This article was downloaded by: [University of Sydney] On: 13 March 2015, At: 04:21 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Women & Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wwah20
Women and Sexually Transmitted Diseases a
Cecilia Leonardo BA & Joan C. Chrisler PhD a
b
Connecticut College
b
Department of Psychology, Connecticut College Published online: 05 Nov 2010.
To cite this article: Cecilia Leonardo BA & Joan C. Chrisler PhD (1992) Women and Sexually Transmitted Diseases, Women & Health, 18:4, 1-15, DOI: 10.1300/J013v18n04_01 To link to this article: http://dx.doi.org/10.1300/J013v18n04_01
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden.
Downloaded by [University of Sydney] at 04:21 13 March 2015
Terms & Conditions of access and use can be found at http://www.tandfonline.com/ page/terms-and-conditions
Women and Sexually
Transmitted Diseases
Downloaded by [University of Sydney] at 04:21 13 March 2015
Cecilia Leonardo, BA Joan C. Chrisler, PhD
ABSTRACT. This paper presents a brief review of historical developments in women's heallh care. It describes lhe current campaign against sexually transmitted diseases (STDs) and assesses the camaign's success in light of its history and the reality of women's ives. The aulhors suggest that women are forced inlo a double-bid in which Uley are expected to take responsibility for Ule prevention of STDs although lhey may not have the ability to do so. Modifications are suggested which take into account gender-role socialization and social group norms.
P
Throughout the nineteenth and twentieth centuries, the treatment and prevention of sexually transmitted diseases (STDs) has been ieplete with moral judgments about those who suffered from them (Brandt, 1985). Medical treatment of women has, in general, been affected by sociocultural influences on their physicians ( E h r e ~ e i c h & English, 1973; Travis, 1988). Current campaigns against STDs which are aimed at women are infused with the same moral judgments found in earlier campaigns against STDs and against physical and intellectual activities which were once thought ,to harm women's reproductive health. The purpose of this paper is to briefly review historical developments in women's health care and to asCecilia Leonardo and Joan C, Chrislcr are affiliated with Connecticut College. Address correspondence to Joan C. Chrisler,Deparknent of Psychology, Connecticut College, New London, CT 06320. Women & Health, Vol. 18(4) 1992 Q 1992 by The Haworth Press, Inc. All rights resewed.
2
WOMEN & IIlMLTtI
sess the current campaign against STDs in light of its history and the reality of women's lives.
Downloaded by [University of Sydney] at 04:21 13 March 2015
HISTORICAL BACKGROUND
Feminist literature has criticized medicine as a major contributor to western sexist ideology (e.g., Delaney, Lupton. & Toth, 1988; Ehrenreich & English, 1973; Wertz, 1983). Writings about the differences between men and women have often relied on biological explanations and medicine has provided those explanations. Women have been viewed as weak and incomplete and men as strong and whole (Ehrenreich & English, 1973). Events in women's reproductive lives, such as pregnancy, menstruation, and menopause, have been perceived as both illnesses and justifications for devaluing a woman's worth (Delaney et al., 1988; Laws, 1983). A result of the perception that a woman is unclean, weak, and ill is the fear that she will infect men. Women have been seen as the source of sexually transmitted diseases, a view which served to validate the sociocultural image of woman as dangerous (Ehrenreich & English, 1973). The Judeo-Christian tradition has held that women are impure; Protestantism has implied that women could gain true spirituality if only they denied their sexuality. Thus, the age-old dichotomy of women as weak, pure, and good or powerful, tainted, and evil. At the turn of the century these two types of women were separated into the "delicate" upper classes and the "robust" lower classes. The upper class women received a surfeit of medical attention while the lower class women received almost none. Yet, the lower classes were viewed as transmitters of diseases, perils to their wealthier contemporaries (Ehrenreich & English, 1973). Today, availability of medical care is still unequally divided along class lines and blame for the transmission of diseases is frequently placed on outcast groups (e.g., the poor, the homosexual, the ethnic minority, the drug addict, the prostitute). Around the turn of the century, close medical attention came to be seen as essential for upper and middle class women, especially to safeguard their reproductive health. Illnesses of many types were traced to malfunctions of the reproductive organs and thought to be
Downloaded by [University of Sydney] at 04:21 13 March 2015
Cecilia Lconardo and Joan C. Cltrislcr
3
