Abstract
Sexually transmitted infections (STIs) and the clinics patients attend for STI management remain stigmatized. Although emphasizing sexual intercourse rather than sexual behaviour as an important factor in STI acquisition may help to destigmatize STIs, this will require a change in the national mindset. A different approach entails destigmatizing genitourinary (GU) medicine/sexual health thereby normalizing the conditions managed in these settings. This may be helped by emphasizing the non-STI-related aspect of GU medicine and by considering a change in terminology that removes the focus from STIs and attempts to absorb the term into the broader category of genital infection.
INTRODUCTION
This paper is a personal view, focusing on stigma and sexually transmitted infection (STI) and addresses two related questions. Firstly, is there a stigma associated with STIs, genitourinary (GU) medicine and GU medicine clinics. Secondly, is this important and if so, what can be done to reduce or remove the stigma?
DEFINITION OF STIGMA
Stigma is a pervasive influence on disease and has recently been highlighted as a topic requiring research at an international level. 1 Ervine Goffman's book entitled ‘Stigma: Notes on the Management of Spoiled Identity’ published in 1963 generated a profusion of research on the subject. He defined stigma as any attribute, trait or disorder that marks an individual as being unacceptably different from the ‘norm’ and which elicits some form of community sanction. 2 Stigma is different from shame, which may be considered ‘self-stigmatization’, reflecting a person's acceptance of the negative aspects of stigma. More recently, Link and Phelan 3 have expanded on Goffman's original definition and consider further interrelated components combining to generate stigma. These include identifying and labelling human differences, stereotyping (linking a ‘labelled’ person to undesirable characteristics), discrimination, and an exercise of power. Scambler 4 categorized stigma as either ‘enacted’, where there is actual public discrimination or unacceptability, or ‘felt’, which refers to the fear of such discrimination. STIs are associated with both. Weiner 5 has argued that when a person is held responsible for an outcome, reactions may include anger, rejection, blame and avoidance of helping. This ‘behavioural causality’ is considered an important dimension of stigma associated with social rejection and is of particular relevance to STIs. 6
The level of stigma attached to a particular condition is both historical and cultural and as such is not fixed. For example, epilepsy has been associated with stigma for at least 4000 years but the condition is now accepted in many, albeit not all, societies. Although much of the literature on stigma has focused on mental illness and, more recently, HIV infection and AIDS, the underlying issues apply equally to all STIs. Considering genital herpes, Breitkopf notes how stigma associated with the condition varies from country to country depending upon attitudes to sexuality and sex. 7
DO PATIENTS WITH A STI FEEL STIGMATIZED?
Is there evidence to support the contention that STIs are stigmatizing? There is ample historical evidence showing castigation and reprobation of people with STIs. 8–12 Although attitudes of both the medical profession and the general public toward STIs have changed, stigma undoubtedly remains. A number of studies have documented negative feelings such as guilt, ‘dirtiness’ and fear of moral judgement among individuals concerned they may have an STI (i.e. ‘felt’ stigma). 13–18 In particular, this has been shown for patients with chlamydial infection, human papillomavirus (HPV) infection and genital herpes. 17,19–22 Using qualitative data from semistructured interviews, Bickford et al. 23 suggest that stigma associated with genital herpes may promote non-disclosure to sexual partners. The perceived link with ‘moral wrong’ and fear of rejection were common themes.
‘Behavioural causality’ and ‘felt stigma’, as outlined above, are of particular relevance to STIs. This is partly the result of the continued belief in the association between STI acquisition and socially and morally unacceptable behaviour, in particular promiscuity. As Brandt and Jones state, ‘it is the stigma associated with sexual behaviour that has been transferred to the infections transmitted by that behaviour … social pathology is superimposed on top of the clinical pathology of the disease.’ 24 The perceived association between promiscuity, STIs and stigma will be discussed later.
Although there is no evidence to show that an individual awareness of STI-associated stigma affects sexual behaviour, there is concern that STI-associated stigma may adversely affect seeking health care, particularly for women. 15,25
IS THERE STIGMA ASSOCIATED WITH GU MEDICINE/SEXUAL HEALTH CLINICS?
