QUALITATIVE
Shefer
et al. / STIs
HEALTH
IN SOUTH
RESEARCH
AFRICA/ December 2002
The Social Construction of
Sexually Transmitted Infections (STIs)
in South African Communities
Tamara Shefer
Anna Strebel
T. Wilson
N. Shabalala
L. Simbayi
K. Ratele
C. Potgieter
M. Andipatin
Since the medical link between sexually transmitted infections (STIs) and HIV/AIDS was
established, there has been an increased focus on the spread of STIs in South Africa. The aim
of this study was to provide an in-depth picture of the dynamics involved in sexuality and the
spread of STIs and HIV/AIDS. The authors present the findings of a focus group study,
which was a part of a larger, national project addressing the broad question of health-care
seeking behavior for STIs. A discourse analysis carried out on 10 focus groups reveals complex and rich narratives on the way in which STIs are constructed in South African communities. The dominant discourses focused on the continuing stigmatization of STIs, causal
explanations, and prevention strategies. The analysis raises important recommendations for
both educational interventions and health services toward the challenge of halting the spread
of STIs and HIV/AIDS.
S
exually transmitted infections (STIs) represent one of the oldest major public
health issues in South Africa, but they have been relatively neglected until the
emergence of HIV/AIDS. More recently, strong empirical evidence of a medical link
between STIs and HIV/AIDS has led to a greater focus on sexually transmitted
infections (Laga, Nzila, & Gorman, 1991; Legion, 1992; Wasserheit, 1992). Although
there are several possible patterns of interaction between STIs and HIV infection,
most research to date has been concerned with the extent to which other STIs (both
ulcerative and non-ulcerative) facilitate the transmission of HIV infection (Buve,
Laga, & Piot, 1993). This link has helped raise the profile of STIs and highlights the
urgency of the need for prevention and control of STIs as a means of limiting the
spread of HIV/AIDS.
In South Africa, the need to curb STI infections is all the more urgent given that
South Africa is believed to have one of the highest infection prevalence rates of
QUALITATIVE HEALTH RESEARCH, Vol. 12 No. 10, December 2002 1373-1390
DOI: 10.1177/1049732302238749
© 2002 Sage Publications
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“classic” STIs in the world (Block & Dehaeck, 1987; Pham-Kanter, Steinberg, &
Ballard, 1996). Although no rigorous national surveillance surveys to determine the
prevalence of STIs have been undertaken to date, it has been estimated that approximately 4 million episodes of STIs occur yearly in South Africa (Department of
Health, 1996; Health Systems Trust, 2000). Furthermore, South Africa is now considered to have the fastest growing AIDS epidemic in the world and the largest number
of people living with HIV. The 1999 survey of HIV seroprevalence among women
attending South African antenatal clinics demonstrated that 22.4% of women
attending such public health facilities were infected with HIV, compared with less
than 1% in 1990 (Health Systems Trust, 2000; McNiel, 1999). In spite of frightening
social, economic, and health costs, STIs have received little attention as a public
health issue in South Africa, with minimal proactivity in controlling their spread
(National AIDS Research Programme of the Medical Research Council, 1993).
One reason why STIs remain a major health problem in South Africa is that the
care and management of patients with STIs is thought to be highly inadequate
(Coetzee & Magwaza, 1997; Schneider, Blaauw, Dartnall, Coetzee, & Ballard, 2001).
As a legacy of apartheid, there continues to be unequal access to quality and adequate medical services for the overwhelming majority of the South African population, who are predominantly Black, poor, and rural. In general, most South Africans
are believed to neither know nor understand the etiology and epidemiology of STIs,
and lack knowledge about control and preventive measures to use against STIs.
One of the major reasons advanced for this situation is the conservatism of both
White and Black segments of the population, which means that discussions of sexual matters in general and STIs in particular remain taboo subjects in many local
communities. This situation has been worsened by the judgmental attitudes of
health care workers and the stigma associated with STIs and seeking treatment, particularly for women (Abdool Karim, Mathews, Gutmacher, Wilkinson, & Abdool
Karim, 1997).
Much of the international and local literature on the social dimensions of STIs
focuses predominantly on cognitive-behavioral investigations of knowledge, attitudes, beliefs, and practices (KABPs) of various population groups with respect to
STIs, particularly AIDS (for example, Beaman & Strader, 1989; Faxelid, Ndulo,
Ahlberg, & Krantz, 1994; Mathews, Kuhn, Metcalf, Joubert, & Cameron, 1990;
Shafer & Boyer, 1991). However, one of the major weaknesses of these studies with
respect to understanding the social construction of STIs more broadly is that many
of them have focused exclusively on people’s knowledge about AIDS, to the exclusion of other STIs. Furthermore, this research has highlighted the difficulties
involved in measuring knowledge and points to a need for researchers to grapple
with exactly what constitutes knowledge in the area of sexual disease and sexual
health, and the contradictions and complexities that emerge when exploring people’s constructions of illness and health. Thus, although South African studies have
shown awareness of AIDS to be apparently high, accurate knowledge about the
modes of transmission and strategies for prevention were considered lacking or
superficial (Blecher, Steinberg, Pick, Hennink, & Duncan, 1995; Mathews et al.,
1990). Different methods of testing knowledge also tended to produce different,
sometimes contradictory, results: Blecher et al. (1995) found that the level of knowledge of AIDS was high when participants (STI patients) were tested by closed questions but was, in fact, superficial when tested by open-ended questions. Asking participants to expand on their understandings of STIs and AIDS through qualitative
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methods of data collection, therefore, allows for exposure of the uncertainties, contradictions, and “wrong” knowledge that people might have about STIs and AIDS.