the result of "unfeminine activities." Sexual desires and behaviors in women were seen as capable of leading to both mental and physical stress (Ehrenreich & English, 1973). Although women were expected to deny their sexuality, they were encouraged to bear children. Women were warned to stay healthy so that they would be able to procreate successfully (Brandt, 1985). Venereal disease was pronounced the biggest threat to a woman's ability to bear healthy children. The stages of syphilis were understood by 1876; the bacteria which causes gonorrhea was identified in 1879. These two diseases were believed by physicians to contribute to the breakdown of the social order; it was feared they would result in the "fall of the race" and the "decline of the family." Thus began the campaign to protect the "good" women (the wives of the Anglo-Saxon elite) from the taint of STDs. The "bad" women (the unmarried, ethnic minority, poor) were seen as the carriers of these diseases. Men were urged not to have sexual intercourse with prostitutes, but it was the prostitutes, not their customers, who were punished (Brandt, 1985). In 1943 penicillin was discovered to be effective against both syphilis and gonorrhea. The prevalence rates of the diseases began a dramatic decrease which lasted until the late 1950s. Rates of STD infection have been steadily increasing since that time. Advances in birth control and the resultant "sexual revolution" have been the most frequent explanations for the rise in the STD infection rate. However, despite the increase in sexual activity, many Americans remained resistant to the discussion of STDs in classrooms and in the media. Funding for the prevention and treatment of STDs was not increased. Regardless of their prevalence, STDs were still equated with sin (Brandt, 1985).
THE SITUATION TODAY How frequently do STDs occur today? See Table 1 for approximate prevalence rates of the most common STDs in the U.S. The figures presented were chosen in consultation with the Center for Disease Control. Comparison between populations is difficult because private physicians tend to under-report cases whereas public clinics tend to be more thorough in their reporting (Goldsmith,
Downloaded by [University of Sydney] at 04:21 13 March 2015
4
WOMEN & HEALTH
1989). Thus, a bias occurs which makes it appear that women from the lower socio-economic classes, have a higher rate of STDs than do older, wealthier women. Despite knowledge of this reporting bias, it is not uncommon for experts to conclude that "STDs occur disproportionately among lower socio-economic groups, primarily among Blacks and Hispanics" (Goldsmith, 1989; p. 3509). The turn of the century division of women into the "good/clean" (those who can afford to visit private physicians) and the "badldirty" (the urban, minority, poor) apparently stillhfluences medical personnel to believe that "routine gonorrhea and chlamydia cultures, Pap smears to detect condylomaacuminata, and serologic syphilis screening are appropriate in large, urban populations of low socio-economic status"' (Nettina & Kaufman, 1980; p. 39). Prostitutes (the prototypical "bad/dirtyH women) are still frequently blamed for the spread of STDs. One researcher recently developed a mathematical model of the spread of the human immunodeficiency virus (HIV) through an infected prostitute, concluding that "in five years a single prostitute could be expected to infect about 20 men and about 0.8 unborn children" (Nahmias. 1989; p. 24). Yet, when researchers abstracted and analyzed records of syphilis patients, they found prostitution to be relatively unimportant in its epidemiology (Goldsmith, 1989). Little concern has been expressed about how many prostitutes a client withan STD might infect. Women visit physicians more often than men (Travis, 1988), are more likely than men to read magazine articles on health and physical fitness (Chrisler & Kaufman, 1988), are: routinely screened for STDs during gynecological examinations, and have thus been given the responsibility for prevention and treatment of STDs. Yet, many women are not able to take up that responsibility. THE CURRENT CAMPAIGN
The current campaign against the spread of STDs is deceptively straightforward. People are asked to (1) limit the number of sexual partners, (2) talk to their partners about STDs, and (3) use condoms. Such a campaign aimed at women is unlikely to be successful be-
Downloaded by [University of Sydney] at 04:21 13 March 2015
Cecilia Leorlardo and Joan C. Chrisler
5
cause it ignores gender-role socialization and the lack of power many women have in their intimate relationships. It is not that women are ignorant about STDs. Television talk shows and magazine health columns have presented much valuable information about AIDS and herpes. Ads urging condom use appear on television and billboards and in magazines. HIV education is taught in 50% of the schools in large, urban districts and a recent study (Brooks-Gunn, Boyer, & Hein, 1988) found that 94% of parents supported it. Sixty-two percent of women in a recent survey (Ricken, Jay, Gotlieb, & Bridges, 1989) admitted that the fear of AIDS had influenced their sexual behavior, yet only 17% reported that they had used or purchased condoms to prevent AIDS. Knowledge appears to be increasing faster than behavior is changing.
