Counteracting Stigma in
Sexual Health Care Settings
Gillian White, Annette Mortensen:
Counteracting Stigma in Sexual Health Care Settings. The
Internet Journal of Advanced Nursing Practice. 2003. Volume
6 Number 1.
Sexual health clinics and the
people who visit them commonly face stigma. Sexually
transmitted infections have historically been used to
divide people into "clean" and "dirty". A grounded
theory study of the work of sixteen nurses in six Sexual
Health services in New Zealand was undertaken to explore
the management of sexual health care. The study
uncovered the psychological impact of negative social
attitudes towards the people who visit sexual health
services and to the staff who work there. Sexual health
nurses manage the results of stigma daily and reveal in
their interactions with clients a process of
The provision of sexual health care is socially complex and
difficult work. A contributing factor is the widespread stigma
associated with sexual health clinics and sexually transmitted
1 . Daily,
nurses encounter people who feel ashamed, humiliated, defensive
and frightened about their situation. Nurses working in sexual
health clinics know how to respond to social, psychological and
cultural reactions based on their experience in practice and are
aware that clients anticipate negative reactions.
Sexual health nurses also encounter negative public and
professional reactions to their work. Other health professionals
and the community may view sexual health nurses, as being
involved with the ‘dirty' aspects of sexuality.
Accordingly, staff in sexual health settings adopt strategies
that convey humanity, safety and normality to counteract stigma.
Counteracting stigma (destigmatisation) is a complex process
during which sexual health care nurses are engaged with
dignifying and advocating for clients who attend sexual health
clinics. The destigmatisation process was uncovered through a
grounded theory study of sixteen sexual health nurses in New
Zealand. In this paper, the study will be described and the
theoretical framework of destigmatisation explained.
The concept of stigmatisation associated with sexually
transmitted infections is well identified in the social science
and medical literature. 1,
Historically, people with sexually transmitted diseases have
been stigmatised. Sexually transmitted infections were incurable
until the advent of antibiotics in the 1940s.1
Prior to this time; syphilis and gonorrhoea were difficult to
treat. Venereal diseases were a serious threat as they could be
fatal, commonly caused infertility, infected neonates, and
caused chronic debilitating illnesses
Although medical treatment has been available for sexually
transmitted diseases since the 1940s, curable diseases such as
chlamydia and gonorrhoea persist, and the prevalence is
Individuals and society use the coping mechanisms of denial and
displacement including, stigmatisation, scapegoating and
discrimination when faced with illnesses that are threatening or
fatal, or for which there is no cure.
Stigma remains a significant barrier to the prevention of
curable infections even when treatment is freely available.
Often society, including some health care professionals consider
that clients have deviated from the norms of respectable
illnesses, and therefore should be punished by being treated as
socially undesirable. The sociological phenomenon of
stigmatising sexual minorities and people with HIV/AIDS and STDs
is well documented in the literature.
6 Stigma operates
when individuals fail to meet what is considered to be normal
and healthy which ‘‘spoils' the social identity, isolating the
individual from self, as well as, societal acceptance'
The tools of derogatory language, mythology and negative
social responses are used to shape attitudes towards targeted
social groups. People with sexually transmitted diseases become
‘them' or the ‘other”. Gilmore and Somerville
9 explored the
process of polarising ‘them', the indecent, dirty and diseased
from ‘us', the decent, clean and healthy. Through
disidentification, scapegoating and discrimination ‘them' become
separate from ‘us'. For instance, the association of genital
wart virus with sexually transmitted diseases has been
recognised as a significant factor in stigmatising women with
cervical cancer. 7
Braun and Gavey 7
in a study of cervical cancer prevention programmes in New
Zealand reported that key informants were not in favour of
associating cervical cancer with the genital wart virus as this
was likely to stigmatise women who developed cervical cancer.
Eng and Butler 8
explored the hidden epidemic of sexually transmitted diseases in
American society. These authors considered that the deeply
embedded secrecy surrounding sexuality was a major contributing
obstacle to effective prevention campaigns. Eng and Butler
8 commented that
while there are consumer-based political lobbies and support
groups for almost every disease and health problem, few
individuals are willing to admit publicly to having an STD.
