables, by sexual orientation.

Table 1
Proportional distribution of demographic. social and economic characteristics of study participants. by sexual orientation. Brazil. 2019.

Characteristics		Heterosexual (n=44.587)	Non-heterosexual (n=720)	Total (n=45.307)
Age range (years)
	18-24	12.15	0.84	12.99
	25-64	70.01	1.00	71.01
	≥65	15.99	0.01	16.00
	Total	98.15	1.85	100.00
Race/colour
	White	43.23	0.86	44.09
	Non-white	54.91	1.00	55.91
	Total	98.15	1.85	100.00
Schooling
	None	5.93	0.01	5.94
	Incomplete lower secondary	27.90	0.11	28.02
	Complete lower secondary	7.26	0.11	7.37
	Incomplete upper secondary	5.70	0.26	5.95
	Complete upper secondary	29.49	0.62	30.11
	Incomplete higher	4.87	0.25	5.12
	Complete higher	17.00	0.49	17.49
	Total	98.15	1.85	100.00
Monthly per capita household income (minimum wages)
	Up to ¼	8.12	0.16	8.28
	From ¼ to ½	14.83	0.15	14.98
	From ½ to 1	29.08	0.46	29.54
	From 1 to 2	27.10	0.46	27.56
	Entre 2 and 3	8.39	0.28	8.67
	From 3 to 5	5.93	0.20	6.13
	5 or more	4.69	0.15	4.83
	Total	98.15	1.85	100.00
Macro-region
	South	14.21	0.33	14.54
	Southeast	42.81	0.90	43.70
	Mid-west	7.36	0.13	7.49
	Northeast	26.27	0.36	26.63
	North	7.50	0.13	7.64
	Total	98.15	1.85	100.00

• Source: 2019 National Health Survey.

Table 2 shows that 58% of the heterosexual women and 61.8% of the non-heterosexual women in the 25-64 year age range had had a Papanicolaou test less than three years earlier.

Table 2
Proportional distribution of time since last Papanicolaou test, by age range and sexual orientation. Brazil, 2019.

Age range (years)	Heterosexual (n=44,587)			Non-heterosexual (n=720)
	Less than three years	Three years or more	Total	Less than three years	Three years or more	Total
18-24	7.06	5.93	12.99	8.33	8.11	16.45
25-64	58.00	13.00	71.00	61.80	18.73	80.53
≥ 65	8.00	8.01	16.01	1.64	1.39	3.03
Total	73.06	26.94	100.00	71.77	14.33	100.00

• Source: 2019 National Health Survey.

A negative association between sexual orientation and time since last Papanicolaou test was shown both among women aged ≥18 years (Table 3) and among those in the 25-64 year age range (Table 4), with respective prevalences of 17% (PR=0.83; 95%CI 0.76-0.90) and 14% (PR=0.86; 95%CI 0.78-0.96) lower among non-heterosexual women.

Table 3
Association between sexual orientation and less than three years since last Papanicolaou test, among women aged ≥18 years. Brazil, 2019.

Sexual orientation	Models
	Crude PR (95%CI)	Adjusted 1a PR (IC95%)	Adjusted 2b PR (IC95%)	Adjusted 3c PR (IC95%)	Adjusted 4d PR (IC95%)	Adjusted 5e PR (IC95%)	Adjusted 6f PR (IC95%)
Heterosexual	1.0	1.0	1.0	1.0	1.00	1.0	1.00
Non-heterosexual	0.91 (0.84-0.99)	0.85 (0.78-0.93)	0.85 (0.78-0.93)	0.84 (0.77-0.91)	0.85 (0.78-0.92)	0.83 (0.77-0.90)	0.83 (0.76-0.90)

• ^a
  Adjusted for age; ^b Adjusted for age and race/colour; ^c Adjusted for age, race/colour and schooling; ^d Adjusted for age and schooling; ^e Adjusted for age, schooling and monthly per capita household income; ^f Adjusted for age, schooling, monthly per capita household income and macro-region of residence.
• Source: 2019 National Health Survey.

