Abstract

This work discusses the health promotion challenges of men who have sex with men (MSM) through the use of data from a conversation circle with people from institutions that provide services to MSM in the Metropolitan Region of Recife. The results allow for the identification of the following challenges for health promotion work, not only for MSM but also for sex dissidents: difficulties with the use of identity categories, stigmatization for providing them with sexual health care, structural racism, the deprivation of liberty, extreme poverty, and literacy.

Key words:
Sexual health; MSM; Prevention; Health communication

Introduction

This work discusses the health promotion challenges of men who have sex with men (MSM) using data from a conversation circle on health promotion for gay men and other MSM. The circle was part of the “Beyond PrEP” seminar, which was organized to launch the plan for the dissemination of scientific knowledge of the Laboratory for the Study of Human Sexuality (LabEshu), which covers 2023 and 2024, as required by the Pró-Humanidades Notice 2022 of the CNPq, which supports one of the research projects developed therein. This study investigates the sexual conduct and vulnerability of young MSM, considering the human immunodeficiency virus (HIV) and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) epidemics, through ethnographic research. In turn, this work considers, among other objectives, the perspective of strengthening the dialogues of organizations that provide services to gay men and other MSM to guide, in the group’s intervention research, questions that germinate in the work of the people who work in these services.

In addition to the seminar and other actions, the plan includes the creation of a website aimed at the public benefiting from the research in question, MSM, to aim for the prevention of HIV, which assumes an important role in the conversation. Importantly, in Brazil, MSM comprise one of the categories most affected by HIV/acquired immunodeficiency syndrome (AIDS)¹1 Brasil. Ministério da Saúde (MS). Boletim epidemiológico Aids. Brasília: MS; 2022.. In recent years, following the moralistic setback on sexuality and gender that has marked Brazilian social life, there has been an almost complete abandonment of what produced the success of the Brazilian response of the 1990s and 2000s, including community mobilization and participation, and robust campaigns focused on the specificities of the different populations most affected by HIV²2 Paiva V, Antunes MC, Sanchez M. O direito à prevenção da aids em tempos de retrocesso: religiosidade e sexualidade na escola. Interface (Botucatu) 2020; 24:e180625.

3 Rios LF, Adriâo KG, Albuquerque AP, Pereira AF. 'Couro no couro': homens com práticas homossexuais e prevenção do HIV na Região Metropolitana do Recife. Saude Debate 2022; 46(Esp. 7):85-102.^-44 Seffner F, Parker R. Desperdício da experiência e precarização da vida: momento político contemporâneo da resposta brasileira à aids. Interface (Botucatu) 2016; 20(57):293-304..

Accompanying the vacuum of prevention, the prevalence of HIV among MSM has increased. Between 2009 and 2016, in Recife, this prevalence increased almost fourfold, from 5.2% to 21.5%⁵5 Kerr LR, Mota RS, Kendall C, Pinho Ade A, Mello MB, Guimarães MD, Dourado I, de Brito AM, Benzaken A, McFarland W, Rutherford G; HIVMSM Surveillance Group. HIV among MSM in a large middle-income country. AIDS 2013; 27(3):427-435.^,66 Kerr L, Kendall C, Guimarães MDC, Salani Mota R, Veras MA, Dourado I, Maria de Brito A, Merchan-Hamann E, Pontes AK, Leal AF, Knauth D, Castro ARCM, Macena RHM, Lima LNC, Oliveira LC, Cavalcantee MDS, Benzaken AS, Pereira G, Pimenta C, Pascom ARP, Bermudez XPD, Moreira RC, Brígido LFM, Camillo AC, McFarland W, Johnston LG. HIV prevalence among men who have sex with men in Brazil: results of the 2nd national survey using respondent-driven sampling. Medicine (Baltimore) 2018; 97(Suppl. 1):S9-S15.. Along these lines, the data published in the latest epidemiological bulletin point to the persistence of this exposure category as one of the most affected by the AIDS virus, with greater concern for the youngest individuals.¹1 Brasil. Ministério da Saúde (MS). Boletim epidemiológico Aids. Brasília: MS; 2022. These data show the need for the development of technologies in sexual health education for MSM based on scientific evidence²2 Paiva V, Antunes MC, Sanchez M. O direito à prevenção da aids em tempos de retrocesso: religiosidade e sexualidade na escola. Interface (Botucatu) 2020; 24:e180625.^,33 Rios LF, Adriâo KG, Albuquerque AP, Pereira AF. 'Couro no couro': homens com práticas homossexuais e prevenção do HIV na Região Metropolitana do Recife. Saude Debate 2022; 46(Esp. 7):85-102..