Although nurses often use interventions to counter
stigmatisation, little is known about the social processes of
managing clients in sexual health services. Research concerning
nurses and sexuality care has mainly focused on values,
attitudes and beliefs. 3,
5 Findings have
indicated a need for more and improved sexuality education. In
order to improve nursing practice, however, sexuality education
needs to be informed by the practical realities of practice
The study undertaken aimed at examining the management of
sexual health practice from the perspective of nurses employed
in sexual health care settings in New Zealand.
14 In the
study a grounded theory approach was used to uncover the
processes of the everyday interactions between sexual health
nurses and their clients. The significance of the study was that
the findings articulated the processes by which the nurses
managed their work, their role and explored the ideological
frameworks that assisted or impeded the sexual health nursing
role. Data collection was guided by the question “How do nurses
manage their encounters with clients in sexual health care
Sixteen sexual health nurses located in both urban and rural
clinical settings in New Zealand were interviewed using a
semi-structured technique. In addition, an expert panel of
sexual health nurses participated in a critical examination of
the preliminary findings. The study gained ethics approval from
Massey University Ethics Committee and the Auckland Health
Funding Authority. Participants self selected having been given
information about the study from service managers. The initial
interviews were minimally structured using questions such as
“tell me about your role,” and “how do you manage difficult
situations?” Following analysis of the early interviews,
theoretical leads were explored in the later interviews.
Examples of leads were listening and reading verbal and
non-verbal cues; building trust and rapport; maintaining
professional boundaries; encountering sexual vulnerability and
Constant comparisons established commonalities and
differences between nurses in their interactive management and
accounted for variations between them. This process was
continued until theoretical saturation was achieved and the
information confirmed the data collected. Informal discussions
with nurses, nursing students and physicians working in sexual
health gave greater scope, meaning, and accuracy to the data.
Substantive coding offered a focus for early data analysis.
Constant comparative analysis gave substance to the data and
coding. Data were reduced into concepts and categories through
line by line analysis looking for words and gerunds that
indicated action. Participants' language was used to ensure the
concepts remained factually grounded in the data. Theoretical
concepts were developed and connected through the reduction of
coding categories. In this way original categories could be
abstracted into a theoretical code. As each theoretical code
emerged new data were compared; previous tentative codes were
recategorised and reorganised.
Selective sampling of the literature reinforced the resulting
conceptual framework. At this stage a core variable emerged
which synthesised a number of related themes of social
interactions and applied to a range of concepts and conditions.
indicated that the core variable is realised when it accounts
for most of the variation in patterns of behaviour and draws
together relationships between concepts and functions to
integrate a theoretical framework. The core variable that
emerged was Destigmatisation.
Process Of Destigmatisation
Health care practitioners have a powerful role in
destigmatising the experience of sexual health care. If the
health care environment for people with sexually transmitted
diseases is to change, it is important that the wider context of
societal attitude is understood and that professional
responsibility is taken to change the secrecy, stigma, and
silence around sexuality. The commonness and normalisation of
prejudice and discrimination against sexual health populations
requires sexual health nurses to work through destigmatising
processes. In general, a lack of sympathy occurs for those
considered sexually careless and irresponsible. Although a
general awareness exists that marginalisation is an indicator
for poor sexual health status, the issue is generally viewed as
a matter of individual risk and lifestyle. STDs are believed by
some health professionals to be the result of immorality and
clients affected may not receive adequate medical or nursing
care. Braun and Gavey 7
state that ‘the stigma that people feel, rather than how
stigmatised they are by others' is distressing and is crucial in
understanding individual reactions to STDs.
Destigmatising in the context of this study means that sexual
health nurses engage in a process to counteract prejudice and
negative social attitudes towards people who attend sexual
health clinics and who have sexually transmitted infections. The
analysis of nurse's counter reactions to stigma is compared to
Gilmore and Somerville's 9
model of stigmatised reactions towards people with sexually
transmitted diseases. The model describes the processes that
characterise stigmatised reactions: disidentification,
depersonalisation, scapegoating, and discrimination. The process
occurs through the nurse's therapeutic engagement with the
client which is one of identification, personalisation,
respect and dignity and empowerment.
