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Sexuality and social vulnerability in face of sexually transmitted infections among people with mental illnesses Sexualidade e vulnerabilidade social em face das infecções sexualmente transmissíveis em pessoas com transtornos mentais Jaqueline Almeida Guimarães Barbosa1, Mark Drew Crosland Guimarães2, Maria Imaculada de Fátima Freitas3 1 Nurse. PhD in Nursing. Member of the Epidemiology and Introduction: Self-care in face of sexually transmitted infections(STI) and HIV/Aids Assessment in Health Research Group-GPEAS, School of Medicine, Universidade Federal de Minas Gerais – UFMG, is related to meanings attributed to sexuality. Objectives: This study aimed at under- member of Collective Health Research Group – NUPESC, standing representations of patients with mental illness about sexuality. Methods: UFMG School of Nursing. Professor at Centro Universitário Metodista Izabela Hendrix. Belo Horizonte, MG – Brazil.
Thirty-nine patients were interviewed in public mental health services in Brazil. The 2 Physician, PhD in Epidemiology. Associate Professor analysis was based on narrative structural analysis. Results: Social representations with the Department of Preventive and Social Medicine, UFMG School of Medicine, coordinator of the GPEAS. about sexuality included sex, gender roles and gender identity, among others, forming Belo Horizonte, MG – Brazil.
a Web of interdependent representations that have important gender asymmetry and 3 Nurse. PhD in Education Sciences. Full Professor with the Department of Mother/Child Nursing and Public imply different vulnerabilities. Participants have limited knowledge on STI and their Health, UFMG School of Nursing, member of the GPEAS, modes of prevention. Conclusions: Mentally ill patients have an excess vulnerability member of the NUPESC. Belo Horizonte, MG – Brazil.
due to social exclusion context, poverty, violence, drug use, prostitution and low self-esteem. It is urgent to fully address health needs, including promoting sexual health and prevention of HIV/Aids of this population.
Key words: Sexuality; Sexually Transmitted Diseases; Mental Disorders; Mental Health Services; HIV; Qualitative Research.
Introdução: o autocuidado diante de infecções sexualmente transmissíveis (IST) e HIV/Aids tem sido relacionado aos significados atribuídos à sexualidade. Objetivos: este estudo teve o objetivo de compreender representações de pessoas com transtornos mentais sobre sexualidade. Métodos: trata-se de estudo fundamentado na Teoria das Representações Sociais. Foram entrevistados 39 usuários de serviços públicos de saúde mental nos estados de Minas Gerias e no Rio de Janeiro. A análise dos dados se deu com base na Análise Estrutural de Narração. Resultados: as representações sobre sexu-alidade englobaram aquelas sobre o sexo, papéis e identidade de gênero, entre outras, formando uma teia de representações interdependentes que apresentaram importante assimetria de gênero e implicaram diferentes vulnerabilidades. Os entrevistados con- hecem pouco sobre as ISTs e sobre as formas de prevenção. Conclusões: pessoas com transtornos mentais têm sua vulnerabilidade agravada pelo contexto de exclusão social, pobreza, violência, uso de drogas, prostituição e baixa autoestima. Faz-se urgente as- Department of Preventive and Social Medicine, UFMG School of Medicine sistir integralmente essa população, incluindo promoção da saúde sexual e prevenção Belo Horizonte, MG – Brazil dos agravos sexualmente transmissíveis. Palavras-chave: Sexualidade; Doenças Sexualmente Transmissíveis; Transtornos Men- Mark Drew Crosland Guimarães tais; Servicos de Saude Mental; HIV; Pesquisa Qualitativa. Rev Med Minas Gerais 2013; 23(4): 441-447 Sexuality and social vulnerability in face of sexually transmitted infections among people with mental illnesses as "asexual" people or having a sexuality that must be restrained.8 It is believed that this complicates the This research originated on the need to advance actions of health promotion for this group. knowledge towards the integrality of care of people Therefore, it is necessary to expand the debate with severe and persistent mental disorders in the face about sexuality and STI and HIV/AIDS prevention of the high and alarming prevalence rates of sexually among people with mental illness in order to learn transmitted infections (STI) and HIV/AIDS detected in the obstacles for self-care in the face of STIs and HIV/ this population in Brazil by the PESSOAS project.1 In AIDS, considering the specificities of this group char- this study, carried out with over two thousand people acterized by social exclusion. This study aimed at in all the national territory, it was verified that this popu- understanding mentally ill people's representations lation has an active sexual life, as well as sexual risk be- about sexuality, focusing on self-care and on the care haviors. The sexually transmitted infection (STI) rates with others in the face of STIs and HIV/AIDS, consid- found were superior to those in the general population.1 ering their life contexts. This study proposes to cor- However, only 8% of the population surveyed re- roborate with data and reflections that may