Table 4
Association between sexual orientation and less than three years since last Papanicolaou test, among women aged 25-64 years. Brazil, 2019.

Sexual orientation	Modelos
	Crude PR (95%CI)	Adjusted 1a PR (IC95%)	Adjusted 2b PR (IC95%)	Adjusted 3c PR (IC95%)	Adjusted 4d PR (IC95%)	Adjusted 5e PR (IC95%)
Heterosexual	1.0	1.0	1.0	1.0	1.0	1.00
Non-heterosexual	0.91 (0.82-1.01)	0.90 (0.81-1.00)	0.91 (0.82-1.01)	0.87 (0.78-0.96)	0.86 (0.78-0.96)	0.86 (0.78-0.96)

• ^a
  Adjusted for age; ^b Adjusted for race/colour; ^c Adjusted for schooling; ^d Adjusted for schooling and monthly per capita household income; ^e Adjusted for schooling, monthly per capita household income and macro-region of residence.
• Source: 2019 National Health Survey.

Discussion

The study reported here showed a negative association, in Brazil, between non-heterosexual sexual orientation and having had a Papanicolaou test less than three years previously, which was consistently confirmed in the crude and adjusted analyses among women aged ≥18 years and, in the adjusted analysis, among those in the 25-64 year age range. In other words, homosexual and bisexual women in Brazil are less likely to have had a Papanicolaou test in the past three years than heterosexual women.

A recent systematic review with meta-analysis¹³, which compared rates of Papanicolaou testing among heterosexual women and women belonging to sexual minorities, found that the latter were 42% less likely (odds ratio [OR]: 0.58; 95%CI 0.48-0.71) to have been tested than the former. Lesbians, in particular, were 54% less likely (OR: 0.46; 95%CI 0.37-0.56) to be tested routinely¹³.

Note that the association found in the study reported here is approximately a third as strong as in the above review, which to a point confirms the high level of cervical cancer screening achieved by Brazil in 2019⁸. Nonetheless, Brazil’s health services, obviously supported by vigorous anti-discrimination policies for LGBT people, must direct efforts to identifying and attracting non-heterosexual women in order to offer them Papanicolaou testing, in that, otherwise, they are less likely to be tested.

The high rates of discrimination perceived or experienced by non-heterosexual women in health services¹⁴ are possible reasons for that likelihood. One nationwide online survey in Brazil¹⁵, which recruited 6,693 persons aged ≥50 years (1,332 of them LGBT) by snowball sampling, showed that 53% of the LGBT participants did not believe that doctors were prepared to deal with the particular health needs of this population and that 9% of those who had a doctor, on revealing their sexual orientation, perceived inappropriate reactions from these professionals. Incidentally, the same survey found that the percentage of homosexual and bisexual women who had had a Papanicolaou test at least once in their life was lower than for heterosexual women (39% vs. 73%; pvalue<0.001)¹⁵.

It is thus indispensable that stronger action be taken in Brazil’s health services to promote respect for sexual diversity⁹. This follows from a study based on data from the first National Health Survey (2013 PNS), which showed that none of the characteristics surveyed (age, schooling, macro-region of residence, having private health insurance, the last doctor’s appointment and the last appointment through the national health service, the SUS) was capable, pragmatically, of influencing a person’s risk, whatever their sex and race/colour, of suffering discrimination for their sexual orientation in Brazil’s health services¹⁶.

Added to this, public health interventions directed to increasing homosexual and bisexual women’s access to cervical cancer screening must be planned-with the support and participation of civil society organisations-and, as soon as they are specified, be systematically practiced in health care establishments. The authors believe that these interventions should include education measures to make this population aware of cervical cancer, the exposures that increase the risk of developing it and the benefits of the Papanicolaou test. Other authors believe that simply using an instrument tailored to assessing the health of LGBT people is a significant strategy for surmounting this structural and organisational barrier to this population’s access to primary health care¹⁷, where the Papanicolaou test is mainly performed².