The process of destigmatisation is diagrammatically
represented in Figure 1.
Nurses form the view that it is the negative characteristics
attributed to people who attend sexual health clinics that is
antisocial and not the individuals who present. Nurses position
themselves to counteract the social stereotypes held of people
who attend sexual health clinics and who have sexually
transmitted infections and HIV/AIDS. An alternative experience
is offered to clients in which nurses deliberately construct
care to overcome anxiety and fear and to turn the event into a
positive experience. The nurse, by identifying how they would
feel in a similar situation, comprehends the social dilemma of
the individual. A process of experiential reframing is occurring
in interactions with nurses, in which clients are able to view
themselves differently from the prevailing external views of
people with STDs. The received view is to label individuals as
sexually indiscriminate, irresponsible, unworthy and deviant.
From the initiation of the interaction with the client, the
nurse is engaged in an intensive process of rapport building. In
the words of one nurse:
you have to have a special skill at developing rapport quickly
with people who are extremely nervous about attending. And very
uncomfortable. It's taken a lot of courage to walk through the
door and I think that they pick up if you're uncomfortable so
nurses have to be, or anyone working in sexual health not just
nurses, nurses have to be particularly aware of their own
sexuality and their own sexuality issues, values and beliefs. I
think that's so important to know that so then if something sort
of hits you in the face, you can think where's this coming from
and then think I know, it's a value I have and it's coming hard
up against that. And just being able to put that aside then and
work with the client in a constructive way rather than a judging
way ... (Jill. 1:69).
The social responses and attitudes of sexual health nurses
are shaped by the wider context of societal prejudices, values
and beliefs. Through a process of self-awareness and reflection
nurses put aside attitudes that may be detrimental to client
care. This is part of an active process of personal and
professional destigmatisation. Gilmore and Somerville
9 state that
the target of stigma must be identifiable, recognisable and
assigned. In the case of sexually transmitted infections, people
are not socially identifiable. Being identified occurs in
private, intimate and vulnerable contexts. The points of
identification are within sexual relationships, with health care
practitioners, and in the act of entering a sexual health
clinic. The meanings that STDs have for people will be
influenced by the responses encountered in each of these
contexts. Health professionals have a powerful role in
determining how the individual will internalise the experience.
One outcome may be the internalising of an experience of open
distaste and condemnation. The health professional in this case
is in the act of assigning the individual with the negative
characteristics associated with stigma, the client in turn
perceives those characteristics as belonging to them. For stigma
to operate effectively the individual must own that they belong
to the stigmatised category. Attending a sexual health service
meets recognisable social criteria for people who should be
stigmatised. Being seen in a sexual health service does identify
people as different individuals from others who do not attend.
Unless the professionals employed in those services construct
the event as other than the social interpretation given to such
health care, client self-labelling is reinforced. Communities
tend to treat individuals and groups in society, associated with
sexual infections as social problems, to be distanced,
separated, and disempowered. One nurse identified the use of
social myth making about marginalised sexual minorities as a
means of distancing ‘them' from ‘us':
think that people making that kind of person different ... they
don't want to be seen as anything like ... what they see as a
sexual deviant, whatever that is ... I think that because it's
... so close, like just the whole sexuality thing, anybody who
perhaps is perceived as being slightly different, the sex
worker; the gay man you make myths about them just to get them
away from being anything like you ... So all it's doing is
making it work so that you're further away from it ... (April,
Having an STD is a common experience, however in health care
it is often treated as if it was extraordinary. Sexual health
nurses recognise the paradox of sexuality. Sex is considered
normal and natural however having a sexual infection is not. One
nurse quoted a colleague as saying:
If you do
something as natural as breathing, you risk getting the
influenza virus, and if you do something as natural as having
sex, you risk getting human papilloma virus (Pia, 1:18).
