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“É difícil falar sobre sobre AIDS & sexualidade no cuidado em Saúde Mental?”: discursos e práticas profissionais em serviços no Rio de Janeiro / "It's hard to talk about AIDS and sexuality in mental health care?": Discourses and practices in services in Rio de Janeiro
Abstract
Despite the advances in the field of mental health resulting from the psychiatric reform and high HIV infection rates among users of mental health services, the lack of STD/AIDS prevention policies for this population, both in Brazil and abroad, is evident. This gap is exacerbated by the difficulty mental health professionals have to deal with mental health service users’ sexual activity, a fact that is supported by the literature and my professional practice as a nurse and researcher in the area of mental health. Based on a qualitative approach, this study analyzes the perceptions and practices related to mental health users’ sexual activity and STD/AIDS prevention of mental health professionals working for three types of services of the Psychosocial Care Network (RAPS) in the municipality of Rio de Janeiro (Rio de Janeiro state, Brazil). From June 2015 to February 2016, eight focus groups were conducted with teams of mental health professional from: a public university institution, a type III psychosocial care center (CAPS III), and an outreach project for the homeless (“Consultório na Rua”). Most of the 61 practitioners (40 female and 21 male) in the focus groups were between 20 to 40 years of age, and there were residents and professionals of several areas (including psychology, nursing, medicine, occupational therapy and social services). The professionals said they were aware users of mental health services are more vulnerable to violence-related issues, including sexual violence. However, sexuality is only approached in the scope of healthcare when a mental health user requests it or if a sexual violence incident occurs. All practitioners said they recognize the importance of approaching sexuality and STD/AIDS prevention issues, but we found that they rarely do this when caring for users of mental health services and that they do not go to team meetings to participate in the discussions. Moreover, those themes are rarely approached during their daily healthcare routine due to a lack of training and knowledge and because the institutions do not provide guidelines and policies. The findings attest to the need and importance of incorporating the topic of mental health users’ sexual activity into the education and training of mental health professionals of different fields in order to avoid sexual abuse and HIV infection. Our conclusion is that, despite the advances brought by the psychiatric reform worldwide and in Brazil in terms of deinstitutionalization and more comprehensive and humanized healthcare, sexuality, sexual health and STD/AIDS prevention have not been incorporated into the debate in the new provisions focused on social inclusion and the recovery of mental health users’ sense of citizenship.
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O objetivo deste estudo foi compreender as formas de viver e de pensar a respeito da sexualidade das pessoas com transtornos mentais. Foram realizadas entrevistas abertas com homens e mulheres em serviços públicos de saúde mental no Brasil e elas foram examinadas com base na proposta de scripts sexuais. Nos scripts sexuais experimentados por homens e mulheres, foram identificados os desequilíbrios próprios dos conceitos de masculinidade e feminilidade da sociedade. As entrevistadas e os entrevistados têm pouco prazer em suas vidas sexuais, com recorrentes denúncias de abuso sexual, inclusive por parte de seus companheiros estáveis; prejuízos; e falta de afeto em suas relações. Além disso, foram encontradas escassas habilidades de autocuidado relativas à saúde sexual, em um contexto marcado pela exclusão social. Os resultados mostraram a necessidade de promover a saúde sexual como um direito humano e combater os estereótipos de gênero que causam muito dano à saúde sexual das pessoas com transtornos mentais.
Objective:
The majority of people in psychiatric care worldwide are sexually active, and studies have revealed sharply elevated rates of HIV infection in that group compared with the general population. Recovery-oriented treatment does not routinely address sexuality. We examined the relationship between gender, severe mental illness diagnosis, and stigma experiences related to sexuality among people in psychiatric outpatient care.
Method:
Sexually active adults attending 8 public outpatient psychiatric clinics in Rio de Janeiro (N = 641) were interviewed for psychiatric diagnosis and stigma experiences. Stigma mechanisms well-established in the literature but not previously examined in relation to sexuality were measured with the Mental Illness Sex Stigma Questionnaire, a 27-item interview about stigma in sexual situations and activities.
Results:
Experiences of stigma were reported by a majority of participants for 48% of questionnaire items. Most people reported supportive attitudes toward their sexuality from providers and family members. Those with severe mental illness diagnoses showed greater stigma on individual discrimination and structural stigma mechanisms than did those with nonsevere mental illness diagnoses, whereas there was no difference on the social psychological processes (internalized stigma) mechanism. Regardless of diagnosis or gender, a majority of participants devalued themselves as sexual partners.