One online survey¹⁸, using respondent-driven sampling, recruited 299 women who had sex with women in South Brazil: 31.8% of them had never had a Papanicolaou test. The main reasons given for not doing so included the fact that they only had sex with other women and were fearful of being mistreated by health personnel¹⁸ . In that regard, it is important that health care personnel avoid the assumption that all patients are heterosexual, as such heteronormative behaviour discourages patients from declaring their sexual orientation¹⁹²¹ and undermines their confidence in the health care professional ^22,23, making it less likely that they will follow his or her recommendations^21,24. Prior studies have shown that, among lesbians, declaring sexual orientation to a health caregiver is associated with greater likelihood of having had a Papanicolaou test in the past three years^25,26.

The findings of this study should be interpreted in the light of its limitations. The use of secondary data precluded assessment of the role of gender identity in the association of interest, given that the 2019 PNS did not collect that information. The cross-sectional design made it impossible to determine a causal relationship between sexual orientation and time since last Papanicolaou test. Classification of both outcome and exposure was based on self-reporting, which may have introduced, respectively, memory bias and prevarication bias. Even though the exposure variable was obtained in such a manner as to minimise such occurrences, the frequency of women self-declared homosexual and bisexual may be underestimated. As a result, and given the possibility of recall bias, the magnitude of the association of interest may also be underestimated.

Even given these limitations, this is the first study in Brazil to explore the association between sexual orientation and time since last Papanicolaou test in a nationally-representative sample, showing that, in comparison with heterosexual women, homosexual and bisexual women are less likely to have been tested in the prior three years. The study thus raises the hypothesis that women in Brazil are at greater risk of receiving a diagnosis of high-grade malignant or pre-malignant cervical lesions, a situation that deserves to be investigated in future prospective research.

