In the following, we present four different discourses that were identified among healthcare workers with respect to their perception of access to healthcare services for SSAM. One discourse turned on the view that there was no major problem with access (although exceptions to the rule could sometimes occur). The three other discourses portrayed access to healthcare as suboptimal, but for different main reasons. One held that SSAM distanced themselves from care, another that healthcare workers directly or indirectly blocked SSAM from care, and a third that structural barriers worked to prevent this group of men to gain access to healthcare.
First discourse: ‘Access to care is not a major problem’
The first discourse we describe held that there was no fundamental or ubiquitous obstacle to healthcare for SSAM in Tanzania. This discourse radiated a clear belief in the ability of the healthcare system to provide gender and sexuality diverse men with the healthcare services they needed. Ezekia and Amani were among those who subscribed to this view,
“Care is always available for MSM, as it is to other populations. I don’t think there has been a problem” Ezekia, IV6
“As I know, like other populations, MSM do not have any problem with accessing healthcare services in health facilities.” Amani, IV9
While these study participants were of the view that access to healthcare was mostly unproblematic for men who have sex with other men, they did not rule out that there could -be challenges at times. Ezekia, for example, was in no doubt that individual healthcare workers had a negative attitude towards SSAM and that this would cause problems in some instances,
“There might be problems with some providers since we cannot all have the same attitude, that comes naturally. But care is available.” Ezekia, IV6
Amani agreed and emphasized the importance of patient complaint in cases where individuals experienced bad treatment in healthcare facilities. Such treatment would need to “be reported to the relevant authorities” so that appropriate corrective action could be taken.
Second discourse: ‘SSAM block themselves from care’
The second discourse we identify partly agreed with the ‘no major problem’ discourse just described. That is, it held that there were no major obstacles to healthcare access caused by the healthcare system itself. However, in this discourse, SSAM were still considered to have healthcare access problems, albeit primarily because they were blocking themselves from appropriate care.
At times, it was as if this discourse existed in opposition to discourses that blame healthcare workers for hindering SSAM from accessing care,
It is hard for us [providers] to give care to people who do not come to the facility, but more importantly, how would facilities put in place services needed by such people when they do not come?” Edgar, GD6
Among the promoted reasons why SSAM did not seek care was a perceived tendency among them to internalize stereotypical negative views of their own kind and to project these onto healthcare workers,
“MSM have something like self-stigma and they put their problems on others [and claim] that we don’t give them care.” Patrick, GD1
Other study participants pointed out that various kinds of fear could make SSAM stay away from care,
“I know that some MSM do not want to come to health facilities to get care even when they are sick. They remain with their problems because of negligence, fear to disclose their sexual information, and fear of stigma and law enforcers.” Edgar, GD6
Even among SSAM who did turn up at clinics, some were said to hold back information about themselves and their sexual practices and identities, and this also contributed to make access to appropriate care difficult,
“I have been working in different facilities, and I am sure it is not easy for any provider to identify mashoga [a Swahili term used to refer to men who engage in receptive anal sex] unless they decide to open up for you. They know how to hide their information about specific health problems and their sexual behaviour, and some describe other problems than those they actually suffer from. Kanjanja, IV17
Third discourse: ‘Health workers block MSM from care’
A third discourse among healthcare workers held that many healthcare professionals actively contribute to limit access to healthcare for SSAM.
Some doctors and nurses were said to disapprove of SSAM and disparage them. Among examples mentioned was that they might refer to such men with insulting descriptors and labels, or verbally abuse them in front of colleagues and other patients. Sometimes they might call attention to SSAM clients by calling on fellow staff members to come and see or surround such them in the clinic.
“For MSM it is really difficult to get care in some facilities, and when it is known to providers that they are MSM, getting care becomes hard. Many of us [healthcare providers] do not accept MSM. I have witnessed some being referred to in bad and harsh language, insulted and given bad names by providers. I remember that one provider called us [other staff members] to come and see what a MSM look like. Such treatment is meant to help them stop their sexual relations and be good people, but they never came back to facilities for care” Bariki, GD5
Another way healthcare workers were said to intimidate SSAM was to deliberately delay them when they sought care. One study participant described that he used this approach himself. He explained how he would first treat all non-SSAM patients and only thereafter the SSAM,
“When I know that an MSM is in the facility for care, I provide services to other patients first and serve him last. He must know that other people are more important than him so that he struggles to change. But also, I need to get enough time to know him and his problems” Hangwa, GD3
Finally, some healthcare providers completely rejected care provision to SSAM.
“Many of us [providers] do not accept MSM. I have been serving MSM for three years now, but many other providers are not willing to give care to MSM and to HIV patients” Bariki, GD5
“If I had a relative choosing to be shoga1, I would stop him because I know he is choosing problems. I have seen that in clinics, it is a problem to get care. No provider would like to associate with practices or people not supported by the laws of the country “Florian, IV1
Fourth discourse: ‘Structural barriers block MSM from care’
The fourth discourse we identify also highlighted access to care as difficult for SSAM, but mainly because of structural barriers.
For one, the existing colonial time law that still prohibits “carnal knowledge against the order of nature” in Tanzania was said to interfere with healthcare delivery to SSAM.
“All problems causing difficulties in accessing care for MSM emanate from the laws. When you have laws that do not support some groups of people, like MSM, such groups will not get services. And even those who do manage to give them care, will not do so in public. The problem and solutions are in the laws and policies” Mangi, IV10
In addition to the law, anti-homosexuality sentiments in the political debate while fieldwork was ongoing was also said to represent a significant structural barrier to healthcare access for SSAM.
Moreover, the anti-gay politics in this country make accessing care very hard. How can MSM seek care while they are being hunted and may be caught in the hospital? You remember what has happened in the last two years… Many of them died and many remained at home with their health problems” Mwemezi, IV3
While fieldwork was ongoing, the Tanzanian media had prominent coverage of political debate that severely critiqued same-sex relations. Among proposals put forward was that the general public should report persons suspected to be gay to the authorities so that they could be punished (31). Some healthcare workers said that some SSAM understandably avoided seeking healthcare in in this period for fear of being arrested.
1Shoga is a Swahili term used to refer to same-sex attracted men who take a receptive position in same-sex sex.