Researchers have made similar distinctions in those studies that have focused
on other STIs. For example, although the vast majority of people might have heard
of STIs (Faxelid et al., 1994), researchers have found that the knowledge of names
and labels for STIs is low, with most participants mentioning no more than three
STIs including HIV/AIDS (Bukenya, 1986; Mofokeng, Bachman, Cooper, &
Coetzee, 1996). Contradictions have also been found with respect to knowing the
causes of STIs. Faxelid et al. (1994), in interviews with STI patients at outpatient clinics, found that although almost all participants knew that STIs are transmitted
through sexual activity, when it came to explaining their own illness, only 34% of
women and 84% of men believed that what they had was a STI. It is clear from these
findings that individuals do not necessarily apply abstract knowledge of STIs to
themselves. Following on from this, most KAPB studies of HIV/AIDS (for example,
Mathews et al., 1990; Searle, 1987; Simbayi, 1999; Strebel & Perkel, 1991) have shown
the lack of a significant link between the amount of knowledge and behavioral practices. Mathews et al. (1990) suggest that attitudes, values and beliefs, cultural
norms, and the influence of family, peers and the media are all important determinants of whether appropriate behavior is adopted.
Consequently, there has been increasing recognition of the limited usefulness of
KABP studies and of the need to conduct qualitative research that explores the complexity of understanding and meaning construction with respect to STIs, HIV/
AIDS, and sexuality more broadly. In South Africa, the focus has been aimed especially at those believed to be at risk for STIs and HIV/AIDS, such as adolescents and
women (Buga, Amoko, & Ncayiyana, 1996; Harrison, Xaba, Kunene, & Ntuli, 2001;
Shefer & Strebel, 2001; Strebel, 1996; Wood & Foster, 1995; Wood, Maforah, &
Jewkes, 1996).
Thus, it is within the context of the need to deepen understandings of the spread
of STIs that we believed it important to conduct research that allows for an exploration of the different ways in which people perceive STIs. Such an analysis further
facilitates an examination of the implications of these social constructions for sexual
and health-care seeking practices.
THE NATIONAL STUDY
This study formed part of a large national study commissioned by the National
Health Department, which examined factors influencing health-seeking behavior
for STIs (Simbayi et al., 1999). The primary focus was on four interrelated areas: general perceptions of STIs, sexual behavior, health care-seeking behavior for STIs, and
the quality of care received when treated for a STI at primary health care (PHC) centers. The study incorporated multiple methods, including both quantitative and
qualitative modes of data collection and analysis.
THE FOCUS GROUP STUDY
Our discussion in this article draws on data from only one of the qualitative methods used, that is, ten focus groups held with participants from diverse communities
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across South Africa. The study targeted four provincial areas of the country: Eastern
Cape, Western Cape, Northwest, and Mpumalanga. It incorporated both rural and
urban populations. Participants for the focus groups were drawn from the communities in which the study took place (which was determined by the National Department of Health), and the researchers relied on local informants or organizations to
set up the groups, which included men-only, women-only, and mixed groups (see
Table 1). All participants were Black and from communities that are economically
disadvantaged. There was some attempt to target those more “at risk,” such as mine
workers, sex workers, young people, and prisoners. The focus group participants
were by no means a representative sample but certainly reflect some of the diversity
of South African communities. A convenient sample of focus group participants
was recruited with the aid of local health care clinics and provincial health administrators. We relied on these community-based sources to set up groups for us, and
these were often formed from existing groups (for example, a group of health care
worker trainees and a group of community members engaged in an activity at a
clinic) or targeted groups in particular settings (for example, a group of prisoners
and a group of sex workers all working at the same venue).
Each focus groups was facilitated by at least one professional registered psychologists paired with trainee research and clinical psychologists. Group sessions
were guided by vignettes with a semistructured interview schedule and usually
lasted between 1 and 2 hours. All groups were conducted in the preferred language(s) of participants. Focus group discussions were audiotaped with permission, transcribed verbatim, and translated into English where necessary. We conducted a qualitative analysis on the texts drawing on discourse analytic techniques.
We adhered to ethical standards for research as stipulated by the Psychological
Society of South Africa. All group members participated voluntarily based on
informed consent and were assured of anonymity and confidentiality. Fieldworkers
recorded no participant names or identifying details, other than the participant’s
number and gender. Demographics, such as gender, age, and marital status, were
not recorded, as we did not feel these were necessarily relevant (given that the sample was not intended to be representative) and wanted to avoid any threatening or
invasive inquiry for ethical reasons.
In this article, we are concerned predominantly with how participants construct meaning of sexually transmitted illnesses—in particular, what discourses
they draw on to talk of and explain STIs and their treatment. Central discourses that
emerge from the analysis of the focus groups are outlined below.
STIGMATIZING AND
“OTHERING” DISCOURSES
The phenomenon whereby many people, including STI patients themselves, distance themselves from the possibility of having or acquiring a STI is undoubtedly
linked with general perceptions of and attitudes towards STIs. Gilmore and
Somerville (1994) describe the stigmatization of STIs as a primitive reaction to disease that divides people and communities into “them” and “us,” involving stereotyping, scapegoating, and discrimination. According to these authors, when the
prevalence of a stigmatizing infection is increased in a minority group, a
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TABLE 1:
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Description of Focus Groups
Area/Town
Description
Large city
Small urban
Small semirural
Small semirural
University, large urban
Large urban
Rural
Large urban
Rural
Small urban
Male prisoners
Male mine workers
Male and female volunteer health workers
Female sex workers
Female students
Female residents
Male and female community members of rural village
Female sex workers/members of sex worker organization
Female church group
Male and female community group
Code in Text
1
2
3
4
5
6
7
8
9
10
marginalized population, or an already stigmatized community, that group is likely
to be singled out as the object of a stereotyping-stigmatizing response in relation to
the infection. The most pervasive stereotype associated with STIs is one of promiscuity. This includes images of sexual looseness, prostitution, dirtiness, and immorality. “Loose women,” particularly, have been considered to be the carriers of STIs
historically. In keeping with this, contracting a STI can produce very powerful experiences of shame, resulting in secrecy and nondisclosure, especially for women
(Faxelid et al., 1994).
