Homosexual experiences of adolescents: considerations for healthcare

Abstracts

We aimed to ascertain the meanings of homosexual relationships among adolescents, in view of contexts of vulnerability that involve exercising sexuality in a homophobic society. We conducted interviews with nine male and four female adolescents who sought healthcare attendance and reported having homosexual experiences. For some of the boys, the homosexual experience occurred circumstantially, due to curiosity and experimentation; for others, it was associated with prostitution. For most of them, it was related to self-reported homosexual identity. Among the girls, two meanings stood out: homosexual activity associated with love and as a possible reaction to sexual violence suffered before the start of the homosexual experience. All the interviewees said that they had never been asked or guided about homosexuality at healthcare services. This study shows that there is a need for a comprehensive healthcare policy for this population, whose sexuality is different from the hegemonic pattern of society.

Adolescence; Homosexuality; Sexual and reproductive rights; Homophobia; Sexual violence

Objetivamos conhecer significados das práticas homoafetivas de adolescentes, tendo em vista contextos de vulnerabilidade que envolvem o exercício da sexualidade numa sociedade homofóbica. Realizamos entrevistas com nove rapazes e quatro moças que procuraram atendimento em saúde e relataram experiência homossexual. Para alguns rapazes, a experiência homossexual ocorreu de forma circunstancial, por curiosidade e experimentação; para outros, esteve associada à prostituição, e, para a maioria, relacionou-se à identidade homossexual autodeclarada. Nas moças, dois significados sobressaíram: a atividade homossexual associada ao amor e como possível reação à violência sexual sofrida antes do início da experiência homossexual. Todos os entrevistados revelaram nunca terem sido perguntados ou orientados acerca de homossexualidade nos serviços de saúde. O estudo evidencia a necessidade de uma política de atenção integral à saúde deste público, cuja sexualidade é diversa do padrão hegemônico da sociedade.

Adolescência; Homossexualidade; Direitos sexuais e reprodutivos; Homofobia; Violência sexual

Nuestro objetivo fue conocer los significados de las prácticas homoafectivas de adolescentes, llevando en consideración contextos de vulnerabilidad que envuelven el ejercicio de la sexualidad en una sociedad homofóbica. Realizamos entrevistas con nueve muchachos y cuatro muchachas que buscaron atención de salud y relataron la experiencia homosexual. Para algunos muchachos, la experiencia homosexual se realizó de forma circunstancial, por curiosidad y como experiencia; para otros, estuvo vinculada a la prostitución y para la mayoría se relacionó con la identidad homosexual auto-declarada. En las muchachas se destacaron dos significados: la actividad homosexual asociada al amor y como posible reacción a la violencia sexual sufrida antes del inicio de la experiencia homosexual. Todos los entrevistados revelaron que nunca nadie les había preguntado u orientado sobre la homosexualidad en los servicios de salud. El estudio muestra la necesidad de una política de atención total a la salud de este público, cuya sexualidad es diferente del estándar hegemónico de la sociedad.

Adolescencia; Homosexualidad; Derechos sexuales y reproductivos; Homofobia; Violencia sexual

Introduction

Adolescence is an age of experimentation in which teens get to know their own erotic body whose boundaries reflect multiple social norms. The majority of people have their first sexual experience during adolescence and the average age at which this event occurs has dropped in both sexes.

With regard to health, adolescents who engage in homosexual behavior are generally more vulnerable due to various individual, social and programmatic factors. This segment of society is less likely to engage in self-care behavior and more likely to suffer violence, and health care services do not take into account sexual diversity¹. In this respect, it is important to reflect on the development of sexuality in order to meet the broad spectrum of demands for sexual and reproductive health care stemming from adolescent homosexuals.

The current dynamics of the AIDS epidemic involves an increase in the number of cases among young men who have sex with men (YMSM), in contrast to other age groups where rates are declining. Prevalence rates of STD and AIDS among sexually active groups are highest among men who have sex with men (MSM)², and YMSM tend to initiate sexual activities at an earlier age and have a greater number of partners than heterossexuals³. Beloqui⁴ highlights that genital-anal contact is anatomically more traumatic and this increases vulnerability to STD.

