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Acta Paulista de Enfermagem

On-line version ISSN 1982-0194

Acta paul. enferm. vol.30 no.4 São Paulo July/Aug. 2017

http://dx.doi.org/10.1590/1982-0194201700058 

Original Articles

Violence and vulnerability to HIV/Aids in young homosexuals and bisexuals

Hugo Fernandes1 

Eleonora Menicucci de Oliveira1 

Renato Nabas Ventura1 

Ana Lúcia de Moraes Horta1 

Celina Daspett1 

1Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brazil

Abstract

Objective

To know the perceptions of young people who identify themselves as homosexuals or bisexuals on experienced violence and identify possible correlations with vulnerability to HIV/Aids.

Methods

Descriptive study with a qualitative approach, using the social representation theory and the concept of vulnerability with thematic content analysis, carried out in the immunodeficiency disorder control center of a public university in the Southeast region of Brazil, which provided multidisciplinary care to HIV/Aids patients. Thirteen seroconverted young people aged between 13 and 24 years participated in the study. The selection criterion was men who identified themselves as homosexuals or bisexuals, according to terminology used in the Epidemiologic Bulletin on Sexually Transmitted Diseases and AIDS of the Brazilian Ministry of Health.

Results

Four thematic categories were found: “homophobia and bullying”, “sexual, domestic, and institutional violence”, “search for support”, and “love and passion”.

Conclusion

Young homosexuals and bisexuals experienced repeated situations of abuse throughout childhood and adolescence, perceiving sexual, domestic, and institutional violence as the most painful and difficult to confront, and which correlate to vulnerability to HIV/Aids.

Keywords Violence; Homosexuality; HIV; Young adult; Sex offenses; Sexual behavior

Introduction

Infection by the human immunodeficiency virus (HIV) has records of its historical series in Brazil since 1984. From the beginning of the epidemic up to the current days, significant epidemiological changes were found in the population affected. In the first decade, with little knowledge on HIV and Aids, adult homosexuals, injection drug users, and sex workers were the most prevalent, representing more than 70% of the notified cases. In mid-1990, the infection became common among heterosexual men and women with low income and education level. Subsequently, the elderly also became target of the HIV due to several factors, such as increase in longevity, lack of information, and personal values distinct from safe sex practices.(1,2)

Among children, notification cases were always increasing, especially associated with vertical transmission. However, as of 2009, a new change in the epidemiological profile of HIV/Aids was found. The notifications showed a significant increase among homosexual and bisexual men aged between 13 and 24 years. The number of notifications still remains in an increasing curve until the current year.(1) This aspect has caused surprise and concern in researchers, educators, activists, and healthcare professionals, such as nurses who provide care to these young people.(35) Concerns are especially directed towards vulnerability of this population, who, unlike the elderly and children, has knowledge and easy access to information on preventive measures to HIV/Aids.

Many researchers bring nuances in their studies, on the situations of violence in the lives of young people; however, without further deepening and leaving gaps on the association of violence with the vulnerability of young men who have sex with men.(37) Therefore, the following question emerges: “Does violence, in its different forms, make young homosexuals and bisexuals vulnerable to HIV/Aids?” Therefore, the objective of the authors of the present study was to know the perceptions of young people who identify themselves as homosexuals or bisexuals on experienced violence and identify possible correlations with vulnerability to HIV/Aids.

Methods

A descriptive study with a qualitative approach was carried out in the immunodeficiency disorder control center of a public university in the Southeast region of Brazil, which provides multidisciplinary care to HIV/Aids patients.

The social representation theory and the concept of vulnerability were used as theoretical-methodological framework. The first seeks knowledge originated from daily life to deal with a particular subject, making it familiar, in addition to seeking dimensions of the imaginary and affective, transcending dichotomy between cognition and emotion.(8) The second examines early speeches of vulnerability to HIV, understanding them and creating substrates to intervene on them in the three interdependent plans proposed: individual, social, and programmatic.(9)

The selection criterion was men who identified themselves as homosexuals or bisexuals, according to terminology used in the Epidemiologic Bulletin on Sexually Transmitted Diseases and AIDS of the Brazilian Ministry of Health. The studied immunodeficiency disorder control center had 22 eligible people; however, those who had cognitive impairment and were under the age of 18 at the time of the interviews were excluded, due to the need for consent signed by parents or legal guardians, who could not be aware of the minor’s sexual orientation, following recommendation of the research ethics committee of the institution.

