April 4, 2002
Stigma and shame associated with STDs and HIV infection are important barriers to appropriate diagnostic and treatment services. Stigma and shame are related but distinct constructs. Stigma is defined as an attribute or label that sets a person apart from others and links the labeled person to undesirable characteristics. Shame is defined as a negative emotion elicited when a person experiences failure in relation to personal or social standards, feels responsible for this failure, and believes that the failure reflects self-inadequacy rather than inappropriate behavior.
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.
The original sample included 2,020 individuals ages 12 to 83 years. Researchers restricted the sample to those ages 14 to 59 to focus on the groups at greatest STD/HIV risk. Researchers found that STD-related stigma was associated with a decreased likelihood of being tested for gonorrhea or HIV during the past year. This association was independent of other factors that may affect testing, such as sex, age, and suspicion of gonorrhea. STD-related shame was not associated with receipt of STD-related care. This is not to say that negative emotions associated with STD/HIV-related care are an unimportant element of people's health care experiences. Rather, the perception that others confer negative attributes to those with STDs is associated with less than optimal STD/HIV-related care.
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.