The title of Scoular et al.'s paper from 2001 remains poignant – ‘That sort of place … where filthy men go …’ Negative feelings about STIs, such as guilt, ‘dirtiness’ and fear of moral judgement, were seen to be transferred to the GU medicine clinic. 25 Similarly, a study of GU medicine clinic attenders in London identified stigma and shame of attending as a major cause of patient anxiety. 16 Patients felt as if they were seen to be promiscuous or irresponsible. These negative views are not limited to patients but apply equally to non-GU medicine health-care workers who see GU medicine services as dealing mainly with gonorrhoea, syphilis and contact tracing. 26 Importantly, chlamydial infection, pelvic inflammatory disease and other sexual health problems, such as recurrent candidiasis and bacterial vaginosis, were not ranked as important or appropriate referrals to GU medicine.
POSSIBLE APPROACHES TO REDUCING STIGMA
Reducing stigma associated with STIs
The major cause of stigma associated with STIs relates to the perceived link with irresponsible sexual behaviour, in particular promiscuity. This may be summarized as ‘STI acquisition ≡ promiscuity ≡ immoral behaviour’, therefore ‘STI acquisition ≡ immoral behaviour’. Changing public moral opinion on sexual behaviour with respect to frequency of partner change and number of sexual partners (i.e. ‘promiscuity ≡ immoral behaviour’) requires a societal mind shift and is likely to remain beyond the remit of clinicians. However, the assertion that ‘STI acquisition ≡ promiscuity’ requires clarification. The association of STI acquisition with number of sexual partners is well documented. 27,28 For example, studies of patients attending London and Sheffield GU medicine clinics reported a significant association between having an acute STI, in particular gonorrhoea and chlamydial infection, and having three or more sexual partners in the previous 12 months. 29,30 There is, however, an important caveat; the relationship between partner number and risk of STI acquisition appears non-linear.
A study of female college students found an eight times increased risk of having an STI with five or more partners during the previous 3.5 years compared with those with one partner. 31 A similar trend has been documented for patients with chlamydia, warts, herpes and hepatitis B infection. 32–34 In the latter study, more than 10 partners resulted in a quantum leap in the risk of hepatitis. 34 The public health message for reducing the risk of STI acquisition is straightforward; ‘the more sexual partners the greater the risk of acquiring an STI’, with the degree of risk rising appreciably at a certain threshold number of partners for some infections. However, the concept of ‘degree of risk’ is crucial and produces a different public message for reducing STI-associated stigma, that is, ‘having sex is a risk factor for acquiring STIs’. This is supported by studies reporting the sexual behaviour of many patients with STIs to be similar to the general population. For example, a study of GU medicine clinic attenders found that 48% of women and 28% of men presenting with an acute STI had only one sexual partner in the previous twelve months, 30 a comparable figure to the NATSAL 2000 study that reported a mean of 1.56 and 0.86 partners in the previous 12 months for single men and women between 16 and 24 years of age. 35 Similarly, studies of patients with chlamydial or gonococcal infection have found that 29–74% report 0–1 partners in the previous 1–12 months. 36–39
A further important point is the reported lack of correlation between the acquisition of viral STIs (in particular, human papillomavirus/genital warts and herpes) and number of sexual partners. A high rate of partner change is considered less important to maintain endemic levels of viral infections that have longer periods of infectiousness than bacterial STIs. 30,40,41
The current HPV vaccination programme provides an excellent opportunity to provide public education and destigmatizing information on STIs. Emphasizing the high prevalence of HPV infection, with up to 80% of young women becoming infected, 42 has been shown to reduce feelings of stigma; 21 sexual intercourse becomes the important factor not sexual behaviour.
