Social Science & Medicine 55 (2002) 467–481
Gender gaps, gender traps: sexual identity and vulnerability to
sexually transmitted diseases among women in Vietnam
Vivian Fei-ling Goa,*, Vu Minh Quanb, A Chungb, Jonathan Zenilmanc,
Vu Thi Minh Hanhb, David Celentanoa
a
Department of Epidemiology, Johns Hopkins University School of Hygiene and Public Health, 615 North Wolfe Street, E6007,
Baltimore, MA 21205 USA
b
National AIDS Committee of Vietnam, Hanoi, Viet Nam
c
Division of Infectious Diseases, School of Medicine, Johns Hopkins University, Baltimore, MA, USA
Abstract
We conducted a qualitative study to explore the pathways by which traditional gender roles may ultimately affect
Vietnamese women’s interpretation of sexually transmitted disease (STD) symptoms and health-seeking strategies.
Data on gender roles, perceptions of types of sexual relationships, perceptions of persons with STDs, and STD patient
experiences were gathered through in-depth interviews and focus groups with 18 men and 18 women in the general
population of northern Vietnam. A framework integrating Andersen’s behavioral model of health services use and
Zurayk’s multi-layered model was used to conceptualize women’s health-seeking behavior for STD symptoms. Both
men and women noted clear gender differences in sexual roles and expectations. According to participants, a woman’s
primary roles in northern Vietnam are socially constructed as that of a wife and motherFand in these roles, she is
expected to behave in a faithful and obedient manner vis a" vis her husband. It emerged that men’s marital and sexual
roles are less clearly defined by traditional norms and are more permissive in their tolerance of premarital and
extramarital sex. For women, however, these activities are socially condemned. Finally, since STDs are associated with
sexual promiscuity, both men and women expressed anxiety about telling their partners about an STD; women’s
expressions were characterized more by fear of social and physical consequences, whereas men expressed
embarrassment. Community level interventions that work towards disassociating STDs from traditional social norms
may enable Vietnamese women to report possible STD symptoms and promote diagnosis and care for STDs. r 2002
Elsevier Science Ltd. All rights reserved.
Keywords: Sexually transmitted diseases; Vietnam; Women; Gender norms; Health-seeking behavior
Background
Sexually transmitted diseases (STDs) are a major
health problem affecting the lives of women in the
developing world. Over 200 million STDs occur every
year among women in developing countries (Aral, 1992)
and they are the second leading cause of healthy life lost
in women aged 15–45 (World Bank, 1993). Among
*Corresponding author. Tel.: +1-410-614-4755; fax: +1410-955-1836.
E-mail address: [email protected] (V.F.-L. Go).
women, the biological and social sequelae of STDs are
particularly profound. Long-term biological consequences include infertility, ectopic pregnancy, reproductive tract cancer, and adverse pregnancy outcomes
(Temmerman, 1994). In addition to the associated
morbidity and mortality, STDs are important cofactors
for HIV transmission (Wasserheit, 1992). Studies have
suggested that STD control may decrease the incidence
of HIV (Grosskurth et al., 1995; Cohen, Hoffman, &
Royce, 1997). On a social level, STD symptoms
are often seen as ‘‘unclean’’ and women with STDs
may be stigmatized. Furthermore, in many developing
0277-9536/02/$ - see front matter r 2002 Elsevier Science Ltd. All rights reserved.
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V.F.-L. Go et al. / Social Science & Medicine 55 (2002) 467–481
countries, a woman’s identity is linked to her status as a
mother, and infertility may be grounds for divorce
(Dixon-Mueller & Wasserheit, 1991). Since early and
appropriate STD treatment can shorten the duration of
infectiousness and prevent transmission, improving
acceptability and quality of STD services could be
important components of STD and HIV control that
address both the biological and social impact of these
illnesses.
In resource-poor settings where diagnostic tests are
prohibitively expensive, the World Health Organization (WHO) recommends syndromic-management
guidelines for treating symptomatic patients at primary
health-care services (WHO, 1993). Despite worldwide
acknowledgement that STD control is a worthwhile
target (World Bank, 1993; Over & Piot, 1996), few
studies have examined the socio-cultural barriers to
implementing the WHO’s recommendation. In societies
with traditional gender norms and relatively low status
of women, STDs may be more stigmatizing and women
may be less able to approach primary health care
services for potential STD symptoms. Programs that
encourage women to seek care for possible STD
symptoms in a community must recognize the sociocultural context of STDs.
We examined the influence of social norms on
women’s perceptions of STDs in Vietnam. While most
cultures use social norms to guide behaviors, social
norms in Vietnam are particularly powerful (Gammeltoft, 1999; Pham Van Bich, 1997; Jamieson, 1993).
Confucian social formulas and moral strictures are
central to the society, which stresses the cultivation of
virtuous conduct. The individual is subordinated for the
good of the community. Socially, this is expressed in five
relationships (ngu luan): ruler–subject, father–son, husband–wife, elder brother–younger brother, and friend–
friend (Marr, 1981). Only the friend–friend relationship
held possibilities of egalitarian dynamics; the others
were inherently unequal. In daily life, strong social
norms guide interactions, which ultimately serve to
preserve this system. Traditionally, women were subordinate to men in every stage of life: daughters to their
fathers, wives to their husbands and in widowhood, to
their sons. Women’s identity was centered on their roles
as wives and mothers.
As Marr (1981) states, ‘‘Foremost was the principle of
chastity (trinh), not only the defense of virginity
before marriage but also absolute faithfulness towards
one’s husband, dead or alive, and a purity of spirit
that was meant to transcend worldly desires’’ (p. 192).
Since independence in 1945, the socialist transformation of Vietnamese society has emphasized women’s
equal capacity to participate in social and political life
(Johansson, Nga, Huy, Dat, & Holmgren, 1998).
However, as Gammeltoft (1999) points out, while
government policies have attempted to increase equality
between women and men, they have simultaneously
perpetuated traditional gender roles. The government
considers women’s traditional roles as mother and wife
critical to the nation’s social and political stability
(Gammeltoft, 1999). Two Government slogans often
promote traditional Confucian female characteristics:
Chastity, hard work and proper behavior. A 1977
government leaflet stated: ‘‘The Party still appreciates
the beautiful and good characteristics of women: women
are hard working, industrious, creative, courageous,
loyal, and altruistic’’ (Gammeltoft, 1999).
Most recently, the Vietnamese government has
liberalized national economic policies to stimulate the
national economy. Since 1988, the policies, collectively
referred to as Doi Moi, have increased the per
capita GNP and strengthened Vietnam’s position as a
global economic player (Chen & Hiebert, 1994). However, these gains may come at the expense of
women’s social, economic, and health status (Beresford,
1994; Allen, 1990; Fong, 1994). For example, the 1988
land reforms dismantled cooperatively managed
farmland into family plots and shifted the power of
land ownership toward men; only the male is named
on the governmental ‘‘Land Use Right Certificate’’ and
the woman’s rights to land in case of widowhood or
divorce have become limited (Gammeltoft, 1999).