Health education in Brazil has a history marked by different conceptions and practices⁷7 Vasconcelos EM. Educação popular e a atença~o à saúde da família. São Paulo: Hucitec; 1999.^,88 Monteiro S, Vargas E, Cruz M. Desenvolvimento e uso de tecnologias educacionais no contexto da aids e da sau´de reprodutiva: reflexo~es e perspectivas. In: Monteiro S, Vargas E, organizadores. Educaça~o, comunicaça~o e tecnologia educacional: interfaces com o campo da saúde. Rio de Janeiro: Editora Fiocruz; 2006. p. 27-47.. An information, education, and communication (IEC) approach with a biomedical focus still prevails, expressed in activities that emphasize compliance with rules for maintaining health. However, another perspective began to emerge in the 1970s. Simone Monteiro, Eliane Vargas, and Marly Cruz underline that “one of the assumptions of this critical perspective is the appreciation of the process of empowering individuals and groups to transform reality as a substitute for the process of persuasion about the risks of disease and health problems or the transfer of information (p. 29)”⁸8 Monteiro S, Vargas E, Cruz M. Desenvolvimento e uso de tecnologias educacionais no contexto da aids e da sau´de reprodutiva: reflexo~es e perspectivas. In: Monteiro S, Vargas E, organizadores. Educaça~o, comunicaça~o e tecnologia educacional: interfaces com o campo da saúde. Rio de Janeiro: Editora Fiocruz; 2006. p. 27-47..

The website that was the subject of our discussions during the event is situated in the second perspective, inspired by Freirean pedagogy⁹9 Freire P. Extensão ou comunicação. Rio de Janeiro: Paz e Terra; 1983., which considers cultural and structural aspects important for changing conduct towards safer sexual practices⁸8 Monteiro S, Vargas E, Cruz M. Desenvolvimento e uso de tecnologias educacionais no contexto da aids e da sau´de reprodutiva: reflexo~es e perspectivas. In: Monteiro S, Vargas E, organizadores. Educaça~o, comunicaça~o e tecnologia educacional: interfaces com o campo da saúde. Rio de Janeiro: Editora Fiocruz; 2006. p. 27-47.^,1010 Parker R. Na contramão da aids: sexualidade, intervenção, política. Rio de Janeiro: Editora 34; 2000..

Monteiro, Vargas, and Cruz⁸8 Monteiro S, Vargas E, Cruz M. Desenvolvimento e uso de tecnologias educacionais no contexto da aids e da sau´de reprodutiva: reflexo~es e perspectivas. In: Monteiro S, Vargas E, organizadores. Educaça~o, comunicaça~o e tecnologia educacional: interfaces com o campo da saúde. Rio de Janeiro: Editora Fiocruz; 2006. p. 27-47. emphasize that although there is some investment in IEC actions in public health, analyses of the quality and repercussions of such activities are still necessary. In the field that interests us, in the period of greater mobilization in health education actions related to HIV/AIDS, the authors indicate that there is little investment in understanding and evaluating these actions.

The website was the subject of the initial lectures and the promotional materials used at the time. In this conversation circle, the materials became the protagonist of the reflections, already being subjected to, without us realizing it at the time, an initial evaluation by event participants. However, we need to be strict. Here, we present the result of a “quasi-evaluation” as defined by Maria Inês Nemes¹¹11 Nemes MIB. Avaliação em saúde: questões para os programas de DST/AIDS no Brasil. Rio de Janeiro: ABIA; 2001. as follows:

In any case, we understand that the dialogue established at the event generated an important research-intervention agenda in which it is not only up to LabEshu or the people participating in the seminar to respond, but also up to civil society collectives, academic groups, and public policy-makers spread throughout Brazil to respond, joining other related proposals to expand and better qualify the health care of MSM and other dissident sex categories¹²12 Brasil. Ministério da Saúde (MS). Desafios da prevenção da epidemia pelo HIV/AIDS junto aos homens que fazem sexo com homens. Brasília: MS; 2002.

13 Brasil. Ministério da Saúde (MS). Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais, Travestis e Transexuais. Brasília: MS; 2013.

14 Gomes R. Narrativas do movimento homossexual brasileiro sobre a saúde de gays e lésbicas. Cien Saude Colet 2022; 27(2):555-565.^-1515 Gomes R. Agendas de saúde voltadas para gays e lésbicas. Cien Saude Colet 2022; 27(10):3807-3814..