Thirteen individuals participated in this study, presented with the letter “E” followed by numeral identification. Approaches and interviews were carried out individually in the nursing office, which was considered a private and safe place, by the first author, who had expertise in data collection, in addition to being an expert in nursing in infectious diseases. A semi-structured script was followed for data collection and the narratives were recorded in MP4, initiated with the guiding question: “If you suffered any kind of violence in childhood or adolescence (or still suffer), tell us what it was like (or is) and how you dealt (or deal) with this experience”. The interviews lasted from 29 minutes to 1 hour and 10 minutes. Subsequently, they were transcribed and analyzed through the content analysis technique, following stages of pre-analysis, examination of material, and treatment of results.(10)

The development of the present study met national and international ethical principles on research involving human beings and was approved by the research ethics committee of the Federal University of São Paulo, under protocol no. 1143/09.

Results

Of the participants interviewed, 11 identified themselves as homosexuals and two as bisexuals. There was a prevalence of white and brown young people with complete high school, diagnosed with HIV or Aids between one and four years, and with steady partners. None lived or worked close to the immunodeficiency disorder control center and all reported to prefer coming to this unit, exactly for not being located in their territory of social conviviality, even if there were specialized services near their home or workplace.

The results showed that the young men experienced several forms of violence in childhood and beginning of adolescence, which led to repercussions in aspects of their lives, such as well-being, interpersonal and family relationships, self-confidence, and self-protection. Four thematic categories emerged: “homophobia and bullying”, “sexual, domestic, and institutional violence”, “search for support”, and “love and passion”.

The thematic category “homophobia and bullying” showed experiences of prejudice during social relationships, especially in school and community where they were integrated. Situations of embarrassment and humiliation made these young men feel vulnerable and threatened in their physical and mental safety.

Repeated situations of swearing, personal insults and insults to their families, verbal and physical abuse, intimidation, threats, thefts, vandalism, and isolation were reported.

Jokes started at around sixth grade. I hated the boys. In the classroom, I only played with the girls, I was always far from the boys. Once, they surrounded me when we were leaving school, saying that they would give me a lesson to learn to be a man. My heart jumps just remembering this. Fortunately, the girls quickly called the inspector, and she stopped them and took me home. Even so, they followed us, swearing me. I almost quit school because of this. I only did not quit it, because my grandmother did not let me do it. E12

I suffered a lot of bullying. At that time, nobody talked or knew about it. Today, I see that the social environment where we live is very cruel. It is not that people are not prepared Many of them are very cruel! They feel pleasure in humiliating. Then, we spend the rest of our lives trying to deal with this. E13

An aspect shown in all interviews was that these expressions of violence were associated with the idea that the victims did not fit themselves in a model of “masculinity”. Because they were different from the masculine, virile, or appropriate type of men, they were abused or rejected by others who regarded themselves as superior, since they were in compliance with the “model”.

At school, physical education classes were spaces of tension and segregation, since practices directed towards girls and boys were more evident, with appeal to distinctions between femininity and masculinity.

When they did not let me play with the girls, I stayed in the stand seeing the boys playing ball. They talked about me during the game, and I felt very humiliated. E2

The thematic category “sexual, domestic, and institutional violence” portrayed the perception of the young men regarding violence itself, since some understood its existence when there was pain (physical or emotional), that is, bullying and prejudice were also types of violence, but perceived in a milder way by them. However, when there was physical contact or abuse that caused high suffering, perceptions on themselves and others changed, becoming more vulnerable and private from defense mechanisms, and causing social and behavioral harm.

