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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”

        

Hatred, Violence and AIDS-Related Stigma

Psychodynamic Processes of a Social Phenomenon

http://www.du.edu/

 

Daniel Whelan, Ph.D. Student
Graduate School of International Studies
University of Denver
Denver, CO

June 1999


Note: This paper is a draft, and is not to be distributed or quoted without express authorization from the author. It is a seminar paper submitted for the course, "Hatred and Group Conflict," INTS 4948 (Professor David Levine).
Comments are welcomed and encouraged. Please send them to me at: dwhelan@du.edu

Introduction: HIV/AIDS-Related Violence

Discrimination against people living with or otherwise affected by HIV/AIDS has been dubbed "the third epidemic" of HIV/AIDS, the first being the spread of the virus itself, followed by the clinical disease, acquired immune deficiency syndrome (AIDS). Every society in the world has provided evidence of HIV/AIDS-related discrimination and violence. As with most forms of discrimination, its manifestations range from the subtle to the fully institutionalized. Some countries have adopted legal protections for people living with HIV/AIDS; however, there is no evidence whether these measures have resulted in reductions in the incidence of HIV/AIDS-related discrimination or violence. In most countries, the law is silent about HIV/AIDS-related forms of discrimination and violence perpetrated by either public or private actors.

In the public health literature—and, increasingly, in the human rights literature as well—writers and analysts have paid a great deal of attention to the influence that violence has on the pace of the epidemic and its social, economic and political consequences. Consequently, combating discrimination and violence have become central to world-wide efforts to respond effectively to the pandemic. Research exploring the gender dimensions of HIV/AIDS risk and vulnerability have demonstrated that male-on-female violence or the threat of violence thwarts efforts aimed at preventing the spread of HIV. Scores of studies show that when women propose risk-reduction strategies such as the reduction of sexual partners on the part of male partners, and the use of barrier methods (e.g., male condoms), violence or the threat of violence is the result. Analysts have demonstrated the counter-productivity of other forms of discrimination on slowing the epidemic, proving that measures such as forced hospitalization, quarantine, and restrictions on freedom of movement and association actually contribute to societal vulnerability to HIV. Fear of reprisals or other government sanctions thwarts public health efforts by driving hard-to-reach populations away from the HIV/AIDS-related prevention, care and treatment services and messages. Thus, the prevention of violence against people living with HIV/AIDS, and punishment of those responsible, are among the most prevalent human rights activities related with HIV/AIDS work.

Although violence itself has remained a prominent subject in the HIV-human rights literature, practically all writing and analysis on the subject follows a familiar pattern of: (a) describing the various manifestations of HIV/AIDS-related violence; (b) discussion of overall prevalence and/or incidence trends associated with other societal reactions to the epidemic, and; (c) recommendations for educational, public health, legislative, and judicial actions to reduce the prevalence and incidence of HIV/AIDS-related violence. Rarely is there any discussion of the motivations of people who perpetrate such violence. The conclusion is that such violence is a "hate crime," a term which seems to bear significant meaning or explanatory value.

Fear is often cited as the primary motivation for HIV/AIDS-related discrimination and violence. Fear in this sense is the fear of contagion, disease, and those who have it. While this seems to make logical sense, it falls short of a much more complex set of psycho-dynamics. In order to gain a deeper insight into the phenomenon of HIV/AIDS-related violence, this paper will explore the literature on psychodynamic processes that further explain violence against people living with HIV/AIDS or perceived to be HIV-positive. It will especially focus on the concept of the stigma of HIV/AIDS as disease and product of other stigmatizing conditions and behaviors. By doing so, the paper will unpack the supposed role of hate as a motivator for violence, and examine the ways in which shame, jealousy, envy, and power contribute to this "third epidemic."

