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Sex, gender, and sexual identities in women’s health

Luciane Marques de AraujoI; Lucia Helena Garcia PennaII
IObstetric nurse, Master's in Nursing from the Federal University of  Rio de Janeiro, Professor, Department of Maternal-Child Nursing Assistant and Doctoral Student of the Graduate program at the State University of Rio de Janeiro School of Nursing. Brazil, Email: lmdearaujo@gmail.com.
IIObstetric Nurse. PhD in Child and Women's Health from the Fernandes Figueira Institute, Oswaldo Cruz Foundation. Associate Professor, Department of Maternal-Child Nursing and the Graduate Program of the School of Nursing at the State University of Rio de Janeiro, Brazil. Email: luciapenna@terra.com.br,

ABSTRACT: This is a theoretical study on the relation between sex, sexual identity, and gender identity, considering the daily professional practice of nurses and doctors in the field of women’s health. The study shows conceptual connections between body, gender, identity, sexuality, and their effects on the categorization of people and health care for the lesbian. It aims at fostering individual and collective reflection among health professionals, in general, and nurses, in particular, on the multiplicity of expressions of gender and sexuality. Reflection is identified as structuring to transforming attitudes and practices in health care and to ensuring higher quality care for lesbians. A respectful relationship builds up the therapeutic environment necessary for expression of those women’s real and unique health needs.

Keywords: Gender identity; homosexuality; violence; women’s health. 



An idea present in our social environment is that there is a fundamental connection between the gender of the body, gender identity and sexual identity.

Despite the connection between these aspects not having any natural basis, the false association between the gender of the body and gender and sexual identities promotes, especially in the women's health field. On behalf of health, and in the case of sexual and reproductive health, prescribing sexuality models considered healthy, normal and discrimination against people who are identified as deviants from the hegemonic heterosexual norm, people who are identified as deviants from standard hegemonic, heterosexual.

The consequences, in the daily practice of health services, are discriminatory professional attitudes that promote the vulnerability of specific groups of people and in the case of this study, women with expression of male gender and mainly the lesbians.

This observation is supported by studies that have identified that there is a lower demand for health services, on the part of lesbians and the reasons mentioned are: the existence of discrimination; women difficulties in assuming homo or bisexuality, by considering the space inappropriate for such; and the denial of the risk for certain gynecological diseases1-3.

It is worth commenting that many of the health problems of lesbians may be motivated by the elevated levels of psychological distress generated by experiences of physical structural and symbolic violence, in the family, at work and in public places to which these women are subject. This includes in health institutions, and this situation has been singled out as proportionately high in several studies on lesbians, when compared to the heterosexual population1-3.

Therefore, with regard to the specifics of lesbian health, what  draws more attention are not situations that relate necessarily the intrinsic characteristics of this group, but those relating to the consequences of the representations of health professionals that fall negatively on sexual practices and ways of life of these women.

From this issue, the intention is to present a theoretical reflection on the concepts of body, gender, identity, sexuality and violence in the field of women's health, which is recognized as structuring for the transformation of attitudes and practices.

Body gender as well as gender and sexual identities

In the human species by biological determination, there are males and females. However, the way of being a man and being a woman is conducted by culture. Thus, the concept of gender from the account of the distinction between the biological dimension and the social dimension of the human being, which means that men and women are products of social reality, of culture, and not a result of the anatomy of their bodies.

This division between male and female in this order of things at the same time, in a state objectified in things, on the whole social world, and corporate state, the bodies and the usual agents, functioning as schemes of perception, thought and action4,5.

The social world builds and imposes a representation about the sexual organs, male and female, and this representation, being incorporated in minds, becomes the foundation of social difference between men and women. Therefore, the biological difference between the sexes comes to be seen as background natural difference socially constructed between the genera. To build this opposition between the male and the female are used diagrams of thought, of universal application, that determine which women are constituted as an entity, defined only by what they lack in relation to man, and he will be responsible for the better part5.

Thus, this levy silent and continues to social roles, counterparts and opposites, the two sexes, male and female, to be built by agents, ends up by transforming this arbitrary cultural in natural, constituting a form of symbolic violence, gender violence6.