The health needs of female adolescents who have sex with other women are different to those of heterosexuals and generally go unnoticed by the health services ⁵. Furthermore, depression and suicidal behavior is more common among homosexuals than in heterossexuals^{6,7, 8}.

Efforts have been made by the health field to understand the homoerotic trajectories of adolescents and the different forms of discrimination that make this group more vulnerable in terms of health. Guaranteeing sexual and reproductive health rights within health services requires a comprehensive and impartial understanding of the technical and human aspects of sexuality as a vital process for every individual. Studies show that young gays and lesbians often decline to seek health services for fear of discrimination or of revealing their sexual orientation, possibly showing that health professionals lack the capacity provide care that considers sexual diversity and the specific characteristics of adolescents who engage in homosexual behavior⁹.

This investigation was motivated by the clinical experiences of adolescent care in a primary health care setting, where we observed the difficulties faced by youth in expressing their health problems related to the fear of revealing their homosexual behavior. Furthermore, given the high prevalence of STDs in adolescent male prostitutes¹⁰and the vulnerability context related to homosexual activity among both male and females, we aimed to obtain an understanding of homosexual behavior among adolescents seeking health services.

Method

Given the nature of the object of study, we opted to use semistructured interviews, a qualitative method designed to gain a deeper understanding of the meaning of phenomena. The target audience was made up of adolescents of both sexes seeking treatment in a primary health care facility for this group who had mentioned homosexual experiences when reporting his/her medical history. The facility belongs to a public university, and is a center of reference for the care of adolescents aged between 12 and 19 years at the primary, secondary and tertiary level. At the primary level, the facility provides treatment for random cases or those referred from other health facilities. The majority of patients who seek treatment at this facility are from a less privileged socioeconomic background. Medical consultations are carried out respecting the adolescent’s rights to privacy, autonomy, confidentiality and secrecy.

Field work

Interviews were conducted between 2004 and 2005. We used convenience sampling adopting the following inclusion criterion: mention by the adolescent during the medical consultation that he/she had had at least one sexual experience with somebody from the same sex. It is important to highlight the difficulties involved in establishing this research sample due to the fact that adolescents who do not accept their own feelings and sexual orientation have difficulty in revealing their homosexual experiences. Eligible adolescents were not invited to participate a priori, since it was our understanding that there could be an association between sexual identity and the health problem for which he/she was seeking care. Therefore, in order to protect and avoid influencing the adolescent, the invite was made only after a second meeting, and thus after having built a certain bond with the patient. One person refused to participate and two adolescents who accepted the invite did not turn up on the day scheduled to conduct the interview. As result of 18 months of field work, 14 adolescents participated in the study; nine male and five female. The participants were interviewed in the health facility.

Data collection and recording procedures

Interviews were conducted following an interview guide that included questions related to the following aspects: personal details, family relationships, history of violence, suicidal ideation, sexual experiences, and health care. The interviews lasted an average of 70 minutes and were recorded and fully transcribed. Notes were made immediately after the interview to record the interviewer’s impressions and relevant information given before the start of recording.

Data analysis

The data was analyzed based on the principles ofhermeneutic-dialectic analysis set out by Minayo¹¹ and according to the following steps: reading and careful rereading of textual data to obtain an overall vision and understanding of the main content; classification of the accounts and cutting and pasting of text according to the categories that emerged from the data, and based the study objectives; identification of the meaning assigned by the subjects to the questions raised seeking to understand the internal reasoning employed by this group; comparison with the study's frame of reference and literature; interpretative synthesis using triangulation¹² by a multidisciplinary team made up of a doctor, psychologist and social worker.