HIV/AIDS as Disease

HIV/AIDS is an infectious (not contagious) disease caused by a viral agent that destroys the human immune system over a period of several years. The virus is transmitted through the commingling of bodily fluids between people. The most common medium of exposure is unprotected vaginal, anal, or oral sexual contact. There are no reported cases of exposure through kissing, biting, or spitting. The second most common means of exposure is perinteral: receiving transfusions of infected blood or blood products, accidental exposure from tainted skin-piercing instruments, or through the sharing of needles and other "works" associated with IV drug use. The third means of exposure is perinatal: between infected mother and fetus (in utero) or between mother and infant during childbirth or breast-feeding.

People living with HIV (before the onset of AIDS) rarely manifest physical signs of the disease. In the final stage of the illness (AIDS), the weakened immune system is increasingly unable to cope with any other infectious disease. Commonly associated with late stages of AIDS are skin lesions associated with a rare skin cancer (Kaposi’s sarcoma) and severe weight loss (commonly referred to as "wasting"). Other physically disfiguring conditions include AIDS-related dementia complex, oral thrush (candidiasis, a white film on the tongue) and infection with molluscum contagiosum, causing disfiguring lesions on the mouth and face.

Since its identification in 1981, HIV/AIDS has appeared in every country of the world. Current estimates place the cumulative number of infections (i.e., since the mid-1970s) at over 47 million. In 1998, 2.5 million people lost their lives to the disease, adding to the 11 million that have died since start of the pandemic. The World Health Organization recently announced that HIV/AIDS is now the fourth leading cause of death throughout the world, and is responsible for more deaths than any other infectious disease.

HIV/AIDS therefore invokes a wide range of mental imagery associated with the body and violence to it. The letting of bodily fluids through piercing and cutting; images of bleeding and blood; deterioration and marking of the skin through eruptions, the notion of "invasion" of the body by an outside agent; loss of mental capacity; wasting and deterioration. In this sense, HIV/AIDS is no different from any other disfiguring disease or condition, in that it invokes a sense of unease to the person confronted with it. As Alonso and Reynolds describe it, "[d]isease is essentially a deviation from what we expect or what we have been told to expect by medical authorities. However, some diseases are imputed with additional meaning and significance…"

The phenomenon of HIV/AIDS is largely socially constructed. Since the beginning of the epidemic, anxiety and fear have predominated as major subtexts of this construction. The language used to describe the epidemic and those associated with it serve as ample demonstration. In the early years, we spoke of the "AIDS crisis." A sense of clearly demarcated boundaries is reinforced by the construction of two camps: "risk groups" and the "general population." In an attempt to mobilize scarce resources in many countries, agencies produce reports that describe an epidemic that is "out of control." The illness is "uniformly fatal;" the epidemic "potentially catastrophic."

These images tend to provoke group anxiety. Herek and Glunt suggest that the sense of urgency and vulnerability lead to a "hypervigilant" style of decision-making. Feeling the sense that there is little time to carefully weigh alternatives to dealing with the "problem," decision-makers tend to resort to paths of least resistance. They find excuses for adopting politically "expedient" solutions based on scapegoating and the assignment of blame on particular groups of people. While this in itself is not the central argument of this paper, I believe such attitudes, especially when legitimized through the political process, play a role in removing important sources of inhibition to those who eventually commit acts of violence against people living with HIV/AIDS.

 

HIV/AIDS as Dis-Ease

To many researchers, the recognition that HIV/AIDS is stigmatizing for its very nature as deterioration of the body is often interrelated to its association with already stigmatizing conditions and behaviors associated with the disease and its transmission. As Herek and Glunt observed in the relatively early years of the epidemic in the U.S., HIV/AIDS-related stigma "is a socially-constructed reaction to a lethal illness that has been most prevalent among groups that already were targets of prejudice."