When I was about five or six years old I was molested by a teenage neighbor. This lasted for three months. E7

One of my cousins was somewhat a psychopath. I hated him. I still hate him… Because I was often alone, he took advantage of the situation and raped me. Then, he blackmailed me saying that he would kill me if I told anyone. I was not sure about what happened there. E13

Later, in adolescence, it did happen again, but with my grandfather. I had to give him oral sex a few times, and he gave me too. I never wanted these things to happen. I never wanted, but they forced me to do that. Even knowing that I was somehow different, I did not want anything of that. E3

Sexual violence in children and young people could cross time, without predictable healing. Telling about what did happen could be part of the trauma’s recovery process. However, telling about the violence suffered by their bodies and psyche to a relative or close person was not a reality in the narratives. The young men felt fear and shame of the occurrence, and telling about it seemed to expose their weaknesses even more.

Because of this, I close myself off from the world. I did not want contact with anybody. I ended up with few friendships. E5

School and church also emerged as entities perpetrators of violence. Unpreparedness of educators with regard to the construction of ideals of genders and social roles was observed. Nine participants mentioned reports of instigation of some form of violence by teachers. In addition, a similar behavior was found in religious leaders due to traditions, dogma, and legacies.

My mother attends an evangelical church. When we were children, she forced us to go to the church with her. She stills attends it. I dated some girls from the church, just to silence people, especially the pastor, who always tried to speak bad things of homosexuals and encourage people to distrust me. I am not what he told them. E1

The thematic category “search for support” portrayed the young men’s need to be accepted and to receive care due to frequent violence. There was a search for solidarity, affection, or even compassion by more “sensitive” and “tolerant” people regarding sexual orientation constructed. Protection and support were sought against the previous categories.

However, support was often weak or superficial, especially due to the lack of knowledge and experience of those who were source of emotional support. Nonetheless, these people were crucial for facing situations of violence and suffering. In the present study, these people were all women: mothers, grandmothers, cousins, and friends, considering the violent image of men and the almost eruption of women’s.

After some time, I told her [mother] and showed a booklet that I got, where there was a huge virus casting a shadow on a little man, and beside it, a huge man casting a shadow on a little virus. I told her that, because of what she had always taught me, I did not want to live under the shadow of the virus. I would fight until the end. I would not die of AIDS! E2

My grandmother is my safe harbor. She always helped me to deal with these things. She used to say that people mistreated and abused me because they were envious (laughs). Deep down, we knew that this was not the reason. Because she is a very simple person, it is difficult to make her understand these things. E10

It was often clear that healthcare professionals such as nurses and psychologists were in charge of support. Medical appointments, group activities, and therapy sessions opened channels for expression of feelings and helped to face situations of violence and live with HIV/Aids. Interactions were more positive when they perceived not being targets of judgment.

The thematic category “love and passion” emerged from the idealization of love as a vehicle for expression of affective and sexual identity. The search for the ideal partner was unanimous in the narratives, placing trust and affection in the other, which were denied in other situations. In love relationships, the passion stage was marked as intense, erotic, and happy; however, it was also quiet, because sexuality remained as a sphere of life of difficult understanding by family and friends. At this time, they did not want to take the risk of judgement. They wanted a safe haven and to forget the forms of violence suffered.

I was in heaven. I was madly in love with him. He was the man of my life. Do you know about stories of prince charming in a white horse? It was him! I cannot explain. E11

He seemed to be a confident, mature, reliable person, and he was exactly what I was looking for. E13

Love as a comfort zone proved to be essential to the young men. However, it also made them vulnerable, since all the participants seroconverted to HIV in steady relationships.

Discussion

The limitation of this study was the need for exclusion of people under the age of 18, which could expand social representations attributed to the theme. Therefore, extension and creation of further meanings seem to be interesting under new methodological prisms.

Nonetheless, the results may help nurses to develop preventive and care actions from the perspective of individuals, and to act in compliance with the assumptions of a culture of peace. Perceiving violence as a factor that causes segregation, pain, and suffering in young homosexuals and bisexuals, enables nurses to understand the impact of the theme on the formation of personal identity and vulnerability to diseases, such as infection to HIV/Aids.