Ethical aspects

This study was conducted in accordance with the norms of the National Health Council Resolution 196/90 and approved by the Research Ethics Committee of the Pedro Ernesto University Hospital of the Rio de Janeiro State University (10/10/2003, application number 811). Furthermore, all interviewees were guaranteed continued health care, thus respecting not only the ethical principles for research involving human subjects, but also meeting the health demands arising throughout the investigation.

Results and Discussion

The age of the interviewees ranged from 15 to 19 years and the first homosexual experience occurred between the age of eight and 18 years. The majority of adolescents were more than two years behind in their schooling, and all interviewees had been exposed to violence in and outside the family, including personal insults, physical aggression, manifestations of homophobia, understood as attitudes that express hate and aversion towards homosexuals. In a study of American homosexual adolescents, Harrison¹³ found an association between openly admitting to being gay and exposure to violence. However, the type of violence experienced by young homosexuals differs depending on whether they are male or female, and has results that can affect their identity and intersubjective relations. Male adolescents mentioned episodes of homophobic violence, while girls were victims of gender-based violence.

Twelve of the 14 interviewees mentioned suicidal ideation or attempted suicide and two of the boys who sought STD treatment were HIV-positive. With regard to sexual orientation, only 64.3% of the interviewees were self-declared homosexuals.

With regard to health care, none of the interviewees had been previously asked by health professionals about homosexual experiences or had received guidance on the issue. However, none of the adolescents mentioned that they had been discriminated due to their sexual orientation. Apparently health professionals reproduce the "heteronormative" view common to almost all cultures¹⁴, acting as if everyone was heterosexual.

The analysis of the boys’ accounts showed that they assigned three distinct meanings to homosexual experiences. For some, the homosexual experience depended on particular circumstances based on curiosity-driven experimentation, while for others it was associated with prostitution. However, for the majority, the experience was a matter of self-declared sexual orientation. The girls’ accounts revealed different experiences, with two meanings of homosexual behavior standing out: homosexual activity associated with loving affection and as a possible reaction to the sexual violence suffered before initiating homosexual experiences.

Casual homosexual experiences

Casual sexual activity and experimentation were mentioned as random occurrences in which the adolescents found themselves involuntarily involved in situations that culminated in homosexual contact. These adolescents showed a feeling of guilt regarding these encounters, despite the fact that such sexual experiences are part of the development of sexuality and did not define their sexual orientation. This feeling is probably influenced by homophobia, which makes them reject the possibility of considering themselves homosexual or bisexual. The sociocultural context governed by compulsory heteronormativity, a social norm in which heterosexuality is compulsory, constructs a necessary and coherent relationship between gender identity, desires and sexual behavior. Heteronormativity defines the social conventions that determine gender and sexuality, marked by an asymmetry between male and female¹⁵where those who do not fit the norm feel inadequate.

The following is an extract from one of the interviewees' accounts:

"I was ten going on eleven. All I know is that it was impulsive. We were all the same age. It began as an exchange of affection, like one of their games and, before we knew it, we were having a relation".

"It was the only time. He started to stroke me, even though I didn’t want it. And, I just let it happen. I tried it; but I didn’t like it".

Casual homosexual experiences during childhood and adolescence are part of the construction of sexual identity, which only acquires its final form generally at the end of adolescence. Comprehensive research about reproduction and the social trajectories of youth in Brazil conducted by Heilborn and Cols (2006) identified various forms of desire that go against heteronormative values¹⁶. Freud, in his essays on sexuality, published for the first time in 1920, raises an important aspect about the understanding of sexual object choice, which presupposes an "original" bisexuality in human beings and, furthermore, that it should be considered that adult sexual posture requires fluctuation and learning from both parts, considering the complexity and various possible subjective arrangements.