This might suggest that we can ignore the stigma associated with the illness itself and move on to a focus on those who have it and why. But it is the combination of stigmas—disease and its identity—which leads to possible explanations of motivations for HIV/AIDS-related violence. One "take" on this issue is that a life-threatening illness (such as HIV/AIDS) confronts the non-infected with a sense of mortality, discomfort, dis-ease, which provokes a sense of anxiety. As Herek and Glunt see it, "healthy individuals distance themselves from death by defining the illness as an affliction of others." The "others"—drug users, prostitutes, gay men, immigrants, even hemophiliacs (who are already ill)—become objects of projection of this "dis-ease" from the non-infected to the infected. Associated with these projections (more of which I will turn to below) is the concept of "transmission." The virus is transmitted, as are blame, shame and feelings of anxiety and anger transmitted in a dynamic movement in and out of psychic realities.

Stigma and HIV/AIDS

According to Alonso and Reynolds, "stigma is a broad and multidimensional concept whose essence centers on the issue of deviance." Stigma can include "the entire field of people who are regarded negatively, some for having violated…rules, others just for being the sort of people they are or having the traits that are not highly valued." Goffman views stigma as

…a powerful discrediting and tainting social label that radically changes the way individuals view themselves and are viewed as persons. When individuals fail to meet normative expectations because of attributes that are different and/or undesirable, they are reduced from accepted people to discounted ones. Thus, the discrepancy between what is desired and what is actual, ‘spoils’ the social identity, isolating the individual from self, as well as, social acceptance.

The word "stigma" has its etymological origins from the Greek word "to brand" or "to mark" (for runaway slaves), and thus "was extended to embrace any mark or sign for perceived or inferred conditions of deviation from a norm." Oddly enough, the word (in its plural form, stigmata, is also used to describe the marks of the crucified Christ that have been documented to have been physically manifested on a small number of "elect" people throughout history. Taking this other meaning of what it is to be "stigmatized" conforms to the psychodynamic phenomenon of projective identification (in the form of envy) felt by the perpetrator of violence toward the stigmatized HIV-positive person.

 

Envy

One way to begin to conceive of a complex psychodynamic process between victim (the person with AIDS, PWA) and the perpetrator of the violence is to consider how it might be possible for the perpetrator to envy the PWA. According to Klein and Riviere, a need to "secure oneself against the loss or danger within and without induces some people to accumulate and store up all the good they can lay hold of," leading to a cycle of envy. In the psychic reality of the perpetrator, PWAs have many things: power, attention, compassion. They have the power to infect, and thus hold the key to causing fear among others, the power to threaten. They have attention: their condition, their "plight" as a community receives media attention. Resources from governments and other agencies and charities are provided for them. There are "AIDS Walks" and "AIDS Rides." People pay attention to them, and give them things they need. Finally, and most importantly, they receive love and compassion. Goffman suggests that no matter how small or bad off a particular stigmatized group is, they are generally given some kind of public presentation. Alonso and Reynolds also point out that "[t]elevision and films, aside from newspapers and magazines, are voracious consumers of human interest stories which allow us to vicariously enter the world of the deviant, the distressed, and the stigmatized. These sources of information have the capacity to enlighten, to liberate and to focus attention and generate sympathy and compassion."

 

 

This photograph, produced in 1992 by the United Colors of Benetton Company, portrays just such a display of love and compassion. Ironically, it also plays on the concept of the "good" stigma of Christ, given the remarkable resemblance between David Kirby (the subject of the photo and a British AIDS activist) and Jesus Christ. This photo campaign generated a great deal of public protest and condemnation.

Another example of the role of envy in hate of people with AIDS can be found by looking closely at the public statements of the Westboro Baptist Church and its leader, Fred Phelps. The organization’s website, "God Hates Fags" offers a whole host of answers to those who want to understand their vitriolic hatred of gays and anything associated with them, including AIDS. In response to the question "Why do you say ‘Thank God for AIDS?’", the response is:

Because God is a sovereign God, and should be thanked for all of His righteous judgments, whether you like them or not. Everyone who gets AIDS gets it as a direct result of God's will (including babies and people who get it from blood transfusions), and He should be blessed for it.