Unlike people with other communicable diseases, people with
STDs are treated as if they were unnatural. People with sexual
health problems frequently report that they are treated in
general health settings as if they were offensive. Having an STD
places people on the social margins along with other stigmatised
social groups. Behaviours towards people who are identified as
having an STD are similar to those towards people who belong to
populations where sexually transmitted infections are considered
to be common, sex workers, injecting drug users, street people,
and gay men. One nurse emphasised that clients were:
disempowered by coming in here anyway. You know, they're under
an awful lot of stress (William, 1:319).
For many people a visit to a sexual health clinic is the
first of experience of being an outsider. Attending a sexual
health clinic is stressful as the client is entering a new
social category and in doing so loses the status and power of
Implications For Nursing Practice And Education
There is a growing recognition in nursing education that it
is an area of specialised practice, however, little is
understood about the social reality of the work. There is a
concern within the profession to improve values, attitudes and
beliefs about sexuality and the practice of sexual health care.
Teaching strategies that raise awareness and desensitise nurses
to the discomfort of discussing sex, need also to incorporate an
examination of the social and cultural context in which sexual
health care takes place. An understanding of the cultural
operation of stigma is essential to nurses who work with peoples
with sexual health care needs.
Understanding the relationship between poor socio-economic
and cultural conditions and poor patterns of sexual and
reproductive self care is significant in future health
prevention and promotion strategies. The practices of sexual
health nurses model brief individualised harm minimisation
strategies that can be used in the time available in a busy
clinical setting. Sexual health nursing presents an opportunity
for the teaching of community based care of marginalised
peoples. Future graduate and postgraduate nursing education
needs to include concepts of shame, stigma and disgrace as
issues of social ill health and dis-ease. Progressively sexual
health care is being presented as a part of the holistic care of
the client, however the implications of the study undertaken are
that the practices are not considered professionally normal,
natural or healthy. For nurses new to the area of sexual health,
the findings of destigmatisation represent the processes
of coming to terms with sex and sexuality. Finding meaning in
sexual health work is balancing the social problems encountered
with the rewards of social agency. New practitioners need to
consider that the work involves a professional commitment to the
rights of women to reproductive choice, to sexual diversity and
to sexual health care for minors. It needs to be professionally
recognised that being involved in work which is contentious and
controversial over a long period of time has a personal impact.
The study reinforces the need for the teaching and incorporation
of nursing debrief and supervision processes.
The process of destigmatisation is the process that
nurses use to manage sexual health care. Through interactions
with clients, colleagues and communities, sexual health nurses
learn the symbolic meaning of work that is involved with
sexuality. Sexually transmitted infections are a social
attribute as much as they are health problem. The experience of
an STD is feeling socially and physically contaminated. The
management of sexual health involves the treatment of infection
and of the social impact of such infections. Destigmatisation is
a conscious process of the reversal of the negative cultural
messages about STDs. Nurses daily are engaged in counteracting
shame, fear and anxiety among sexual health clients.
Destigmatising is a concept for care that is based on the
human rights and dignity of each individual in health care. A
positive experience of health care with a stigmatised disease
can alter client self-perception and self-esteem.
The secretiveness and silence that impedes sexual health care
and stigmatises both clients and practitioners needs recognition
as a social system which health services continue to perpetuate.
The study presents a model for the treatment of stigma that can
be applied in other areas of health care. It is evident that
individual nursing practice is reflective of the social norms
and attitudes of the workplace, which in turn reflect a wider
social context. Setting standards of dignity, decency and
respect for sexual health care populations is an environmental
issue that requires interdisciplinary workplace consensus. There
are few models of care based on the knowledge and experience of
nurses in sexual health practice that are available to inform
the social management of clients. It is recommended that nursing
care is reexamined from the perspective of the theoretical
framework of destigmatisation and in particular the role
of advocacy and social empowerment in nursing.
Financial assistance for this study was received from the
Australian Sexual Health Nurses Association, the SmithKline
Beecham Award, the New Zealand Nurses Education Research Fund,
and the Graduate Research Fund, Massey University
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