References

• ¹ Vaccarella S, Lortet-Tieulent J, Plummer M, Franceschi S, Bray F. Worldwide trends in cervical cancer incidence: impact of screening against changes in disease risk factors. Eur J Cancer 2013; 49(15):3262-3273.
• ² Instituto Nacional de Câncer José Alencar Gomes da Silva (INCA). Coordenação de Prevenção e Vigilância. Divisão de Detecção Precoce e Apoio à Organização de Rede. Diretrizes brasileiras para o rastreamento do câncer do colo do útero. Rio de Janeiro: INCA; 2016.
• ³ Luizaga CTM, Jardim BC, Wünsch Filho V, Eluf Neto J, Silva GA. Recent changes in trends of mortality from cervical cancer in Southeastern Brazil. Rev Saude Publica 2023; 57:25.
• ⁴ Claro IB, Lima LD, Almeida PF. Cervical cancer guidelines, prevention and screening strategies: experiences from Brazil and Chile. Cien Saude Colet 2021; 26(10):4497-4509.
• ⁵ Pimple S, Mishra G, Shastri S. Global strategies for cervical cancer prevention. Current Opinion in Obstetr Gynecol 2016; 28(1):4-10.
• ⁶ Santos MO, Lima FCS, Martins LFL, Oliveira JFP, Almeida LM, Cancela MC. Estimated cancer incidence in Brazil, 2023-2025. Rev Bras Cancerol 2023; 69(1):e-213700.
• ⁷ Brasil. Ministério da Saúde (MS). HPV [Internet]. [acessado 2024 dez 24]. Disponível em: https://www.gov.br/saude/pt-br/assuntos/saude-de-a-a-z/h/hpv
  » https://www.gov.br/saude/pt-br/assuntos/saude-de-a-a-z/h/hpv
• ⁸ Silva GA, Damacena GN, Ribeiro CM, Alcantara LLM, Souza Júnior PRB, Szwarcwald CL. Papanicolaou test in Brazil: analysis of the National Health Survey of 2013 and 2019. Rev Saude Publica 2023; 57:55.
• ⁹ Brasil. Ministério da Saúde (MS). Secretaria de Gestão Estratégica e Participativa. Departamento de Apoio à Gestão Participativa. Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais, Travestis e Transexuais. Brasília: MS; 2013.
• ¹⁰ Carvalho AA, Barreto RCV. The invisibility of the LGBTQIA+ people in the databases: new possibilities in the 2019 National Health Research? Cien Saude Colet 2021; 26(9):4059-4064.
• ¹¹ Stopa SR, Szwarcwald CL, Oliveira MM, Gouvea ECDP, Vieira MLFP, Freitas MPS, Sardinha LMV, Macário EM. National Health Survey 2019: history, methods and perspectives. Epidemiol Serv Saude 2020; 29(5):e2020315.
• ¹² Brasil. Ministério dos Direitos Humanos (MDH). Secretaria Nacional de Cidadania. Manual Orientador sobre Diversidade. Brasília: MDH; 2018.
• ¹³ McDonald KM, Delgado A, Roeckner JT. Papanicolaou test rates among sexual minority women: a systematic review and meta-analysis. LGBT Health 2022; 9(1):1-7.
• ¹⁴ Brown R, McNair R, Szalacha L, Livingston PM, Hughes T. Cancer risk factors, diagnosis and sexual identity in the Australian Longitudinal Study of Women's Health. Womens Health Issues 2015; 25(5):509-516.
• ¹⁵ Crenitte MRF, Melo LRD, Jacob Filho W, Avelino-Silva TJ. Transforming the invisible into the visible: disparities in the access to health in LGBT+ older people. Clinics 2023; 78:100149.
• ¹⁶ Jomar RT, Fonseca VAO, Ramos DO, Marinho GL, Guimarães RM, Gomes MCA, Meira KC. Prevalência de discriminação percebida por orientação sexual nos serviços de saúde do Brasil: Pesquisa Nacional de Saúde, 2013. Cad Saude Colet 2021; 29(n. esp.):187-198.
• ¹⁷ Ferreira LM, Batista GG, Bouillet LEM. Barriers to access to Primary Care for the LGBTQIA+ population: an integrative review. Rev Med Bras Fam Comunidade 2024; 19(46):3549.
• ¹⁸ Fontanari AMV, Bauer GR, Churchill SM, Costa AB. Gynecological care among Brazilian women who have sex with women: a respondent-driven sampling study. LGBT Health 2023; 10(4):287-295.
• ¹⁹ Sharek DB, McCann E, Sheerin F, Glacken M, Higgins A. Older LGBT people's experiences and concerns with healthcare professionals and services in Ireland. Int J Older People Nurs 2015; 10(3):230-240.
• ²⁰ Bjorkman M, Malterud K. Lesbian women's experiences with health care: a qualitative study. Scand J Prim Health Care 2009; 27(4):238-243.
• ²¹ Barbara AM, Quandt SA, Anderson RT. Experiences of lesbians in the health care environment. Women Health 2001; 34(1):45-62.
• ²² Elliott MN, Kanouse DE, Burkhart Q, Abel GA, Lyratzopoulos G, Beckett MK, Schuster MA, Roland M. Sexual minorities in England have poorer health and worse health care experiences: a national survey. J Gen Intern Med 2015; 30(1):9-16.
• ²³ Steele LS, Tinmouth JM, Lu A. Regular health care use by lesbians: a path analysis of predictive factors. Fam Pract 2006; 23(6):631-636.
• ²⁴ Stein GL, Bonuck KA. Physician-patient relationships among the lesbian and gay community. J Gay Lesbian Med Assoc 2001; 5(3):87-93.
• ²⁵ Reiter PL, McRee AL. Cervical cancer screening (Pap testing) behaviours and acceptability of human papillomavirus self-testing among lesbian and bisexual women aged 21-26 years in the USA. J Fam Plann Reprod Health Care 2015; 41(4):259-264.
• ²⁶ Tracy JK, Schluterman NH, Greenberg DR. Understanding cervical cancer screening among lesbians: a national survey. BMC Public Health 2013; 13:442.

• 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
  07 Aug 2026
• Date of issue
  July 2026

History

• Received
  19 Sept 2024
• Accepted
  27 Mar 2025
• Published
  29 Mar 2025