Could this be envy? To receive God’s will, even in the form of punishment from Him, is a considerable source of envy for those who may never receive any form of attention from God, or never know "God’s will." After all, God "should be thanked for all of His righteous judgements."

Another source of envy of PWAs could also emanate from the associational stigma of HIV/AIDS with behaviors of those stigmatized by the disease itself. In reviewing several different stigmatic frameworks associated with HIV/AIDS, Alonso and Reynolds cite six main sources of HIV/AIDS-related stigma. In their view, the illness is:

  1. associated with deviant behavior;
  2. viewed as the responsibility of the individual;
  3. represents a character blemish because it is though to be contracted through a morally sanctional behavior;
  4. perceived as contagious and threatening to the community;
  5. associated with an undesirable and unaesthetic form of death, and;
  6. not well understood by the lay community and viewed negatively by health care providers.

A focus on the first three is illuminating, since they may indeed represent the most important reasons why HIV is stigmatizing. They also represent significant associations with enviable character traits. Numbers four and six, which are often cited as "reasons" for the passage of discriminatory policies and practices to "protect" the public health, mask the deeper lying causes of stigma. The association of HIV/AIDS with deviant behavior could be thought of as envy of behavior that is "free of responsibility." The stigmatized (in this case, PWAs) are an expression of the vitality that those "outside" lack.

Envy produces feelings of inadequacy and a sense of anger and injustice. However, perpetrators of violence identify with their victims through envy of what they have. It may thus create the first of the necessary conditions for hatred to turn into violence. Through a process of projection, perpetrators must be able to sense in their victims a place where they can feel justified in taking away from them those things that make them the object of envy: their vitality.

 

Projection

Projection is a psychodyamic process wherein the perpetrator projects some part of himself onto another person by attributing to that person qualities that will therefore provoke a response consistent with the attainment of a sense of justice. "All painful and unpleasant sensations or feelings in the mind are by this device automatically relegated outside oneself; one assumes that they belong elsewhere, not in oneself…we blame them on to someone else." Feeling that the danger is placed outside of us, perpetrators of violence are then in a position to channel the anxiety and anger they feel toward this object (person) who now contains the evil. They are now a suitable target for aggression.

Another concept that is helpful in thinking about projection as a process for stigmatizing people living with HIV/AIDS is projective identification. We may split the externalization of our feelings and search for "containers" to carry both good and bad qualities about ourselves. The concept of shame is critical here, as the projection of shame onto an external community is a powerful mechanism for ridding ourselves of this feeling. And studies show that people living with AIDS absorb these projected feelings of shame, turning the psychic fantasy of the persons projecting the shame into an actuality.

In this sense, attitudes toward people living with HIV/AIDS can be understood according to the psychological needs they meet. According to Herek and Glunt, anti-gay attitudes help "fix past or anticipated experiences with gay men/lesbians into existing cognitive categories. Expressing those attitudes can help individuals improve their self-esteem, reduce anxiety, secure social support. So, for example, a fundamentalist Christian will condemn a gay men in order to affirm her vulnerable sense of self as a "good Christian." She then interprets AIDS as God’s punishment for homosexuality. In order to conform to the notion of being a good Christian, she will further condemn a person living with HIV/AIDS to boost her self-esteem even more.

The connection between projection, responsibility, blame and condemnation (and, even action) is a powerful one. Following the model used by Volkan, the projection of one’s "good" self into a container for that good (such as a Christian community) means that we also need a place to project our "bad" self (feelings of shame) into an "enemy" community: people with AIDS. But in order not to lose the good and bad of ourselves, we need to continue an identification—a lasting relationship—with those containers. So a person stays active in the Church, and continues to condemn and attack PWAs and homosexuals. This seems to make perfect sense in understanding what motivates Fred Phelps and his right-wing organization (called a "church") to actually place on their website an image of murdered gay college student Matthew Shepard, surrounded by flames, screaming for help from the depths of hell.