Therefore, the masculinization of the male body and the feminization of the female body are enormous and endless tasks that, without doubt, require usually a spent considerable time and effort, determine the somatization of relation of domination and is thus naturalized5.

As well as the school, the health institution is one of the institutions that implement the process of schooling of the body, the disciplining of bodies, the pedagogy of sexuality and the production of masculinity and femininity. The purpose of these investments is the production of a man and a woman civilized, capable of living in consistency and adequacy in society, reiterating identities and hegemonic practices while subordinates, denies or refuses the other7,8.

The heteronormality structure a habitus that takes an agent to see and think about the sexuality as unique and exclusively heterosexual order what you can do with that, on the one hand, there is a lack in dealing with the plurality of sexual orientation and, in another, produce-if difficulties of people reveal their homosexuality9.

So much that in the area of women's health the idea prevalent among the agents is one that presupposes as standard of normality that the female matches all attributes of femininity and the taste for doing sex exclusively with men, i.e. the female must match a feminine gender identity and sexual identity of the hetero orientation.

In our environment, it is very common that the same tasks can be considered noble, when carried out by men, or insignificant when carried out by a woman5. In contrast, the women who occupy hierarchically superior positions attribute many more masculine traits than the others10.

There is also a certain social consensus to assign traits to male individuals who occupy the highest echelons and dashes female individuals who occupy subordinate positions. The recognition of a belonging to a group, male or female, heterosexual or homosexual, refers to the integration of agents in a social space, but at the same time, these agents are trying to find a specific place in the same social space, they seek differentiate themselves, distinguishing themselves10.

Therefore, social identity refers to a feeling of similarity to some other while the personal identity refers to a sense of difference compared to the same others. Personal identity corresponds to what is perceived as exclusively his and, therefore, separate from the group10.

Recognize that an identity supposes affirmatively respond to questioning and establish a sense of belonging to a social group of reference and we all belong to distinct groups simultaneously. There is nothing simple or stable in all, because these multiple identities and backgrounds may charge, at the same time, distinct loyalties, divergent or even contradictory. We are subject to many identities, transient and contingent8.

Gender identity concerns the subjective perception of being male or female, the sense of belonging to one or another gender, as the attributes, behaviors and roles conventionally established for men and women. With respect to how someone feels, identifies oneself, if presents and how it is perceived, as male or female, or even a mix of both, independent both of gender and sexual orientation.

Since sexual identity refers to two different issues: on the one hand, it is the way a person is perceived in terms of their sexual orientation, the gender of the people who elect as objects of desire and affection. On the other hand, is the way they make it public, or not, this perception of themselves in certain environments and situations11.

Sexual orientation is not a free and voluntary choice; however, their publicization is. Coming out as gay, lesbian or bisexual, before friends and family, or in more public contexts, is an affirmation of belonging and taking a critical position on social norms11.

Sexual identity corresponds to the way a person is perceived and is expressed in terms of their sexual orientation, such as homosexual, heterosexual or bisexual, and the contexts in which this guidance can be assumed by the person and/or recognized in their surroundings. With respect to outbreaks of feelings, attraction, desire and fantasies, misguided emotional desires, interpersonal bonds, and essential relationships11. Sexual identity is an unstable construction, changeable, volatile, contradictory social relationship and not finalized.

Sexual and gender identities produce in the midst of dynamic arrangements of social relations and cultural meanings. They may be more or less durable, varying from case to case, and certainly are subject to a variety of contingencies and influences11.

However, the bodies are not as evident as usually thought. Neither the identities are a direct consequence of the evidences of the bodies7. Either way, we have invested a lot in the bodies. We have learned to classify the subjects by forms as they are corporally.

The bodies are signified by culture, and continually altered by it. Perhaps we should ask, first of all, as determined characteristic started to be recognized as a defining mark of identity; what meanings that, at this time and in this culture, are being assigned to such mark or appearance. It may occur that the desires and needs that someone experiences are in disagreement with the appearance of their body7,8.

The body is not a fact of nature, ready and finished. It is unstable and dynamic. Its needs and desires are changed with the passage of time, with the change of eating habits and life, with the diseases, with various forms of care and with the new forms of medical and surgical intervention11.