Throughout the talk on STIs in the focus groups, it was clear that there are still
powerful stigmas attached to having an STI, with those infected constructed as
“other” and deviant. In particular, the popular association of STIs with sexual promiscuity was evident, as well as a discourse on “dirty blood,” which is a consistent
thread in the dominant construction of STIs in this study (see Figure 1 for transcription conventions).
Interviewer:1 Are there certain types of people who are prone to having STIs?
Participant: Yes there are. These are the people who are promiscuous. If a person has one
partner, the likelihood of getting STIs is very slim. (1, M)2, 3
Participant 1: I think one gets this problem when one comes into contact with a wrong
person. A person who sleeps around and that kind of thing . . .
Participant 2: So, like people who do it for money. They come into contact with many people and when one comes into sexual contact with them, one may get this problem
from dirty blood. (our emphasis) (2, M)
Generally, participants expressed emotions of humiliation, fear, and discomfort
in relation to having a STI, which also served as inhibiting factors for their seeking
health care:
Interviewer: How did you feel about going to the hospital?
Participant: Well, I, at first, I did not like the idea. I just did not feel like telling anyone
about it because I was embarrassed.
Interviewer: Why were you embarrassed? If I recall clearly, when one has a sore hand they
can easily go to the hospital. So what was the problem then?
Participant: I was just scared. (1, M)
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Transcription Conventions
… - text omitted
= participant interrupts
[ ] - pause, silence
:: - drawn out word
/ - participant cuts in during a monologue
[text]
- explanatory text or what was probably meant by the participant or clarification of
what was said.
FIGURE 1:
Transcription Conventions
Highlighting the stigmatization and discomfort associated with STIs were the
common use of euphemistic and distorting labeling practices used not only by community members but also health providers, as evident in the following two quotes:
Interviewer: So, are there particular words they give to people who have an STI?
Participant 1: Yah there are, if Phindi is having STI and tells one that she has this illness . . . they [community members] will call her PZZ, there is a name they use, PZZ
Participant 2: [Laughs]
Participant 1: Phindi Zifo Zonke [person’s name before the Zulu term “all diseases”]—
“Phindi All Diseases” [laughter].
Participant 1: SZZ, you will hear them calling you “all diseases” [Several voices at once].
Participant 2: This makes difficulty even to share this with your friends that you’ve got
this illness because of the labels they give to people. (3, M & F)
Participant 1: Oh, they [health care workers] call HIV “case”!
Participant 2: Yah it is a case.
Participant 2: Yah they say HIV is “the case” [laughter].
Participant 1: They do not call you by your name, they do not take you as a human
being—they name you “the case.” (3, M & F)
Both of these quotes illustrate the use of obfuscatory labels in speaking of people with STIs and HIV, which, rather than protecting the patient, serve to dehumanize and objectify, frequently creating discomfort around disclosure. Some of the
labels for STIs highlight the negative construction of these illnesses as dirty, such as
the popular term vuilsiekte (Afrikaans for “dirty illness”) and the common notion of
dirty blood, as in the earlier quote.
In general, it was felt that there is much secrecy surrounding sexually transmitted infections, on the part of both community and professional health workers:
I can tell you in Zulu that these diseases are not known and they are secretive [] even
the doctors are not telling them. (9, F)
People are not open about this sex, about this sickness [] people are very secretive.
(8, F)
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The second quote highlights the way in which the general construction of sexuality, in particular the repression of sexuality more broadly, influences attitudes
toward STIs, as expressed here:
Nowadays people are taught in the rural areas about safe sex which was [] never
done before, which was a complex thing, it was a thing which was dividing the family, you mustn’t speak about sex, you mustn’t speak about periods. No man must
hear that you got your periods [] not even your friends . . . It was something very
secret and when we were sick we are given herbs, not taken to a doctor. (our emphasis) (8, F)
As emerges between the lines above (rural areas), a discourse drawing on
notions of culture and tradition is used regularly to explain the secrecy surrounding
sexuality. This is more clearly expressed here:
I think another thing is this, in our culture, there are certain things, I mean, that you
don’t say because [inaudible] but in our culture we are not talking, we are not talking openly about sex. (5, F)
Participants frequently spoke about the difficulties in being honest about having an STI in their community and the dangers of their conditions “spreading”
through the community, which ultimately center around a fear of alienation and
stigmatization. For example,
I think what causes the problem is—if, say, a certain man has this kind of a problem,
he will of course think of tell[ing] friends about it. But the problem is that one tends
to think that if you tell one of your friends about this problem he will go about telling others that Mr so and so has this kind of problem. So this thing will spread. (1, M)
Although the stigmatization of STI patients was spoken about throughout the
groups, it was also evident, as illuminated by the literature, that there are gender
differences in the way in which STIs are perceived. Frequently, STIs appear to be
constructed in more positive ways for men, with the occurrence of such an illness
seen as representative of successful masculinity. In the study by Faxelid et al. (1994),
more women than men expressed shame about having the disease. Indeed, some
men considered having the disease a sign of manhood. Similarly, in this study, the
men frequently viewed an STI as a source of pride or proof of masculinity rather
than a humiliation:
With men, let me speak [on] behalf of men, with men we do really not hide. If I have,
maybe gonorrhea I will go to men and say “hey men, I’ve got gonorrhea can you try
[refer] me [to] an imbiza [traditional healer] then men will refer me to an imbiza, then
they will cure me, it is easy with us, we can talk—with women, it is where the stigma
lies [] it’s mostly with women, with men no [] m::hh, [referring to the women in the
group] women would you talk to your men, mother mh ?
And a man mh [] man can have pride to call other man to look at his penis if it is sore,
a man has guts to do that but with women. (3, M & F)
This experience is in line with the popular construction of masculinity as driven
by inherent, essentialized sexual urges, what has been termed the “male sexual
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drive” in the literature on heterosexuality (Hollway, 1989). Male sexuality is
explained as follows:
Participant 1 (m): Is there a guy who does not want sex?