The Doi Moi policy also has an impact on women’s
daily work life, as men increasingly move into nonagricultural work and women are left with a double
agricultural and domestic work load (Beresford, 1994).
Although it is difficult to draw a causal link between
economic reforms and women’s workloads, several
studies have noted that women work longer hours since
the economic reforms (Allen, 1990; Beresford, 1994).
Finally, the economic reforms of Doi Moi have resulted
in a shrinking public health sector and increased reliance
on private doctors to deliver health services. This has
made high quality health services less accessible to the
poor (Ensor & San, 1996) and may affect the healthseeking behavior of women affected by socially stigmatized infections such as STDs.
Against this contextual backdrop, gender definitions
that guide normative interpretations of STDs have
particular social meanings for Vietnamese women.
These meanings and definitions influence the recognition
of symptoms and their introduction into the clinical
arena by women.
Perceived morbidity and health-seeking behavior for
STDs
A woman’s willingness to acknowledge an STD
symptom depends, in part, on the social acceptance of
STDs in her family and community (Kleinman, 1980).
V.F.-L. Go et al. / Social Science & Medicine 55 (2002) 467–481
In India, three qualitative studies on women’s
perceptions of STDs found that stigma associated
with STDs was crucial in infected women’s willingness
to report STD symptoms (Patel, 1994; Bang & Bang,
1994; Mulgaonkar, Parikh, Taskar, Dharap, & Pradhan,
1994). Gorbach, Hoa, Eng, and Tsui (1997) and
Whittaker (1999) have explored women’s perceptions
of reproductive tract infection (RTI) symptoms in
Vietnam, providing valuable insight into individual
and community level beliefs and behaviors related to
RTIs. Our study enhances these studies by focusing on
the link between traditional gender roles, community
perceptions of STDs and women’s health-seeking
behavior for RTI symptoms.
Even when women recognize STDs, they do not
necessarily seek care for their condition. Several studies
have found that the attitudes of husbands and mothersin-law restricted women from getting gynecological
examinations (Bang et al., 1994; Field et al., 1998;
Erwin, 1993). In the context of family planning,
Gammeltoft (1999) highlighted the importance of social
and moral relations in women’s contraceptive choices in
Vietnam’s Red River delta. The study found that
intrauterine devices (IUD) are approved by most
husbands since such a device does not interfere with
male sexual pleasure, pose any threat to male health, is
reversible, and is perceived to be more effective than
traditional methods. Gammeltoft’s (1999) analysis of
the widespread use of the IUD, despite complaints of
severe side effects, encapsulates the pattern of everyday
social relations where women often feel they have to
submit to and comply with their husbands’ decisions.
Other studies conducted in Africa have suggested that
shame and fear of stigma may inhibit health-seeking
behavior (Sajiwandani & Baboo, 1987; Green, 1992;
Moss et al., 1999; Manhart, Dialmy, Ryan, & Mahjour,
2000). Investigations suggesting a relationship between
stigma and reported STD symptoms highlight the need
to expand upon these studies to contextualize the
meaning of STDs and to determine their influence on
women’s recognition and subsequent health-seeking
behavior.
Conceptual approach
To understand the meaning of STDs in the context of
Vietnam, it is necessary to examine social norms or rules
of conduct that specify appropriate behavior in Vietnamese society. Specifically, this study aimed to address
five questions: (1) What are the traditional gender roles
in northern Vietnam? (2) What are the perceptions of
different sexual relationships? (3) What are common
perceptions of STDs? (4) How do traditional gender
roles shape perceptions of STDs? and (5) What are the
implications of the relationship between traditional
gender roles and perceptions of STDs for interventions
469
aimed at promoting early and appropriate STD treatment for Vietnamese women?
To conceptualize women’s health-seeking behavior
for RTI symptoms, we use a framework that synthesizes
Andersen’s paradigm (Andersen, 1995) and a multilayered framework developed by Zurayk et al. (1993).
Andersen assumes that most actions are under volitional
control, placing the need for care as the immediate
determinant of health services. The need for care, in
turn, is seen as a function of enabling or impeding
factors, which are determined by predispositions to use
services. While Andersen’s model acknowledges the
‘‘external environment’’ as an input for understanding
use of health services, it focuses on the individual. We
modify Andersen’s model by integrating the social
environment/culture as an intrinsic part of women’s
decision-making process. Drawing upon Zurayk’s framework, which focuses on the relationship between
social factors and the individual by approaching
decision-making as a multi-layered process that starts
with background resources (the social context of ill
health) and moves to the most proximate (medical-risk)
factors, we thread social context throughout our framework.
Starting from the most proximate factors, we consider
perceptions of STDs (e.g., shameful) to be an impeding
factor directly affecting women’s perceived need for
care. For example, women will be more likely to tolerate
pain and illness and less likely to seek care if their
conditions are stigmatized. Since STDs are associated
with sex, perceptions of STDs are shaped by perceptions
of sexual relationship. Moving up one layer, we assert
that perceptions of sexual relationships are a function of
traditional gender roles, which are determined by the
final layer, predisposing factors (social structure). In this
study, we used this model to guide data collection and
analysis and to understand how social structure affects
health-seeking behaviors.
Methods
This research was conducted as part of a multidisciplinary project on the epidemiology of RTIs,
including STDs, in northern Vietnam. The site of the
study, Hai Phong, is a province in northern Vietnam
with a population of 1.7 million in 1998. As a large port
province in Vietnam, Hai Phong has an estimated
600,000 transient residents and more than 4000 injection
drug users (IDUs). Hai Phong is experiencing one of the
most rapidly increasing HIV epidemics in Vietnam
(Quan, Long, & Dondero, 2000). The number of cases
(415) detected in the first six months of 1998 was 11
times higher than the number detected over the past 5
years combined (Hai Phong AIDS Committee, 1998).
The National AIDS Committee of Vietnam (NAC) has
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V.F.-L. Go et al. / Social Science & Medicine 55 (2002) 467–481
identified Hai Phong province as a top priority for
future STD and HIV interventions.