Homosexual experiences from prostitution

Another meaning assigned to the homosexual experiences of the boys relates to prostitution, which was observed in the accounts of both the adolescents that considered themselves heterosexual and those that were openly homosexual. In both cases, the justification for this practice was financial gain. The heterosexual adolescents however regret doing it, but do not feel any less ‘macho’. They mentioned being harassed by older men and were bitter about the hardship they have to suffer due to lack of money. We noted that the adolescents apparently consider it natural to engage in homosexual practices through prostitution, masking its inherent violence, not only in structural terms, but also the violence that results from the unequal power relationship between the perpetrator and the adolescent prostitute. It is important to note that male prostitution among male adolescents and young adults is recognized as an important factor that heightens vulnerability to HIV/AIDS¹⁸.

The behavior of these adolescents was forged through relations and by meanings of sexuality constructed throughout history and at different social levels that encompass macro-social and socio-historic issues and the specific aspects of interpersonal relationships. The subjectivity of these individuals and their conduct is strongly influenced by social determinants¹⁹.

Self-declared homosexual identity

The third meaning of homosexual experience mentioned by the majority of the male interviewees was associated with self-declared homosexual identity. The first homosexual experience of these adolescents was generally at a young age, during childhood or preadolescence and sometimes with partners who were a lot older. It is interesting to note that this early initiation into homosexual activity was not seen as abuse or sexual coercion, but as natural, since the homosexual sexual experience was "consented to/expected/desired." The sexual activity of these adolescents was intense and usually unprotected. Heilborn and Cols¹⁶ observed that the number of partners is much greater among male homosexuals/bisexuals than among women homosexuals/bisexuals. The male imperative makes having sexual relations practically compulsory, replicating the standard behavior of heterosexual men and showing that the affective and sexual trajectory of youth appears to be strongly structured by gender patterns. Furthermore, the vulnerability of these self-declared gay adolescents is aggravated by the perception of the masculinity of the other as a factor of attraction, which appears to represent an increased risk of contracting HIV, as shown by a study conducted with YMSM in the United States²⁰.

With respect to the construction of the homosexual identity, a large part of the interviewees had sexual relations with women, expressing the need to test their desires and be certain of their sexual orientation. During the construction of homosexual identity, initially the individual feels different to his/her peers of the same sex and age, without understanding why. He/she then goes through a confusing period in which any homosexual impulse is ignored. When he/she eventually decides to experiment contact with another person from the same sex he/she feels bad about not conforming to his/her family’s expectations and the hegemonic sexual norms imposed by society. Guilt related to internalized homophobia, which contributes to low self-esteem, was also evident²¹.

Sexual orientation is defined during adolescence. However, an individual’s perception of his/her sexual identity may occur before the first homosexual experience. It is beyond the scope of the present article to attempt to describe the complexities of the identification process. Suffice to say that it is lived by the subject as transgression, provoking feelings of strangeness when an individual becomes aware of homosexual desires. The conflicts disappear as the individual gradually comes to accept and recognize him/herself as homosexual. However, the discovery and admittance of homosexual feelings does not eliminate the suffering that results from the mismatch between his/her sexual orientation and that legitimized by society, as the following extracts exemplifies:

"What you are most likely to hear in this study is that the person doesn’t become gay. People are born that way, with it inside them. ... I repressed myself a lot before, you know? I was unhappy. There was that thing, you know, [I thought], is this abnormal"?

"I think that I have been interested in men since I was little. I have always seen myself as man-woman. I felt really alone when I was little. I was always slightly effeminate. Today, I accept myself more. I don’t act like an ET anymore. You know, an ET in the middle of a crowd, who no one recognizes".

In a study conducted with homosexual men, Nunan²² reports that all interviewees said that they were born homosexual; none of the interviewees stated that they had chosen to be homosexual. The first sexual relation of the majority of those interviewed by Nunan was with a woman, as a way of experimenting and being certain about their sexual orientation.

With respect to the sexual development of the adolescents interviewed by the present study, when telling us about their sexual history, some, paradoxically, mentioned their childhood experiences and associated being gay with the fact that they had been abused. They used a past marked by violence to justify the present, as the following extract shows:

"I had my first sexual relation when I was eight, with a man. I ended up liking it. This influenced my path, definitely. I did it with others and became more and more accustomed to it".