Achieving a sense of justice for that which a perpetrator has lost into the projected object (a sense of vitality) or in order to be "good" by attacking that which is "bad" is that which allows a perpetrator to dismantle the truth and remove those barriers that separate impulse to act from the actual act itself. When considering the social weight that burdens individuals stigmatized for their sexuality, the psychic pain of being gay (especially when being gay is so closely associated with getting HIV) might be enough to lead to violence through of fit of evacuation. Gilligan’s contention that psychic pain is worse than physical pain is useful for thinking about this particular psychodynamic process.

 

 

Conclusion

This paper has explored some of the psychodyamic processes that contribute to violence against people living with HIV/AIDS. Scores of stories about such violence, from people being beaten or otherwise abused physically, taunted, harrassed, fired from jobs, or having their houses burned, are legion throughout the world. Violence against people living with HIV/AIDS has been shown to fuel a larger cycle of vulnerability to the epidemic and its social and economic impact.

For some of the individuals who perpetrate such violence, public health campaigns aimed at educating the public about the realities of HIV/AIDS may only reinforce a strong sense of already-existing envy. For those people, no blanket policy or campaign to reduce HIV/AIDS-related stigma may ever influence their real or potential violence. However, for many other potential perpetrators, the strengthening of those barriers between impulse and action—those other "realities" that may allow a person to think for a moment before evacuating a rage upon a victim—may alleviate some instances of HIV/AIDS-related violence. But as this paper has also shown, it is critically important for those designing stigma-reducing policies and programs to recognize the intricate relationship between different stigmas that interact at the intersection of HIV/AIDS, including gender and sexuality. Furthermore, care must be taken so as not to fuel one kind of public anxiety in an attempt to "get the message out" or respond to a sense of "out of control" urgency. These efforts have been shown, in many instances, to exacerbate public anxiety about HIV/AIDS.

Notes

 Throughout this paper I will be using the term "HIV/AIDS" to describe the bio-medical/health condition that begins with infection by the human immunodeficiency virus (HIV), progresses toward a set of clinical conditions that together constitute a diagnosis of acquired immune deficiency syndrome (AIDS). Where a distinction is made between "HIV" on the one hand and "AIDS" on the other, it is because I am referring specifically to, for example, the clinical definition of AIDS (i.e., a CD-4 count at or below 200 per cubic milliliter of blood, and one or more of a series of "opportunistic infections" commonly experienced by people with severely suppressed immune systems.

 

. See, for example, U.N. Commission on Human Rights, Second International Consultation on HIV/AIDS and Human Rights, Report of the Secretary-General. U.N. Doc. E/CN.4/1997/37.

 

 Daniel Whelan, Gender and HIV/AIDS: Taking Stock of Research and Programmes, (United Nations Joint Programme on HIV/AIDS, 1999), 11.

 

Sofia Gruskin, Katarina Tomasevski and Aart Hendriks, "Human Rights and Responses to HIV/AIDS," in Jonathan Mann and Daniel Tarantola, eds., AIDS in the World II (London: Oxford University Press, 1996), 327.

 

For example, there have been studies that have looked at correlations between the rise or fall of reported HIV-related violence and, for example, a famous person "coming out" with the news of his HIV-positive condition.

 

Robert D. Redfield and Donald S. Burke, "HIV Infection: The Clinical Picture," in The Science of AIDS: A Scientific American Reader (New York: W.H. Freeman and Co., 1989), 68-70.

 

United Nations Joint Programme on HIV/AIDS (UNAIDS) and the World Health Organization (WHO), AIDS epidemic update: December 1998, 2

 

UNAIDS, "AIDS Moves Up to Fourth Place Among World Killers," UNAIDS Press Release , May 11, 1999.