Vietnam is divided into 61 provinces, which are
subdivided into districts and then villages or
‘‘communes’’. In order to increase generalizability and
explore rural/urban differences, we purposively selected
one rural (An Hung) and one urban commune (Ha Ly)
for intense study. These communes were geographically
accessible and demonstrated local commitment to
participate. Data were collected through the combined
use of two qualitative techniques: in-depth interviews
and focus group discussions (FGDs). These methods
have complementary strengths and weaknesses. The
primary strength of a focus group is the synergistic
influence of the group setting, which may result in the
elicitation of data or ideas not obtained in individual
interviews (Stewart & Shamdasani, 2000). In addition,
focus groups can provide insights into community
norms by the assessment of consensus within a group
on a topic or viewpoint. However, responses from
members are not independent of one another, which
may restrict the generalizability of results. Furthermore,
the results obtained in a focus group may be influenced
by a dominant member if more reserved group members
are hesitant to participate. The drawbacks of focus
groups are the strengths of in-depth interviews, which
enable an interviewer to have a series of independent
and individual interviews with the participants (Spradley, 1979).
Our qualitative research, conducted by a team of four
women from Hanoi included in-depth interviews and
focus group discussions. The team leader, an author of
this paper, helped develop and pilot test the qualitative
guides. She and another member of the team, both with
Masters degrees in Sociology and over 5 yr of experience
in qualitative HIV/STD research in Vietnam, conducted
and transcribed in-depth interviews and focus group
discussions. Two team members with Bachelor degrees
in English translated transcripts and served as notetakers during FGDs. The team was intensively trained
during a 1-week workshop in interview techniques such
as probing, framing, summarizing, and checking to
guide participants through the range of topics.
Participants were recruited into the study by referral
from local public health professionals and through a
snowballing technique. In order to be eligible for the
study, men and women had to (1) be aged 18–49; (2)
provide informed consent; and (3) be a resident of a
project commune. A staff member of the commune
health station visited potential participants at their
homes to invite them into the study. The research plan,
instruments, and consent forms were reviewed and
approved by the National AIDS Committee of Vietnam,
Johns Hopkins University School of Hygiene and Public
Health Committee on Human Research, and the
National Institute of Health Office for Protection from
Research Risks. Written consent was obtained from all
participants.
In-depth interviews
Topics covered during in-depth interviews included
perceptions of types of sexual relationships in the
community and perceptions of people with RTIs and
STDs. Interviews were semi-structured and included
questions asked of each informant. Responses were
open-ended, allowing for probing to clarify responses.
Four males and four females (two of each from An
Hung and Ha Ly) were identified and interviewed indepth. Interviews were conducted in a private place in
the homes of the participants and lasted between 1 and
2 h. In order to understand the experiences and healthseeking processes of STD clinic patients, four additional
informants (two males and two females) were identified
from the Hai Phong STD Clinic in Ha Ly. STD patients
provided information on their experiences, interpretation, and health-seeking behaviors for potential STD
symptoms.
Focus groups
Focus group discussions explored life in the commune, traditional gender roles, perceptions of types of
relationships in the commune and attitudes and perceptions about STDs. Four FGDs were conducted (two in
each commune), each consisting of six same-gender
adults from the community. A total of 24 adults (12
males and 12 females), none of whom had participated
in the in-depth interviews, participated in the groups.
The FGDs were held in private, non-medical settings
and lasted from 1 to 2 h. Discussions were conducted by
a moderator and a note-taker. To elicit information on
social norms, the moderator followed a FGD guide that
contained specific questions and presented a number of
scenarios, asking participants to respond to probes.
Interview and FGD guides were developed in English,
translated into Vietnamese, back-translated into English
and field-tested with similar populations in Hanoi. All
interviews and FGDs were tape-recorded and transcribed by the moderator/interviewer within 3 days of
the interview and transcripts were translated into
English onsite by two translators within 1 week of
completing the interview. To check the reliability of
translations, an independent translator spot-checked all
transcripts. The translations from one translator were
found to be consistently inadequate. Therefore, all
transcripts from this translator were re-translated by a
fourth, independent translator in Hanoi and this process
resulted in a more satisfactory translation.
In addition to recording interviews and FGDs,
interviewers took notes during the interviews to document the mood, tone, and group dynamics that might
V.F.-L. Go et al. / Social Science & Medicine 55 (2002) 467–481
not be captured on tape. Interviewers expanded these
notes within a day of the interview.
Expanded notes and transcripts from both the focus
group discussions and interviews were computerized.
These data were reviewed for main themes and issues
and then coded for retrieval and analysis. Matrices were
developed for each of the codes to note common threads
and contrasts in the statements.
Results
This study explores the pathways by which traditional
gender roles, as described by men and women, may
ultimately affect Vietnamese women’s recognition of
RTI symptoms and health-seeking strategies within a
complex social environment. The results are reported
according to the following categories: (1) life in the
commune; (2) traditional gender roles; (3) perceptions of
sexual relationship types; (4) perceptions of persons with
STDs; and (5) case studies of STD clinic patients.
Life in the commune
Urban: Ha Ly
The majority of participants from Ha Ly viewed their
life in the commune as very difficultFcomplaining of
pervasive unemployment, crime, and drug use. Many
attributed the spread of ‘‘social evils’’ to economic
hardship in the commune. One woman summarized
these feelings:
The livelihood of the people here is hard. Men resort
to drug addiction, fighting, stealing things in
considerable number due to unemployment; and
women have to work in nha hang (bars) or do the
jobs that are not respected by the society.
A man expressed a similar opinion and felt worried
that economic and social turmoil in Ha Ly would lead to
diseases such as HIV/AIDS:
Our life here is very miserable in comparison with
that in big cities like Hanoi and Ho Chi Minh city.
everything is worse. social evils have become a
serious problem throughout Hai Phong. the number
of drug addicts is very big. even those who are
arrested by the policemen once or more, they never
stop. future generation will be put at risk of aids,
drug abuse. many fatal diseases are coming closer.
Rural: An Hung
Focus group participants in An Hung described their
life as difficult, but manageable. One woman explained,
‘‘the rice, vegetable that we produce can assure our
471
lives’’. Although their income was largely dependent on
their farms, most participants agreed that it was
necessary to supplement farming with additional work:
The income of people here, at least one person of
each family has got to have extra work. In general
most people here farm and every family has one
person who does extra work to add to the family’s
income.
However, despite the economic hardships, consensus
was reached in the male groups that visits to sex workers
and drug addiction were not widespread in the
commune. One man summarized it by stating, ‘‘So far,
there have been no records of any social evils in the
community’’. Focus group facilitators noted in both
groups that women participants seemed notably shy to
speak about social evils.
Traditional gender roles
‘‘You are rich thanks to your friends, you are socially
superior thanks to your wife’’. (traditional Vietnamese
proverb)
The ideal woman
Across all four focus groups, participants often
referred to four tu duc (traditional qualities), taken
from orthodox Confucian text, that were expected from
a Vietnamese woman: cong (hard-working), dung
(attractive physical appearance), ngon (appropriate
speech), and hanh (virtuous). One woman explained,
‘‘According to the set norms of our ancestors, a woman
had to have all four’’. A woman in Ha Ly elaborated:
I suppose a woman doesn’t need to make a lot of
money, but she should be gentle, virtuous and
courteous in speech. Her appearance is not necessary
to be very beautiful, but should be tidy, clean in
dress.