Homophobic violence has an impact on the life of these adolescents and limits their access to social protection, schooling and employment, resulting in lack of economic resources and leading to social marginalization, which often results in the need to resort to prostitution²³. Adolescent homosexuals are often pressured to hide their sexual identity as a mechanism to avoid rejection and hostility, aggravating the usual adolescent concerns during this phase of development and often causing problems¹³. Homophobia contributes to the adoption of high-risk sexual practices and can mean that adolescent gays isolate themselves²⁴ because they do not have the courage to reveal their sexual orientation^{25, 26}, only manifesting their sexual preferences to a limited few.

The health system is organized around the needs of the heterosexual population. Health professionals almost always assume that an adolescent is heterosexual, which makes it more difficult for the individual to reveal their real identity. Therefore, homosexual activity lacks legitimacy in society, which often forces homosexuals behind closed doors, thus reinforcing the moral degradation discourse and destroying self-esteem, hindering the adoption of safe sex practices, and often leading to alcohol and drug use²⁴. The adolescents interviewed by this study told of degrading treatment by the family when they revealed their sexual orientation such as humiliation and emotional abuse, and beatings, which in some cases led to fractures and permanent scares. Many gays under the age of 18 are thrown out of home and, having nowhere to live and no one to turn to, go into prostitution as male prostitutes or transvestites. Many, unable to stand the violence find that suicide is the only solution to free themselves from this suffering²⁷.

Homosexual activity related to loving affection

The main meaning assigned by the female interviewees to the homosexual experience related to the love they feel for their partners. With respect to the girls’ relationships, affection overrides sexual desire, following the hegemonic pattern of femininity associated with romantic love. The affectional bond predominates as the following extract shows:

"Before we have sex, it’s not about pleasure. We show the love we feel for each other, you know? Sex is like, normal. But, like, I lie down in bed with her, have sex with her, I have sex out of love, not out of pleasure".

Our findings are corroborated by the literature that shows that female homosexuality is quite different from male homosexuality when it comes to partners. For women, sex is associated with affection. The same cannot be said for men, who tend to have various sexual relations in the same day with strangers just for pleasure²⁸. Loyola²⁹ highlights that sexual pleasure for women is a slow process constructed with love. On the same line, Palma³⁰ suggests that female couples are characterized by intense companionship, with a strong emphasis on mutual emotional support. Sexuality does not have the same emphasis among lesbians that it does in gay men, since the choice of partners, even casual ones, is not made based on sexual attraction, but on love. This behavior follows the norms of a predominantly patriarchal and heteronormative society. Patterns of behavior, values, and gender norms throughout history are manifested and assimilated as natural, and are reflected in the affective and sexual relations and health of the subjects. Men and women are instigated to take on different roles, where love and affection is the prerogative of the female sex. Women have impregnated their bodies and subjectivity with the attributes of romantic love.

The association between homosexuality and love observed in the girls’ accounts was predominant not only in terms of sexual identity, but was also necessary for maintaining the integrity and unity of the subject. Some manifested symptoms of depression and suicidal thoughts in relation to the loss of the object of their love, which was unbearable for them

With respect to the homosexual partnerships of these adolescents, it is apparent that the relational structure served to replace a nuclear family that was lacking. Their stories demonstrate a desire to find a father or a mother: someone to care for them. The homosexual relationships came to satisfy this need and fill this emotional void. Therefore, the principal motive behind the homosexual choices of the girls apparently differs in essence to that of the boys. We can infer that suicidal ideation among gay men is more related to homophobia, while in women it is associated with the loss of the object of their love.

Homosexual activity associated with sexual victimization

Sexual violence mentioned by the girls was perpetrated by men from their family or social circle before their first homosexual experience. All belonged to dysfunctional families without one or both parents. The father figure painted by the girl’s stories was either unknown, or represented abandonment and rejection, resulting from a physically or emotionally absent father.

