Abstract
In Brazil, the inclusion of minorities and the most vulnerable members of the population in the health service is still a challenge for health planners. This study analyzed the perception of men who have sex with men (MSM) treated in health units with the onset of a sexually transmitted disease (STD). It consists of qualitative research involving 21 MSM, contacted in a non-governmental organization (NGO) and in the Testing and Counseling Center (TCC) in Fortaleza, Ceará, Brazil. The data were collected during two periods: from February until May 2007 and from September until October 2008 by using focused interview, and were organized by subject matter according to the content analysis technique of Bardin. The references to the theoretical concepts of the symbolic violence by Bourdieu and stigma by Goffman were the foundation for the analysis. The results indicate that MSM experienced situations of symbolic violence and avoided seeking primary health care service fearing prejudice and being stigmatized. Even when they sought these services, they tended to demonstrate masculine behavior in order to not be indentified as to their sexual orientation. We concluded that MSM feel excluded and discriminated against in the primary health care service. More studies related to this subject matter are needed to help implement health care policies facilitating the inclusion of and to welcome this group of the population into the general health care service.
Introduction
I
Homosexuals have conquered their space socially in many ways; however, much must be done to recognize their right to health care without suffering any type of discrimination or rejection. It is a challenge to include people vulnerable to sexually transmitted diseases (STDs) and HIV/AIDS as well as discovering the best way to guarantee this segment of the population access to treatment. The inclusion of groups and minorities considered vulnerable in the health service is a challenge and research in this area is still initial, yet positive. 3 This challenge is greater when experienced by homosexuals, a group generally excluded from primary health care.
When homosexuals with STDs need access to the health service, they feel intimidated. 4 They generally have great difficulty obtaining treatment, which may be why they tend to look to private pharmacies for treatment, as usually occurs, for example, with people with STDs. 5
STDs are diseases very prevalent in the general population. Treatment for carriers, as well as defining specific prevention strategies are necessary and urgent. If not managed properly, STDs can lead to a series of complications, or in extreme cases, even death. STD treatment should deal with syndrome management; the main objective is immediately breaking the transmission chain. 6 The control of STDs requires effective care and guaranteed access for segments of the population considered vulnerable, among them MSM.
Moreover, in Brazil, attention to the health of homosexual communities has focused for many years only on HIV/AIDS. Specialized services were implemented that focused on treatment of homosexuals with the HIV virus, to the detriment of other health problems, including STDs, also common in this segment of the population. One reason for this is the social repercussions of the AIDS epidemic among MSM, which stigmatized them and deemed them responsible for the propagation of the disease. 7
When MSM need treatment in a primary health service unit, they encounter many obstacles. At this treatment level, many questions regarding personal behavior and diseases cause symbolic and practical problems. The relationship between homosexuals and health professionals is key for inclusion in the treatment program for STDs, as well as for understanding the disease itself. 8,9 In these situations, homosexuals seem to look for those services that are specifically aimed at the gay, lesbian, bisexual, and transgender (GLBT) communities because confidence in the professionals and a guarantee of anonymity are important factors when deciding to seek these services.
In primary health care services, homosexuals are generally subject to restrictions, discrimination, unwilling professionals, and substandard treatment. This occurs because these units do not offer a welcome environment and the professionals are not capable of working with this clientele, even though health planners are historically worried about this social segment. 10
Based on these facts, the objective of this study was to analyze the perceptions of MSM with STDs regarding treatment in health units in the city of Fortaleza, Ceará, Brazil related to stigma and symbolic violence.
Theoretical Concepts
Our theoretical concept analysis of the relationships between caregivers and MSM was based on that of Pierre Bourdieu with views that complement those of Erving Goffman. The first author was chosen for the importance of his theory, which is not often used in the health area even though the symbolic violence concept is widely used by French and Brazilian scholars in, among others, the educational setting. 11 This concept transmits the values of social domination and social hierarchy, reproducing symbolic powers such as school, family, media, and many others. They are natural and incorporated, not only by their subjects, but also by institutional, social, and collective rules as well. From this not historical naturalization, symbolic power can freely and almost unconsciously exercise a violence that exerts a prereflective obedience from the dominated, which many times is not clearly manifested in the most diverse social situations.