Methodology

The website “Alice Bee no Vale das Ninfas” (www.alicebeesha.com.br) consists of the following six pages: “Alice Bee” (presents the character who guides and talks with the visitors throughout the pages, i.e., a drag queen), “Homosexualidades” (presents the research project to which the site is articulated), “O Vale das Ninfas” (presents the homosociability territories of the Metropolitan Region of Recife (MRR)), “Baphons” (presents a kind of newscast of the events of the RMR gay scene), “Na Agonia do Tesão” (presents information and prevention measures), and “Troca-troca” (the communication channel between visitors and staff). “Na Agonia do Tesão” features postpornographic materials, a theoretical-political perspective of action that reconfigures an important way of learning about different sexualities in the West, pornography¹⁶16 Gagnon J. Uma interpretação do desejo: ensaios sobre o estudo da sexualidade. Rio de Janeiro: Garamond; 2006., in a movement to question the oppressive values of sex, gender and sexuality¹⁷17 Sarmet E. Pós-pornô, dissidência sexual e a situación cuir latino-americana: pontos de partida para o debate. Periodicus 2014; 1(1):258-276.. Based on the results of our research³3 Rios LF, Adriâo KG, Albuquerque AP, Pereira AF. 'Couro no couro': homens com práticas homossexuais e prevenção do HIV na Região Metropolitana do Recife. Saude Debate 2022; 46(Esp. 7):85-102.^,1818 Rios LF, Vieira LL. Sobre a "mundiça" e as "bichas cocotes": georreferenciação e classe social nos circuitos gay do Recife. Periodicus 2023; 1(18):217-250., we describe five sexual scenes on the website in such a way that they allow for a reflection towards the redescription of scripts¹⁶16 Gagnon J. Uma interpretação do desejo: ensaios sobre o estudo da sexualidade. Rio de Janeiro: Garamond; 2006., with the hope of promoting a nonoppressive, safe, and pleasurable sexual culture.

The five stories, which are believable, presented in carousels of cards address the following themes: 1) the withdrawal of condoms in scenes of steady partnership without the mediation of testing, 2) unsafe sex among friends and a lack of knowledge of postexposure prophylaxis (PEP) and HIV infection, 3) unsafe sex among strangers and the use of PEP, 4) the correct use of antiretroviral therapy (ART) by people living with HIV in serodiscordant and nontransmissible relationships, and 5) preexposure prophylaxis (PrEP). Two of these stories are in printed format and were distributed to event participants, who also received printed promotional material, with quick-response (QR) codes and website addresses.

“Beyond PrEP” was attended by 40 people and began with a presentation by Prof. Karla Galvão Adrião on the epistemological, theoretical, ethical-political, and methodological perspectives that have historically guided the actions of LabEshu, created in 2005 in the Department of Psychology, Federal University of Pernambuco. Next, Prof. Luís Felipe Rios presented the theoretical bases that guide the production of health education materials in the laboratory, justifying the website “Alice Bee no Vale das Ninfas” and its pages.

After a break for snacks and coffee, people returned to the auditorium for conversation. Taking advantage of the provocation of the first speaker - that the arrangement in the auditorium would not be the most appropriate for the intervention methodologies of LabEshu, especially for holding a conversation circle - the group decided to rearrange the chairs, and the people in the auditorium formed a circle in front, with the people who were not able to get in repositioned themselves by moving as close to it as possible. The auditorium turned into a kind of arena.

Conducting the circle were Prof. Luís Felipe Rios, João Pedro Dias, and Júlio Luckwu, the last two scientific initiation scholarship holders. In addition to students, teaching professionals, and bodies of educational institutions, representatives of different institutions that provide some type of service, not only to MSM but also to other sex, gender, and sexuality dissidents, were included (see Chart 1).

We didn’t have a time for introductions, but each person was asked to identify themselves and briefly talk about themselves and their institution, when they wanted to collaborate in the conversation. Only the following two triggering questions were necessary: “What do you observe about HIV prevention today in the work in the communities/with the people for whom you provide services, especially MSM? In what way do you think LabEshu can help, that is, themes that could guide our research and interventions”? We asked these questions in three or four different ways to ensure that we were receiving the best ideas possible.

The process took just over one hour and a half. After some participants apologizing in advance for not knowing all the letters of the dissident sex alphabet and/or for using a term incorrectly, the group’s work facilitators provided the welcoming, which marked the difference between an environment of argumentation and that of dialogue.⁹9 Freire P. Extensão ou comunicação. Rio de Janeiro: Paz e Terra; 1983.^,1919 Romao J, Carrao E, Cabral I, Coelho E. Círculo epistemológico: círculo de cultura como metodologia de investigação. Educ Linguagem 2006; 9(13):173-195.As was stated, “We are in a protected space; here, it is possible to make mistakes. The most important thing is to be able to talk and bring up our questions”.

This work seeks to locate the main themes that emerged during the meeting. However, we go a little further, bringing references only sketched by our team at the time of the event to generate a discussion of the associated themes. This is positioned writing and meets the interests of LabEshu and the project “Sexual behaviors of young men who have sex with men and HIV vulnerability to COVID-19”. Certainly, any other person participating in the conversation circle would present the same facts but with inflections more related to their institutional positions.

A first version of the text was made available to event participants on the LabEshu blog. We informed participants by email, providing a deadline for suggestions for improvements and contributions. Participants were informed that their suggestions would be incorporated into the text in a future rewriting and that the product would be submitted for publication in a specialized journal. There were a few suggestions, which we obtained through random face-to-face meetings with participants, regarding the use of more appropriate terms for some categories and how to better situate the event within which the circle took place. People participating in the circle formally authorized the use of their names and institutions in any IEC materials arising from the seminar.

Results and discussion: circle movements

The first movement of the circle led us to reframe the scope of the project and the public that benefited from the communication pieces presented. The representatives of Trans Space, one of five centres that perform free transgenitalization procedures in Brazil, highlighted the importance of working on vulnerability to HIV for the public benefiting from the service, but there was fear of reinforcing stigmas that associate HIV/sexually transmitted infections (STIs) with transgender people.