contrib- ported condom use in all intercourses, and 40% had ute to the development of new strategies for sexual never used it.2 In addition, 30% reported sexual inter- health care, in the perspective of integrality of care. course in exchange for money or drugs, and 18% had al- Studies in the field of representational phenomena ready suffered some kind of sexual violence. Although are of great interest and have provided important in- 61.5% of the researched institutions had patients known sights for coping with vulnerability to STIs and HIV/ to be HIV infected, just a minority had actions of sexual AIDS, considering that people also guide their be- health promotion or condoms available.2 havior from their repertoire of beliefs, values and atti- In order to face such problem, it is assumed that it tudes, including those about sexuality9, which justifies is necessary to consider the complexity of the subjec- the choice of this theoretical referential. In addition, tive aspects involved in the subjects' actions regarding sexuality is closely related to gender issues, which their experience of sexuality, which comprises, among have become the theoretical basis for this analysis.10 others, sexual practices, eroticism, desire, pleasure, gender identity and roles, affection, otherness, as well as their own health.3 Besides, it is necessary to con- sider the psychosocial aspects involved in self-care for sexual health, this being little considered in preventive This is a qualitative research, based on the Social approaches. Such approaches are characterized as Representations Theory, considered as essential in the generalizing and repressive, and they also consider be- analysis of socio-psycho-cultural aspects that permeate haviors only as the result of rational decisions. Many au- the health-disease process and its social practices.11 In thors have signaled the limitations of these educational this study, actions are taken as a present dimension of actions, as they do not contemplate the plurality of the social representations, seeking the understanding of meanings of sexual practices of different social groups the representation-action complex and its consequenc- and do not reach them in a similar or effective way, and es in the social reality. Every representation is consid- they point to the need of advances in this field.4-5 ered as social,12 and, accordingly, the use of the word However, the psychosocial aspects involved in sex- "representations" is adopted, once all of them are built ual experience and self-care are not results of great in- within social practices and interactions among people. vestiture of health professionals when dealing with this The subjects were adults with severe and persistent population group, 6-7 and are poorly known. The existing mental disorders receiving care at public mental health studies show that men consider themselves as having services. The inclusion criteria were not to be in crisis greater sexual desire than women, the reason why they and to agree to participate in the interview, after knowl- justify their "impulsive" behavior in their sexual experi- edge about the research and signature of the Informed ence. On the other hand, women have their sexual expe- Consent Form. Among those who met these criteria, rience more linked to affection, and act reservedly due the selection of participants occurred randomly. The to the social repression towards their sexual behavior. interviews were carried out in two psychiatric hospitals It is worth mentioning that patients with mental in Belo Horizonte, Minas Gerais, and in two outpatient illness are often considered by health professionals mental health services, one in Betim, Minas Gerais, and Rev Med Minas Gerais 2013; 23(4): 441-447 Sexuality and social vulnerability in face of sexually transmitted infections among people with mental illnesses the other in Carmo, Rio de Janeiro, Brazil, services to Twenty were hospitalized and nineteen were outpa- which the researchers had greater access. All of them tients in substitutive services. Regarding their psychi- were public services, and at the outpatient services, atric diagnoses, 80% had severe psychosis and 20% men and women spent the day together. At the hospitals, retardation, dementia and epilepsy. Twenty-two had here was no coexistence between the different sexes.
some kind of income and the rest lived with the help There was not a previous definition about the num- of family or on charity. Ten participants were illiter- ber of patients, and data saturation was the criterion ate, eighteen studied for four years at most, and ten used for interruption of collecting new interviews. The for eight years at most. Most of the respondents lived project was approved by the participating healthcare ser- with someone. Three had lived in the streets. vices and by the National Committee for Research Ethics Among the women, fourteen had had stable relation- (CONEP number 592/2006). The subjects were ensured ship, but only three lived with their partners at the moment the right to refuse participation in the research, and con- of the interview. Eight men had already had a partner, but fidentiality and information anonymity was assured.