The young men in the present study reported a long history of homophobia and bullying throughout their lives. The society perceives them as different from the collective imaginary standard of masculinity. The social image of people inferior to others made them suffer situations perceived as even more violent, especially sexual abuse, domestic abuse, and institutional violence practiced at school and in the name of religion. Within this context, the search for support and understanding was attempted, but it was poor, sometimes provided by professionals, such as nurses and psychologists after discovery of the infection by HIV.

Surrender to passion and love emerged from empirical material, as a comfort zone after tumultuous childhood and adolescence. In general, people have individual preconditions for reduction of vulnerability to HIV/Aids, of cognitive, behavioral, and social nature.(9) Love does not seem to be the only element of rupture of these preconditions, but the deep fragility of recognizing themselves, caused by the violence experienced and lack of emotional support.(11)

Bullying is a common problem in the education area. Sexual orientation is one of the five main causes of aggressive and violent behavior of students. However, it leads to repercussions for the healthcare area, since it involves determinants on the healthillness-care process of students(7) and implies the quality of relationships and self-esteem of young men who have sex with men,(11) which are aspects found in this study. It is up to educators and healthcare professionals to exhaustively search for information and dialogues that value peace and respect for differences.(1214)

Unhealthy and aggressive environments negatively affect the health of young homosexuals, bisexuals, and other men who have sex with men, leading to isolation and silence with regard to sexuality, and placing them at risk of infection by HIV.(15) The high prevalence of domestic, sexual, and institutional violence implies changes in the meaning of interpersonal power, socialization, self-knowledge, self-judgement, and images that are constructed from domestic and institutional spaces, and territories of conviviality,(1618) as shown in the narratives of the participants interviewed.

Also occurring with women, sexual violence was directly associated with imaginary relationships of power between “male” and “female”.(19) In the case of this study, young men with a more fragile look, more delicate physical features, or effeminate were considered inferior than men who followed prevalent standards of masculinity, rooted as one of the greatest “Latin heritage”.(6,17)

Seeking support from a reliable person, friend, or family is common to everyone who experiences situations of violence, since expressing feelings may be a way to face reality. However, support found by young homosexuals and bisexuals was fragile, because of the fear of disclosing aspects of their lives that could generate judgment. In addition, the lack of knowledge of parents or family when dealing with aspects regarding sexuality, generated insecurity and provided little support.(20) Therefore, healthcare professionals are presented as support elements, even without strong bonds with the young. Therefore, training for providing care and for the use of instruments to early identify violence(21) and provide intervention is of utmost importance.

Finally, young gays and bisexuals, due to the conjuncture of violence and social segregation, secretively seek love out of their families and circle of friends, with intense affective dedication to those who give them security, without rationalizing the feeling roused, increasing vulnerability and risk to HIV/Aids,(22,23) as found in the thematic category “love and passion”.

Conclusion

Young homosexuals and bisexuals reported frequent situations of violence in childhood and adolescence; however, they perceived sexual, domestic, and institutional abuse as more vigorous or intense than bullying and prejudice. They showed difficulties in dealing with this, generating social isolation and search for support. This support was perceived as fragile in family, friends, or people who were sensitive to their feelings. In the face of the suffering, they deeply surrendered themselves to affective-sexual relationships. Situations of violence associated with deep passion affected cognitive, behavioral, and social preconditions for reduction of vulnerability to HIV/Aids, that is, made them more vulnerable. Nurses were sources of support and embracement after the discovery of seroconversion. Nurses must give an attentive look to forms of violence against young homosexuals and bisexuals, in order to prevent harm, in addition to an attentive listening without judgment, seeking a culture of peace and tolerance.

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Received: June 07, 2017; Accepted: August 07, 2017

Corresponding author Hugo Fernandes Rua Napoleão de Barros, 754, 04024-002, São Paulo, SP, Brasil. hugoenf@yahoo.com.br

Conflicts of interest: Horta ALM is the associated editor of the Acta Paulista de Enfermagem and did not participate in the evaluation process of this manuscript.

Collaborations

Fernandes H, Oliveiras EM, Ventura RN, Horta ALM, and Daspett C contributed to the conception of the study, analysis and interpretation of data, writing of the article, and final approval of the version to be published.

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