Participant 2 (f): There is one.
Participant 1: You lies.
Participant 1: If you want to buy a shoe what do you do? No. You do not look for the size.
Participant 3 (m): You try it on . . .
Participant 1: I mean, let us look here, the mere fact is that, let us not betray each other. The
real fact is that women will always be women, let’s put it like that, I can go further.
Participant 4: Men will be always men. (3, M & F)
For women, the stigma was far more derogatory and representative rather of
loose women. Such constructions emerge out of the gendered construction of sexuality, given the double standards applied to male and female promiscuity, whereby
men are frequently rewarded for active sexuality whereas women are punished and
stigmatized for the same practices:
Participant 2: I have seen that women and men are given different names, the other is seen
as sleeping around and deserves to get illness because of behaving in that way, but if it
is a man [] the person will be seen differently or=
Participant 3: Eh::h in other words, the woman would be called prostitute, bitch, a male
will be called a man so the issue is with man. (3, M & F)
Furthermore, as emerges in the construction of the causes below, STIs are constructed as “female” illnesses, frequently blamed on women, particularly by male
participants, with women seen as responsible for starting and spreading them:
It’s mostly women who commonly have these STIs. You do talk to your partner but
sometimes they don’t listen. The thing is what they have is like compost, you do not
really know what’s happening. (our emphasis) (1, M)
EXPLANATORY DISCOURSES ON
SEXUALLY TRANSMITTED INFECTIONS
Participants’ explanatory models of STIs further highlight the way in which these
illnesses are negatively constructed in South African communities. A number of
participants expressed popular nonmedical explanations alongside the medical
versions, constructing the causes of STIs as mystical and extra-human, as in this
example:
Interviewer: OK, are there any other ways of contracting STIs besides having had sex with
an infected person?
Participant: Yes there are things like pubic lice, which are seen as STIs but these come
through bewitchment. I agree you can get them through your partner but the main
cause is bewitchment. (1, M)
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As mentioned, there was a common perception that women are at the root of,
and therefore to blame for, STIs; for example:
Interviewer: Okay, how did you get this drop [colloquial term for STIs], and what did
you do?
Participant 1: I got it from my girlfriend. I’m not sure as to what really happened but as
soon as I noticed there was something wrong, I went to the hospital.
Interviewer: Gentlemen, as you hear, he says it’s his girlfriend, how does one really get
drop?
Participant 2: You get it through having sexual intercourse with a girl who is not clean on
the inside. (1, M)
A woman can get this kind of a problem from a man, but it is rare. It is rare, really.
Usually these kind of problems are gotten from women. (2, M)
The construction of woman as to blame for STIs appeared to center around their
particular physiology, which is constructed by men as inherently prone to illness, as
naturally “fertile ground” for infection—“like compost, you do not really know
what’s happening” (in the quote above) or “mold” (below). Furthermore, women
are accused of not succeeding in keeping themselves “clean” enough, again reproducing the construction of female sexual physiology as particularly prone to infection and “dirt”:
I believe it’s females who cause these STIs. You find that the person only wipes the
vagina instead of washing properly. This then resembles bread with mold, then the
charges [text unclear] of uncleanliness formulate. (1, M)
Another of the frequent reasons given for women’s responsibility for STIs centered around their use of “potions” to increase male pleasure, specifically by creating the pretence of virginity and/or a “tighter,” dry vagina. Substances mentioned
frequently included zambuk (a medicated ointment for drawing skin infections, like
boils), snuff (tobacco inhaled through the nose), and various purgatives (such as
laxatives). For some, any medication taken by a woman is viewed as potentially
responsible for the creation of an STI:
Participant 1: Maybe Jabu has sex with her girlfriend . . . and the girlfriend had used one
of the things they put on the vagina like snuff, zambuk, all those things . . .
Participant 2: I think, maybe Jabu’s girlfriend was cleaning herself by taking pills to
purify herself.
Participant 3: . . . even disprin [a mild painkiller] can cause gonorrhea. (3, M & F)
Women’s promiscuity (rather than men’s) is further cited as a cause of STIs, as
in this example, which also highlights the significance of a discourse of “blood,”
emerging earlier in notions of unclean blood and here as “mixed” blood’, in understandings of STIs:
What I think is the problem is that you find that there are women who have sexual
intercourse with several men. For instance, today she sleeps with me and we have
sex. The following day she meets another man and they do the same thing we did a
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day before. So, she comes into contact with many different blood and it mixes with
her blood. So, in her is a mixed blood. Therefore, when yet another man sleeps with
her (perhaps the third man or so) he will get a problem because he finds mixed blood
in her. That is how one can get such a problem. (2, M)
Some women were believed to consciously create a STI by way of reprisal to
their men. Such constructions again draw on a discourse of supernatural powers, in
particular the popular association of women with witchcraft, and the notion of their
magical powers to “mix potions” to damage men:
At times it happens that people do it deliberately, like women. Say you have a relationship with her. Sometimes they think that they are clever. They drink all sorts of
things. These things mix up in her body and they make her blood dirty. It is like that.
(2, M)
Another popular understanding was that STIs are caused by women’s use of
contraceptives, which, again, inadvertently blames women, even when apparently
acting responsibly and appropriately:
My boyfriend said that I gave him this disease and I got it from the family planning
method I am using [] and he is blaming me now/OK/because of the family [planning] that I am using, because he doesn’t want me to use it. (5, F)
The male discourse on women as responsible for STIs did not go unchallenged,
and the discourse of blame was also directed toward men, with women raising
men’s role in STI causation:
Participant 5: A lot of the time women get blamed, that they are rotten there—maybe
they’re having other sexual relationships [] but in fact men bring the disease to their
wives [].
