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derstanding prejudice of psychic suffering individuals about sexuality

Rev Bras Enferm. 2020;73(2): e20190270 http://dx.doi.org/10.1590/0034-7167-2019-0270 7 of ABSTRACT Objectives: to understand the conceptions of individuals in psychological distress about their sexuality. Methods: qualitative study held at a Psychosocial Care Center. Fifteen people assisted in the service participated. A semi-structured questionnaire and script with identification data survey and guiding questions were applied. Data were analyzed by Content Analysis. Results: the following categories emerged: Prejudice of assisted people regarding homosexuality; Prejudice of assisted people regarding the expression of sexuality and the social context; Prejudice to the affective relationship among people assisted in CAPS; Prejudice of people assisted in the expression of female sexuality; Prejudice of society to the sexual orientation of assisted people. Final considerations: sexuality understanding showed that these are conceptions linked to prejudice and stigma of society. Although sexuality was present, it is clear that it was surrounded by taboos, myths and value judgments, in which the only way to deal with it was through repression. Descriptors: Psychological Stress; Prejudice; Nursing; Mental Health; Sexuality.


INTRODUCTION
Human sexuality is considered an expression influenced by biological, physiological, emotional, social and cultural factors that affect the life and health of each individual (1) .
As it is a natural phenomenon, it is susceptible to historical, social and cultural influences. In this sense, it is society and culture that designate whether or not certain sexual practices are appropriate, moral or immoral, healthy or unhealthy (1) .
Sexuality is an inherent dimension of each person, present in all aspects of life, which influences the way each person manifests, communicates, feels and expresses. It can be seen as an identity, spelled out in the way the individual establishes a relationship with himself and the world, and is present from before birth to the moment of death. It is an integral part of human personality and its development is completed as a basic human need such as desire for contact, intimacy, emotional expression, pleasure, love and affection (2) .
However, the theme of sexuality has been veiled over time, resulting in often distorted conceptions. It is related to erroneous subjectivities that generate popular myths, rumors and beliefs, promoting sexual taboos arising from ideas that generate social discrimination. Thus, sexuality has broad and complex conceptual dimensions and can be described in different ways, depending on beliefs and prejudices (3) .
It is important to emphasize that the human being is marked by desires, eroticism and feelings of love, presenting the peculiarity of seeking a way to supply their emotional and affective needs (4) . However, when it comes to the sexuality of individuals in psychological distress, in addition to being marginalized from their social context and marked by stigma, they are seen as asexual, devoid of love desire and incapable of concrete affective life, undervalued the potentialities of affective relationships (5) .
There is a lack of information about the sexuality of individuals in psychological distress, making them hostage to the prejudiced image that society gives them so much.
It is believed that this research, by addressing human sexuality from the perspective of people assisted in a mental health care service, brings to light new data on this theme. It is in the context of nursing care that many users will bring, explicitly or not, their doubts, their myths and fears related to sexuality. However, it is observed that professionals are not always able to investigate complaints related to sexuality and to provide information, showing unpreparedness and lack of knowledge (3) .
This paper aims to understand the perception of sexuality from the perspective of individuals in psychological distress in order to bring knowledge about the theme, reflect the myths, taboos and prejudices involved, allowing to propose actions that contribute to appropriate intervention.

OBJECTIVES
To understand the conceptions of individuals in psychological distress about their sexuality.

Type of study
This is a qualitative, descriptive study with a theoretical and methodological approach to Bardin Content Analysis (6) .

Study setting
This study carried was out at a Psychosocial Care Center (CAPS (Centro de Atenção Psicossocial) III -Adult) based in the central region of São Bernardo do Campo, in the metropolitan region of São Paulo. This municipality is divided into 8 territories or program areas, being CAPS III -Adult responsible for the care of 3 territories and their respective neighborhoods, configuring the Mental Health equipment with greater care coverage and local reference.

Data source
The study participants were a total of 15 people assisted at the mental health service, of both sexes. They were selected from the indication of the reference teams, with the inclusion criteria: adults in the age range of 20 years complete to 50 years incomplete, with cognitive ability to respond; a minimum of 6 months in CAPS and a maximum of 2 years of continuous stay; treated in non-intensive and semi-intensive treatment.

Ethical aspects
The study followed the legislation on human research.