Table I APPROXIMATE PREVALENCE OF SELECTED SEXUALLY TRANSMITTED DISEASE IN THE U.S.
STD
Year
Total Cases
Chlamydia
1986
4,400,000
Gonorrhea
1988
750,000
Hepatitis B
1987
300,000 '
HPV
1987
12,200,000 "
HSV 2
1980
25,000,000 "*
Sy~hilis
1988
Celcs & Toomcy (1990)
** Stone (1989) ++*Johnson et al (1989)
35,000
6
WOMEN & HEALTH
Downloaded by [University of Sydney] at 04:21 13 March 2015
Seeing STDs as a Threat
In order to attempt to follow the suggested steps to prevent STDs, a woman has to see STDs as a threat to herself. For some women, STDs are just one of many risks they face daily. These women may be more directly concerned with the threat of physical violence or the search for adequate food and shelter. Typically, such women feel powerless to change their iives (Mays & Cochran, 1988) and cannot be expected to feel entitled to change their sexual patterns. Furthermore, to see AIDS as a threat to herself, a woman has to accept the fact that she is sexually active. This may be particularly difficult for young women in a society that has traditionally divided good women and sexual women into different groups. Women who are taught to feel ashamed of their sexuality may also be likely to deny it. As with birth control, a woman will not take precautions against STDs if she views sex as an event that happens to her rather than one she can control. Finally, many modem Americans still hold onto romantic notions about love and sex which make it difficult for them to believe that their partner could transmit an STD to them. This refusal to assume that anyone, even the nice person with whom one is in love, could have an STD is problematic in a society in which sex has become a means to intimacy, rather than its result (Rashish, 1991). Just as smokers believe that cancer is something that happens to others, many patients receiving treatment for STDs simply did not believe that they were at risk. Taking Precautions
I. Limit the number of partners. In a recent study of over 1,000 women's attitudes toward AIDS, Worth (1989) discovered that many of the subjects did not understand what was meant by the advice to "limit the number of partners." It meant different things to different women. Some thought that it meant one should avoid one-night stands, although serial monogamy was safe. Others thought it meant to limit the number of partners in one day or at one time. The campaign is thus hindered by the use of terms which
Downloaded by [University of Sydney] at 04:21 13 March 2015
Cecilia Leoitarrlo at~dJoan C. Clrrisler
7
are not explained because it is assumed that certain background knowledge is available. It takes only one person to infect another. More partners increase the risk of being exposed to STDs. When experts state that "the incidence of infection increases with frequent, casual, sexual intercourse," (Enterline & Leonardo, 1989; p. 10) others may infer that it is the action of having many partners that leads to STDs. Such an inference reflects the societal 'ideal of monogamy, an ideal which is not attained or even desired by everyone. Many of the women in Worth's (1989) study had long term, primary relationships in which they often relinquished control, and sometimes sexual satisfaction, to uphold the ideal of the happy couple. Women in such relationships will sometimes engage in sex with other partners for various reasons. For economically deprived women, especially those with drug habits, sex is an economic commodity, a way "to earn a good living." More commonly, due to sexual dissatisfaction with their primary partner, women reported that they would seek "affection" from others. Sex in the primary relationship was dictated by the man. T o limit one's partners would mean giving up income or enjoyable sex (Worth, 1989), which they were not likely to decide to do, 11. Discuss STDs with partners. People are encouraged to discuss their sexual histories and their experience with STDs with their partners prior to sexual activity. The purpose is to allow the partners to estimate the relative risk of infection. It is an unrealistic expectation for several reasons. First, the advice assumes sexual equality in intimate relationships, which is often not the case. If a woman begins to ask a man about his sexual history, it may appear that she is trying to question his authority and cause conflict. To maintain peace and protect herself from his anger and possible physical violence, she may prefer to suppress her questions (Worth, 1988). Second, the advice is based on the assumption that the couple is both comfortable enough and intimate enough to discuss sex. Cultural norms still dictate that discussion of sex with casual acquaintances is taboo (Fisher, 1988). Sexual partners can be casual acquaintances or even strangers, and couples who have known each other for some time may still not be comfortable frankly discussing sexual experiences. Third, it takes