This centre was also interested in creating communications that would allow them to address specific issues of their beneficiary audience at a distance via the internet. This centre reported some investment in exploring online possibilities in the most critical period of the coronavirus disease 2019 (COVID-19) pandemic, but this was restricted to individual and group consultations. The question posed in the arena was as follows: how can these forms of action be leveraged in health, expanding the resources of the online dimension?

Between the lines, participants pointed to a little expression of transgender people (those whose gender identity differs from the sex assigned at birth) ²⁰20 Vergueiro V. Pensando a cisgeneridade como crítica decolonial. In: Messeder S, Castro MG, Moutinho L, organizadores. Enlaçando sexualidades: uma tessitura interdisciplinar no reino das sexualidades e das relações de gênero. Salvador: EDUFBA; 2016. p. 249-270. in the materials, especially in the stories of “Na Agonia do Tesão”.

From MSM to sex dissidents

These statements led us to note the limits and scopes of our research and interventions with MSM. We explained that the justifications for the project were based on epidemiological data related to the vulnerability of young MSM¹1 Brasil. Ministério da Saúde (MS). Boletim epidemiológico Aids. Brasília: MS; 2022.^,55 Kerr LR, Mota RS, Kendall C, Pinho Ade A, Mello MB, Guimarães MD, Dourado I, de Brito AM, Benzaken A, McFarland W, Rutherford G; HIVMSM Surveillance Group. HIV among MSM in a large middle-income country. AIDS 2013; 27(3):427-435.^,66 Kerr L, Kendall C, Guimarães MDC, Salani Mota R, Veras MA, Dourado I, Maria de Brito A, Merchan-Hamann E, Pontes AK, Leal AF, Knauth D, Castro ARCM, Macena RHM, Lima LNC, Oliveira LC, Cavalcantee MDS, Benzaken AS, Pereira G, Pimenta C, Pascom ARP, Bermudez XPD, Moreira RC, Brígido LFM, Camillo AC, McFarland W, Johnston LG. HIV prevalence among men who have sex with men in Brazil: results of the 2nd national survey using respondent-driven sampling. Medicine (Baltimore) 2018; 97(Suppl. 1):S9-S15.. We recall the history of the concept of MSM, including the difficulties, at the beginning of the epidemic, in accessing men at risk of HIV because they did not identify as gay or homosexual. MSM was a category created to broaden the view of researchers and public policy-makers and to consider the difference between sexual identities and practices and the need to adapt the epidemiological facts (who is at risk and why) to intersubjective contexts (identities and sexual cultures) in the production of IEC health material²¹21 Deverell K, Prout A. Sexuality, identity and community: the experience of MESMAC. In: Parker R, Aggleton P, organizadores. Culture, society and sexuality: a reader. London: UC; 1999..

Transgender men can also be considered MSM if they have sex with cisgender/cis men (those whose gender identity corresponds to the sex assigned at birth)²⁰20 Vergueiro V. Pensando a cisgeneridade como crítica decolonial. In: Messeder S, Castro MG, Moutinho L, organizadores. Enlaçando sexualidades: uma tessitura interdisciplinar no reino das sexualidades e das relações de gênero. Salvador: EDUFBA; 2016. p. 249-270. or transgender men and may be included in the study sample. MSM also have sex and interact with transvestites, trans women, and cis women. To the extent that narratives about the people in these population categories emerge in interview situations, they became the object of reflection. Transgender people were also the subjects of our observations.

If the research is based on the categorical approach explained, young MSM, life is sovereign. In addition, in real life, people even use categorizations to guide their experiences, but the experiences themselves blur the limits of analytic constructions. In other words, people in different sex-gender and sexual identity positions socially and sexually interact with MSM, which has either direct or indirect implications for health. Thus, this topic is our focus.

On the basis of these provocations, we committed to fine-tuning our listening and gaze to explore the complexity of the contexts in which lesbian, gay, bisexual, transgender, queer, intersexual, asexual, nonbinary people and people in other dissident sex categories (LGBTQIAN+), and also heterosexual people interact in the understanding and construction of actions related to vulnerabilities to HIV and violence, expressed both in academic texts and educational productions.

In the case of the demand for a transgender space, we paid more attention to scenes with transgender men and women interacting with cis men, transgender men, and nonbinary people as well as the many nuances of sexuality and gender.

Dissident sex populations, HIV, and stigmatization

On the issue of (re)stigmatizing the beneficiary population of the Trans Space by working on prevention and linking HIV and transgenderism, an old dilemma was re-established. During the Brazilian response to AIDS in the 2000s, this dilemma was actualized in the controversy that occurred within the MSM Committee, which advised on HIV prevention actions for this population in the Brazilian Ministry of Health. Whether such actions were appropriate, addressing the people identified, epidemiologically and through common sense, as those most affected by HIV and AIDS, was considered.

