April 4, 2002
In one study, 59 percent of men who had never been tested for HIV cited fear of negative social consequences as an important reason for not seeking testing. Stigma may influence pregnant women's refusal to be tested for HIV despite the benefits of treatment during pregnancy. A recent Institute of Medicine report identified stigma as a key element of the "hidden epidemic" of STDs in the United States. An additional implicit characteristic of stigma is that it represents socially shared knowledge understood even by the targets of the stigmatizing attitudes and behaviors. Thus, shame can be an internalized reaction to stigma.
The purpose of the current research was to examine relationships of stigma and shame with two types of STD-related care: receipt of a test for gonorrhea during the past year and receipt of at least one HIV test in the previous year. Receipt of gonorrhea or HIV screening requires care seeking by individuals and communication with clinicians that may be affected by stigma, shame, or both. In the case of both gonorrhea and HIV, screening provides an opportunity for risk-reduction interventions among those who are not infected. Among those infected, effective treatment and control strategies can reduce the risk of sequeale and limit transmission to others. STD/HIV-related care could therefore be improved through a better understanding of factors such as stigma or shame that may act as barriers to appropriate screening.
Data were collected in 1998 as part of the Gonorrhea Community Action Project, a multi-site research program designed to evaluate STD-related care from the multiple perspectives of clients, providers, and health care systems. Two dependent variables were chosen: gonorrhea testing and HIV testing. Respondents were asked, "In the past 12 months, how often have you been to a doctor, hospital or clinic to get tested for gonorrhea?" A similarly phrased question assessed HIV testing in the past year. STD-related stigma and STD-related shame were measured via items developed for the current research. A larger set of items was developed to assess personal reactions to STD and STD-related testing as well as perceptions of others' responses to these issues.
The researchers' finding that stigma, rather than shame, may be a barrier to STD-related care seeking highlights the potential difficulties facing interventions designed to improve STD-related care seeking. "Increasing knowledge or health care access may not address the barriers posed by STD-related stigma," the authors concluded. "Community-wide interventions, advocacy, and education might be expected to achieve some gains, although the (not uncommon) opinion that acknowledgement and discussion of issues such as STD/HIV prevention connote approval of proscribed sexual behaviors makes such approaches difficult to implement."
American Journal of Public Health
03.02; Vol. 92; No. 3: P. 378-380; J. Dennis Fortenberry, M.D., M.S.; Mary McFarlane, Ph.D.; Amy Bleakley, M.P.H.; Sheana Bull, Ph.D.; Martin Fishbein, Ph.D.; Diane M. Grimley, Ph.D.; C. Kevin Malotte, Dr.P.H.; Bradley P. Stoner, M.D., Ph.D.