Of these characteristics, most participants highlighted
virtueFparticularly, with respect to the husband. One
woman explained, ‘‘I don’t know much about the ideal
woman of other men, but my husband wants his wife to
be faithful first’’. A male participant voiced a similar
opinion, stating, ‘‘My ideal woman must be faithful’’.
All four focus group discussions emphasized that a
woman’s primary role revolves around the family.
An ideal woman must be soft, obedient, know how to
care for her husband and children, parents, brothers
and sisters. (Man, Ha Ly)
As I think, it’d be better if a woman was born with a
pretty appearance but the best is that she should be
able to do her role in the family. The woman is the
mother with pregnancy, birthgiving and bringing up
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V.F.-L. Go et al. / Social Science & Medicine 55 (2002) 467–481
the child right from the first days. The woman is very
important in the family, especially in the present
society with numerous social evils, the woman has to
guide and educate her children to help them avoid
these evils (participants nodding in agreement).
(Woman, Ha Ly)
Descriptions of a woman’s traditional role did not
differ significantly between communes. However, men’s
groups highlighted desirable female characteristics not
covered in women’s groups. Several male participants
added that ‘‘acceptance’’ of a husband’s imperfections
was expected from a woman:
An ideal woman must be tolerant and merciful,
because in a family, the man is easy to make
mistakes. It is inevitable. The woman must be
merciful, sympathetic. I think most Vietnamese
woman are. (Man, Ha Ly)
Furthermore, male participants debated the value of
beauty while the women uniformly ranked beauty as a
secondary quality. One man stated that ‘‘ywhen
seeking a woman to get married to, any man would
look for a sweet, healthy, well-behaved, faithful, and
beautiful woman’’. Another disagreed:
I think I am an ordinary person so I do not prioritize
beauty when I look for a woman to get married to. I
should choose a wife who has good health condition
and knows how to support the family. (Man, An
Hung)
The ideal man
There are no equivalent traditional norms for men in
Vietnamese society. The most frequently mentioned
traditional male roles and characteristics were ‘‘having a
stable job’’, ‘‘being socially respected’’, and resisting
‘‘social evils’’. Although discussions about men’s roles
were similar in male and female groups, female
participants emphasized resistance to ‘‘social evils’’
more heavily:
I expect men to get full education in order to hold
some position in the society for their wives and
children to rely on. In addition, these men shouldn’t
indulge themselves in ‘an choi’ (extravagant entertainmentFused here as euphemism for drinking and
visiting prostitutes). (Woman, Ha Ly)
I think the ideal man has to be kind, not drink much
alcohol, not play cards and have extramarital affairs.
(Woman, An Hung)
Discussions seem to suggest that men are naturally
tempted by gambling, drugs, and commercial sex while
women are not. Despite the vast differences in tradi-
tional roles of men and women, discussion emphasized
that both men and women are expected to behave in
socially approved ways.
I think he must be the breadwinner of the family. He
also has the right way of behaving with others in his
neighborhood, village and in the society. (Man, An
Hung)
The most important thing for the woman in the
society as well as in the family is su cong bang (respect
from others). (Woman, Ha Ly)
Deviations from social norms
Social norms exert tremendous power in shaping
behavior in the communities. The community may
ostracize individuals that deviate from traditional roles.
The impact of such stigmatization extends beyond the
individual, and applies to the entire family. A male
participant, formerly a drug addict, described the
difficulties in reversing social labels:
I myself used to be a bad individual but I am leading
a normal life now. In the past I lived a meaningless
life because I was cornered by life but now I have
changed my life and do my best to earn money for
my wife and my children’s living. However, some
people still believe I’m a drug addict. Nobody wants
to talk to my wife and my children. They did not
allow me to row the boat for money. (Man, Ha Ly)
Consequences for deviating from traditional roles
often depended on the nature of the offense and showed
clear gender variation. All of the women participants
agreed that they would have to accept a husband who
succumbed to ‘‘social evils’’. A female participant from
An Hung described women’s lack of choice:
I think everyone wants to have an ideal man.
However before getting married, it is impossible to
know well the husbands. We chose health and kind
man, but later when we have lived together for many
years, the man starts playing cards (here used as
euphemism for social evils). But at that moment, we
have to accept the fact and can’t do anything to
change the situation.
Another woman in Ha Ly related her own experience
with her husband who frequented sex workers:
When getting married my husband was good man.
But now he has given into social evils so I must give
him advice. Even though he is a really bad man and
he doesn’t listen to my advice, I have to accept him.
V.F.-L. Go et al. / Social Science & Medicine 55 (2002) 467–481
In contrast, if a woman deviated from the social
norm, her husband maintained the locus of controlFhe
could either forgive her or punish her. If a woman is too
talkative, the woman may be guided by her husband:
I think when the wife [is too talkative] first or second
time, the husband sometimes gives his wife advice.
(Woman, An Hung)
If a woman was unfaithful, the consequences might be
more severe.
There are a few men who advise their wives like that,
however most of them often curse and beat their
wives. Naturally, men can’t be patient and endure
like woman. Most of them are hot-tempered and so
they often beat their wives. (Woman, Ha Ly)
Overall, deviations from social norms have family
consequences that follow traditional gender roles.
Women are expected to accept their husbands’ deviations while men may select a range of socially acceptable
responses to their wives’ behaviorFfrom forgiveness to
physical punishment.
473
If she is cung ran (strong enough to protect her
virginity), her husband will give her more respect in
married life. (Woman, An Hung)
If a girl comes to live in her husband’s family with her
virginity, she can feel proud of herself and live with
chin chan (dignity). (Woman, An Hung)
These sentiments suggest that a woman’s power is
vested in her virginityFby losing her virginity, she
relinquishes power. An analogy of a game emerged in
women’s discussions where the prize was taking a
woman’s virginity. The main concern was that once
the man is ‘‘victorious’’, the woman drops in ‘‘value’’.
When the man succeeds in having the girl have sexual
intercourse with him, they will think of other, more
beautiful girls. So women always pity the victims.
The woman who does not protect herself will suffer
from its results. (Woman, An Hung)
Once a man has been successful in conquering a girl,
he wants to conquer another girl at once. (Woman,
An Hung)
Male groups echoed their female counterparts.
Perceptions of sexual relationship types
Premarital sex
When questions on premarital sex were posed,
responses in all four focus groups focused on repercussions to the woman. The omission of men in these
discussions suggests the underlying assumption that men
are inherently sexual and therefore premarital sex for
them was socially acceptable. Overall, opinions about
premarital sex were not notably different between
communes or between male/female groups. However
women’s discussions were more animated than men’s,
suggesting they felt more strongly about this topic.