only two kept a stable marital relationship. Relationship Open and in-depth interviews were conducted with instability was attributed to situations of aggressiveness, 39 people with questions about their sexuality experi- partner infidelity, drug and/or alcohol abuse. ence (when it started, about their partners, if they had Twenty respondents had children, but six did not suffered sexual violence), if they knew about or had had keep any contact with them. All respondents report- STIs and HIV/AIDS, how they protected themselves. The ed having few friends and little family support. The interviews were conducted in private rooms and record- use of illicit drugs was stated by 25% of the respon- ed with an electronic recorder, and later transcribed.
dents, and of alcohol by 30%, which was justified as Content analysis of the interviews was based on a way of relieving anxiety and sadness. It was also as- the proposed narrative structural analysis 13. Initially, sociated to the context of drug addiction where they a thorough analysis of each interview was conducted, live: I used to see everybody using it and I wanted to seeking the overall sense of the content. Later, each use it too (E14). In all statements, it was observed low speech object was numbered in sequences, which self-esteem and the feeling of inferiority related to so- were then grouped together by the subjects covered. At cial prejudice due to their mental disorder: They have that moment, it was possible to unveil the respondents' prejudice because I am like this (E16). set of representations by means of their judgments, val-ues , opinions, statements and practices. Finally, a com-parative analysis of all the interviews was performed, The respondents' way
with the final categorization of the meanings found, of living and thinking sexuality
which were interpreted in the light of the literature and of the researchers' reflection. NVIVO® software was used for the organization of the collected data. The sexuality theme has shown to be little talked There was no intention to relate the ways of living about, even among couples, which proves it to still re- and thinking sexuality with any issues related to the main a taboo: About that [sexuality] I talk to no one subjects' clinical diagnosis, because it is considered (E7). Among those who reported talking to someone that, regardless of the specificity of their mental disor- about their sexuality, they say that they were repressed der, all of them need health professionals' monitoring.
or censored, and then they kept quiet: I used to tell my friends everything, but they got mad, and now I don't tell them any more (E8). None of the respondents reported talking about this subject to a health professional. Among women, sexual practices were conceived as an integral part of other life projects, like getting Characterization of the
married and starting a family, being connected with studied population and its social context
affection. The beginning of sexual life for the female respondents seemed to happen unexpectedly and conducted by men older than them: When it hap- Twenty two men and seventeen women aged be- pened, I didn't know the difference between being or tween 18 and 72 years old participated in the study. not a virgin […](E31). Unplanned pregnancy was a Rev Med Minas Gerais 2013; 23(4): 441-447 Sexuality and social vulnerability in face of sexually transmitted infections among people with mental illnesses common occurrence. Five female respondents had in their reports, their difficulty in finding partners was their sexual initiation through acts of sexual violence, outstanding, which proved to be the greatest motiva- two of which committed by members of their fami- tor in their resort to sex professionals along their lives. lies. None of them reported the crime to a Police au- They reported difficulties also related to their sexual thority, nor did they get support from their families: performance: I went to bed with a woman but, at the I told my mother about it [the rape suffered], but she moment, the thing [penis] didn't get up! (E39), which didn't believe it and said I was crazy. Then I left home they attributed to the drugs used in treating their men- and went to live in the streets (E4). tal disorder. They also complained about the lack of Along the lives of the female respondents, there places to have sexual intercourse. are many reports of sexual-affective experience with Among those who lived a stable relationship, many neglected affection, kept for many years mainly due reported having extramarital affairs, a behavior report- to financial dependence. Most of them reported per- ed naturally, and also mandatory for the gender: One forming sexual practices only to satisfy their part- cannot refuse when a woman offers (E3). Masturbation ners, seen as beings focused on sex, considering as is also seen as normal, practiced even inside the health a wife's duty to provide pleasure to her partner: When centers. There were even reports of homosexual rela- he wanted to have intercourse, he had to have it. I got tionships (two), which was reported as something ex- angry […] felt rage and sorrow, and did it [sex] just to perienced with suffering due to social prejudice.
