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Aproximação à intimidade masculina no âmbito da saúde sexual: uma reflexão sobre práticas metodológicas no processo de investigação
Approaching male intimacy in the sphere of sexual health: reflections on methodological practices in the investigation process
Alexandra Tereso – Tereso, Alexandra (alexandra.tereso@esel.pt)
Instituição: ESEL/CIDNUR
ORCID: https://orcid.org/0000-0002-4746-3649
Resumo
Na opção por procedimentos pouco padronizados de recolha de informação, a análise critica dos métodos de pesquisa tendo em conta as particularidades do objeto de estudo é fundamental para o desenvolvimento de um processo de investigação rigoroso e produtivo. Este artigo pretende apresentar uma reflexão em torno das opções e das práticas metodológicas na aproximação à intimidade masculina, englobando as representações sociais dos homens sobre saúde e doença sexual, as suas experiências e a utilização dos cuidados de saúde. Recorrendo aos contributos de vários autores, destaca-se a investigação qualitativa como opção metodológica, a entrevista como técnica de recolha de dados, a seleção e o acesso aos participantes. Na abordagem acerca da entrevista incluem-se as possibilidades e dificuldades decorrentes da interação entre o investigador e os participantes, os desafios relativos às especificidades dos entrevistados e as implicações da identidade do investigador.
Palavras-chave: Pesquisa qualitativa. Masculinidades. Metodologia. Sexualidade
Abstract
When opting to use non-standardized data collection procedures, the critical analysis of research methods considering the particularities of the object of study is essential to ensure a rigorous and productive research process. This article presents some reflections about methodological options and practices that can be used to approach male intimacy, considering men’s experiences with sexual health articulated with social representations and health care utilization. Drawing on the contributions of several authors, we focus on qualitative investigation, the use of interviews for data collection and the selection of and access to participants. Concerning interviews, we highlight the possibilities and challenges of investigator-participant interaction and issues related to the specificities of interviewees and the investigator\'s identity.
Keywords: Qualitative research. Masculinities. Methodology. Sexuality.

Introduction
The invisibility of men as subjects of sexual and reproductive health care accentuates the complexity of the approach to this matter. This is compounded by the intimate, private, and subjective1 nature of this issue, which forms the basis of the social representations of male sexual and reproductive health. On the one hand, this reality has to do with the individual conscience situated in the private realm of sexual relations and is thought of as belonging only to individual subjectivities. Yet, on the other, sexual health/disease processes lend this issue a character of public permeability, by which complex relations between individual sexual behaviors and attitudes, social factors, gender roles, and health care utilization are constructed2.
Viewed from this perspective, social representations take on special relevance since they influence individuals’ perceptions of themselves and others. They are translated into behavior and group relations and emerge as socially elaborated and shared modes of knowledge, contributing to the construction of a reality that is common to a certain social group3-5.
Flick6 defends that qualitative investigation entails the correct choice of appropriate theories and methods that fit the complexity of the object of research, the recognition and analysis of different perspectives, reflection about research as part of the process of knowledge production, and the assessment of a variety of approaches and methods. Besides these aspects, and as an integral part of knowledge production, the author includes the interaction of the researcher with the field and research subjects. This warrants special attention when addressing male sexual health and sexuality, insofar as the latter constitutes a phenomenon that is traditionally confined to intimate and closed spaces7 and difficult to broach.
In the production of knowledge about men’s experiences with sexual health articulated with social representations and health care utilization, the analysis of methods employed to approach male intimacy reinforces the centrality of qualitative methodology.
Methods
Reflection on methodological options and practices in the realm of male sexual health and sexuality calls for the mobilization of various authors to anchor the analysis of qualitative investigation as a method, the interview as a preferred data gathering technique (highlighting the possibilities and difficulties of investigator-participant interaction, the challenges related to the specificities of interviewees, and the identity of the investigator), and the selection of and access to participants. Clarifying the concept of methodology, Minayo et al.8 highlights that its definition encompasses theoretical concepts of approach, the set of techniques that enable the construction of a reality, and the creative potential of the investigator. In the approach presented, the bibliographic search is intended to place “the desires of the researcher and the authors involved face-to-face on their horizon of interest”9(p.53), helping form the basis for options and reflection.
Qualitative investigation as an option
In contrast to the scientific research paradigm based on quantitative methods, qualitative investigation developed in the 1960s and 1970s adopting an epistemological position described as interpretivist10.
Describing the main contrasts between qualitative and quantitative investigation, Clark et al.11 highlight that the former is characterized as: focusing on the participant’s point of view rather than on that of the investigator; implying close involvement between the investigator and the people being investigated; prioritizing the theory and concepts that emerge from the date; focusing on the dynamics of the research process rather than a static image; tending to be less structured; having a predilection for a contextual understanding as opposed to generalization; appreciating the richness and depth of data instead of reducing it to validity criteria; and embracing the micro and addressing meanings. The authors also stress that qualitative investigation valorizes the description and contextual understanding of social behavior, values and all other aspects that can be considered11.
The study of male sexual health and the need to approach male intimacy requires the investigator to accept the challenges posed by the complexity of qualitative methods. This entails sensitivity, because of the delicate nature of the topic – which touches the intimate sphere of all individuals – and the ways in which it can be camouflaged in the public sphere, in which sexual health care is inscribed1.
Flick6 argues that qualitative research is not based on a single theoretical and methodological concept and that its practice is characterized by a multiplicity of theoretical approaches and their respective methods. In the topic presented here, the opinions of each subject are the point of departure, followed by the study of the organization of interactions during the course of experiences of sexual health and disease, of the pursuit of the reconstitution of the structures that make up the social space and of the latent meaning of sexual health care seeking.
The interview as a data gathering technique and investigator-participant interaction
The elected technique for data gathering in the planning of qualitative studies is the interview. Interviews can take a number of forms, including group or individual interviews, which can be semi-structured (semi-standardized), unstructured (non-standardized or open)12, or structured (standardized). The latter is mostly used in quantitative studies13. Despite taking several different forms, the interview obliges the researcher to carry out methodological planning guided by the objectives, research questions and purpose of the research. It is therefore important to have in mind and define the following at the outset: the type of interaction the researcher intends to establish with the interviewee; the degree of intensity and/or extensiveness of the information to be gathered; and the formulation and structure of the instrument14.
A focus group is a specific form of group interview intended to explore group dynamics15. Although focus groups as a method of data collection did not arise from a qualitative tradition, they are an alternative to bear in mind when wanting to add richness to the data13,16. This technique, which has several advantages – such as allowing the researcher to record non-verbal data – can pose certain challenges when approaching men’s sexual health or sexuality. These include the difficulty participants have in talking about intimate matters in a group, their poor grasp of these topics – which may lead them to refrain from sharing their ideas and opinions for fear of not being able to express themselves properly17 – and ethical challenges faced by investigators in ensuring the confidentiality of data and pseudonymization of participants18.
One of the advantages of the individual interview is that it affords researchers opportunities to collect insights into meanings and senses14, providing access to the social representations of participants, their conception of reality and the meaning they assign to their actions19. Individual interviews are useful for investigating underexplored study topics that participants are not familiar with20.
In qualitative research, depending on the nature of the information that the researcher wants to obtain, it may be necessary to develop a guide containing a thorough selection of topics that the researcher wishes to gauge interviewees’ reactions to. The researcher should also consider the possibility of tailoring the guide to each specific situation and the peculiarities of each respondent.
Another option that is particularly well-suited to data collection is the semi-structured interview. The use of trees to present topics and questions, which are selected based on the interview’s answers to preceding questions, elicits responses and avoids asking irrelevant questions6, which can be particularly useful when participants have a poor grasp of the topic and refrain from expressing themselves.
In a study of older adults’ experiences of sexuality, Soares and Meneghel7 elected to use semi-structured interviews addressing topics concerning sexuality and other aspects of daily life. Surprisingly, the authors found that many of the researchers who participated in interviewing the participants had not approached issues relating to sexuality because they found it difficult to talk about this topic with older people. In this respect, it is important to reflect on the concept of the interview, insofar as there is an underlying concept of interaction and the interview may be considered either the object or the instrument of sociability21. Bearing in mind the object of study and the perspectives of some authors who emphasize that interviewers are active participants in the interaction with interviewees, underlining the importance of framing according to the contexts and situations in which the interview takes place,22 it is important to reflect on some of the specific features of this technique.
Inquiry into a topic loaded with subjectivity, such as men’s sexual health – irrespective of sexual orientation – requires investigators to question their own particularities: What does it mean to the investigator to have men\'s sexual health as an object of study? What are the main constraints/strengths of using interviews as the preferred data collection method when addressing such an intimate and private matter? What strategies need to be planned to access the “lived experience” of men, when seeking to encompass the discursive, the symbolic and the institutional4?
Fontana and Frey22 suggest that characteristics such as interviewer age, sex and experience have a relatively small impact on responses in semi-structured interviews. However, according to Clark et al.11, aspects such as race, social class, sex and interviewer-interviewee interactions may be considered constraints. Fontana and Frey22 add that the interview takes place in a context of social interaction and is influenced by this context. They go on to say that attentive interviewers recognize this fact and are sensitive to how interaction can influence interviewees’ responses. Converse and Schuman23 suggest that interviewers should be aware of differences between participants and able to make the proper adjustments in response to unanticipated developments.
The fact that semi-structured interviews allow researchers to hear every participant’s viewpoint, provide flexibility (including asking new questions to follow up and clarify a interviewees’ replies), afford interviewees freedom of expression and guide the interviewer on the points to be addressed11 are some of the reasons why researchers choose this method. To respect the freedom of expression of participants it is vital to consider the following: the interviewee’s preferences regarding where the interview will take place; the measures taken to safeguard interviewee privacy; interview duration; the interviewee’s willingness to respond questions; and the investigator’s interviewing skills. Attention should also be paid to ethical aspects, including the need to remind participants that they may refrain from answering specific questions and are free to withdraw from participation in the study at any time without giving an explanation.
Challenges related to specific interviewee characteristics
When conducting an interview, it is important to consider the specific characteristics of the interviewee which, according to Ghiglione and Matalon24, can be divided into cultural, mnemonic, cognitive, motivational, and conjunctural aspects. With regard to cultural aspects, it is important to consider the interviewee’s “verbal capital” and how this influences their understanding of questions. Studies involving taboo topics that are not part of everyday conversation can come up against lack of interviewee verbal capital regarding the topic. As a result, participants may have difficulty finding the right terms to express their thoughts and opinions and talk about sexual health and sexual problems. Many interviewees, regardless of age or social class, may lack the necessary sexuality and sexual health vocabulary, hindering their ability to respond easily and fluidly. In a study using semi-structured interviews to collect data, Tereso1 came up against replies like: “I just know terms that are not very appropriate”; “among ourselves, we call it (…)”. Challenges highlighted by the author included interviewees having difficulty saying that they used prostitutes and talking about male genitals, sexually transmitted infections, sex, masturbation and ejaculation problems.
Cultural factors include aspects related to interviewing techniques, apprehensiveness about being interviewed, and problems with recording24. With regard to studies on aspects relating to sexuality and sexual health, the investigator should use language that is comprehensible, reformulate questions when necessary, use non-verbal language, facilitate communication and plan the positioning of the recorder to minimize interviewee discomfort.
Mnemonic factors refer to the interviewee’s ability to recall information related to the topic24. In this type of study, this may not be a problem.
Cognitive factors are linked to interviewees’ personal experiences, emphasizing the importance of their frame of reference. “Given that an individual’s frame of reference determines the connotations of the words used, thus partially defining their meaning, it is essential to understand it”24 (p. 74). These factors, which encompass education, experience, and moral, religious and political convictions, among others, should be born in mind, not only when developing the interview guide, but also when conducting the interview. Each interview is a moment of social interaction in which the investigator appropriates a multiplicity of frames of reference and variety of connotations of terms related to the object of study. Each route taken should enable the integration of strategies that facilitate interaction and understanding of the language and vocabulary used by the participants, which should facilitate communication1.
Motivational factors include interviewee motivation to participate in the interview and desirability bias (for example, when the respondent seeks to be seen as someone who does not violate social norms)24. During the course of the interview, the investigator should ponder the need to employ motivational strategies, including more intimate questions about sexual problems, which most men have difficulty mentioning and need the interviewer’s help1.
Conjunctural factors include aspects that emphasize the relevance of the theme related to the concerns of interviewees and that can reveal the importance interviewees attach to the issue at the time of the interview. At the end of the interview, it is important that the information gathered by the investigator is clear in relation to the topics addressed and current concerns of participants.
According to Fontana and Frey,22 it is vital to understand the respondent’s worldview and the factors that may stimulate or block responses. When the phenomenon under study encompasses sexual health, particularly that of men, there may be issues that are difficult to broach because they are fraught with stereotypes and taboos related to masculinity and sexuality that hinder understanding. In this respect, a careful analysis of the alternative approaches to the topic may be the secret of success for accessing an interviewee’s experiences concerning sexuality and sexual health1.
Identity of the investigator
Another aspect that warrants consideration in this area of investigation is the identity of the investigator and its influence on interaction with the interviewee.
In each approach to an interviewee it is important to reflect about the extent of information to be made available. While it is fundamental that investigators identify themselves, and ethically unacceptable to make up an identity, decisions regarding disclosure of identity can depend on the circumstances. According to Costa,25 the investigator’s social class and occupation influence the data collection process and should be taken into consideration.
There is currently no consensus about the influence of the investigator’s gender identity26. In this regard, Flick6 states that: “Investigators and their communications skills are the main ‘instrument’ of data collection and cognition” (p. 56), diminishing the impact of investigator gender on interviewee interaction. During the course of the study undertaken by Tereso1, the investigator’s gender and the fact that she was visibly pregnant led to concerns about accentuated “exoticism” in her relationship with the male interviewees. While, on the one hand, “exotism” may contribute to objectivity, on the other it can “conceal the meaning of a range of social cues (that the investigator may not even notice) and bias the interviewer’s interpretation (…)”25 (p. 147). In this case, despite initial concerns, for Tereso1, being pregnant revealed itself to be a positive factor in the interaction with some participants, who mentioned that it helped them talk about more delicate topics (“you know, it\'s easier because I don\'t see her as a woman…”), assigning the interviewer an asexual status.
In this respect, when planning and carrying out interviews it is important to consider the specificities of the investigator, interviewee, contexts, social situation in which the interview takes place24, and definition of data analysis techniques.
Regarding aspects related to social situation, it is important to pay attention to the place where the interview will take place, interview duration, the interviewee’s willingness to respond questions and the investigator’s interviewing skills. When choosing the place where the interview will be conducted, the investigator should always respect participants’ preferences and suggestions, even if this implies some added concerns for the interviewer when seeking to provide the best conditions to generate an intensive examination of the phenomenon27 and audio record the interview.
Concerning data treatment and analysis, it is vital to ensure the rigor of interview transcripts13 and respect the ethical principles governing the protection of data and participant identity10. In qualitative investigation, when data collection is delimited using the saturation criterion, it is not always easy to foresee the amount of data that will be collected. Faced with the possibility of lengthy transcripts full of ambiguous terms, defining data storage and organization procedures in advance can facilitate analysis. Depending on the study objectives and data characteristics, investigators can opt to use content analysis software like IRaMuTeQ, WebQDA and NVivo, which speeds up the analysis process.
Selection and access to participants
While not an imposition, the participant selection process usually starts before the formal development of the study and focuses on previously identified relevant cases1. In this respect, it is important to stress that, whether performed prior to or after study development, successfully understanding the phenomenon under study depends largely on adequate case selection. Wright28 and Stake27 defend that in qualitative studies it is better to select a sample of cases that permit the widest possible diversity of explanations about the phenomenon than seek representativeness. Wright28 goes on to highlight that the selected cases constitute opportunities to study the phenomenon.
Studies about the topics referred to in this text are situated in an underexplored field and selected cases should embrace the wider field and provide depth of analysis29-31. During study conception in research involving male sexuality and/or sexual health, the investigator needs to clearly define the units of observation as a point of departure, organize them logically into a group of participants and aim for the “maximum variation”32 necessary to meet the objectives.
Final considerations
The above reflections seek to help researchers who are considering the use of qualitative methods to study issues related to sexual health and sexuality.
Qualitative investigation is an interesting option when it is intended to identify the various dimensions involved in a phenomenon and deepen understanding based on the viewpoint of participants. However, while the qualitative approach opens up a world of possibilities, it also guards some limitations, namely those arising from the specificities of sexuality and sexual health as areas of study. Due to the inherent subjectivity of these topics, research in this area especially require objectivity and rigor, which should underpin any investigation process. Within this not always easy to manage web of challenges, it is important to find the balance between the need to respect interviewee freedom and the need for the investigator to provide direction to the research to permit the organization of data collection. Choosing the semi-structured interview challenges the objectivity of the interviewer in the face of the subjectivity of the topic and entails (re)understanding and having to deal with gender stereotypes (held by the researcher and others) and taboos – which can sometimes make narratives unintelligible – and accepting the limits imposed by the prudishness of those involved.
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