Data collection
Data were collected between February and May 2014, through an individual interview composed by questions such as CAPS activity time, service activities, diagnosis, gender, age, religion, sexual orientation, marital status and also for four guiding questions: How do you understand human sexuality? How do you perceive your sexuality as having a mental disorder? How do you perceive the coping with the sexuality of individuals with mental disorders by the team that works in this institution? Does the institution in which you are being treated have any norms or rules of approach to sexuality? Which one? What is your opinion?
The interviews were scheduled and held in a private room at the service itself. The average duration of the interview was 50 minutes, all recorded on digital media and fully transcribed. To preserve their identity, we chose the codename for the deponent, followed by Arabic numbering, according to the order in which the interviews occurred.

Data analysis
Data were organized and analyzed by Content Analysis according to pre-analysis; material exploration; and treatment of the results obtained, inference and interpretation (6) , giving rise to five categories: Prejudice of assisted people regarding homosexuality; Prejudice of assisted people regarding the expression of sexuality and the of Understanding prejudice of psychic suffering individuals about sexuality Ziliotto GC, Marcolan JF. social context; Prejudice to the affective relationship among people assisted in CAPS; Prejudice of people assisted in the expression of female sexuality; Prejudice of society to the sexual orientation of assisted people.

RESULTS
Of the 15 individuals who participated in the study, seven were male and eight female, aged between 20 and 50 years. Diagnoses ranged from bipolar affective disorder, paranoid schizophrenic disorder, schizoaffective disorder, and unspecified nonorganic psychosis.
Regarding sexual orientation, one participant reported being bisexual, ten heterosexual and four homosexual. Most claimed to have evangelical religion, but were also reported to spiritualist and Catholic. One deponent reported not having religion. Regarding marital status, most reported being single, married and widowed. The following categories were developed.

Prejudice of assisted people regarding homosexuality
It is noteworthy in this category that homosexuality was thematic crossed by prejudice and discrimination.
Through the speech of the subjects, one can see the presence of a hegemonic idea inserted in the social imaginary, that human sexuality must be heterosexual and accepting the opposite can mean meeting something considered unnatural. Individuals who considered themselves homosexual and bisexual felt prejudice that they condemned so much because they suffered when they were viewed with inferiority. Their impressions of themselves, coupled with prevailing prejudice, devalue themselves, denying themselves and running away from themselves, sometimes attacking another homosexual to try to distance themselves from their own desire.

Prejudice of assisted people regarding the expression of sexuality and the social context
The subjects reported the presence of prejudice regarding the most diverse forms of expression of sexuality, such as manifestations of affection and caring, sexual relationships performed before marriage, virginity loss, unwanted pregnancy, casual sexual intercourse and age differences between partners were identified as inappropriate.

Prejudice to the affective relationship among people assisted in CAPS
It is possible to verify through the speeches of the deponents the presence of prejudice that spreads in human relations, taking different forms and turning against their own peers, in order to crush any intention of affective ties that may be established between them.

Prejudice of people assisted in the expression of female sexuality
In the speeches there is prejudice against the expression of female sexuality, because it runs away from the idealization rule of the culturally constructed woman figure. Sexist ideas to female sensuality, misconception of frigidity and obligation of sexual intercourse in marriage were reports.
In the reports of the deponents there is the conception that sexual intercourse is an organic necessity for men and an obligation for women. This conception is seen as a norm created to be naturally accepted by women.

Prejudice of society to the sexual orientation of assisted persons
Respondents described that sexuality and sexual orientation were targets of discrimination and prejudice, especially when relating these traits as belonging to minorities expressing their homosexual orientation. There was intolerance and violence against those conceived as strangers, different, who do not conform to the norms. Religion appears in a hegemonic perspective and contemplated the notion of heterosexuality as a correct manifestation of sexuality, reinforced by the idea of procreation, representing very little the creative psyche of the human being, because one does not simply live on basic biological impulses.