In our social environment, normal men should feel and express themselves as male and normal women as female. Everything that flees to this parameter of normality, imposed by social order, tends to be considered as deviation, disorder, and disturbance. Thus, effeminate men, masculine women, transvestites, transsexuals and intersex are examples of the deviant gender norm. Outside this, some people who identify themselves as gays and participate in the gay community, but may not have any homosexual activity. In contrast, other people can be homosexually active and refuse this label12,13.

Sexuality, stereotypes and violence in the healthcare field

Sexuality refers to cultural elaborations on the pleasures and the exchanges and social body. It is, therefore, a dynamic concept, which is subject to several uses, multiple and contradictory interpretations and that is subject to political debates and disputes.

Sexuality is, above all, a construction of bodies, desires, behaviors and identities. Sexuality involves a continuous process, and non-linear, of learning and reflection through which we drew up the perception of who we are11.

A form of sexuality is so widespread, naturalized and acts as a reference for all subjects. Thus, heterosexuality is conceived as natural and also as universal and normal. Therefore, companies build the contours milestones of borders between those who represent the norm and those who are outside it7,8.

Those who perceive themselves with interests or distinct desires of standard heterosexual, often are negatively stereotyped, leaving few alternatives but the silence, the concealment or segregation. The production of heterosexuality is accompanied by rejection of homosexuality, which is expressed, many times, by declared homophobia7.

The stereotypes are the common traits that individuals tend to perceive between persons belonging to the same category. Classically the stereotypes are defined as a set of beliefs concerning the characteristics of a group. They allow you to define and characterize a group, describe its members quickly and cost-effectively in cognitive, are simplifications10.

Often people tend to stereotype over the members of the groups not belonging to the members of the groups to which they belong. It was observed that the tendency of individuals to realize their groups of belonging as more heterogeneous or more differentiated10.

It is very common that the constitutive traits of a stereotype have negative connotations, as is the case of lesbians. Thus, these traits can take professionals to make a negative result on a woman, not because of their specificities or of their conduct, but simply due to their membership of a group that is the object of a stereotype. This phenomenon corresponds to the preconception that designates the trial a priori and generally negative who are victim’s members of certain groups, such as in the case of women whose gender identity and/or sexual does not correspond to the expected for their biological gender. The stereotypes are the cognitive substrate of prejudices and generate discrimination10.

Discrimination is the negative behavior in relation to the individual members of an out-group dynamics. In most cases, include harmful behaviors that its authors misrepresent or try to mask10.

Discrimination, motivated by gender and/or sexual identities, it constitutes in a violence, which is at the same time symbolic, gender and homophobic.

Thus, the symbolic facet of homophobic violence is strongly articulated gender violence6, it is motivated by intolerance to what is understood or recognized as noncompliance with the order man / male, woman / female.


The social world through your order imposes a scheme of perception that is recognized as a natural categorization between two groups of people, delimited by a rigid boundary imposed by the binary paradigm. This model rejects the existence of legitimate public and a multiplicity of gender and sexuality expressions. To homosexuals it argues then the discretion or the concealment that they are ordinarily obliged to impose. Thus, the homosexual applies to himself the categories of perception of the dominator, which makes you feel now ashamed and frightened face the possibility of being rumbled, and now, desirous of being recognized by peers.

The application of this paradigm in the field of women's health may contribute to the cognitive construction about lesbians among its staff, nurses and doctors, has negative connotations and thus are prone to the development of related practices. It is recognized that in this field, the position occupied by these agents, guarantees them possibilities for the exercise of the power to levy and even inculcating, based on tacit recognition of a specific technical competence.

The discriminatory procedures need to be analyzed in the light of human rights, with a view to protecting the health and sexual and reproductive choices of people. Sexual health cannot be conceived by health professionals, from principles of personal moral, religious or other, who recognize a single model of sexuality considered healthy, normal. To improve the quality of health care, on the contrary, it is essential to develop affirmative actions by freedom of sexual expression.

Laws or policies will not suffice if no transformation of mentalities and practices, hence the structuring role that acquire shares that promote discussion of these issues, motivate individual and collective reflection and contribute to overcoming and eliminating any prejudicial treatment.


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Direitos autorais 2014 Luciane Marques de Araujo, Lucia Helena Garcia Penna

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