In other words, mentioning the categories in mass campaigns could reinforce the stigma that associates homosexuals with AIDS, making those people who did not see themselves as part of such categories feel out of risk of becoming infected with HIV. At the same time, the degrees of stigma and discrimination could increase, which could lead to the segregation by those seen as not affected by the epidemic (supposedly heterosexual people) for fear of “contagion”. This segregation was manifested by different nuances of violence. Notably, by themselves, MSM and those people in other categories more affected by HIV, such as female transvestites and transsexuals, were already stigmatized before the identification of the disease in the world, with the scientific understanding that the stigma itself was one of the components that made them more vulnerable to HIV infection and AIDS¹²12 Brasil. Ministério da Saúde (MS). Desafios da prevenção da epidemia pelo HIV/AIDS junto aos homens que fazem sexo com homens. Brasília: MS; 2002..

In the case of MSM, the other argument to construct the abovementioned dilemma was as follows: it was necessary to reach MSM who did not identify as gay and/or who did not frequent the usual social spaces for gay people, where there was a massive presence of governmental organizations and not government agencies, by taking preventive action. Likewise, there was an understanding that it was necessary to destigmatize homosexuality in the broader society.

The resolution of the dilemma was collectively constructed within the Committee itself, which included representatives from government spheres at different levels, civil society, and academia. The Committee came to understand that it was possible to take more comprehensive media action, with the effect of reducing the vulnerability of MSM to HIV without having to emphasize AIDS, promoting the destigmatization of homosexuality through a public campaign. The theoretical basis for this position came from the theory of vulnerability and the ways of intervening in public health - in what are called structural interventions¹⁰10 Parker R. Na contramão da aids: sexualidade, intervenção, política. Rio de Janeiro: Editora 34; 2000.. The campaign was then produced and aired on prime-time TV¹²12 Brasil. Ministério da Saúde (MS). Desafios da prevenção da epidemia pelo HIV/AIDS junto aos homens que fazem sexo com homens. Brasília: MS; 2002.^,2222 Brasil. Ministério da Saúde (MS). Campainha - Campanha HIV, 2002 [Internet]. 2002. [acessado 2023 mar 27]. Disponível em https://youtu.be/KI1VGM7UQwA
https://youtu.be/KI1VGM7UQwA... .

However, this situation also meant that specific materials were needed for environments where gay-identified MSM were present, both talking directly about HIV prevention and mobilizing them for political participation, which resulted in a plurality of information on different subjects that impacted the susceptibility of these individuals to the virus and their access to preventative measures¹²12 Brasil. Ministério da Saúde (MS). Desafios da prevenção da epidemia pelo HIV/AIDS junto aos homens que fazem sexo com homens. Brasília: MS; 2002..

The association made in the circle was that the Trans Space already works, structurally, to decrease the prevalence of HIV among beneficiaries since access to the transsexualization process and other actions offered are means for social insertion with dignity and political and identity recognition. The facility, the Hospital das Clínicas of UFPE, where the space is located is a federal entity. In addition, all participants agreed on the importance of producing IEC strategies for issues that make the transgender population even more affected by the HIV/AIDS epidemic²³23 Magno L, Silva LAVD, Veras MA, Pereira-Santos M, Dourado I. Estigma e discriminaça~o relacionados a` identidade de ge^nero e a vulnerabilidade ao HIV/aids entre mulheres transge^nero: revisão sistemática. Cad Saude Publica 2019; 35(4):e00112718. than are the gay and MSM population.

Synergy of oppressions: class/income, race, deprivation of liberty, and literacy

In the circle, visibility was given to other population categories that in the synergy of oppressions that mark Brazilian society, are in even more delicate situations of vulnerability: people deprived of their liberty, homeless people, and those people affected by systemic racism, especially those residing on the outskirts of the metropolitan region. In other words, racism affects the abovementioned populations to a great extent.

Deprivation of liberty

Representatives of prison care reported the existence of Casa das Dindas, territories in prisons where LGBTQIAN+ people - usually people who perform femininity - reside. They noted the team’s effort to offer dignity to the public, which, owing to the stigmatization itself, lives in subhuman conditions and faces difficulties in accessing basic housing, hygiene, and health resources.

These representatives reported difficulty in the use of denominations that are associated with social movements and academic word. The categories used in the movements and in the literature are often not expressed or do not have the same meaning within prisons, which creates obstacles to understanding in the search for subsidies and in the work itself.

At LabEshu, some people are researching this topic in prison contexts, either directly or indirectly addressing dissident sex people²⁴24 De Paula L. Sexualidades Encarceradas: afetos, desejos e prazeres no cotidiano do cortiço-prisão feminino do interior pernambucano [dissertação]. Recife: Universidade Federal de Pernambuco; 2018.^,2525 Silva PG. A experiência de encarceramento sob a ótica da população LGBT: uma análise a partir da criação das alas LGBTs em unidades prisionais masculinas [dissertação]. Recife: Universidade Federal de Pernambuco; 2020.. We plan to organize a workshop in the future where these issues can be explored in greater depth. However, as already anticipated, we note that the categories of the movement and the academy used to name people should serve as references. The fluidity, circumstantiality, and polysemy of the expressions used to refer to dissident sex persons must be considered, and those individuals receiving the care, not those providing the services or those involved in social movements, should be the ones to give meanings and names to their identities.