 

Angelo A. Alonzo and Nancy R. Reynolds, "Stigma, HIV and AIDS: An Exploration and Elaboration of a Stigma Trajectory," Social Science and Medicine (41) 1995, p. 305.

 

Gregory M. Herek and Eric K. Glunt, "An Epidemic of Stigma," American Psychologist (43) 1988, p. 888.

 

Alonso and Reynolds, 303.

 

A. Birenbaum and E. Sagarin, Norms and Human Behavior (New York: Praeger) 1976, p. 33, as cited in Alonso and Reynolds, p. 304.

 

E. Goffman, Stigma: Notes on the Management of Spoiled Identity (New Jersey: Prentice-Hall) 1963, as cited in Alonso and Reynolds, p. 304.

 

Bernard Weiner, Judgements of Responsibility: A Foundation for a Theory of Social Conduct (New York: Guilford Press) 1995, pp. 53-54.

 

Melanie Klien and Joan Riviere, Love, Hate and Reparation (New York: Horton) 1964, p. 25.

 

Goffman, 25, as cited in Alonso and Reynolds, 304.

 

Alonso and Reynolds, p. 304.

 

Westboro Baptist Church Website, "Frequently Asked Questions (FAQ)", http://www.godhatesfags.com/wbcfaq.html#AIDS

 

Alonso and Reynolds, p 305.

 

Klein and Riviere, 11.

 

Gill Green, "Attitudes Towards People with HIV: Are They as Stigmatized as People with HIV Perceive Them to be?" Social Science and Medicine, (41,4) 1995, 558-559.

 

Herek and Glunt 889.

 

Vamik D. Volkan, The Need for Enemies and Allies: From Clinical Practice to International Relationships (New Jersey: Jason Aronson) 1994.

 

Westboro Baptist Church Website, http://www.godhatesfags.com/memorial.html

 

See generally, James Gilligan, Violence: Reflection on a National Epidemic, (New York: Vintage Books) 1996.

 

Gilligan, 33.

 

References

Angelo A. Alonzo and Nancy R. Reynolds. 1995. "Stigma, HIV and AIDS: An Exploration and Elaboration of a Stigma Trajectory." Social Science and Medicine (41): 303-315.

Gilligan, James. 1996. Violence: Reflection on a National Epidemic, (New York: Vintage Books).

Green, Gill. 1995. "Attitudes Towards People with HIV: Are They as Stigmatized as People with HIV Perceive Them to be?" Social Science and Medicine (41,4): 557-568.

Gruskin, Sofia, Katarina Tomasevski and Aart Hendriks. 1996. "Human Rights and Responses to HIV/AIDS," in Jonathan Mann and Daniel Tarantola, eds., AIDS in the World II (London: Oxford University Press), 326-340.

Herek, Gregory M. and Eric K. Glunt. 1988. "An Epidemic of Stigma," American Psychologist (43): 886-889.

Katz, I., D.C. Glass, D. Lucido, and J. Farber. 1977. "Ambivalence, Guilt and the Denigration of a Physically Handicapped Victim." Journal of Personality (45,3):419-429.

Klien, Melanie and Joan Riviere. 1964. Love, Hate and Reparation (New York: Horton).

Redfield, Robert D. and Donald S. Burke. 1989. "HIV Infection: The Clinical Picture," in The Science of AIDS: A Scientific American Reader (New York: W.H. Freeman and Co.), 63-73.

United Nations Joint Programme on HIV/AIDS (UNAIDS) and the World Health Organization (WHO). 1998. AIDS epidemic update: December 1998 (Geneva: UNAIDS and WHO).

Volkan, Vamik D. 1994. The Need for Enemies and Allies: From Clinical Practice to International Relationships (New Jersey: Jason Aronson).

Whelan, Daniel. 1999. Gender and HIV/AIDS: Taking Stock of Research and Programmes. Geneva: United Nations Joint Programme on HIV/AIDS (UNAIDS).