The concept of stigma has received increasing attention and become central in discussions about diseases and services all over the world, especially the health systems. This attention has generated sophisticated analysis boards, in which the concept's explicative capacity is valued along with its possibilities. 12,13 Stigma represents a special relationship “between the attribute and the stereotype,” considering that the attribute places a profound discredit to who owns it, for the stereotype is rooted profoundly in the thought processes of social agents. 14
According to Goffman, 14 the marks and the signs that stigmatize individuals have a central factor for the most diverse everyday interactions. The body is the central vehicle and fundamental as a visible stigma transporter or as the potential attribute that can cause a powerful social discredit. In general, however, the attribute is only negative in places where the socially constructed stereotyping is extremely negative and constitutes for us a symbolic violence. In social areas where people do not consider that attribute a stereotype it leads to discredit; the attribute neither attracts nor reproduces a structural violence based on discrimination.
For homosexuals, if the stigma is not visible, covering up of the condition impedes a genuine relationship, for the fear of being “discovered” generates mistrust. This fact impedes a contextual and adequate treatment to fulfill the needs of both the patient and the health policies goals suggested by the health system especially for this group.
Therefore, those who are stigmatized are predestined to manage an unbelievable identity or take it on. Social condemnation many times takes on a nonexplicit but powerful violence. This management becomes more of a social ability for the stigmatized person to perceive or imagine he perceives the nuances of repulsive behavior in personal interactions. They start to hide their face, change their speech, their posture, and their wardrobe, as a way of avoiding being stigmatized. In other words, “they stop considering themselves a common, total creature, reducing themselves to a damaged and diminished person.” 14
We share the idea that social interaction occurs in a symbolic framework, made by all of society, and therefore we believe that a fundamental approach—and extremely relevant one—is that of Bourdieu in his work, i.e., the concept of symbolic violence. 15 This concept seems to have structural characteristics of the social group that make stigma (or any other process of disqualification of social distinction) takes on a “natural” position and “naturalized” in the social dynamic. In this way, the relationships between the individuals are not symmetric or equal, but determined by asymmetric and different levels, both concrete and symbolic. Objectively, the leadership positions, employment, and the different social micro-powers are unequally distributed in society. Subjectively, in the same way, the symbolic and mental structures present themselves to the “social actors” as socially established and hierarchal. The categories of treatment in a social reality are incorporated by social agents in many ways, which means that people judge and evaluate others according to criteria shared by groups in society.
Therefore, during a long socialization process, the hierarchal and social domination is incorporated in the mental structures actively mobilized by social relationships. The differences and hierarchies not perceived as such, nonverbal or not explicit, are incorporated in the working social structure. In this case, the health system ends up performing violence considered “normal,” because it is done without thinking by these individuals. This type of not unmasking the hidden structures in the institutions and the people that work in them is a never-ending source of the violence that is part of our everyday lives. In this way, symbolic violence takes on the meaning presented by Bourdieu, a “violence that extorts submission, which is not perceived as such based on ‘collective expectation,’ instilled in social beliefs.” 15 Symbolic violence is the practical effect of stigma that weighs heavily on these groups that have external markings that are not legitimate and are condemnable, as pointed out by Goffman.
This violence is the result of an economic, a social, and a symbolic dominance among groups and offers a power that many times is transformed into symbolic capital: an ability to find people who accept dominance and submit themselves in an “unreflective” way to the actions of symbolic violence.
In this mental and social framework, in an allusion to the metaphor so important to symbolic interactionism that we could name stage or scenario, the interactions happen and the internal values comes into play. This scenario previously constructed predisposes the social agents to react in a prereflexive way according to an arbitrary social framework deeply incorporated in individuals. Face to face with a stigma factor according to Goffman's ideas, the social structures play a role and interfere with the social interactions, therefore being governed by the participants and altered, however without being completely voluntary and “free.”
For this reason, we valued both concepts in our research because homosexuality, along with STDs, generates great stigma that then represents a breakdown in social interactions. This stigma plays an important role of catalyst for symbolic violence. In summary, the internalization of the social structure on the internal psychic function reproduces an unequal and violent relationship on the everyday social interaction, but it is invisible, in a way, because it is structural. 16,17
Methodology
We used a qualitative approach that sought to evaluate the most subjective and internalized social aspects of MSM when seeking treatment for an STD in the health care service.
The qualitative methodology was chosen because it can bring forth sensitive questions related to MSM perceptions of the health care services, especially primary care. We initially found that MSM were significantly underrepresented in the health units and difficult to contact in these locations, making the qualitative methodology the most adequate to understand the phenomenon.
