By Fanny Procureur (University College London)

Men who have sex with men (MSM) in Senegal face violent homophobia and a very challenging socio-legal context because homosexuality is still illegal in the country. MSM constantly live in fear of being denounced and taken by the police or beaten up. They are left with no choice but to either leave the country, or live hidden from society. In this context, access to healthcare for MSM including HIV testing and treatment may be impacted by MSM’s fear of stigmatising attitudes within health facilities. Our qualitative study describes relationships between health facility staff and MSM and analyses its effects on access to healthcare by MSM. The data used was collected through a field survey based on observations and qualitative interviews conducted in 2019 and 2020 with 16 MSM, 1 NGO staff and 9 health care providers in Dakar (the capital city) and Mbour (second biggest city on the West Coast) hospitals.

Key findings

Our study published in Health Policy and Planning found that MSM and health care providers have respectful relationships. On the one hand, health care providers are tied to their professional duty to care for MSM and recognise the right to health, even if they do not necessarily personally support homosexuality. On the other hand, trusting in health staff’s professionalism and medical confidentiality, MSM generally feel safe in their care pathway and appreciate being treated equally to other patients. This is quite surprising given that many other studies in similar contexts show that stigma was strong in healthcare settings and that it was the main reason for MSM not to seek care.

However, we did find that MSM identified many fears associated with their health facility visits, namely the following:

1. Strong stigmatising attitudes from non-medical staff around the hospital (such as security guards and cleaners)
2. Fear of meeting a relative when going in for HIV testing or care and thus risking being associated with the MSM community
3. Fear of HIV status disclosure
4. Fear of potential conflicts or tensions with other MSM communities

This study is unique as it is the first in Senegal to ever include security guards and cleaners in its respondents. Our study shows that according to MSM, hospitals are divided into several areas, based on the stigma they expect. It is important to differentiate felt or perceived stigma, meaning the expectation of discrimination and consequential shame and enacted stigma, referring to the experience of actual unfair treatment by others. Even if most stigma discussed by participants in this study is felt, it is important to map out MSM’s care trajectories and spaces in which they feel more or less comfortable as it has a direct impact on their health seeking behaviours. Understanding “smaller spaces” where stigma is enacted is also key to identify all types of stakeholders working within them, including non-medical staff.

Conclusion

This study demonstrates that even if health care providers have respectful care relationships with MSM, a lot of work still needs to be done on improving hospital environments for MSM, particularly around the hospital and in areas in common with the general public. This has some challenges given that having dedicated entrances and care areas for MSM could also constitute a potential stigmatising factor. We strongly recommend urgent training for non-medical staff in and around the hospital in stigma reduction interventions such as the LILO (Looking In, Looking Out), which has already been used in Senegal with health care providers and the police.  Indeed, even if non-medical staff are not strong in numbers, their attitudes strongly impact MSM’s trust and wellbeing in healthcare settings.

Image credit: Nio Far (2021). Unreleased documentary directed by A. Lepine, U. Paya and JN Senne.