Conclusions and implications for practice:
Adults in psychiatric outpatient care frequently reported stigma experiences related to aspects of their sexual lives. From the perspectives of both HIV prevention and recovery from mental illness, examinations of the consequences of stigma in the sexual lives of people in psychiatric care and improving their measurement would have wide applicability. (PsycINFO Database Record
"Descrever a experiência de Triestre, ainda hoje em plena atividade,
não constitui tarefa fácil, exatamente pela riqueza multifacetada dos seus
conteúdos e significados básicos. Mas a autora o faz com competência,
instiga o debate em um campo que vem passando por profundas
reformulações. O enfoque principal é a apreensão das estratégias e dos
momentos significativos do processo de transformação institucional que se
desenvolveu no período compreendido entre 1971, início da experiência, e
1978, quando foi aprovada pelo parlamento italiano a Lei nº 180. " resenha de Francisca Bezerra de Oliveira
We conducted the first study to examine rates of sexual activity, sexual risk behaviors, sexual protective behaviors, injection drug use (IDU), needle sharing, and knowledge about HIV/AIDS among outpatients with severe mental illness (SMI) in Rio de Janeiro, Brazil. Using a measure with demonstrated reliability, we found that 42% of 98 patients engaged in vaginal or anal sex within the past three months. Comorbid substance use disorder was significantly associated with sexual activity. Only 22% of sexually active patients used condoms consistently, despite having better HIV knowledge than those who were sexually abstinent. Overall, 45% of patients reported not engaging in any HIV protective behaviors. There were no reports of drug injection. Adults with SMI in Brazil are in need of efficacious HIV prevention programs and policies that can sustain these programs within mental health treatment settings.
This chapter discusses how professionals in the field of psychiatry take different stances and perform different roles regarding patients' sexual activities performed in a psychiatric institution. It analyzes how Mental Health Care Professionals (MHCPs) from the Institute of Psychiatry of the University of Rio de Janeiro voice their perceptions and positions regarding the sexuality of psychiatric patients. The study lies in the fields of Mental Health and Applied Linguistics (Ribeiro 1994, Pinto et al. 2005; Ribeiro & Bastos, 2005). It assumes that professional discursive practices are regulated through an institutional order as described by Sarangi & Roberts (1999). The data derives from a multidisciplinary focus group discussion among Mental Health Professionals (doctors, psychologists, nurse technicians, among others) on how the group views sexuality, mental health, and HIV/AIDS. Such focus groups discussions were part of an umbrella research project, the Interdisciplinary Project in Sexuality, Mental Health and AIDS (PRISSMA - Projeto Interdisciplinar em Sexualidade, Saúde Mental e AIDS) that anchored the creation of a Brazilian intervention program for the prevention of HIV infection for psychiatric patients with acute mental problems held at the Institute of Psychiatry, Federal University of Rio de Janeiro – IPUB/UFRJ, Brazil.
Realizou-se estudo descritivo e transversal com 242 alunos matriculados no internato em medicina de duas universidades públicas e duas faculdades privadas em Teresina, Piauí. Foi aplicado questionário semiestruturado para conhecer como a sexualidade humana foi ensinada nos cursos médicos. A taxa de resposta ao questionário foi de 86,3%. O ensino da sexualidade foi identificado por 95,2% dos alunos em algum momento do curso. As disciplinas que mais falaram sobre o assunto foram: ginecologia (91,9%), psiquiatria (55,3%), psicologia médica (30,6%) e urologia (24,1%). A sexualidade foi tema de aula em apenas 8,4% dos relatos, mas foi comentada em outras aulas, como: câncer (70,9%), aborto (67,5%), DST e HIV/Aids (67%). Quando o docente falou sobre sexualidade, enfatizou as disfunções sexuais (84,1%), com menor evidência para homossexualidade (50%) e direitos sexuais e reprodutivos (40,6%). Os alunos apontaram influências positivas do ensino da sexualidade na graduação (96,1%). Esses dados indicam que a sexualidade foi ofertada com destaque para a discussão de aspectos biológicos e de doenças associadas à sexualidade, com menor ênfase na construção social do tema e orientação sexual.
Introduction More than 30 studies in the USA and Canada have documented alarmingly high rates of HIV risk behavior in adults with serious and persistent mental illness. Several studies around the world have documented rates of HIV infection among psychiatric patients that are much higher than those for the general population in the same regions(Table 8.1). Clinicians working with patients with chronic mental illness are in a unique position to promote healthy behaviors, reduce transmission of HIV, encourage early detection and treatment, and improve care. To fulfill this role, clinicians may need to enhance their skills and comfort in delivering services to HIV-infected patients. Case study: HIV testing of a man with a history of schizophrenia and substance abuse Andrew is a 46-year-old African-American man with schizophrenia who spent most of his adolescence in psychiatric hospitals and substance abuse treatment clinics. When Andrew was in his mid-30s, his father died suddenly of a heart attack. After his father's death, his mother, who also suffered from schizophrenia, committed suicide. Andrew became deeply depressed and was hospitalized in a psychiatric facility. After he was discharged, Andrew remained depressed and relapsed into injection drug use. His sister helped him get treatment and stay off drugs. After having gone without psychiatric care for a few years, Andrew presents to an outpatient psychiatric clinic. As part of the initial assessment, the psychiatrist elicits Andrew's risk behaviors for HIV infection and learns of his past history of drug injection. After a few meetings during which the psychiatrist develops a trusting relationship with Andrew, the psychiatrist suggests that Andrew be tested for HIV. © Cambridge University Press 2005 and Cambridge University Press, 2009.