The study was done in Fortaleza, the capital city of the state of Ceará, located in northeast Brazil, in which health care is provided by the Brazilian National Health System, called Unified Health System (Sistema Único de Saúde; SUS). The health system was made possible due to social movements in Brazil and created by a federal law added to the Federal Constitution in 1988. The Unified Health System seeks to offer the entire Brazilian population access to the public health care service. In Fortaleza this service consists of a hierarchal network of 1712 health units, including the public and private services as well as laboratories and blood bank.
In primary care, these services are provided through the Family Health Program (PSF) of the Unified Health System, which has these fundamental principles: holistic, quality, equality, and social participation. The clientele is limited, making it possible for the family health staff to bond with the patients, establishing coresponsibility and compromise between the professionals and the community. Their objective is to provide the best resolute care.
Originally, the study was to be field work in the STD reference units; however, because of the male homosexual's difficulty accessing these services, the research locations had to be modified. The option was to look for participants in other institutions: a non-governmental organization (NGO) and the Testing and Counseling Center (TCC). These social institutions historically developed a different relationship with the study group, in which welcoming, easily accessible, and prompt treatment prevail.
The TCC treated on an average of 300 patients per month. It is a service associated with the public Unified Health System that offers examinations to detect syphilis, HIV, hepatitis B and hepatitis C. It offers STD/HIV/AIDS counseling and provides condoms. These services are places to develop new health education technologies, involving an interdisciplinary staff providing complete care. The staff generally tries to maintain an interpersonal relationship with the patients to gather information through communication, listening, and emotional support. The NGO has as its mission the fight for human rights for the GLBT population and to maintain projects aimed at the prevention of STD/HIV/AIDS.
The data were compiled during two periods: from February until May 2007 and from September until October 2008. The second period was used to increase the sample. The sample comprised 21 MSM, 18 years old and older, who were HIV positive or presented with STD/HIV at the time of the interview and who did not have a private health care plan. All of them would have to have a confirmed clinical or laboratory diagnosis. There were many difficulties in contacting MSM at the NGO and the TCC. However, the 21 participants were considered satisfactory due to the repetitiveness and similarities found in those interviewed, causing data saturation. We used a focused interview with Merton's perspective, with closed questions and open subject matter. 18 This method offers the participants more freedom of expression when asked personal questions and allows more details regarding the subject matter. The interview encompassed various social demographics: information regarding the STD, where and how the treatment occurred, and the study's main question related to the MSM perceptions of the health care service treatment. The question sought to identify the interpersonal relationships, stigma, prejudices, and the service's availability to meet the health care demands of this population.
The compiled interview data was organized, explored, read, and reread with the intent of finding the most recurrent and basic elements of the participants' discourses, disclosing hidden content, and establishing a bond between these findings and the research's theoretic references.
The interviews were divided into groups identifying their similarities and their divergences. Later the data were organized into two themes: symbolic violence and stigma as encumbrances for MSM to access the health care service and the health service as a place linked to symbolic violence.
We considered the content of the testimonial interviews significantly unique. The objective was to discover the communication nucleus which frequently appeared is significant for the chosen analytical objective. 19 Symbolic violence and stigma were the guidelines to analyze the data and led the procedures for the thematic discussion.
The research received the approval of the ethics and research committee of the University of Fortaleza. The participants signed a free and open consent form, guaranteeing content privacy, anonymity, and the option of stopping if they wished.
Results and Discussion
The research included 21 participants ages 21 to 50 (average age, 25.9; standard deviation, 5.34). Their academic history varied from unfinished elementary school to college graduates. At the time, 17 participants were working and had an income that varied from below the minimum salary, 5 earned minimum wages, while 4 had no income.
Nine interviews were held at the NGO and 12 were held at the TCC. Five of the participants were HIV positive, 9 said they had or have had gonorrhea, 5, syphilis, 3, genital herpes, 7, genital warts (HPV), and 1 with hepatitis B. We observed that some had more than one STD.
Symbolic violence and stigma as encumbrances for MSM accessing the health service
This category presents the experiences that MSM having a STD had while they looked for the health care service. Practically all these participants (17) referred to the fact that they sought specialized treatment services whenever they showed some sign or symptom of STD. They claim that in these health care units there are defined strategies and capable professionals which provide welcome and humane care.