Downloaded by [University of Sydney] at 04:21 13 March 2015
8
WOMEN & HEALTH
considerable self-esteem and courage for some women to assert themselves in an, intimate relationship; women "have to ask themselves if they are important enough to themselves to risk rejection by a man" (Cochran & Mays, 1989) who may not want to wear a condom. Women have been socialized to put the needs and desires of others before their own. Fourth, many STDs do not have external symptoms, so infected partners may be unaware of their medical condition. Men are not routinely screened for STDs and may not know they ale infected until the disease progresses. Fifth, people may lie about their medical condition (Cochran & Mays, 1989) if they think it will lead to rejection. 111. Use a condom. Condoms form a barrier between partners which prevents the exchange of fluids. They are currently the only form of prophylactic available which effectively prevents the spread of STDs and, therefore, their use should be encouraged. The prevention of AIDS has become a major selling point for condom manufacturers and advertisements for the products have become common. Condoms are fairly easy to obtain and relatively inexpensive, yet for poor women the cost may be too high. Condoms are free at many birth control clinics, but utilization of clinic services is typically low (Cochran & Mays, 1989). Cost and availability are factors in condom use, but other factors play a more significant role. Condom use, like talking to one's partner about STDs, is dependent on a woman's ability to be assertive in an intimate relationship. Traditional gender-roles require women to follow the lead of their partners in romantic and sexual situations. To ask a man to use a condom upsets these expectations. Because condom use has to be renegotiated with each sexual encounter, the issue of control is brought up repeatedly. Each time the "women are vulnerable to the emotional, sexual, physical, or economic vicissitudes of their relationship at the moment" (Worth, 1989; p. 304). To ask a p'artner to use a condom for STD prevention is to suggest the existence of other sexual partners, which violates the romantic monogamy ideal and can threaten the relationship. Fears of threatening the relationship may take precedence over fears of STD infection as partners are often more willing to risk infection than to risk ruining a relationship (Cochran & Mays, 1989; Worth, 1989). Worth (1989) found that women were more assertive about the
Downloaded by [University of Sydney] at 04:21 13 March 2015
Cecilia Leonardo and Joan C. Cl~risler
9
types of sexual activities in which they would engage than they were about requesting condom use. In our society, a man's sexual needs are believed to take precedence over a woman's. Sex with a condom is thought to be less comfortable or exciting for men and so women are often reluctant to insist that one be used. Similarly, "suggesting condom use means that a woman is sexually active, that she is available for sex, and that she is seeking sex" (Worth, 1989; p. 303). Such a frank admission of sexual desire violates the sexual double standard; this is not an e k y thing for many women to do. Prostitutes have been found to use condoms more often than other women (Cochran & Mays, 1989; Stadlander & Kok, 1989). Prostitutes have more power over their clients than they do over their other partners; they have the ability to deny their services or to charge more for them if the men refuse to use condoms. In their primary relationships, women prostitutes are less likely to insist on condom use than they are with their clients. Research suggests that HIV infected prostitutes were generally infected by their primary sex partner or drug use rather than by their clients (Mays & Cochran, 1988).