DISCUSSION
Ideas that reject homosexuality have been realized, and people who do not exclusively share heteronormativity are destined for less human, unnatural, or abnormal status. The nature of sexual identity is seen as a sexual choice or preference that offends morals and morals (7) .
Thus, as regards prejudice against homosexuality, the data in the first category are similar to those of research conducted with university students. Results show that students reveal moderately negative attitudes towards both lesbian and gay men, suggesting subtle prejudice against this group (8) .
Stereotypes that homosexuals are inferior human beings or have moral defects are maintained in society. However, the homosexual individual often does not passively accept society's negative views about his or her sexuality, making these images so widespread that it is difficult to stop internalizing them to some degree. Homosexuals who internalize these beliefs may feel inferior to heterosexuals, and even homosexuals, unable to achieve goals that contradict prejudice (9) .
In this sense, the internalized sexual prejudice experienced by the deponents can be defined as the acceptance by homosexual individuals of the negative attitudes conveyed by society towards homosexuality. This acceptance would result in negative feelings about the self. In other words, the subject comes to believe that the self is inherently bad, worthless, or repulsive, and that much of his personal problems stem from this (9) .
Regarding internalized prejudice or internalized homophobia, as it is also called, reports of deponents who reported having homosexual and bisexual orientation and considered the expression of homosexuality and transvestism inappropriate.
The prejudice internalized by the deponents makes it difficult to develop relationships of affection and friendship. Once ashamed and humiliated by their social conditions and the discrimination they suffer, individuals bring prejudice into their hearts and reproduce it among their peers. It can be said that when the stereotype is too strong or pernicious, subjects tend to accept it and incorporate it into their self-image, causing negative feelings about their own sexual orientation to be generalized to the self as a whole. Often unknowingly, they assume as their own the perversities that are spread by the prejudiced ideas to which they are targeted (10) .
In a society where homosexual and even bisexual people are seen at least inferiorly, individuals in psychological distress with bisexual or homosexual orientation feel what they are condemned by other people. Their impressions of themselves, coupled with prevailing prejudice, devalue themselves, causing them to deny themselves as people and run away from themselves, often feeling aversion and attacking another homosexual to try to distance themselves from their desire (11) .
Related to internalized prejudice, we perceive the denial of the possibility of developing affective and sexual relationship when dealing with individuals in psychological distress, related to the universal image of being affected by aggressive behavior, with poor appearance and hygiene, which in turn influence in the expression of sexuality.
From this initial perception, the presence of individuals' prejudice regarding various forms of expression of sexuality, such as simple manifestations of affection and caring, sexual intercourse before marriage, loss of virginity, early pregnancy, casual sex, and attention, draws attention. age differences between partners, seen as inappropriate.
This is because, as we see today, for many centuries, sexuality has been considered as the expression of "low instincts, indecency and boldness" that should be fought, subdued and controlled. Religious morality regards it as a "necessary evil" because it is intended for the procreation of the species. In this way, fantasies and sexual acts are considered sinful, sources of guilt and guarantee of punishment (12) .
Religious morality influenced conceptions regarding the manifestation of sexuality. Thus, premarital sexual intercourse, casual sex without a steady partner and unwanted pregnancy are experiences that follow against the moral principles established by certain religions. Religious morality influenced conceptions regarding the manifestation of sexuality. Thus, premarital sexual intercourse, casual sex without a steady partner and unwanted pregnancy are experiences that follow against the moral principles established by certain religions. Rigid religious doctrines create expectation of equally restrictive attitudes toward premarital and casual sex (12) .
In this sense, female sexuality has been understood for many centuries to be non-existent, since women and their sexuality were seen only as linked to the reproductive function. Although this theme is conquering space in society and has been presenting itself as something that should be exposed and dialogued, it is also clear that addressing these issues still yields taboos, myths and prejudices, making many women unable to talk about it. This phenomenon consequently restricts women with regard to the exploitation and appreciation of their desires (13) .
Concerning prejudice against female sexuality, the myth of passivity and female frigidity emerged from the narratives, being the man who has more libido compared to the woman. This statement is linked to a rigid and repressive sexual formation. This formation prevents women from taking the initiative in the sexual act or in the ritual of sensuality, reinforcing the idea that it is up to the men to take initiatives, otherwise the woman is seen as immoral (13) . This data makes us reflect on the behavior and thoughts that are permeated by the symbolism that delimits that allowed by the dominant (male) and the dominated (female) (14) .
As our study presents a majority of female deponents, the idea that female sexuality is something that still bothers some women is noteworthy. As if wondering how to act, marry a virgin or lose her virginity, take the initiative in dating or wait for a man's attitude, have casual sex or wait longer. Despite all the female achievements over time, women still worry about how society will react to their behavior and expression of sexuality (14) .
Although women have gained autonomy, there is still some fear about female sexuality to pursue blameless satisfaction.
Social, religious and cultural aspects continue to mediate this relationship, causing blockages for satisfactory performance without guilt or obligation (13) .
It has been found that there is a taboo in society about a woman's love life, where she has to be faithful, even though she has no fidelity of the man in the relationship, she has to be submissive to this partner. They are treated as an object of satisfaction, disposable and determined by the market. With this, sexual intercourse became just an act of easy access to male pleasure.
Sexual intercourse, for some individuals, is seen as a commitment to marriage, so only in this context is it allowed. There is a conception that sexual intercourse is an organic and natural necessity for men and an obligation for women. This conception is verified as a norm and myth created by men to be naturally accepted by women, making the figure of man distinct from women (15) .
In this sense, male infidelity is justified, especially when it is assumed that if a woman is frigid and a man in need of sexual intercourse, he should be sexually attended anyway.
On the other hand, lesbianism is seen as sexual orientation that gives men pleasure, strengthens the male fetish by sex with two women and reinforces their masculinity (16) .
In sexual orientation, in addition to all prejudice against homosexual persons, while male homosexuality is rejected and synonymous with fragile masculinity, female homosexuality is seen as a sexual fetish for men, reducing them to objects of desire (17) .
It is observed in this study that the individual identified as homosexual can hardly protect their sexual privacy in the public space simply by being systematically challenged in the name of their erotic preference.
There is the presence of violence, intolerance and cruelty against those conceived as strange, different, which do not conform to the norms established by the white, heterosexual, bourgeois, capitalist, individualist and narcissistic majority, when we come to discriminate individuals for their physical, anatomical, genetic, social, identity or sexual particularities or singularities (18) .
This highlights the rigidity that society judges and preaches as acceptable forms of heterosexuality. The conditions for being a typical man or woman are very harsh and rare are the cases in which this occurs naturally. Men and women often find themselves pursuing this ideally imposed model that disrespects the very spontaneity and beauty of human sexuality.