I do not go to the health care units near my house; I go to the reference center right away. There they respect the person. The people are prepared to receive this type of person, with this type of problem; they are capable people that are prepared to care.
I did not go to the health care unit near my house. I go directly to the reference center. I go there because I will be well received, well treated, and people will calm me down.
The participants perceived differences between the welcome at the STD reference center and the treatment at the primary health care units. This situation compromises the quality of the relationship with the health professionals and consequently the search for the service. Many feel discriminated against before seeking the health service, which is a consequence of the prejudice behavior Brazilian society.
It was a little difficult to arrive at the health care unit, because I am homosexual. There was that prejudice. He is gay, he has AIDS …
I do not go to the health unit for treatment. There everybody knows I am gay. When I have a problem with a venereal disease, I do not go there, I do not go because I do not trust them, I think they will mock me.
Those HIV-positive patients who were found in the reference hospital for treatment of HIV/AIDS or another STD had their follow-up treatment eased by an internal reference mechanism among the specialized hospital professionals. We perceive from the testimonials that follow that these units give special care to HIV-positive patients with other STDs.
I told my doctor I had an STD and he sent me to an infectious disease doctor who treats STDs … It was easy since I do my HIV treatment at that hospital. Because if I was HIV negative and went there now, it would not be easy, my friend. That I can assure you. (HIV positive).
I had an STD and I spoke to my doctor. He sent for follow-up treatment in the same hospital. When I left the ambulatory, I made an appointment with the doctor, I waited a little while and she took care of me. (HIV positive).
When a person does not have the HIV virus and has an STD, an appointment is more difficult. The initial barrier is related to stigma and symbolic violence that they experience. The organization of the reference network and counter-reference is a challenge for the Unified Health System to implement effectively. This tends to worsen with STD patients because they avoid the care health service due to a feeling of discrimination.
To break the STD transmission chain, guaranteed access to health care services is one of the fundamental requirements. Therefore, it is of great urgency that professionals be trained to welcome the specific needs of homosexuals and create strategies that make access to the care easier for them, because early treatment is extremely necessary.
We also perceived an appeal of the social network was a key factor for the participants to use the health care service. For example, having a relative or a friend working at the unit eased the trauma felt in the different sectors of the unit:
It was easy, because my sister works at the unit. I called her and she set an appointment for me to go. I did not wait, did not get in line or anything.
I spoke to my friend, then she had me wait for the doctor to see me. She spoke to him, then she sent me to see the doctor.
We noticed that on a daily basis, MSM with STDs had difficulty accessing the health care system for a variety of problems. In reality, these problems are not exclusive of homosexuals, considering it is also a structural and organizational condition of the system. Another study of men with STDs in Fortaleza, Ceará, Brazil also found the access difficult. 20
It is not easy because you always have to look for a public health care unit, it is complicated. You have to go before daybreak, arrive early, to get an appointment number.
It was difficult because of the hour. You have to leave at 5.00
What is the use of going to the health care unit if there is no medicine there to treat the disease? A person who earns a minimum salary cannot afford to buy it. That keeps the client away from the unit.
The unit's pharmacy never had the medicine … many times I went there and they did not have the medicine … I had to buy it and it is very expensive.
People with STDs are ashamed and afraid to suffer discrimination. When the homosexuals look for primary health care units, the care is limited to follow-up at a specialized service at this care level. Along with the problem of lack of medications, there is also a failure to supply an adequate number of condoms and an insufficient number of capable professionals to welcome and counsel the STD patients. This reduces the presence of these patients and strengthens the feeling of stigma and symbolic violence. Access to the health care service is a problem that needs to be confronted by the health leaders and competent organizations.
The health service as a place to break down stigma and symbolic violence
This section reflects on the role the health service plays in breaking down symbolic violence and stigma perceived and experienced by MSM. Culturally, STD/HIV/AIDS patients and homosexuals frequently experience situations of prejudice in society. It can be stated that the burden of stigma and the constrictions of symbolic violence are more intensive among MSM with STD/HIV/AIDS. Even when they are not verbally discriminated against, they are in places where gestures, postures, and nonverbal offenses show the power of a violence that is manifested in a symbolic way according to what is considered legitimate or not legitimate in society. Symbolic violence is the practical effect of stigma that burdens these groups, having external marks for being part of what is illegitimate or condemnable.
