Becoming your own doctor. Healthcare-seeking, stigma, and related challenges among persons with same-sex sexuality in East Africa

Sammanfattning: The health among men and women with same-sex sexuality experience, i.e. attraction to and/or sexual relations with someone of the same sex, in Sub-Saharan Africa is an increasing public health concern. Prior research on men who have sex with men (MSM) has demonstrated that their healthcare utilisation is limited due to stigma and discrimination. However, little is known about the extent to which the healthcare needs of persons with same-sex sexuality are being met, and if unmet needs exist, what could be done to meet this challenge. Thus, the general aim of this thesis was to gain a better understanding of healthcare-seeking behaviours and unmet healthcare needs among persons with same-sex sexuality in Tanzania and Uganda. A multifaceted approach was employed, including quantitative cross-sectional and qualitative interview studies. Data were obtained from in-depth interviews with 12 self-identified MSM carried out in 2012 (Study I), a survey study among 570 university students with same-sex sexuality experience carried out in Uganda 2010 (Study II), a survey study of 296 MSM recruited through respondent-driven sampling carried out in two cities in Tanzania in 2012, 2013, respectively (Study III), and 16 in-depth interviews with pharmacy workers carried out in Tanzania 2016 (Study IV). Qualitative content analysis and grounded theory were used for the analyses of the interview transcripts in Study I and Study IV, logistic regression analysis was used in Study II, and population proportions in Study III were estimated through RDS Analyst. Study I revealed that a multi-layered stigma shaped men’s perceptions and experiences of healthcare services, which resulted in delay or avoidance of services as well as self-treatment. Study II showed that unmet healthcare needs and unmet needs for sexual health counselling services were associated with poor mental health and exposure to sexual coercion among students with experience of same-sex sexuality. Study III showed that RDS networks were significantly larger in size in the larger city with more specialised networks compared to the smaller city. Despite this, a larger number of seeds, or initial recruiters, were not required in the smaller city to achieve minimum sample size for recruitment purposes. The qualitative findings from Study IV revealed that pharmacy workers perceived themselves as being involved in a transition process from having limited engagement in the care of MSM clients to becoming regular service-providers to this group. Transgression of provider-client boundaries and financial interests emerged as underlying factors for unauthorised and incomplete drug provision. All in all, this thesis suggests that persons with same-sex sexuality in Uganda and Tanzania have healthcare needs that are not currently being met. Given the efforts to control HIV and other sexually transmitted infections (STI) in these settings, adequate healthcare provision for these groups is of the utmost importance. The findings of this thesis suggest that there is a need for specialised services that provide places free of discrimination, and with sensitised providers trained to meet the physical and psychological health needs of persons with same-sex sexuality. Social networks should be used not only to disseminate HIV/STI prevention messages but also to encourage healthcare-seeking by providing information about available services. However, in light of current punitive legislation against homosexuality in both countries, governments need to carefully review how the laws impact on the healthcare-seeking and healthcare needs of same-sex sexuality populations. Since many same-sex practising men and women also have sexual relations with the general population, the health of persons with same-sex sexuality should be viewed as a general public health matter.