Some of the interviewees established a connection between the violence they experienced and their homosexual choices:

Gosh, I was interested in a person from the same sex as me...? I don’t know if it is because of the abuse I suffered, you know? But I prefer to be by the side of someone from the same sex as me. I feel safe. Being with a friend who is concerned with your well-being.

The above extract demonstrates the impact that absent mothers and fathers can have, showing the importance of the feeling of being taken care of in a homosexual relationship. The adolescent girls looked for older more experienced women, who probably play the male role of provider and protector in the relationship. However, their stories also suggest asymmetrical and unequal relationships in terms of sex, in much the same manner as male/female relationships.

Final considerations

This study shows that sexual behavior among homosexuals varies greatly. It is probable that the number of youth with homosexual tendencies is much greater than those involved with someone from the same sex, or those that embrace gay identity. Women tend to define their sexual orientation in terms of romantic behavior, while men emphasize desire and sexual behavoir³¹.

The care and treatment received by both the girls and boys interviewed by this study did not consider their sexual orientation, corroborating other studies that show that health professionals do not ask about and are often ignorant of the sexual tendencies of patients, presupposing that they are heterosexual, thus representing another form of violence experienced by this group and making it difficult for its members to express their needs^{32, 33}. These findings signal the need for actions to improve health services in order to deliver adequate services to these adolescents and guarantee the sexual and reproductive health rights of those individuals who do not fit into the social conventions determined by heteronormativity³⁴.

Various studies show that for an adolescent to reveal his/her sexual orientation during health care they need to be asked, and therefore health professionals need to show an open and welcoming attitude. This approach increases the possibilities of effective preventative and therapeutic interventions, including screening for HIV^{35,36, 37, 38}.

Lionço³⁹ highlights that health policies directed at the LGBT population must promote equity, and recognize and reflect about the vulnerability of this group, both in terms of human rights and, more specifically, sexual and reproductive health rights.

The spectrum of meanings assigned to homosexual experiences by the interviewees show that they live in a context of increased vulnerability in terms of health. Some suffer from a "synergy of vulnerabilities"²³ owing to oppression, marginalization and exposure to violence. It is therefore essential to identify and obtain an in-depth understanding of the particularities of sexual behavior among this group in order to effectively tackle diseases such as AIDS⁴⁰. It is important to emphasize the importance of stimulating a reflection about high-risk sexual practices among adolescents and young adults given their lack of awareness of the AIDS epidemic and the fact that the sexual activity of this group comes after the advent of the cocktail of antiretroviral drugs which has led to a change in the concept of the disease from fatal to chronic.

Finally, we would like to emphasize the need for a comprehensive health care policy that targets this group in order to meet the legitimate health demands of its members, which requires the acceptance and acknowledgement of the value of sexuality, regardless of the reproductive end.

Our study has certain limitations, since it relied on a random sample of adolescents receiving treatment a public health facility. The simple fact of being in the facility indicates that these youngsters were seeking help, thus revealing a certain degree of self-care. It could be said therefore that the interviewees were different to other homosexual adolescents in school and other social settings. Furthermore, the sample was restricted to adolescents from a less privileged socioeconomic background.