Among the participants of this research, we noticed the interference of cultural questions breaking down a prejudice posture of health professionals especially related to sexuality and homosexuality as illustrated in the following:
When I sought a proctologist to do routine exams … entering the office … I was treated in a way as if … he wanted to embarrass me, you know?
I felt strange, because many people were looking at me like this: a gay in the STD room, and I saw some people talking and looking at me. I could tell they were talking and looking at me out the corner of their eyes.
They kept looking. Looking and mocking, looking as if I was insignificant. I felt humiliated because even though I am homosexual, I am a person, I am a human being. It is complicated, you see people looking at you and judging you without knowing what you are really doing there. Wondering if you have or do not have a disease, if you are a bad person or not, because being homosexual is not … it is something we were born with.
The participants stated in the interviews that not looking like a homosexual facilitated social interaction. This factor reinforces the hypothesis of their suffering prejudice and discrimination.
For me it was not difficult, because I am not feminine looking.
It was and was not so difficult, because by my appearance you cannot tell I am homosexual, that I am gay.
I do not usually say I am gay, because in my opinion people like to mock. I do not appear to be gay. I am a normal person.
The fact that they do not appear gay and consequently omit this information brings up an important situation when treating MSM in the health service, omitting important information related to sexual behavior. A study made in Brazil with MSM21 showed that homosexual identity is linked by characteristics that seek to distinguish the subgroups among themselves, by social and sexual behavior. This discrimination follows a logical classification and many times a hierarchy of the individuals within the social space, as Bourdieu demonstrates well. 22
Open relationships, understanding, and acceptance of sexual orientation of the health care patients are necessary for direct social interaction during treatment. The elucidation of internalized stigma by the individuals becomes the tonic of day to day relationships at the health care units. It is a constant source of adaptive efforts and negotiation to adopt preventative measures.
The same study with MSM showed that many implemented strategies for the individuals appear as elaborate and complex forms of personal identity and management of body appearance. Homosexuals define themselves in many ways and according to a variety of notions depending on subjective and physical characteristics. 21
Therefore, an apparent homogeneousness hides an infinitive number of self-definitions that seek to diminish the role of stigma. This ability can take the stigmatized, to the limit of self-exclusion, to foresee the discriminatory process by which they can imagine or anticipate what will go on in the health care units and the health care services.
The MSM with STDs experience many difficulties accessing the health service, a situation broken down into stigma and symbolic violence to which they are submitted. Those who referred to easy access used the social capital, for example, being a relative or a friend of a professional working at the unit, facilitated their access to the service. A long wait to be treated, difficulty traveling, and a limited number of appointments per day were also found to be difficulties and deserve special attention by authorities to create health policies in order to solve the treatment and access barriers.
Thus, there is a need to identify inclusion strategies for homosexuals in the health care programs and services, specially the primary care. The organizations responsible for the health care policies should promote a permanent educational process with professionals looking to implement adequate and affective treatment for this clientele.
Other studies should be done regarding treatment and access for homosexual people in the health care service with the objective of providing information to implement health care policies that welcome, diminish the stigma, facilitate diagnosis and treatment of STDs, as well as strengthening educational strategies and promotion of e a healthy lifestyle.
It is worth pointing out that this study could benefit from the theoretical contributions of Pierre Bourdieu, specially his discussions of the sociology of the body, as well as, his concept of symbolic violence. 23 This subject matter appears to have been explored very little regarding access to the health services and also the inclusion into society. New efforts are urgently needed since homosexuals need to feel welcome and receive quality care at all levels of health care, within a social space where stereotyping and discrimination do not prevail.
Footnotes
Acknowledgments
Our most sincere thanks to: the president of the NGO who allowed access to the participants that were interviewed; the TCC staff who graciously permitted the interviewers to enter the field of study, especially Verônica Linhares and Fátima Salgueiro, social workers, who contributed to the progress of the study; and all of the participants in the project.
Maria Alix Leite Araújo participated in the elaboration of the project, analyzed the data, wrote and revised the article's final version. Miguel Ângelo Montagner discussed the project from the theoretical perspectives of Bourdieu and Goffman, analyzed the data, wrote, and revised the article's final version. Raimunda Magalhães da Silva participated in the project objectives and data collection as well as the final version. Fagner Liberato Lopes e Maria Michele de Freitas participated in the elaboration of the initial research project, the collection of the data, and the initial version of the text.
Author Disclosure Statement
No competing financial interests exist.