Having an STD When an STD is diagnosed, the patient is asked by the clinician
to inform their sexual partners in order that the partners may seek immediate treatment. During the treatment, the partners must abstain from sexual intercourse or use a condom. Again, this is deceptively simple. STD patients will only inform their partners if they care about them and know where to find them. In her experience counseling women with STDs, the first author has found them unwilling to inform their partners when they are no longer involved in the relationship or when they did not get the infection from their primary partner. Reaction to the diagnosis of an STD is sometimes guilt; more often it is anger at the partner who transmitted the infection. Informing a partner about the diagnosis is likely to result in the end of the relationship as it makes clear that one or both have had other sexual partners. If a woman does not have the power to ask her partner to take
Downloaded by [University of Sydney] at 04:21 13 March 2015
10
WOMEN & HEALTH
precautions against STDs, it is unlikely that she has the power to insist that he seek treatment and comply with the treatment regimen. It may also be difficult for her to comply. Some STDs, such as gonorrhea and chlamydia, do not produce obvious symptoms in women, but the medicalions given to cure them produce side effects. If a woman who isn't feeling ill is given medication which makes her feel ill, her compliance with the treatment regimen is likely to be low (Enterline & Leonardo, 1989). Other STDs, such as herpes and venereal warts, require a lengthy series of treatments. Many follow up visits are necessary and patient motivation must be high (Enterline & Leonardo, 1989). The instruction to abstain from sex or use a condom during treatment is not as serious a problem for diseases such as gonorrhea and chlamydia which can be cured in a few weeks as it is for diseases such as venereal warts which can take up to six months to eradicate (Enterline & Leonardo. 1989). Changes in sexual behavior must be lifelong for those diagnosed with herpes or AIDS. Again, women who do not feel that they can exercise control in their relationships cannot initiate the required changes. For women who rely on sexual activity for income, an STD is, at the very least, a financial strain. SOCIAL INFLUENCE AND BEHAVIOR CHANGE
Fisher (1988) has developed a social influence model to explain how social networks and reference groups affect an individual's HIV risk-taking decisions. This model seems to us to be equally valid for other STDs. When the values underlying AIDS preventive behaviors are inconsistent with group norms, the group will engage in normative processes which will inhibit AIDS preventive behaviors and increase risk. When the values are consistent with group norms, the group processes will be supportive of AIDS preventive behaviors. The aim of any group is to maintain the status quo. When the status quo is threatened, sanctions are imposed on the offending individuals (Fisher, 1988). Examples of such sanctions are abuse from a partner, ostracization due to promiscuity, and curt treatment from medical personnel. Such sanctions are very real to many women who may not have the emotional or economic resources to cope
Cecilia Leonardo and Joart C. Cltrisler
II
Downloaded by [University of Sydney] at 04:21 13 March 2015
effectively with them. Fisher (1988) has also pointed out that members of a social network or reference group are especially effective in influencing change in their peers. A woman is more likely to listen to her friends than to the Surgeon General. Therefore, to influence behavior change effectively, (1) the behaviors need to be consistent with group values and (2) the influence may need to come from someone who appears to be a member of one's peer group.
Effectively Combatting the Spread of STDs The current campaign against the spread of STDs is too limited in its scope. It focuses on select populations and does not take into account variations within and between the populations. Women do not have the same resources as men and the campaign needs to become more comprehensivein order to account for these differences. This can be accomplished by (1) increasing and adjusting funding levels, (2) increasing awareness of STDs, and (3) eliminating the double bind of traditional gender-roles. I. Increasing and adjusting funding levels. In 1989 the National Institute of Health allocated $604 million for AIDS research; the other STDs were allotted $60 million (Goldsmith, 1989). The fact that AIDS is the newest and most deadly of the STDs is a major reason why its funding is ten times higher than the others put together. One thud of the budget for the other STDs is spent for research on herpes, a disease which can be contained, but not cured. Of the remaining $40 million, first priority is given to gonorrhea research, second to chlamydia, third to HPV (human papilloma vhslvenereal warts). The most prevalent STD among women is chlamydia, which affects 15-20% of young women (Goldsmith, 1989). Venereal warts is the second most common STD among women and is believed to be a principal cause of genital cancers (Goldsmith. 1989). One cannot help but notice that government funds are spent primarily on those STDs which affect men more frequently than women. Aside from the AIDS budget, funding for STD research has not significantly increased over the last decade. More funds are urgently needed for STD programs. Willard Cates, Director of the Center for Disease Control's Division of STDs, has recommended a creative
Downloaded by [University of Sydney] at 04:21 13 March 2015
12
WOMEN & HEALTH