References

• ¹ Rios LF, Pimenta C, Brito I, Terto Júnior V, Parker R. Rumo à adultez: oportunidades e barreiras para a saúde sexual dos jovens brasileiros. Cad Cedes. 2002; 22(57):45-61.
• ² Ministério da Saúde. Departamento de DST, Aids e Hepatites Virais. Aids no Brasil [Internet]. Brasília (DF): MS; 2013 [acesso 2013 Maio 14]. Disponível em: http://www.aids.gov.br/pagina/aids-no-brasil
  » http://www.aids.gov.br/pagina/aids-no-brasil
• ³ Rios LF. Parcerias e práticas sexuais de jovens homossexuais no Rio de Janeiro. Cad Saude Publica. 2003; 19 Supl 2:S223-S32.
• ⁴ Beloqui JA. Risco relativo para aids de homens homo/bissexuais em relação aos heterossexuais. Rev Saude Publica. 2008; 42(3):437-42.
• ⁵ Almeida G. Argumentos em torno da possibilidade de infecção por DST e aids entre mulheres que se autodefinem como lésbicas. Physis. 2009; 19(2):301-31.
• ⁶ Teixeira-Filho FS, Rondini CA. Ideações e tentativas de suicídio em adolescentes com práticas sexuais hetero e homoeróticas. Saude Soc. 2012; 21(3):651-67.
• ⁷ Remafedi G. Adolescent homosexuality: dare we ask the question? Arch Pediatr Adolesc Med. 2006; 160(12):1303-4.
• ⁸ Remafedi G. Suicidality in a venue-based sample of young men who have sex with men. J Adolesc Health. 2002; 31(4):305-10.
• ⁹ Meckler GD, Elliott MN, Kanouse DE, Beals KP, Schuster MA. Nondisclosure of sexual orientation to a physician among a sample of gay, lesbian, and bisexual youth. Arch Pediatr Adolesc Med. 2006; 160(12):1248-54.
• ¹⁰ Taquette SR, Vilhena MM, Santos UPP, Barros MMV. Relatos de experiência homossexual em adolescentes masculinos. Cienc Saude Colet. 2005; 10(2):399-407.
• ¹¹ Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. São Paulo: Hucitec; 2006.
• ¹² Minayo MCS, Assis SG, Souza ER. Avaliação por triangulação de métodos. Rio de Janeiro: Editora Fiocruz; 2005.
• ¹³ Harrison TW. Adolescent homosexuality and concerns regarding disclosure. J School Health. 2003; 73(3):107-12.
• ¹⁴ Berg-Kelly K. Adolescent homosexuality: we need to learn more about causes and consequences. Acta Paediatr. 2003; 92(2):141-4.
• ¹⁵ Butler J. Problemas de gênero: feminismo e subversão da identidade. Rio de Janeiro: Civilização Brasileira; 2003.
• ¹⁶ Heilborn ML, Cabral CS. Trajetórias homo-bissexuais. In: Heilborn ML, Aquino EML, Bozon M, Knauth DR, organizadores. O aprendizado da sexualidade: reprodução e trajetórias sociais de jovens brasileiros. Rio de Janeiro: Garamond, Fiocruz; 2006. p. 361-97.
• ¹⁷ Freud S. Three essays on the theory of sexuality. In: Freud S, organizador. Complete works. Tomo II. 4a ed. Madrid: Biblioteca Nueva; 1981. p. 1169-284.
• ¹⁸ Parker R. A construção da solidariedade: aids, sexualidade e política no Brasil. Rio de Janeiro: Relume-Dumará; 1994.
• ¹⁹ Knauth DR, Heilborn ML, Bozon M, Aquino EML. Sexualidade juvenil: aportes para as políticas públicas. In: Heilborn ML, Aquino EML, Bozon M, Kanuth DR, organizadores. O aprendizado da sexualidade: reprodução e trajetórias sociais de jovens brasileiros. Rio de Janeiro: Garamond, Fiocruz; 2006. p. 399-417.
• ²⁰ Fields E, Bogart LM, Smith KC, Malebranche DJ, Ellen J, Schuster MA. HIV risk and perceptions of masculinity among young black men who have sex with men. J Adolesc Health. 2012; 50(3):296-303.
• ²¹ Blais M, Gervais J, Hebert M. Homofobia internalizada como mediador parcial do bullying homofóbico e autoestima entre jovens de minorias sexuais em Quebec (Canadá). Cienc Saude Colet. 2014; 19(3):727-35.