Study limitations
The study has limitations because it was conducted in a single unit with a population restricted to a few assisted individuals. Sexuality manifestation was linked to rigid institutional rules that were not appropriate to the contemporary changing paradigm of psychiatric care regarding sexuality and the so-called Brazilian Psychiatric Reform.

Contributions to nursing
The results presented here are important for nursing, in the sense that those of individuals affected by psychic suffering presented a pulverized view of human sexuality, manifesting prejudice according to their own framework built from real experiences experienced throughout life. Although sexuality was present in the daily routine of care, it is clear that it was surrounded by taboos, prejudices and value judgments. The theme of human sexuality, which is established historically and culturally, could take on a new shape with reflections on theoretical foundations that consider the subjective dimension of caring, care, body, sexuality and the subject, fundamental to circumvent myths, taboos and prejudices that make it impossible to express human sexuality.

FINAL CONSIDERATIONS
Understanding the manifestation of the sexuality of individuals in psychological distress attended at a CAPS III -Adult evidenced that they were conceptions that maintained as main axis the notion of prejudice and stigma that society has in relation to homosexuality. This understanding is maintained in accordance with established social norms.
The influence of social and individual rigidity on the acceptance of sexuality or the diversity of sexual orientations can make it difficult to accept one's identity and self-esteem. We verified that this fact configures a possible picture of internalized homophobia, which can lead to feelings of guilt and shame in front of the manifestation of one's sexual orientation.
Expressions of affection and caring, premarital sexual relationships, loss of virginity, and casual sexual intercourse have been identified as inappropriate and targets of individual prejudice towards the forms of expression of sexuality that are commonplace in our society. Although sexuality was present in the daily lives of assisted people, it is clear that it was surrounded by taboos, myths and value judgments, in which the only way to deal with it was through repression.
Sexuality needs to be approached as a phenomenon inherent to every human being, inscribed in spaces that generate discussions and reflections. The sexuality of users and all professionals should be considered, especially those of nursing, as they also manifest sexuality in care.