Participant 2: Ja, these men are the problem. Most of the time, they bring diseases to the
family. (6, F)
Another causation provided for STIs emerges through a pathologizing discourse—that they are a consequence of an abusive or problematic sexual relationship. In the following example, a young woman’s sexual experience with an older
man is viewed as a negative experience for her, thus creating a STI. The example is
interesting in that although it emerges out of a problematic experience, it ironically
promotes a positive discourse on women’s sexuality and desires (i.e., an acknowledgement of women’s sexual desires), which has been viewed as a marginalized
discourse in talk on sexuality, both nationally (Shefer & Foster, 2001; Wood & Foster,
1995) and in international literature (for example, Holland, Ramazanoglu, &
Thomson, 1996):
We do not think she is enjoying sex with an older man. When he reaches climax she
surely does not get an orgasm. The burning urine is caused by the sperms she does
not omit out . . . These sperms then cause complications inside and results in the
bad discharge. This all happens because the girl did not enjoy sex with the older
man. (6, F)
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In some groups, a racialized discourse in discussions on the causes of STIs
emerged, with STIs viewed as a “White” illness, thus “othering” the illness for Black
participants. The following quote highlights the deep embeddedness of a discourse
of sexualized racism, which clearly has its roots in the apartheid taboos on sexual
relations across races:
Participant 1: You get these diseases from running around with White men.
Participant 2: Black men don’t seem to give us problems. (4, F)
DISCOURSES ON PREVENTION
AND INTERVENTION
Discussions about health-seeking behavior for STIs further highlighted central
aspects of their social construction by participants. There was much talk about the
use of alternative methods of intervention—both preventive and curative. The use
of preventive and curative methods for STIs when not using condoms emerged particularly, but not only, in the sex worker groups. Methods mentioned highlighted
the dangers, pain, and discomfort involved in alternative “cures” and included a
discourse of dirt/cleansing. Having an STI, particularly for the women, is constructed as “dirty,” as involving “contaminated blood” and therefore needing to be
sanitized by as stringent a “cleanser” as possible. Popular cleansers included “dip”
(apparently those used to disinfect animals from ticks, fleas, etc.), potassium permanganate, and Jeyes Fluid (popular as a toilet cleaner). For example,
Interviewer: But otherwise if you insist on using condoms they look for someone else?
Participant 1: Yes they do. So what we do—we drink “ama double buy” . . . and clean
ourselves
Participant 2: We also drink dip. This is the dip you mix with water. We drink this in the
morning so as to cleanse ourselves of this contaminated blood and leave it behind in
the toilet if possible. You then are OK. You can do this for a week . . .
Interviewer: Please tell me more about these double buys.
Participant 3: OK, that’s potassium permanganate, something like that, that’s what they
use and Jeyes Fluid [strong toilet disinfectant].
Interviewer: Do you drink it?
Participants: Yes/yes we do/all
Interviewer: What does it do?
Participant 3: It cleans you from within and it’s also some sort of laxative.
Interviewer: Whoow.
Participant 3: It works—it cleanses us—but it’s dangerous. (4, F)
Men appeared to use equally painful alternative methods of intervention in
attempting to “drain” the infection by putting physical pressure on the penis—
“hammering” it, in one case. Such responses also emphasize the construction of the
illness as something distasteful and invasive that should be acted on aggressively:
Interviewer: Is there anything else you used for treatment before going to the hospital?
Participant: I asked others and they said you should just put the penis on a hard surface
then you hawer [hammer] it.
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Interviewer: What? [background laughter] What did they say?
Participant: Someone said at the hospital they use the same kind of treatment. They just
use a rubber hammer. Instead of going there, I tried to do it myself. (1, M)
In discussion on health-seeking behaviors, in some groups a wariness of Western medicine and a clear support for indigenous healers emerged. Some spoke of
how the clinics deal only with the symptoms, whereas healers address the roots of
the illness. This can be viewed as a valuable insight into the social construction not
only of STIs in certain communities but also perceptions of Western medicine,
which influence the use of public clinics for STIs. For example,
I am talking from experience. If I am sick, they will be able to give me an injection
and pills. But as time goes on you find that when you urinate the urine is burning
but if you go to the traditional healers they are able to cure this illness completely.
They give you traditional medicine and you get healed. In the Western way of treatment, the symptoms do seem to go away but when you have sexual intercourse
with a woman the problem reappears. But if you go to a traditional healer the problem will not reappear at all. (2, M)
Discussions of intervention through clinics and other medical routes also illuminate the way in which STIs are othered and negatively constructed, even by those
apparently well educated about them. Thus, many participants spoke about clinic
staff’s disrespect, rudeness, and judgmental attitudes toward and stigmatization of
their illness. For example,
They make you feel like a fool, a piece of rubbish, until you don’t even know yourself anymore. You regret you actually went there, and all the time they’ll be shaking
their butts and walking around. . . . You’d probably just think of leaving the place, if
you think of how humiliated and put down you’ll feel when she finds out what disease you have. (6, F)
The following quote highlights both the alienating experience of labeling and a
related lack of confidentiality:
Participant 1: Sisters [nurses] are the one’s who call the people “cases.” If you go there
and speak with them about your problem, your problem is supposed to be secretive,
it is between you and the sister attending you but when you come back next time the
other sister which was not there you will hear them saying “[name] there comes that
case.”
Participant 2: Nurses are the ones who label people, calling them cases, it’s really them
and they discuss your problem.
Participant 3: Makes you feel bad. (3, M & F)
Some felt that STI patients, especially those with HIV, are alienated by discriminatory and exclusionary practices in clinics:
Participant 1: They are isolated in the clinics.
Participant 2: Yah, they discriminate and isolate them.