• ²² Nunan A. Homossexualidade: do preconceito aos padrões de consumo. Rio de Janeiro: Caravansarai; 2003.
• ²³ Parker R, Camargo Júnior KR. Pobreza e HIV/aids: aspectos antropológicos e sociológicos. Cad Saude Publica. 2000; 16 Supl1: S89-S102.
• ²⁴ Ortiz Hernandez L, Garcia Torres MI. Opresión internalizada y prácticas sexuales de riesgo en varones homo-y bi-sexuales de México. Rev Saude Publica. 2005; 39(6):956-64.
• ²⁵ Teixeira-Filho FS, Rondini CA, Bessa JC. Reflexões sobre homofobia e educação em escolas do interior paulista. Educ Pesqui. 2011; 37(4):725-41.
• ²⁶ Pocahy FA, Nardi HC. Saindo do armário e entrando em cena: juventudes, sexualidades e vulnerabilidade social. Rev Estud Fem. 2007; 15(1):45-66.
• ²⁷ Mott L. Os homossexuais: as vítimas principais da violência. In: Velho G, Alvito M, organizadores. Cidadania e violência: Ed. UFRJ; 1996. p. 99-146.
• ²⁸ Fry P, MacRae E. O que é homossexualidade? São Paulo: Abril Cultural, Brasiliense; 1985. (Coleção Primeiros Passos)
• ²⁹ Loyola MA. A sexualidade nas ciências humanas. Rio de Janeiro: EdUERJ; 1998.
• ³⁰ Palma YA, Levandowski DC. Vivências pessoais e familiares de homossexuais femininas. Psicol Estud. 2008; 13(4):771-9.
• ³¹ Savin-Williams RC, Cohen KM. Homoerotic development during childhood and adolescence. Child Adol Psychiatr Clin North Am. 2004; 13(3):529-49.
• ³² Barbosa RM, Facchini R. Acesso a cuidados relativos à saúde sexual entre mulheres que fazem sexo com mulheres em São Paulo, Brasil. Cad Saude Publica. 2009; 25 Supl 2:S291-S300.
• ³³ Valadão RC, Gomes R. A homossexualidade feminina no campo da saúde: da invisibilidade à violência. Physis. 2011; 21(4):1451-67.
• ³⁴ Vilhena MM, Taquette SR. Adolescência e homossexualidade: uma leitura psicanalítica. In: Malagutti W, Bergo AMA, organizadores. Adolescentes: uma abordagem multidisciplinar. São Paulo: Martinari; 2009. p. 353-67.
• ³⁵ Igartua K, Thombs BD, Burgus G, Montoro R. Concordance and discrepancy in sexual identity, attraction, and behavior among adolescents. J Adolesc Health. 2009; 45(6):602-8.
• ³⁶ Kipke MD, Kubicek K, Weiss G, Wong C, Lopez D, Iverson E, et al. The health and health behaviors of young men who have sex with men. J Adol Health. 2007; 40(4):342-50.
• ³⁷ Hoffman ND, Freeman K, Swann S. Healthcare preferences of lesbian, gay, bisexual, transgender and questioning youth. J Adolesc Health. 2009; 45(3):222-9.
• ³⁸ Silenzioa VMB, Dubersteina P, Tanga W, Lu N, Tu X, Homan CM. Connecting the invisible dots: reaching lesbian, gay, and bisexual adolescents and young adults at risk for suicide through online social networksstar. Soc Sci Med. 2009; 69(3):469-74.
• ³⁹ Lionço T. Que direito à saúde para a população GLBT? Considerando direitos humanos, sexuais e reprodutivos em busca da integralidade e da eqüidade. Saude Soc. 2008; 17(2):11-21.
• ⁴⁰ Bernstein KT, Liu KL, Begier EM, Koblin B, Karpati A, Murrill C. Same-sex attraction disclosure to health care providers among New York City men who have sex with men: implications for HIV testing approaches. Arch Int Med. 2008; 168(13):1458-64.

• Translated by James Allen

Publication Dates

• Publication in this collection
  21 Aug 2015
• Date of issue
  Oct-Dec 2015

History

• Received
  03 July 2014
• Accepted
  15 Mar 2015