Abstract
Persons with severe mental illness (SMI) engage in risky sexual behaviours and have high prevalence of HIV in high-income countries. Little is known about sexual behaviours and HIV risk among persons with SMI in sub-Saharan Africa. In this qualitative study we explored how SMI may influence sexual risk behaviours and sexual health risks in Uganda. Individual semi-structured interviews were conducted with 7 male and 13 female psychiatric patients aged 18–49 years. Participants were interviewed in hospital when clinically stable and capable of giving informed consent. Interview transcripts were analysed using manifest content analysis, generating the categories: (1) casual sex during illness episodes, (2) rape by non-partners, (3) exploitation by partners, (4) non-monogamous partners, and (5) sexual inactivity. Our findings suggest that SMI exacerbated sexual vulnerability in the women interviewed, by contributing to casual sex, to exploitative and non-monogamous sexual relationships, and to sexual assault by non-partners. No link could be established between SMI and increased sexual risk behaviours in the men interviewed, due to a small sample of men, and given that men's accounts showed little variability. Our findings also suggest that SMI caused sexual inactivity due to decreased sexual desire, and in men, due to difficulties forming an intimate relationship. Overall, our study highlights how SMI and gender inequality can contribute to the shaping of sexual risk behaviours and sexual health risks, including HIV risk, among persons with SMI in this Ugandan setting.
Highlights
Improving health and rights of persons with mental illness is a global public health priority [1]
Our findings suggest that severe mental illness (SMI) exacerbated sexual vulnerability in the women interviewed, by contributing to casual sex, to exploitative and non-monogamous sexual relationships, and to sexual assault by non-partners
No clear link could be established between SMI and increased sexual risk behaviours or sexual health risks in the men interviewed, due to a small sample of men and given that men’s accounts showed little variability
Summary
Improving health and rights of persons with mental illness is a global public health priority [1]. Socio-economic disadvantage, stigmatisation and human rights violations make persons with mental illness vulnerable beyond the effects of the mental illness itself [2]. One domain of vulnerability concerns sexual health and HIV risk. In high-income countries, persons with severe mental illness (SMI; i.e. schizophrenia, bipolar affective disorder and other psychoses) have been found to have a higher HIV prevalence than the general population [3], attributed to sexual risk behaviours and injecting drug use [4]. High-risk behaviours among persons with SMI have been suggested to stem from both psychiatric symptoms and from the social consequences of the illness (e.g. homelessness, substance use) [4,5]. Childhood sexual abuse may be a risk factor for sexual risk behaviours in persons with SMI [6]
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