Participant 3: Yes, they do isolate, for instance like here . . . They do not treat people in the
same way so if you are a patient you can see that you are not welcome and you will
end up stopping to come for the treatment because you are not accepted. I think this is
lowering their self-esteems and make them to lose hope that they can be
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cured . . . There at hospital if someone has AIDs they will shout at people around the
victim and [tell] them to stay away from the victim and the nurses will shout at others
to double their gloves. . . . Now the people know that if the nurses say to others “3 or 4
gloves” they know that the patient is suffering from STIs. (9, F)
Gender and class differences also emerged as playing a role in how patients are
treated, which illustrates the differential stigmatization of the illness. Some participants felt that men were treated better than women were and that status and class in
particular played a role in this:
Participant 1: They treat men differently. They take care of them.
Participant 2: They don’t give us the same treatment.
Participant 3: They actually laugh, swear, and shout at us.
Participant 1: If your boyfriend takes you there, they help you both. (4, F)
Participant 1: And the other thing . . . with hospitals and clinics . . . If P [name of participant] as [a] male has one of these diseases the nurse will say nothing to him, but if I,
myself as female goes inside with the same disease they will say a lot. That is why it
looks as if females are the ones who spread this disease because they are confronted,
shouted [at] and get names that they do not even expect. One rather stays with it . . .
Participant 2: Is the problem in the clinics that they treat male and female differently?
Participant 3: Even for male/it depends who you are/they consider your status, if they
do not know you they will play around with you, even if you are male! (3, M & F)
Furthermore, the popular notion that women are to blame for STIs was apparently also prevalent among clinic staff, as illustrated in this quote:
Participant: I once had it [an STI] and the nurses did explain the treatment to me. I
enquired if it was OK to bring my partner and they said I should. I went to fetch her.
After examination, it was confirmed I had got this from her.
Interviewer: Who confirmed this?
Participant: The doctor did. (our emphasis) (1, M)
Sex workers spoke about specific forms of discrimination that they experience
in clinics, with some having been refused any help because of the double stigma
attached to their occupation and illness by clinic staff. Furthermore, when they did
receive help, they spoke of being “disciplined” and scolded by clinic staff:
You know they [sex workers] find it very difficult at some clinics because you know
the reception you get there—its not always nice especially when they know you are
a sex worker, you know. I am not going to tell everybody the clinic is nice, they are
treating me nice. They treat the sex workers like shit . . . [name of clinic] they look
down on sex workers. (8, F)
Participant 2: They [clinic staff] first want to know how you might have gotten the illness.
If you tell them that you are a prostitute then it becomes difficult to get treatment. If
you do not tell them then you are given all the treatment you need . . .
Participant 1: They say we are bitches. (4. F)
In the following example, the lack of confidentiality and abusive treatment
experienced at clinics emerges strongly through stigmatizing and racist discourses:
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I once went to the clinic here in the location at [name of clinic]. . . . There I told the sister my problem. They asked us one by one as we were sitting there. One sister
shouted in front of people saying that she had heard that we were sleeping with
White men without using condoms. She said those White men were going to give us
AIDS. She shouted [at] me in front of people who were there and she never talked to
me in private. I was very angry so I left. (4, F)
The only positive moment in the excerpt is the participant’s resistance to the
abusive treatment and therefore challenge to the negative and stigmatized construction of both her identity and illness.
CONCLUSIONS
The focus group analysis highlights the deep entrenchment of the stigmatization of
STIs in the communities under study. Othering and distancing rhetorical strategies
are prolific in the discussions on STIs, and it is those constructed as “deviant,” particularly sex workers, “loose” women, and, arguably, women in general, that continue to be blamed for the spread of sexually transmitted infections.
This discourse of othering and blame took a variety of forms. Women blamed
men for having multiple partners and bringing STIs home to their monogamous
partners. No matter what the truth of the matter, such a discourse facilitates
women’s denial of their own vulnerability to STIs. Although men were blamed for
the spread of STIs because of having multiple partners, this was often naturalized,
whereas women were degraded and stigmatized for having multiple partners.
Thus, promiscuity, with its stigmatizing connotations of deviant sexual practices,
continued to be the most pervasive stereotype associated with STIs, especially for
women. A prevalent discourse of women as responsible for the spread of STIs
hinged around notions of the female body as vulnerable to infection, manifesting
particularly through the construction of the vagina as a compost-like environment
in which diseases can easily form and breed. The negative construction of female
genitalia and, by extension, female sexuality was particularly clear in this image.
Gender differentiation was, therefore, evident throughout the “blame” discourse. Although women blamed men and other women for the spread of STIs,
men, for the most part, blamed women, especially “certain kinds” of women. For
men, though, there was clearly ambiguity around the status of having a STI. Given
the hegemonic construction of masculinity, having a sexually transmitted infection
signalled a positive moment for men, albeit a problem, given its proof of their sexual
success as men. At the same time, men shared with women the view of STIs as an
invasive force that had to be dealt with aggressively. The unsympathetic construction of STIs as dirty and tainting to the self, which sets it apart from other illnesses,
further reproduces the stigmatization of having an STI for both men and women.
A number of significant areas for intervention emerge out of the findings of this
study, which can be outlined as follows.
First, it is evident from the group discussions that people’s understandings of
the causality and spread of STIs are frequently incongruent with Western medical
knowledges about these infections. Such findings draw attention to a widespread
context in which the medical term STI and the biomedical explanations of the etiology of these, might not be understood or accepted by patients because they are
incompatible with how they make sense of sexual health generally and their
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particular episode specifically (Coetzee, Visser, Mofokeng, & Hennink, 1996). The
inconsistencies in this study, therefore, support findings from previous studies (for
example, Evans & Lambert, 1997) that notions of sexual health and illness are not
always defined and experienced as they are by the biomedical discourse. Taking
this into account, there is a need to reassess continually the parameters in which
STIs, with their different symptoms, are experienced and defined by people in different communities, and to use these definitions in health promotion campaigns
rather than persisting in using a medical category (STI) and medical explanations
that might be foreign to people. Furthermore, it was clear that people’s knowledge
of STIs was overlain by a wide range of complex, emotionally loaded constructions
of these illnesses, and by gender and sexuality. The importance of understanding
communities’ constructions of STIs further reinforces the need for more qualitative
research into the social construction of sexuality, health, and illness. Although this
study has made a start in its exploration of community knowledge about STIs, further research on the alternative constructions of STIs is required, particularly within
the diversity of communities that exist in South Africa.