satisfy him. I saw it as my duty as a wife to satisfy him Among men, there were also reports of sexual vio- (E33). Thus, they feel used: He just wanted to use me lence, in one case during childhood, and the other at the and thought I had to give him everything. He arrives, psychiatric hospital by colleagues at the infirmary. And uses you, then throws you away like toilet paper (E16). they also did not report the incident, which is believed After long periods of unsatisfactory sexual-affec- to have resulted from their embarrassment in doing so. tive experience, many of the female respondents re- Some respondents reported prostituting them- ported leaving their partners, and also leaving their selves with men, which was also connected to pov- sexuality experience as they thought that a new sex- erty and drug abuse. There were young respondents ual-affective involvement was not worth it, and also who said they had never had a sexual intercourse, considering their inability to control their fecundity: which was attributed to fear of contracting diseases Sex is no good; Men are only good at putting kids into and to religious precepts, showing the influence our bellies (E24). A minority reported having sexual of such factors on the sexual experience: The Bible intercourse with several partners, which was related doesn't allow any of this (E10); Sex is getting a disease to the hope of conquering a stable partner. Masturba- (E26). Respondents over 50 years of age reported tion was not part of their sexual trajectories, repre- stopping having sexual intercourse not only for fear of senting something shameful.
diseases, but also for considering themselves past the The female respondents that reported never hav- age for sexual intercourse: I'm passed that age (E36). ing sexual intercourse (two) attributed their behavior Mental health services are seen both by men and to fear of pregnancy once they believe that, if they got women as unsuitable places for a sexual intercourse: pregnant, they would be abandoned as they see happen We come here to get treated (E2). However, they stat- to other women around them. There was report of sex ed that some sexual practices did occur furtively at performed in exchange for money (two respondents), which was connected to poverty and drug abuse, and one of them had a history of sexual violence.
As for the men, sexuality was highly valued, main-
Self-care and care for the other in the face
ly as a factor of identity, and sex was practiced regard- of the risk of contracting STI and HIV/AIDS
less of affective involvement. Most of them sought brothels for their sexual initiation. Performance and sexual pleasure were their main focus: Intercourse Except from one respondent who had graduation without pleasure doesn't count as intercourse (E12). in the health field, the group had superficial and even Among men, it was also observed the desire to mistaken information on STI and HIV/AIDS: I've already establish a stable relationship: I want to get married, heard about it, but I don't know what it is (E25); I think you all it takes is someone who wants me (E39). However, can get it from kissing (E19). Nevertheless, they recognize Rev Med Minas Gerais 2013; 23(4): 441-447 Sexuality and social vulnerability in face of sexually transmitted infections among people with mental illnesses the possibilities of transmission of health problems via There were some who reported interrupting the sexual intercourse. AIDS is the most feared among the use claiming that the condom bursts, which leads to STIs due to its representation as ‘destructive and deadly'. evidence of inability in the use. Condom use was also Only a minority claimed to have received information on jeopardized by drug or alcohol abuse, which was stat- STIs and HIV/AIDS at mental health services.
ed by a female respondent who knew to be HIV posi- Generally, STIs are seen as ‘street diseases, which tive: When we drink, we do things we shouldn't and lead the men to see the risk only in sex profession- afterwards we don't even remember very well what we als and ‘cheap' women, and the women in men who did. She said she does not reveal her diagnosis to her frequent brothels. However, not even when they re- partners for fear of losing them. Substance abuse was lated with these people was condom use guaranteed. shown to make self defense even more difficult in situ- It was observed that they feel safe with the fact that ations of sexual abuse: In these situations, we can't the partner has a healthy appearance: Just by look- even defend ourselves (E9). ing, I can tell when a person has a disease (E1). Some In some reports, demotivation and meaningless- rely on the fact that the partner will tell them if they ness of self-care was verified as a result of social and have any STI, and others on the fact that they will be family neglect: Nobody gives a damn for me, why warned if they relate with risky partners: Everybody care for myself? (E17). It is worth pointing out that the warns you when someone is sick (E30). In their re- group expressed interest in learning about STIs and ports, it was outstanding the sensation of safety with HIV/AIDS: It's good and necessary (E7). partners they knew, being enough the fact that they lived in the same neighborhood: There's no risk with her because I already know her (E22). Even in cases in which the respondents had a more accurate perception of the need of self-care, The representations about sexuality encom- which happened as a result of STI experiences with passed meanings about sex, gender identity and themselves or with people close to them, condom roles, practices and sexual partners, forming a net use was not constant. Among men, the difficulties of interdependent representations. They were struc- were associated with the great valorization attributed tured by factors like age and religion, among others, to sexual pleasure: I can't resist the temptation of hav- but mainly