However, it is important to remember that academic classification has other purposes. For example, cis women, transgender men and transgender women, or anyone using oestradiol-based hormones cannot use the on-demand PrEP regimen²⁶26 Brasil. Ministério da Saúde (MS). Nota Técnica nº 8/2023-CGAHV/.DCCI/SVS/MS [Internet]. 2023. [acessado 2023 jan 31]. Disponível em: http://azt.aids.gov.br/documentos/SEI_MS%20-%200030684487%20-%20Nota%20T%C3%A9cnica%20563.2022.pdf
http://azt.aids.gov.br/documentos/SEI_MS... . However, in prison, perhaps the categories of transgender man and transgender woman do not make any sense. There are “papais”/daddies²⁴24 De Paula L. Sexualidades Encarceradas: afetos, desejos e prazeres no cotidiano do cortiço-prisão feminino do interior pernambucano [dissertação]. Recife: Universidade Federal de Pernambuco; 2018. in the field of male transgenderism and “bichas”/faggots, and “travestis”/transvestites in the female field²⁵25 Silva PG. A experiência de encarceramento sob a ótica da população LGBT: uma análise a partir da criação das alas LGBTs em unidades prisionais masculinas [dissertação]. Recife: Universidade Federal de Pernambuco; 2020.. The suggested path forward is to listen to the prison care facility, as well as the associated movements, and adapt the concepts to the native language to produce dialogic actions.

Race: methodological challenges in research and access to prevention

In terms of race, we were reminded that black and mixed-race men have greater difficulty accessing PrEP than do other individuals. The representatives of the NGO Gestos and the Specialized Care Service Gouveia de Barros were categorical in pointing out that PrEP, given the peculiarity of its use and the way in which it has been disseminated, is used mostly by gay men, white people, middle-class people, and university students²⁷27 Vasconcelos R. Entre erros e acertos, oferta gratuita de PrEP no SUS completa 5 anos [Internet]. 2023. [acessado 2023 mar 28]. Disponível em: https://agenciaaids.com.br/noticia/rico-vasconcelos-uol-entre-erros-e-acertos-oferta-gratuita-de-prep-no-sus-completa-5-anos/
https://agenciaaids.com.br/noticia/rico-... .

These representatives asked the following question, in an inaudible voice and updated by the very bodies of those who answered the call of the event, mostly white people: to what extent did our material and our investigation address the racial issues that associate the MSM and other LGBTQIAN+ people with HIV and AIDS?

The answer was: We have tried hard. Brazilian-style racism often hinders our intentions to analyse the impacts of race in the intersubjective context of exposure to HIV. In a team formed, for the most part, by Scientific Initiation Scholarship holders, each person who enters into racial issues must be trained, which implies instigating him or her to describe racism differently, including erotic nuances.

To explore this field, the analytical tool we use involves body stylization, defined as aesthetic configurations that result from body arrangements (physical constitution, gestures, clothing, adornment, accent, smell, taste, texture, etc.), with identity enunciation effects, with implications for the production of meanings (dispositions, meanings, values, emotions) that mediate the action³3 Rios LF, Adriâo KG, Albuquerque AP, Pereira AF. 'Couro no couro': homens com práticas homossexuais e prevenção do HIV na Região Metropolitana do Recife. Saude Debate 2022; 46(Esp. 7):85-102..

That is, we aimed to identify racialized configurations, as they are called, and their effects on interactions. As an example of how we have been using the concept, we explain how an analytical difficulty occurred at the beginning of the project in terms of using the self-classification of gender for data analysis. Most of the people interviewed said they were male. We decided to perform a “heteroclassification”. In a workshop with all the team members, on the basis of the observations and recall data from the interviews, we arrived at the main categories, choosing names that best expressed the configurations (there are several ways to refer to gender, which, in practice, correspond to certain nuances, which were explored later times in the analyses) and classified our interviewees.

The data were thus able to “speak”, showing how pintosas (men who configure femininity, who are supposedly passive/who are penetrated) are those that suffer the most discrimination and violence, are less desired, etc., compared to boys (sic.) (men who configure masculinity, those that identify as gay men, and those that are allegedly active/who are penetrators). Following the analyses, the figure of the cafuçu (a black or mixed-race man, not identified as gay, who configures masculinity and rudeness and who is supposedly active) emerged.