Second, the powerful role of gender difference and power inequality in the construction of STIs also highlight some important points about intervention strategies. It is more than evident, then, that as with understanding the barriers to safe sex
practices, the construction of STIs is interwoven with gender power relations and
gender stereotypes. We cannot address safer sex practices without addressing the
traditional constructions of masculinity and femininity. In particular, dominant
modes of heterosexual negotiation need to be challenged in order to shift the way in
which men and women relate to one another sexually. It is also clear that there are
dangers associated with targeting those who have multiple partners, traditionally
one of the central targets of STI/HIV education, as this reinforces the pervasive stereotype that a particular kind of lifestyle (judged as immoral and deviant) is responsible for the spread of STIs. This discourse perpetuates the construction that STIs
come from “outsiders” or “guilty minorities,” who contaminate an innocent population at large (Strebel, 1996). It also reinforces the notion that “this cannot happen to
me,” which reproduces and legitimizes unsafe sex practices. Because focusing on
the practice of having multiple partners perpetuates the blaming of others and
assists in the general denial of one’s own risk for STIs, it is important that programs
promoting health become more inclusive, with the emphasis on the vulnerability of
all people to ST infection.
Third, at the level of health care for individual STI patients, it is clear that service
providers need to be informed at far deeper levels than simply understanding and
managing STIs. Negative constructions of STIs and sexuality in general by clinic
staff are endemic to treatment received and act as an inhibiting force in clinic attendance. In this respect, it is clear that particular emphasis needs to be placed on counselling that is gender sensitive and framed within a progressive understanding of
sexual practices. Wherever possible, space needs to be made for patients to speak
about some of the difficult relationship and identity issues that such an illness might
raise. Myths about promiscuity, and all the stigmas associated with it, need to be
tackled directly and consistently as part of an attempt to demystify sexuality generally. Furthermore, a dialogue about sexuality and relationship issues needs to occur
together with the promotion and demonstration of condoms. For this to be successful, health providers must be sensitive to the complexities of relationships, including the effect of gender power relations on sexual negotiation. Furthermore, health
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providers themselves must be able to explore their own prejudices and deconstruct
the dominant constructions of STIs, gender, and sexuality.
In conclusion, it is clear that this qualitative study, based on community discussions about STIs, has pinpointed some of the significant problems hindering STI
control. Misconceptions and stereotypes of how (and by whom) STIs are spread are
pervasive and continue to influence the ways in which people think about STIs and
to impede safer sex practices. The tendency to externalize the problem of STIs is
common and interwoven with complex gender relations, and this also undermines
attempts to control STIs. Educational interventions that address such issues and
extend their emphasis to include issues of gender and sexuality need to be more
widespread. In addition, health providers require support and further training in
order to be equipped to counsel on issues of sex and sexuality. At a broader level, the
high profile of AIDS and the positive efforts that have been made to promote AIDS
awareness and education provide a valuable space in which essential educational
interventions about other STIs can also be advanced. Such a context also opens the
way for a proliferation of challenge and intervention in the realm of gender and sexuality more broadly.
NOTES
1. In most groups, there were two facilitators to accommodate language needs.
2. Each excerpt is identified by membership in group from 1 to 10 as elaborated in Table 1, and
gender—M or F.
3. Some participants were speaking in their second language, which explains certain grammatical
mistakes in the quotes. Most of the dialogue, however, was translated from a local language into English.
REFERENCES
Abdool Karim, Q., Mathews, C., Gutmacher, S., Wilkinson, D., & Abdool Karim, S. (1997). HIV/AIDS and
STDs in South Africa: The national HIV/AIDS and STD review. Pretoria, South Africa: Department of
Health.
Beaman, L., & Strader, M. (1989). STD patients’ knowledge about AIDS and attitudes towards condoms.
Journal of Community Health Nursing, 6, 155-164.
Blecher, M. S., Steinberg, M., Pick, W., Hennink, M., & Duncan, N. (1995). AIDS—Knowledge, attitudes
and practices among STD clinic attenders in the Cape Peninsula. South African Medical Journal, 85,
1281-1286.
Block, R., & Dehaeck, C. M. C. (1987). Human papillomavirus and the squamous epithelium of the female
genital tract. South African Medical Journal, 72, 557-558.
Buga, G., Amoko, D., & Ncayiyana, D. (1996). Sexual behavior, contraceptive practice, and reproductive
health among school adolescents in rural Transkei. South African Medical Journal, 86, 523-527.
Bukenya, G. B. (1986). Knowledge about sexually transmitted infections shown by people attending the
STD Clinic at Port Moresloy General Hospital. Papua New Guinea Medical Journal, 29, 295-299.
Buve, A., Laga, M., & Piot, P. (1993). Where are we now? Sexually transmitted diseases. Health Policy and
Planning, 8, 277-281.
Coetzee, N., & Magwaza, S. (1997). Assessing the quality of care provided for patients with STDs in primary
health care clinics: The development of an instrument for use by district clinic supervisors. Unpublished
manuscript, Department of Community Health, University of Cape Town, South Africa.
Downloaded from qhr.sagepub.com at PENNSYLVANIA STATE UNIV on September 18, 2016
Shefer et al. / STIs IN SOUTH AFRICA
1389
Coetzee, N., Visser, H., Mofokeng, M., & Hennink, M. (1996). Missed opportunities for partner notification in sexually transmitted disease clinics in Cape Town. Southern African Journal of Epidemiology
and Infection, 11 (2), 44-47.
Department of Health, Directorate of HIV/AIDS and STDs. (1996). Consensus seminar on the syndromic
management of sexually transmitted diseases in South Africa. Holiday Inn, Johannesburg International
Airport, Johannesburg.
