The challenge of living with HIV and being a ‘real man’ – the intersection of stigma and masculinity

Intersectionality of HIV stigma and masculinity in eastern Uganda: implications for involving men in HIV programmes.

Mburu G, Ram M, Siu G, Bitira D, Skovdal M, Holland P. BMC Public Health. 2014 Oct 11;14:1061. doi: 10.1186/1471-2458-14-1061.

Background: Stigma is a determinant of social and health inequalities. In addition, some notions of masculinity can disadvantage men in terms of health outcomes. However, few studies have explored the extent to which these two axes of social inequality intersect to influence men's health outcomes. This paper investigates the intersection of HIV stigma and masculinity, and its perceived impact on men's participation in and utilisation of HIV services in Uganda.

Methods: Interviews and focus group discussions were conducted in Mbale and Jinja districts of Uganda between June and October 2010. Participants were men and women living with HIV (n = 40), their family members (n = 10) and health providers (n = 15). Inductive analysis was used to identify mechanisms through which stigma and masculinity were linked.

Results: Our findings showed that HIV stigma and masculinity did not exist as isolated variables, but as intersecting phenomena that influenced men's participation in HIV services. Specifically, HIV stigma threatened masculine notions of respectability, independence and emotional control, while it amplified men's risk-taking. As a result, the intersection of masculinity and HIV stigma prevented some men from i) seeking health care and accepting a 'sick role'; ii) fulfilling their economic family responsibilities; iii) safeguarding their reputation and respectability; iv) disclosing their HIV status; and v) participating in peer support groups. Participation in some peer support activities was considered a female trait and it also exacerbated HIV stigma as it implicitly singled out those with HIV. In contrast, inclusion of income-generating activities in peer support groups encouraged men's involvement as it enabled them to provide for their families, cushioned them from HIV stigma, and in the process, provided them with an opportunity to redeem their reputation and respectability.

Conclusion: To improve men's involvement in HIV services, the intersection between HIV stigma and masculinity should be considered. In particular, better integration of and linkage between gender transformative interventions that support men to reconstruct their male identities and reject signifiers of masculinity that prevent their access to HIV services, and stigma-reduction interventions that target social and structural drivers of stigma is required within HIV programmes.

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Editor’s notes: Both stigma and masculinity can affect men’s health seeking behaviour. This article builds on previous research in Uganda on how stigma affects how men cope with HIV. It draws on the concept of intersectionality to examine how the structural vulnerabilities of stigma and masculinity intersect. It explores the perceived influence of this intersection, and the extent to which it may further disadvantage men in their participation and utilisation of HIV services. Drawing on qualitative research from eastern Uganda, this study explores how various signifiers of masculinity undermined men’s health by restricting their participation in peer support groups and HIV services. Signifiers of masculinity included physical and emotional strength, respectability, and involvement in multiple sexual relationships. Some signifiers of masculinity were also often intertwined with HIV stigma, for example men’s reluctance to adopt a sick role was reinforced by the fact that HIV was a stigmatised disease. Furthermore, shame, secrecy, a perceived sense of powerlessness, and loss of respect were often contrary to masculine notions of respect. Similarly, stigma was also shown to interact with masculine provider role identities. As a result, men sought to avoid the additional shame of not being able to provide for their families by planning to work, and therefore not prioritising clinic appointments or participation in unpaid group activities. 

Through this research, the authors argue that stigma and masculinity, rather than being understood as unilateral variables, should be considered in conjunction. This is important in order to explore how these variables might amplify or otherwise modify each other to determine men’s willingness to participate in HIV services. The authors highlight a number of implications of their research. First, HIV programmes should mobilise communities to discuss the possible harmful effects of adhering to prevalent masculine notions of risk-taking, independence, and emotional control. Second, social protection and livelihood activities targeting men living with HIV and their families should be integrated into HIV programmes and peer support group activities. Third, social support networks of men living with HIV should be bolstered in order to help men deal with stigma.

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