Reducing stigma associated with GU Medicine and GU medicine/sexual health clinics
This is closely linked to the concept that the stigma associated with STIs is projected onto the services for their care and control. 25,43 One approach to destigmatize GU medicine is therefore through destigmatizing STIs, as advocated by a number of authors. 25,43,44 This is certainly valid and possibly achievable through appropriate public education but, as suggested above, the required societal mind shift is likely to be slow to achieve. A different and potentially easier approach would be to attempt to distance STIs from GU medicine by promoting GU medicine as a medical specialty that deals with genital and sexual health problems; STIs are included but diluted by the much wider remit. This is converse to previous suggestions and is an attempt to normalize the conditions seen at GU medicine clinics by normalizing the clinics that manage the conditions. Although most GU medicine practitioners manage a wide range of sexual health problems, possibly appreciated by medical colleagues, this important aspect of our work may benefit from greater emphasis. Promoting GU medicine clinicians as STI practitioners works against the destigmatizing aspect of the non-STI work. The advantage of the ‘destigmatizing GU medicine’ approach is the ability to implement at a local rather than at a national level, although combined local initiatives may well result in national change. There is sufficient evidence to support an approach that emphasizes a shift in focus from STIs and promotes the non-STI aspect of the GU medicine workload when interacting with the public and non-specialists. For example, considering data from United Kingdom GU medicine clinics, from just over one million diagnoses made in 2007, 20% were for non-STIs. Many GU medicine practitioners have an expertise beyond STIs and manage patients with, for example, genital dermatological conditions, vulval disease and psychosexual problems, with some achieving national and international recognition for their non-STI related work. Importantly, although practitioners in GU medicine may consider it appropriate to manage non-STI-related conditions, some of our colleagues may still prefer not to refer and patients not to attend what they perceive as an STI clinic. A further reason for promoting our services as ‘GU medicine’, with less emphasis on STIs. Data showing similar sexual behaviour between GU medicine clinic attenders and the general population further aids the destigmatization process. For example, a study of London and Sheffield GU medicine clinics found that 53% of patients reported 0–1 sexual partners in the previous 12 months, with 26% reporting two partners and only 20% more than two partners. 30
Practices that reinforce the link between GU medicine and GU medicine clinics with STIs in the public eye and the non-GU medicine clinical domain serve to reinforce an inappropriate message. A few possible approaches to help avoid the ‘STI reinforcement message’ are listed in Table 1.
Possible approaches to help avoid an ‘STI reinforcement message’
GU = genitourinary; STI = sexually transmitted infection
In conjunction with the points made above and elaborating on point (iii) in Table 1, one could suggest a shift in terminology from the term ‘STIs’ to ‘GU infections’ or ‘genital infections’, thereby including, appropriately, conditions such as candidiasis, bacterial vaginosis, UTIs, prostatitis, etc. Genital infections may thus be sub-divided into non-sexually acquired (GINSA) and sexually acquired (GISA), with the emphasis on ‘genital infection’. Conditions such as hepatitis and HIV infection would be classified as sexually acquired non-genital infections, if acquired by the sexual route. The work of the GU medicine practitioner is now promoted as the diagnosis and management of infectious diseases, in particular genital and some blood borne viruses, and non-infectious conditions, such as genital dermatoses, psychosexual problems, etc. STIs obviously remain, but not by name, and are diluted by the other aspects of GU medicine.
CONCLUSION
Destigmatization should be considered an important component of modernizing sexual health but often fails to feature prominently in discussion. 45 Patients with non-sexually acquired genital infections and other genital conditions will continue to attend our clinics and are well managed by practitioners trained in GU medicine. Whether GU medicine can develop services for chronic conditions, such as prostatitis, given the strengthened focus on STIs, has been questioned. 46 However, the move towards managing uncomplicated STIs in the community setting provides an ideal opportunity for promoting GU medicine for the management of patients with diverse sexual health problems in addition to the more complex STI cases. Destigmatizing STIs require a shift in mindset. By focusing on STIs in our discussions and interactions with the public and medical colleagues, GU medicine clinicians will continue to reinforce the image of being STI clinicians. Emphasizing, but not necessarily promoting, the non-STI aspects of our work and moving to the term ‘GU infections – sexually acquired and non-sexually acquired’ may be helpful as initial steps in the process of destigmatizing STI in the UK.
Following a landmark international conference ‘Stigma and Global Health: Developing a Research Agenda’, a call was made for research incorporating both a qualitative and quantitative approach. 47 With the excellent epidemiological data on infection prevalence using NAATS combined with data on sexual behaviour, the developments in sexual health care including, for example, herpes simplex virus serology and human papilloma virus vaccination, and the wide sexual health remit of GU medicine departments, this may be an ideal time for launching a ‘destigmatizing’ and linked research programme in the UK.