Most women believed a woman should not have
premarital sex in order to maintain the respect of their
boyfriend, future husband, and husband’s family. The
following quotes elucidate social norms regarding a
woman’s virginity:
Because of doi moi (opening of the economy), things
are much more open, which often leads to excessiveness. For instance when in love, the woman can’t
know if the man truly loves her while she shows all
her love for him. If you meet a ‘So Khanh’ (playboy)
and you are easy, he will behave terribly after [having
sex]. Therefore young women should protect themselves. There are many other ways to show their
emotions, not only by letting men have free sexual
relationships like that. Men always expect some selfrestraint from women. (Woman, Ha Ly)
I think they shouldn’t have sexual intercourse
before marriage, because after that, they will
probably not marry each other. The man may think
that the woman is easy to sleep with other men. You
know, in Viet Nam, the girl’s virginity is still very
important. It will be difficult for the girl to find a
husband if she loses it. Even if she does get married
(later) to another man, her husband will likely not
forgive her when he realizes that his wife had sex with
another man. Their life will be miserable. (Man,
Ha Ly)
Some female participants empathized with a woman’s
‘‘emotions’’ but felt a woman should ‘‘protect herself’’.
A woman from Ha Ly summarized this view:
Once a couple is too deep in love, it’s hard to keep the
woman’s virginity. I know some couples in love. I
know they have sexual relationships but I just take it
normally because when a woman loves her husband
or her boyfriend, she always wants to devote all her
instinctual emotion for him to know her love.
Women are always the weaker sex. They always
want to show their entire sincere heart to their lovers.
But we can’t know whether those men will be kind to
us or not.
None of the focus groups reached consensus on the
community’s role in enforcing norms on premarital sex.
One woman from An Hung explained that the community may intervene: ‘‘Some rumor may aim at making
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the girl ashamed and they try to stop it’’. But a woman
from Ha Ly voiced a different opinion, ‘‘They
(the community) suppose it’s no good but they don’t
care’’. One man from An Hung explained that despite
overall disapproval, the community must accept premarital sex since norms are changing with a developing
economy.
Everybody is sad when an unmarried couple has
sexual relationship before the wedding, especially the
parents. However the young have been affected by
lots of social factors like black-market videotapes.
Our country is in modernization and industrialization and the norms of love have changed too. We
have to accept if our daughter has sexual relationship
before wedding.
Extramarital sex
‘‘A real and heroic man can have five wives and seven
girlfriends but a virtuous woman only has one
husband in her life’’. (traditional Vietnamese proverb)
In-depth interviews and focus groups revealed that
traditional gender roles engender a clear double
standard for extramarital sex. In interviews, the majority
of participants believed that extramarital sex was
becoming increasingly common in An Hung and Ha
Ly. In An Hung, one woman explained:
There are some cases in this community. They tell
their wives that they have something to do such as
going fishing or working in the fields but in fact they
stay with prostitutes. Prostitutes have moved into the
village.
Several participants pointed out the association
between prosperity and extramarital sex:
With mass media, films, videotapes which are flowing
into Viet Nam, people seem to have more extramarital affairs then previously. In general, when the
society develops, they often think of such entertainment. People who want to have gan trang (women
selling white goodsFslang for sex worker) are the
rich ones. The poor people pay much attention to
earn a living but not to entertainment. (Woman, An
Hung)
Main customers of prostitutes are rich people as they
only think about entertaining themselves when they
have money; the poor are busy with worries about
life. Men away from home, away from their wives tot
vao (jump in) bars. God knows it! Nobody knows it,
even their wives! (Man, An Hung)
One woman in Ha Ly whose husband was diagnosed
with gonorrhea felt that an increase in income facilitated
her husband’s affairs.
Our life was getting better off with improved
economic conditions and my husband is the type of
man who wants to please people, so he followed his
friends to come here and there and got engaged in
that kind of relationship.
All the men and women interviewed believed that
‘‘yit is more possible to forgive men than women’’ for
committing adultery. One man from An Hung stated,
‘‘For the same mistake, still the women are to blame
more severely. Somehow, it has always been the case’’. A
woman from Ha Ly expressed similar views:
As a rule, there may be no problems if a man has love
affairs but a sharp criticism will come to a woman
with this. In my opinion, we should not make such a
distinction though I myself a bit tend to put more
blame on the woman (smiling).
When the interviewer asked why social standards
differ for women and men, participants frequently
mentioned women’s roles in the family. For example,
one woman from Ha Ly explained,
Women often have to accept the burden of the
family. Indeed they have much more duty and
responsibilities to their husbands, their families.
And because men are more free than women so they
often have such extramarital affairs.
Another elaborated on women’s duties:
The duty of women to their husbands and children is
harder than men. If women neglect their duties to the
family, it will not only make the family fall into
pieces but also make their children unhappy.
Another voiced a similar opinion: ‘‘Of course I’ll
criticize the woman more because women should take
more care of the family. Anyway, men might have more
thoang (open) relationships’’.
Male participants made a distinction between visiting
a sex worker and having a love affair. One man explains
the difference:
Visits to cave (French for nightclub, here used as
euphemism for CSWs) are more acceptable than
extramarital affairs because in dealing with cave, it is
said to be an binh tra tien (you eat the cake and then
pay for it). Things are over after it finishes. Yet there
are a lot of bonding emotions in lover’s relationships.
Adulterous relationships demand both money supply
and frequent exchanges. (Man, Ha Ly)
When interviewers asked what motivates men to have
extramarital sex, male participants blamed the natural
V.F.-L. Go et al. / Social Science & Medicine 55 (2002) 467–481
imbalance between men and women’s sexual drives. As
one man states, ‘‘yit is man’s nature that causes him to
have affairs’’. Another man provided an example:
‘‘[Men] have relationships with prostitutes when their
sexual instinct develops too strongly and their wives
can’t meet their demand. So they come to do what they
want’’. A man from Ha Ly explained why he visited sex
workers while he worked for one year in a province
away from his family:
Everyday after finishing work, my friends and I went
together to bia om (hugging beer pubs) or karaoke
bars and we did have sex with sex workers who were
in the restaurants. During that time I was feeling
lonely and having money so I had sexual contacts
with restaurant workers several times.
Both men and women who were interviewed pointed
out that ‘‘badly behaved’’ wives justify husband’s
extramarital affairs.
Maybe the woman’s behavior is more and more
impossible or it is harder and harder to please them,
so men will have to seek lovers. (Woman, An Hung)
475
unsympathetic because, ‘‘I think they are people who
day an mong lam (eat hard but work lazily)’’.
Strong social norms discourage women from engaging
in affairs as ‘‘women may be afraid of judgement while
there is less social criticism towards men’’. As one man
explained, while a man may feel it is ‘‘acceptable’’ that a
man has ‘‘five wives and seven lovers,’’ a woman ‘‘would
be absolutely criticized’’ if she had an extramarital affair.
When an interviewer asked a woman in An Hung if she
would ever be tempted to have an affair, she responded,
‘‘I would never do ity [because] yif you are seriousminded, friends will respect you better’’. As a result,
‘‘yfor women who have love relations, they feel
ashamed and embarrassed but for men like me, they
think that it is normal, that it is not against the law so
they do not feel afraid’’.
Whereas social norms prohibit women from having
extramarital affairs, women are expected to accept this
behavior from their husbands.
In general it is not accepted by the community but
the wives have to ‘‘chirp their lips’’ (purse lips with
sound) and accept. It is their fate to suffer. (Woman,
Ha Ly)
Indeed, several female participants agreed with a
woman from An Hung who explained,
When the husband of a badly behaved wife has
lovers, people feel pleased, but they will be against a
man who seeks lovers while his wife is a good and
hard-working woman. However, the husband is the
one who decides to change his behavior or not. (Man,
Ha Ly)
While extramarital sex for men is tolerated by the
community, it is done discretely. As one man pointed
out, local men go to prostitutes outside their area since
‘‘ynobody is foolish to have relation with gai ban hoa
(girls selling flowersFeuphemism for commercial sex
workers) in the area they are living in’’.
According to the majority of participants, women’s
motivations for extramarital affairs are not sexual or
emotional but purely financial. A woman from Ha Ly
explained, ‘‘Some other girls are not serious-minded,
running after money’’. Another woman added, ‘‘yit is
not because they want to do it. A beautiful girl would
seek relationship with rich men who can afford and help
her for a good life’’. Indeed, one woman from An Hung
believed that it was inconceivable for a married woman
to have affairs to meet emotional or physical needs: ‘‘I
don’t know any cases that women are willing to have
such sexuality’’. One female told the story of her friend
whose husband forced her to have an affair for economic
benefits: ‘‘The man wanted to be promoted to higher
position, so he forced his wife to have sex with another
man’’. While a few ‘‘pitied’’ women who participated in
extramarital affairs, most interview participants were
If a man leaves (has an affair), it is the woman’s duty
to do everything to encourage him to return. In this
situation, he will be to blame. And about the
disgraceful woman [who has an affair], it is impossible to forgive them. It means that I drastically
criticize such bad women.
Focus groups expanded upon individual interviews,
providing a range of opinions on men’s personal
responsibility for engaging in extramarital sex. Discussions also elucidated An Hung’s strong community role
in enforcing social norms. While focus group participants drew less on personal experience and generated a
wider range of opinions, overall findings supported indepth interviews.
Consensus was reached in all groups that women
should never, under any circumstances, engage in
extramarital sex. Discussions also confirmed that traditional family roles translated into gender-based consequences for extramarital affairs. A male focus group
participant in An Hung explained:
It is said that a man in the family is like the roof of a
house and the woman is like the shoulder strap to
raise the roof. A house has one roof but many
shoulder straps. The woman has to take care of many
tasks. If a woman has a love affair, she might not
have time for her duty to look after the children so
her sins would be considered more serious than a
man. When a man has a love affair, it is does not
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V.F.-L. Go et al. / Social Science & Medicine 55 (2002) 467–481
matter since his children are being taken care of by
the wife. That is why, for a long history, men have
been offered more lenient consequences for the same
situation.
Perceptions of RTI symptoms, including STDs
The way that women interpret biological consequences of RTIs/STDs may be influenced by the
same gender roles and social norms that shape views
of promiscuity. Our data show that vaginal discharge and genital ulcers may be attributed to
‘‘women’s diseases’’ or ‘‘STDs’’. As one woman in An
Hung stated,
People don’t know or can’t distinguish the symptoms
of (STDs and RTIs). If people suspect they have
STDs, they will take exam in a place which is far
from their acquaintances to keep their diseases a
secret. [RTI] patients often take treatment at commune health station.
Both ‘‘women’s diseases’’ and STDs are considered to
be socially undesirable, though STDs have significantly
more severe consequences.
Women’s diseases
According to individual interviews, women’s discharge or itchiness may be caused by ‘‘unclean water
or not taking a bath often’’. Focus groups reached
consensus that these diseases may be fairly common
in rural areas. The majority of participants believed
that benh phu nu (women’s diseases) befall women who
are forced to work in poor conditions or who are
slovenly.
Women do often get women’s diseases since they use
unclean water taken from ponds. Rural women
usually have to get into ponds to get water-fern for
pig-raising you know. (Woman, Ha Ly)
I am an educated woman, so I always keep myself
clean and sanitary. (Woman, Ha Ly)
These quotes suggest that presence of women’s
diseases is associated with being dirty. Because this runs
counter to gender expectations of ‘‘tidiness,’’ having a
woman’s disease may be seen as socially undesirable.
STDs
In-depth interviews illustrated that STDs, including
HIV, were strongly associated with promiscuity. In Ha
Ly, women believed that persons with STDs have ‘‘lang
nhang, cap bo, cap bich’’ (different words for extramarital lovers). Consistent with findings on social gender
norms about extramarital sex, men with STDs were
those who were thought to be ‘‘curious’’ while women
with STDs were believed to be ‘‘prostitutes’’.
If the victims (of STDs) are men, people think it is
because of their workFthey have to go on business
trip often. If they are women, they are thought to be
prostitutes. (Man, Ha Ly)
Another woman in An Hung described characteristics
of persons with STDs:
Most STD or AIDS patients are young people.
Because now they see many more bad films, they are
curious and they want to try to have sex with
prostitutes. Few married people have the diseases.
Prostitutes also have the diseases.
The majority of participants felt that people who had
STDs were personally responsible for the cause.
I think getting STDs is not because of one’s fate. It is
because of his or her lifestyle. They cannot blame
their fates. If they concentrate on working and were
faithful to their spouses they would not get STDs.
(Man, Ha Ly)
The men in An Hung echoed this opinion:
It is their fault. I think yco lau moi co khoiy (there
is no smoke without fire). He must have sexual affairs
that put him at risk for getting the disease.
Indeed some felt that ‘‘only unfaithful people can get
the disease. If people only have sex with their own
spouses, they will never get the diseases’’.
Only two participants presented a different
view, believing that wives are often victims of their
husband’s behavior. The following quote summarizes
this view.
If men have diseases, they will be able to transmit the
diseases to their spouse when they have sex with their
wives without condoms. (Man, An Hung)
Regardless of the amount of personal responsibility
assigned to STD patients, the majority of participants
expressed pity for them and felt it was important to help.
I think that when they get the diseases, they have to
suffer a lot. Now it is the moment to help them
overcome their difficulties, loneliness and disappointment. (Woman, An Hung)
We should not turn our back on people; we shouldn’t
discourage them. If they feel they are hated or
cornered, they will transmit the disease to others.
(Man, Ha Ly)
V.F.-L. Go et al. / Social Science & Medicine 55 (2002) 467–481
477
In focus group discussions, participants were asked,
‘‘What would you do if your spouse found out he/she
had an STD?’’ While discussions were not different
between communes, they varied significantly by gender
and conformed to sexual roles and expectations.
Although many women participants expressed panic,
worry and even temporary anger, consensus was reached
in both female focus groups that women would remain
loyal to their spouses.
a love affair. I will divorce my wife immediately if she
does it. (Man, An Hung)
I must be very frightened at first. I’ll read newspapers to find out more and ask qualified people
to get better knowledge and prevention. But
I won’t leave him alone. He is my husband. (Woman,
Ha Ly)
The moderator reversed the scenario and asked
how they believed their wives would respond it
they had an STD. The majority of participants stated
that expected reactions from wives would be significantly more lenient. One man admitted there would be
familial and social consequences if people knew he had
an STD.
In this situation, at first, I would be angry with him
and then I would think no good will come from
behaving like that. Too many quarrels can lead the
family to fall into pieces. It is better to be patient.
(Woman, An Hung)
Another added,
Vietnamese women are used to suffering. (Woman,
An Hung)
The moderator asked them how their husbands
would react if they had an STD. Within both
female groups, there was consensus that their husband
would have a much more severe reaction. Many
expressed fear:
No, they won’t [be as understanding as women]. Men
are very hot-tempered. They often have quarrels with
their wives and even beat their wives. (Women, An
Hung)
Another joined in,
I’m sure they will beat their wives.
The male focus groups corroborated women’s discussions. Several men stated they would ‘‘beat’’ their wife
and/or divorce her.
If my wife were a victim (had an STD), I would
divorce her. First because she is not faithful with me,
and has an affair with another man. We’d better get
divorced; there is no more happiness. Faithfulness is
the first valuable quality of Vietnamese women.
(Man, Ha Ly)
I will find out if she is not faithful with me. Frankly
speaking it is acceptable for a man who looks for a
love affair but not for a woman. Only a woman who
wants to earn money without working hard looks for
The first thing a husband should do is to look into
the situation leading her to have an affair, before
making a decision about what to do. But I assume
that I would definitely take some physical action (all
laugh). (Man, An Hung)
I would probably be laughed at, even looked down
upon by my friends or my wife and children would be
hurt. My family would not accept me as a member. If
it is curable, I would come back when I could get rid
of it.
However, most believed that their wives would accept
them.
Most women would forgive their husbands when
they do something bad, even if they have diseases
(STD) (laughing very loudly). (Man, An Hung)
Case studies of STD clinic patients
The following two case studies of women who sought
treatment from the Hai Phong STD clinic are presented
to illustrate different scenarios of women’s experience
with STD symptoms.
STD clinic patient A is a 38-year-old woman from
Ha Ly, currently separated from her husband. Her
symptoms started out with mild itching and then
became more severe. She explains that there was
‘‘ymore and more itching. For several days I am
crazy with itch. I cannot sleep’’. Additional symptoms appeared, ‘‘Then appeared red spots, the red
spots spread to the anus and it hurt to urinate.’’ She
suspected her husband right away because ‘‘I am an
educated woman, I keep myself sanitary and clean’’.
Furthermore, she explained, ‘‘to tell you to the truth,
my family is not happy. My husband has come to
share life with another womanyhe might call at sex
services as well’’. Her husband repeatedly denied
having an STD, so she went to his private doctor who
told her, ‘‘Your husband has gonorrhea. You should
remind him to be careful with sex’’. She felt very
worried about her symptoms, ‘‘For 3 nights now, I
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V.F.-L. Go et al. / Social Science & Medicine 55 (2002) 467–481
have gone crazy and there appears a big worry in me
because I don’t know if it’s light or serious. I am so
miserable.’’ This was her first time to the STD
clinic. Before coming here she had talked to a friend
who advised her to treat herself with ‘‘an insertion
pill of Lincocine’’. She avoided going to a healthcare
provider because, ‘‘I felt worried, lacked
self-confidence and was afraid that the doctor
would not be enthusiastic to me. My one wish is
that I can receive warmth and consideration from
doctors so that I feel safe and comfortable’’. The
‘‘itch kept coming back,’’ so she visited a private
doctor who said, ‘‘I had fungus because I was dirty’’.
She replied ‘‘No, not because I am dirty.
Maybe because of my husband’’. The doctor insisted,
‘‘No, not because of your husband. Only because
you are not clean’’. She felt offended by this
doctor since, ‘‘yto tell you the truth, I am extremely
clean’’. Unsatisfied with the service and the results,
she went to a hospital for treatment where ‘‘they just
examined me, prescribed medicine and I automatically bought the medicine’’. They did not discuss the
diagnosis or potential cause of the symptoms with
her, ‘‘they did not care to listen to my insisted guess
of possible diseases’’. The treatment here was
ineffective as well. Her friends urged her to go to
an STD clinic for testing and this is what brought her
to the clinic.
STD clinic patient B is a 31-year-old married woman
from a rural commune in Hai Phong province. She
described her symptoms, beginning with ‘‘slimy
substance that came out in great amount and I had
itchiness and small spots on the two sides. I now have
mun com (white rice grain lumps). When I have sex
with my husband I feel pain’’. She felt the discharge
was the most severe, ‘‘from morning until evening I
get changed more than once and I find that I have a
lot of discharge and it is very smelly, yellow, not
white as always and it is very solid as flour’’. At first
she believed her symptoms were due to nhiet (heat)
until she began to suspect her husband, whose
unusual behavior alerted her: ‘‘He tried to take the
excuse of going out to watch football in the
neighbor’s house, not at home. He had bad
temperament then. Normally he was very emotional
to me. How come he suddenly came to the neighbor’s
to watch football while we had a TV at home? After
one week, he turned back home and had sex with me.
Right after that, I felt itch and very uncomfortable’’.
Her suspicions aroused, she ‘‘asked him at once’’ if he
had an STD. At first he ‘‘refused to tell me the truth.
But one week later after he finished treatment, he
admitted that he ‘‘got the disease’’. When she told her
mother-in-law, she ‘‘blamed me for his mistakes’’.
And later when my husband got the disease and I and
my husband had some quarrels, my husband’s great
family blamed me again’’. She has been to the STD
clinic several times. When she first got her
symptoms, she self treated by ‘‘wash and insertion’’.
When she found that to be ineffective, she
went to a private doctor. She didn’t ‘‘like him, and
felt ‘‘uncomfortable’’ with him because he ‘‘was a
hard man’’. Finally, she came to the STD clinic for
tests.
These case studies illustrate the similarity between the
two paths that led women to recognize STD symptoms
and to seek care at an STD clinic. Common factors that
prompted the women to ultimately seek care in the STD
clinic were perceived severity of symptoms, suspicion
and subsequent confrontation with husband, persistent
distrust of husband despite denials, and a series of
unsuccessful treatment attempts.
Discussion
These data present the socio-cultural context of
Vietnamese women and men and its impact on the
perception of STDs. By integrating social and individual
factors, our framework was useful in conceptualizing
and presenting the pathways by which traditional gender
roles may influence Vietnamese women’s interpretation
of STD symptoms and health-seeking strategies.
Our male and female participants associate STDs with
promiscuity and for women, having an STD would
represent a violation of deeply embedded social norms
about gender roles and expectations. These findings
correlate well with findings from quantitative assessments of health-seeking behavior in other populations
(Gorbach, Hoa, Eng, & Tsui, 1997; Sajiwandani &
Baboo, 1987; Moss et al., 1999).
Our study suggested that economically, life in both
project communes is difficult. According to focus
groups, ‘‘social evils’’ are spreading more rapidly in
Ha Ly than in An Hung. Many participants from Ha Ly
attributed the spread of ‘‘evils’’ in Ha Ly to economic
hardships as the unemployed turn to drug use and sex
work in despair. Our data suggested that there are
stronger community norms governing unsanctioned
behaviors in An Hung, where ‘‘social evils’’ are
perceived to be less widespread.
Our findings on traditional gender roles corroborate
other studies which have examined gender relations in
Vietnam (Gammeltoft, 1999; Pham Van Bich, 1997).
Women’s roles are clearly delineated by traditional
norms stating that a woman should be hard-working,
clean, well-spoken, and virtuous. Her primary roles are
as a wife and a motherFand in these roles, she is
expected to behave faithfully and unquestioningly
V.F.-L. Go et al. / Social Science & Medicine 55 (2002) 467–481
towards her husband. In contrast, men’s marital and
sexual roles are less clearly defined by traditional norms.
Most participants described an ideal man as one who
has a stable job, is socially respected, and does not
engage in ‘‘social evils’’. It appears that social norms are
less strongly enforced for men than women, as wives are
expected to bear the burden of their husband’s deviations.
Traditional gender roles shape community perceptions of premarital and extramarital sex. For men, who
are believed to have a natural sexual drive, these
activities are socially sanctioned. Women are expected
to be faithful and devoted to familial duties and
engaging in these activities may have severe physical
and social repercussions. It appears that extramarital sex
engenders stronger disapproval than premarital sex and
both husband and community are likely to intervene to
stop a married woman from engaging in such activities.
Women interpret discharge, itching, and genital ulcers
as either benh phu nu (women’s diseases) or, more
severely, as cac benh lay truyen qua duong tinh duc
(diseases transmitted sexually). Similar to Whittaker’s
(1999) study, we found that ‘‘women’s diseases’’ are
associated with being ‘‘dirty’’ and ‘‘lazy’’ and are
therefore considered socially undesirable. We extend
these findings to show that STDs evoke stronger
disapproval. Men and women expressed anxiety about
telling their partners if they had an STD; women’s
expressions were characterized more by fear, whereas
men expressed embarrassment. The characteristics of
shame and fear associated with STDs may be barriers to
women’s health-seeking behaviors. When women did
seek care, our two case studies, though limited by a
small sample size, illustrated that providers may be
perceived as ineffective and judgmental and therefore
unacceptable.
In some cases, focus group discussions may not be
appropriate to discuss sensitive topics in settings with
strong social norms. However, we found that scenarios
enabled participants to de-personalize situations, yet
respond based on personal experiences and beliefs. Most
groups were dynamic and intense, peppered with heated
discussions about gender roles and sexuality, although
in one group, people seemed awkward and reluctant to
speak. However we attribute this awkwardness to the
inevitable variability of group dynamics rather than
normative pressures. While in-depth interviews provided
direct insight into personal experiences, some interviewees seemed more guarded, perhaps because the
conversation was focused entirely on the interviewee,
rather than on a broader group. Gammeltoft reported a
similar finding in her qualitative study in the Red River
delta: ‘‘I was surprised at the openness with which
sexuality and gender relations were often discussed in
these groups; in some respects, group discussions turned
out to be much better ways of researching personal and
479
sensitive issues than individual interviews’’. (Gammeltoft, 1999, p.49).
Health programs that aim to prevent RTIs and
encourage health-seeking in Vietnam may need to
acknowledge the deep-rooted social norms associated
with symptoms and STDs. As Craig (2000) found in his
study of popular medical practices in Vietnam, biomedicine only offers variously reliable and accessible
facilities often known by word of mouth and recommended to family and neighbors. Simply educating
women and providers about RTI symptoms and the
biomedical consequences of RTIs may prove to be
ineffective in this setting. At the same time, dismantling
norms that have existed for centuries in Vietnam is an
unrealistic and, perhaps, undesirable, goal for a health
intervention. However, by disassociating RTI symptoms
from traditional norms, women may be more likely to
acknowledge symptoms and seek care. This might be
accomplished in several ways. First, health education
messages should target social networks and discuss STD
symptoms in the context of RTIs. As shown, changing
community-wide perceptions of STD symptoms may
require the targeting of both men and women. Exclusion
of men would ignore the reality of social norms and
gender dynamics in Vietnam and would assume that
women have the power to unilaterally change perceptions of STDs. As Craig (2000) notes, social networks
are a critical factor influencing health-seeking behavior:
‘‘the family conference is an important forum for
deciding on which treatment option to resort to. Family,
neighbors, other mothers all offer advice and claim to
have experience and their particular authority and
advice may determine patterns of resort to care and
outcomes’’ (p. 708). Messages may be disseminated in
separate informal health sessions for both men and
women, highlighting socially acceptable causes of RTIs
(e.g., endogenous and iatrogenic infections). Second,
interventions such as those shown to be effective by
Kelly (1991), which use community leaders to spread
education messages, may be effective in changing
community-level perceptions of STDs. Finally, efforts
should be made to provide local health providers with
information on diagnosis, treatment, and counseling of
women on sensitive issues such as STDs to ensure that
women receive satisfactory and non-threatening care
when they do seek treatment.
Acknowledgements
The authors would like to thank Nguyen Thi Thanh
Tam, the Hai Phong Provincial AIDS Committee and
Ha Ly and An Hung Commune Health Stations for
their technical support and Drs. Kenrad Nelson, Andrea
Gielen and T. Christopher Mast for their helpful
comments and suggestions. This research was supported
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V.F.-L. Go et al. / Social Science & Medicine 55 (2002) 467–481
by the Fogarty International AIDS Program and the
National Institutes of Mental Health (#R03 MH5848201).
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