Our current path, in addition to exploring native classifications in practice (cafuçu, boy padrão, bicha poc, bicha cocote, etc., all of which are racially marked)¹⁸18 Rios LF, Vieira LL. Sobre a "mundiça" e as "bichas cocotes": georreferenciação e classe social nos circuitos gay do Recife. Periodicus 2023; 1(18):217-250., brought us closer to the discussions of racial heteroidentification committees in public universities²⁸28 Dias GR, Tavares Junior PR, organizadores. Heteroidentificação e cotas raciais: dúvidas, metodologias e procedimentos. Canoas: IFRS Campus Canoas; 2018. from the perspective of tightening the criteria for classifying our interviewees and the people they interact with during field observations.

In health communication materials, we are seeking to use counterintuitive about relationships, working on the racial issues related to sexuality to produce reflections on the stylizations, for example, of the active black man, the passive maricona, and the white person who makes decisions about prevention. These and other stereotypes have negative effects on prevention and, above all, reinforce the oppression of such individuals.

Nevertheless, as an example, in the first “Na Agonia do Tesão”, entitled “Amor e condom”, there is an interracial couple, in which the white man is older and pintoso (effeminate) and the black man is a younger, cafuçu-style man. The latter would “comer”/penetrate the former. However, the images show that the black man interrupts the sex when he was about to be penetrated. The reason for this interruption was a lack of condoms. The black man triggered the conversation, which the literature refers to as negotiated security - testing and making agreements before stopping regarding the use of condoms. In our materials, race appears less in the texts themselves and is expressed mostly in the images. In daily life, interactions are undertaken in a thoughtless way, mediated by images, which produces emotions (desire, fear, disgust, etc.) and dispositions for action.

Homeless population

Still bringing the discussion about PrEP as a guide to reflect on social markers and access to and usability of the recently released IEC material, representatives of Street Clinic stressed that the MSM to which they provide care often face difficulty using other medications, such as those for tuberculosis, which would certainly extend to PrEP.

In the lectures that preceded the circle, we recalled that free access to PrEP and its daily use require discipline that is based, for example, on the necessary link to health services, with regular exams and routine medical appointments, in addition to the correct use of the medication, whether in terms of continuous use or on-demand PrEP²⁶26 Brasil. Ministério da Saúde (MS). Nota Técnica nº 8/2023-CGAHV/.DCCI/SVS/MS [Internet]. 2023. [acessado 2023 jan 31]. Disponível em: http://azt.aids.gov.br/documentos/SEI_MS%20-%200030684487%20-%20Nota%20T%C3%A9cnica%20563.2022.pdf
http://azt.aids.gov.br/documentos/SEI_MS... ^,2727 Vasconcelos R. Entre erros e acertos, oferta gratuita de PrEP no SUS completa 5 anos [Internet]. 2023. [acessado 2023 mar 28]. Disponível em: https://agenciaaids.com.br/noticia/rico-vasconcelos-uol-entre-erros-e-acertos-oferta-gratuita-de-prep-no-sus-completa-5-anos/
https://agenciaaids.com.br/noticia/rico-... . For some people of dissident sexuality, having a drug that is known to be prescribed for HIV can be another source of stigma and discrimination. This situation is also true when implementing access to ART for people living with HIV and AIDS (PLWHA). Certainly, studies of adherence to ART can help us think about strategies for the implementation of PrEP²⁹29 Teixeira PR, Paiva V, Shimma E, rganizadores. Tá difícil de engolir? experiências de adesão ao tratamento anti-retroviral em São Paulo. São Paulo: Nepaids; 2000..

In another discussion in the circle, led by the professionals of Street Clinic, it was noted that many MSM who use the service have sex with men in exchange for money to buy drugs but do not perceive themselves as being gay, bichas, or prostitutes. We ask where these men are. We no longer saw prostitutes in the traditional spots of male prostitution in the studies already conducted at LabEshu³⁰30 Souza Neto EN, Rios LF. Apontamentos para uma economia política do cu entre trabalhadores sexuais. Psicol Soc 2015; 27(3):579-586.. At this point in the circle conversation, another high point, at least for the research group, was reached.

According to the research group and corroborated by other people present, male prostitutes were still on the streets, perhaps more or less in the same places already ethnographed by us. However, according to the descriptions of our interlocutors, stylization has changed. Instead of the prostitutes (stylistically close to what the fags call cafuçus/blacks and boys padrão/white), we have noiados - men who are usually black, very thin, poorly dressed, and with poor body hygiene and who, according to our interviewees, perform chupa chupa (oral sex) for crack money.

Certainly, we have not been listening to this audience because our networks of informants for the interviews were comprised of both poor and well-off people, who, even if they have sex with the abovementioned people, either do not report it or do not provide descriptions that help us identify them.

The team was impressed with our “myopia”. How could we not perceive these people on the streets in our observations? Was it due to our elitism? Have we naturalized the figure of the male escort from our own desires? The fact is that we missed the hustlers in the downtown streets, and we believed that they had migrated to the saunas in search of a safer environment in which to do business. This situation may have occurred, but what the participants in the circle suggested was that if that happened, then men with other stylizations took over the sex business on the street. The circle played its dialogic role and replaced researchers’ experiences and questions for investigation this stage allowed the researchers to tinker with what had become or was already familiar.

Literacy: who would reach Alice?