Evans, C., & Lambert, H. (1997). Health-seeking strategies and sexual health among female sex workers
in urban India: Implications for research and service provision. Social Science & Medicine, 44, 17911803.
Faxelid, E., Ndulo, J., Ahlberg, B. M., & Krantz, (1994). Behavior, knowledge and reactions concerning
sexually transmitted infections: Implications for partner notification in Lusaka. East African Medical
Journal, 71, 118-121.
Gilmore, N., & Somerville, M.A. (1994). Stigmatization, scapegoating, and discrimination in sexually
transmitted infections: Overcoming “them” and “us.” Social Science & Medicine, 39, 1339-1358.
Harrison, A., Xaba, N., Kunene, P., & Ntuli, N. (2001). Understanding young women’s risk for HIV/
AIDS: Adolescent sexuality and vulnerability in rural KwaZulu-Natal. Society in Transition, 32(1),
69-78.
Health Systems Trust. (2000). South African Health Review 2000. Durban: Health Systems Trust.
Holland, J., Ramazanoglu, C., & Thomson, R. (1996). In the same boat? The gendered (in)experience of
first heterosex. In D. Richardson (Ed.), Theorising heterosexuality (pp. 143-160). Milton Keynes, UK:
Open University Press.
Hollway, W. (1989). Subjectivity and method in psychology: Gender, meaning, and science. London: Sage.
Laga, M., Nzila, N., & Gorman, J. (1991). The interrelationship of sexually transmitted diseases and HIV infection: Implications for the control of both epidemics in Africa. Antwerp, Belgium: Collaborating Centre on
AIDS, WHO.
Legion, V. (1992). Breaking the chain: STDs and HIV. World AIDS, 22, 18-21.
Mathews, C., Kuhn, L., Metcalf, C. A., Joubert, G., & Cameron, N. A. (1990). Knowledge, attitudes, and
beliefs about AIDS in township school students in Cape Town. South African Medical Journal, 78,
511-516.
McNiel, D. (1999, May 28). Loose talk about AIDS causes more deaths. Mail & Guardian, p. 32.
Mofokeng, M., Bachman, M., Cooper, D., & Coetzee, N. (1996). Management and control of STDs: Perspectives of health service providers at the Site B Health Complex and users of an STD clinic in Cape Town. Cape
Town, South Africa: University of Cape Town.
National AIDS Research Programme of the Medical Research Council. (1993). AIDS Bulletin, 2(2), 1-24.
Pham-Kanter, G. B. T., Steinberg, M. H., & Ballard, R. C. (1996). Sexually transmitted diseases in South
Africa. Genitourinology Medicine, 72, 160-171.
Schneider, H., Blaauw, D., Dartnall, E., Coetzee, D. J., & Ballard, R. C. (2001). STD care in the South African private health sector. South African Medical Journal, 91(2), 151-156.
Searle, E. S. (1987). Knowledge, attitudes, and behavior of health professionals in relation to AIDS. The
Lancet, 8, 119-121.
Shafer, M., & Boyer, C. B. (1991). Psychosocial and behavioral factors associated with risk of sexually
transmitted diseases, including human immunodeficiency virus infection, among urban high
school students. Journal of Pediatrics, 119, 826-833.
Shefer, T., & Foster, D. (2001). Discourses on women’s (hetero)sexuality and desire in a South African
local context. Culture, Health, and Sexuality, 3(4), 375-390.
Shefer, T., & Strebel, A. (2001). Re-negotiating sex: Discourses of heterosexuality among young South
African women students. Journal of Psychology in Africa, 11(1), 38-59.
Simbayi, L., Strebel, A., Wilson, T., Andipatin, M., Msomi, N., Potgieter, C., et al. (1991). Sexually transmitted diseases in the public health sector: Perceptions, sexual behavior, health care-seeking behavior and quality
of care. Belville, SA: Department of Psychology, University of the Western Cape.
Simbayi, L. C. (1999). AIDS awareness and sexual behavior change in South Africa. In K. Hope (Ed.),
AIDS and development in Africa: A social science perspective (pp. 153-164). New York: Haworth.
Strebel, A. (1996). Prevention implications of AIDS discourses among South African women. AIDS Education and Prevention, 8(4), 352-374.
Strebel, A., & Perkel, A. (1991, June). AIDS knowledge, attitudes, practices and psychological processes among
Black South African university students. Poster presentation at the Seventh International Conference
on AIDS, Florence, Italy.
Downloaded from qhr.sagepub.com at PENNSYLVANIA STATE UNIV on September 18, 2016
1390
QUALITATIVE HEALTH RESEARCH / December 2002
Wasserheit, J. N. (1992). Interrelationships between human immunodeficiency virus infection and other
sexually transmitted infections. Sexually Transmitted Infections, 19, 61-77.
Wood, K., & Foster, D. (1995). “Being the type of lover . . . ”: Gender-differentiated reasons for non-use of
condoms by sexually active heterosexual students. Psychology in Society, 20, 13-35.
Wood, K., Maforah, F., & Jewkes, R. (1996). Sex, violence, and constructions of love among Xhosa adolescents:
Putting violence on the sexuality education agenda. Tygerberg, South Africa: Medical Research Council.
Tamara Shefer, Ph.D., is an associate professor in psychology and the director of women and gender
studies at the University of the Western Cape.
Anna Strebel, Ph.D., is a consultant researcher/director of HEADWAYS Research Training & Development Consultancy, Cape Town, South Africa.
T. Wilson, M. Psych., is a clinical psychologist in private practice.
N Shabalala, M. Psych.
L. Simbayi, Ph.D., is Director of the Human Sciences Research Council, Cape Town, South Africa.
K. Ratele, Ph.D., M. Andipatin, M.A., and N. Shabalala, M.A., are researchers in the Psychology
Department, University of the Western Cape.
C. Potgieter is an associate professor in psychology at the University of Pretoria, South Africa.
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