by gender, which showed great asymmetry ing sex without condom (E2). in the ways of living and thinking sexuality between Among the few who reported using condoms, it men and women. Such asymmetries are related to was observed that the use resulted from a demand conceptions of masculinity and femininity, based on from the sex professional partner. Women reported dif- dichotomies of sexuality of biological nature that as- ficulties in negotiating condom use with their partners: sociate values such as instinctivity and initiative to My husband came to me and said: why do you want men, and passivity and submission to women. These to use a condom? Do you have another man? (E33). are conceptions that generate and feed the inequal- Condom use was connected with the idea of marital in- ity of conditions between men and women, propiti- fidelity. It is noteworthy that many female respondents, ate abuse of power and favor vulnerability for both. though claiming to know a condom (always the male Such conceptions have their origin in the patriarchal type), stated never having had or handled one. The fe- model, learned since childhood and internalized by male condom proved to be unknown by all. the individuals as natural, and are permanently fed There were reports of interruption of condom use back in a complex process of cultural elaboration. after the couple's cohabitation, which was related to This explains their strong anchorage and allows the greater intimacy and confidence in the partner, and understanding of the difficulties in modifying behav- the fear of affecting their conjugality. Some women iors, once social acceptance depends on following with marital relations said they did not protect them- pre-established scripts3 for men and women. selves because they believed their partners ‘take care Patients with mental illness know little about STI of themselves' so as not to transmit infections, which and HIV/AIDS prevention, and those who had more some men claimed that they did, but in an inefficient knowledge found difficulty in condom use, which was way: When I had the disease, I spent five days away related to lay and unfounded beliefs about STIs and from home not to transmit it to my wife (E38). contraceptive methods, to their confidence in their Rev Med Minas Gerais 2013; 23(4): 441-447 Sexuality and social vulnerability in face of sexually transmitted infections among people with mental illnesses partners, to the hierarchy between genders and to the adoption of alternative practices of healthy and neglect on the part of the health services. The sexual- safe sex like masturbation; education for prevention ity theme was not discussed at those services, which and defense against acts of sexual violence; sensibi- could be a result of the taboo around the subject, lization of family members about their importance which is also present among health professionals. in the education process for these people's sexual The findings are similar to those found in studies health; increment of negotiation skills for condom carried out even with other social groups 14-17, and in use so that they can persuade their partners with- those groups knowledge about STIs was broader. The out the risk of losing them, by simulating situations great specificity of people with mental disorders is similar to those they really live; encouragement for their social context, marked by poverty, ignorance, the partners' participation in actions of promotion of abandonment, prejudice and drug addiction. In ad- sexual health. All health professionals can contribute dition to making self-care more difficult, this context to the necessary advancements by qualifying them- favors situations of greater vulnerability such as sex selves in dealing with the right of people with mental for money and sexual violence. illnesses to a healthy experience with sexuality.
The context where the experience of sexuality O Projeto PESSOAS foi financiado pelo Departamen- occurs for people with severe and persistent mental to de DST, Aids e Hepatites Virais, Ministério da Saúde, disorders is of great vulnerability, resulting mainly através da colaboração entre o Governo Brasileiro e a from their social arrangements and contexts. STI and UNESCO (Projeto 91BRA3014). MIF Freitas é bolsista do HIV/AIDS prevention actions are almost inexistent Programa de Pesquisador Mineiro da FAPEMIG; JAG in this population, which jeopardizes their rights to Barbosa foi bolsista da CAPES; MDC Guimarães é bol- sexual health. It is necessary to consider this popu- sista de produtividade em pesquisa do CNPQ.
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October 2015 EurEau's Contribution to the European Commission's Strategic Approach on Veterinary Pharmaceuticals in the Environment Globally, pharmaceutical products are regularly administered to both livestock and domestic animals. This is essential for animal welfare and the economy, but doing so ultimately means that pharmaceuticals end up in the aquatic environment. Animals reared commercially are the highest consumers of these products and therefore veterinary medicines are largely a rural, rather than an urban, issue. EurEau believes that good agricultural and animal husbandry practices should be promoted and incentivised. Doing so will reduce the overall amount of pharmaceuticals in the environment and protect water resources, including those used for the abstraction of drinking water. As the main route for veterinary pharmaceuticals to the aquatic environment is diffuse, addressing their use at the source is the most effective solution.

Published on Web 12/03/2008 A Robust Platform for the Synthesis of New Tetracycline Cuixiang Sun, Qiu Wang, Jason D. Brubaker, Peter M. Wright, Christian D. Lerner, Kevin Noson, Mark Charest, Dionicio R. Siegel, Yi-Ming Wang, and Department of Chemistry and Chemical Biology, HarVard UniVersity, Cambridge, Massachusetts 02138 Received August 21, 2008; E-mail: