Abstract and Background
Background: As stigma is a socially constructed concept, it would follow that stigma related to sexual behaviours and sexually transmitted infections would carry with it many of the gender-based morals that are entrenched in social constructs of sexuality. In many societies, women tend to be judged more harshly with respect to sexual morals, and would therefore have a different experience of stigma related to sexual behaviours as compared to men. While a variety of stigma scales exist for sexually transmitted infections (STIs) in general; none incorporate these female-specific aspects. The objective of this study was to develop a scale to measure the unique experience of STI-related stigma among women.
Methods: A pool of items was identified from qualitative and quantitative literature on sexual behaviour and STIs among women. Women attending a social evening program at a local community health clinic in a low-income neighbourhood with high prevalence of substance use were passively recruited to take part in a cross-sectional structured interview, including questions on sexual behaviour, sexual health and STI-related stigma. Exploratory factor analysis was used to identify stigma scales, and descriptive statistics were used to assess the associations of demographics, sexual and drug-related risk behaviours with the emerging scales.
Results: Three scales emerged from exploratory factor analysis – female-specific moral stigma, social stigma (judgement by others) and internal stigma (self-judgement) – with alpha co-efficients of 0.737, 0.705 and 0.729, respectively. In this population of women, internal stigma and social stigma carried higher scores than female-specific moral stigma. Aboriginal ethnicity was associated with higher internal and female-specific moral stigma scores, while older age (> 30 years) was associated with higher female-specific moral stigma scores.
Conclusion: Descriptive statistics indicated an important influence of culture and age on specific types of stigma. Quantitative researchers examining STI-stigma should consider incorporating these female-specific factors in order to tailor scales for women.
Stigma has long been a part of our social existence, with the original Greek translation referring to a physical sign exposing a moral imperfection. While in today's society the physical mark need not be present, the moral associations have remained intact. The topic of sexually transmitted infections (STIs) presents a good example of the dynamic and socially fluid nature of stigma, as opposed to the stationary, objectified definition it is sometimes given. In relation to the categories of stigma outlined in Goffman's (1963) foundational work, STIs could be argued to cross all three – stigma of the body, of moral character and of tribe. In addition, for any one individual, STIs could also blur the boundaries of the discredited – one who is overtly stigmatized – and the discreditable – one who may be able to conceal their stigmatizing feature – depending on the nature of social interaction at any particular time.
Sexual morals have typically had a gender imbalance, leading to a stronger social stigmatization of women. Many societies and cultures view promiscuity among men favourably (e.g., as a measure of virility or status), while promiscuity among women is viewed as undesirable and immoral. In the late 19 and early 20th centuries, the social and medical standpoints on the spread and prevention of STIs were influenced strongly by these gender stereotypes. For example, in World War I, STI prevention flyers were used to warn soldiers away from the 'dirty' women who would infect them with STIs, which they might then pass on to their 'good' wives. Prior to available treatment, the impact of STI sequelae was so great among soldiers, some states enacted laws against 'promiscuity', and many single women were arrested or detained for such things as being out at a bar or club on their own. Today's views on sexual behaviours and STIs may not be as overtly imbalanced, but there remains an underlying gender bias in the stereotypes and the meanings associated with STIs, resulting in different stigma experiences and generally higher negative impacts among women.
The continued impact of the good/bad dichotomy on women's perceptions of STIs is captured in the qualitative work of Nack (2002). In her work, discourse evolved around sexual behaviour norms and behaviour that was deemed appropriate for women evolved around the moral division of respectable or 'good girls' and disreputable or 'bad girls', leading to the development of the idea of 'tribes of womanhood'. Membership in the 'good girl tribe' or morally-correct category, whether through actual behaviour, avoidance of STI or concealment of behaviours or diagnoses, was precarious, while membership in the 'bad girl tribe', was easy to gain and often thought of as irreversible.
In addition to the potential psychological harms an individual might deal with when faced with a positive STI test result, there may also be an impact on testing and treatment behaviours at the population level. In part, this may be explained by the additional STI-related stigma that can arise within health care settings (e.g., patients must reveal the relevant details of their sexual behaviour in order to seek help from caregivers, thereby risking becoming discredited; patients may also fear being discredited to other clinic staff who may have access to their charts). Patient comfort, appropriate staff communication, confidentiality and respect for the feelings of the women have been identified as key stigma-related factors that need to be addressed in the provision of STI services. A similar study in the southern U.S. outlined four important concepts of stigma that surfaced from qualitative focus groups, including religious ideation of health care workers affecting their views of 'promiscuous' women, privacy fears among men, racial attitudes and stigma transference or fear of being labelled. Thus, the ability to present safely and comfortably in a clinic setting can be disturbed by actual or perceived discriminating attitudes of the other clinic attendees, the doctors and nurses, or other clinic staff.
Stigma scales exist for general disabilities, mental health, and more recently for HIV/AIDS. There are, however, few scales that examine stigma in relation to STIs (notably, Fortenberry's stigma and shame scales) and none that incorporate female stereotypes related to sexual morals, as well as the perceptions of both the community in general and health care professionals in particular. The purpose of this study was to develop a stigma scale specific to women, which encompassed a broader range of the stigma experience associated with sexuality and STIs. The present paper outlines the preliminary development of such a scale, and assesses the demographic and behavioural characteristics associated with the resulting scales.