The “disorganization” that arose in the circle did not end there. In the context of criticism, which was very delicate and pointed in new directions, we began to realize the limits of our recently released productions. Materials that no matter how much they addressed racial and class issues between the lines, would most likely be effective only for literate queers.

The question that the circle posed to us was as follows: how can devices (educational materials, supplies, and access to them) suitable for homeless people, people deprived of their liberty, black men from the periphery, and nonliterate people be produced? In the case of the first two categories, these people would not have access to computers or cell phones, either due to cost or legal prohibition. In the case of poor, although of the use of smartphones is at a high level, there is also a large presence of functionally illiterate people. Our material requires that people have the capacity for formal reading, even though it uses images to express stylizations and emotions, which compete in the “drama of unsafe sex”.

Therefore, the circle did its job and made us reflect. We are willing to face challenges that belong to all people committed to the promotion of human dignity in health, in the accountability system, in social action, for MSM, and, more broadly, because they are all socially enmeshed LGBTQIAN+ people.

Contributions to an LGBTQIAN+ health agenda

Gomes¹⁵15 Gomes R. Agendas de saúde voltadas para gays e lésbicas. Cien Saude Colet 2022; 27(10):3807-3814., continuing a study on the health narratives of the Brazilian gay and lesbian movement¹⁴14 Gomes R. Narrativas do movimento homossexual brasileiro sobre a saúde de gays e lésbicas. Cien Saude Colet 2022; 27(2):555-565., submitted an agenda of topics, reiterated as relevant to such action, for the appreciation of the people who were his interlocutors, namely, “physical or psychological violence; to lesbians related to uterine and breast cancer; mental health; training of health professionals; AIDS prevention and care; assisted reproduction for lesbians; care for gay men related to urological and proctological care; development of informational materials on health in general; and information and treatment of sexually transmitted infections” (p. 3807).

The themes unveiled by our discussion circle reinforce many of those themes identified above¹⁴14 Gomes R. Narrativas do movimento homossexual brasileiro sobre a saúde de gays e lésbicas. Cien Saude Colet 2022; 27(2):555-565.^,1515 Gomes R. Agendas de saúde voltadas para gays e lésbicas. Cien Saude Colet 2022; 27(10):3807-3814., which impact the provision of care not only in the field of HIV/AIDS and MSM but also for all letters of the sex-dissident alphabet, which can be summarized as follows: 1) difficulty with the use of the categories of identity × fluidity of experiences; 2) the possible reinforcement of the stigmatization of these populations for providing them with sexual health care; 3) structural racism and its broad impact on the vulnerability of people living in the periphery, people deprived of their liberty, and people living in extreme poverty; and 4) illiteracy that hinders access to many of the IEC health materials.

Certainly, the themes and developments listed throughout the text pose important obstacles in the promotion of comprehensive health for LGBTQIAN+ people, contributing to other research and intervention agendas.¹²12 Brasil. Ministério da Saúde (MS). Desafios da prevenção da epidemia pelo HIV/AIDS junto aos homens que fazem sexo com homens. Brasília: MS; 2002.

13 Brasil. Ministério da Saúde (MS). Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais, Travestis e Transexuais. Brasília: MS; 2013.

14 Gomes R. Narrativas do movimento homossexual brasileiro sobre a saúde de gays e lésbicas. Cien Saude Colet 2022; 27(2):555-565.^-1515 Gomes R. Agendas de saúde voltadas para gays e lésbicas. Cien Saude Colet 2022; 27(10):3807-3814. The discussion that was held during our conversation circle can help us better qualify blind spots, such as the difficulty in the use of dissident sex vocabulary and its impact on the action of professionals and the production of the IEC materials. The discussion also highlights the nuances provoked by each “letter” given the intersections of social markers - producers of oppression. In other words, how structural racism, class, and literacy impact health promotion actions often makes actors invisible or prevents full access to information, as the criticisms of our own website reveal.

Final considerations: the circle continues

We did not leave that auditorium/arena, on the eighth floor of the Center for Philosophy and Human Sciences, with answers. Answers require further considerations. We should look at what has already been done and continue to exercise imagination and creativity to establish new tools for such work. In addition, for those who believe that the circle stopped moving when we handed over the keys to the auditorium, please know that the circle is powerful and keeps moving.

In the conversations after the meeting, we thought that perhaps the use of videos and animations that are all over Instagram and WhatsApp could be more accessible to poorly literate and functionally illiterate people who have cell phones and use these applications and other applications that share what they find interesting, and, in the case of the latter, voice messages. The audio narrative of the site could also be a way in which to include the above people and people with visual impairments.

The challenge on the streets, however, remains and needs to be faced. We reiterate the invitation to Clinic Street to join LabEshu in re-listening to the people who use the service, with a view towards inventing methods of sexual health intervention right there on the street.

The golden age of the Brazilian response to AIDS taught us that fruitful dialogue among civil society, academia, and service providers was one of the elements that made this response an international model. Thus, this approach is our best strategy to keep the circle spinning!

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