approach to the use of government funds to combat STDs. He has called for the integration of STD prevention into education programs in such diverse areas as ren natal care and mental health in order to reach more people. He believes that it is essential to bring the information to the public rather than wait for them to come to the clinic to get it (Goldsmith, 1989). The integration of STD information into other educational programs is a good idea, but it will not work unless these other programs, which are also struggling for increased funding, have the economic support that they need to be successful. 11. Increasing awareness of STDs. Since the onset of the AIDS prevention campaign in the mid 1980s, the American public has become much more aware of STDs. Condoms are now openly advextised and clinics routinely screen for more kinds of STDs. If we can continue to encourage open discussion of STDs, we can create an atmosphere in which victims are less likely to be thought deserving of their illness and less likely to be blamed for bringing it on themselves. We must also strive to make the values underlying STD preventive behaviors acceptable to the general public. Fisher (1988) has suggested that STD preventive behaviors should be promoted in much the same way as fads, so that to change one's behavior would have implied rewards such as increased popularity and social acceptance. The campaigns to reduce smoking and alcohol use have had such results for some segments of the population in recent years. Another approach is to incorporate the group values into STD preventive behavion. For example, the campaign might suggest that it is "macho" to "protect your woman" by using a condom (Fisher, 1988). Furthermore, there must be an increased awareness of STDs among medical personnel. As pointed out earlier, only about 10% of p r i ~ n a care r ~ physicians "even ask their patients questions that might reveal their risk for STDs" (Goldsmith, 1989). Decisions about whether or not to screen patients for STDs are often based on inaccurate assumptions resulting from stereotypes. III. Eliminating the double-bind of tradirional gender-roles. Women are in a double-bind because they are expected to be responsible for the sexual health of the couple, yet they do not have the power to take the necessary action. One way to eliminate this
Downloaded by [University of Sydney] at 04:21 13 March 2015
Cecilia Leonardo and Joan C . Cl~risler
13
double-bind is to increase men's responsibility through more screening. In some cases it is actually easier to test men for STDs than to test women. For example, the male test for chlamydia involves only a urine sample which costs about 20 cents to analyze; the female test involves taking a vaginal culture and its analysis is more expensive (Goldsmith, 1989). However, increasing the man's sense of responsibility without increasing the woman's sense of control can have negative effects on the psychology of women. Women must be helped to achieve equal power in their intimate relationships. This can be done by increasing the social status of women economically and politically, by presenting as role models peers who are happy and equal in their intimate relationships, and through both group (community and school based programs) and individual (medical and psychotherapeutic) educational efforts.
CONCLUSION
It is time to break away from the historical trend of using women's physiology to subjugate them. Sexually transmitted diseases should no longer be thought of as if they were punishment for women's sexual activity. The high incidence rates presented earlier clearly demonstrate that STDs are a problem for our entire society and cannot be relegated to any particular segment. Blaming the victims will not help to eradicate these diseases. The current campaign against STDs needs to be altered to take into account the unequal power distribution in intimate relationships. Women should no longer be expected to shoulder the entire responsibility for the couple's sexual health. However, until women achieve equal status with men in their personal relationships, as well as economically and politically, they will not have the power or the resources they need to protect themselves against STDs. NOTE 1. This is also the population most likely to be studied by researcl~crsworking on STDs. Most of the literature we reviewed for this paper was primarily concerned with the urban, minority poor. A broader range of populations should be studied.
WOMEN & HEALTII
Downloaded by [University of Sydney] at 04:21 13 March 2015
REFERENCES Brandt, A. (1985). No magic bullel: A social lrisrory of vcncreal diseases in the United Slates since 1880. New York: Oxford University Press. Brooks-Gum, J., Boyer, C. B., & Hein, K. (1988). Preventing HIV infection in children and adolescents: Behavioral research and intervention strategies. American Psycltologist, 43, 958-964. Cates, W., & Toomey, K. E. (1990). Sexually transmitted diseases: Overview of the situation. Primary Care, 17, 1-27. Cluisler, J. C., & Kaufman, S. G. (1988, April). Health autonomy: An exploration of licallh promoling attitudes and behaviors in college slude~ts.Paper presented at the meeting of the Eastern Psychological Association, Buffalo, NY. Coehran, S. D., &Mays, V. M. (1989). Women and ADS-rclated concerns: Roles for psychologists in helping the worried well. American Psyclrologisl, 44,529535.
Delaney, J., Lupton, M. J., & Tolli, E. (1988). The curse: A cultural history of mcnstrualion. Chicago: University of Illinois Press. Eluenrcich, B., & English, D. (1973). Complaints aand disorders: The sexual politics ofsickness. Old Westbury, NY: Feminist Press. Enterline, J. A,, & Leonardo, J. P. (1989). Condylomata acuminata (venereal warts). Nurse Practitioner, 14(40), 8-16. Fisher. J. D. (1988). Possible effects of reference group-based social influence on AIDS risk behavior and AIDS prevention. American Psycltologisl, 43.914-920. Goldsmith, M. (1989). "Silent epidemic" of "social disease" makes STD experts raise their voices. Journal of the Americati Medical Association, 261, 35093510.
Jolmson, R. E., Nd~arnias,A. J., Magder. L. S., Lee. F. K., Brooks, C. A., & Snowden, C. B. (1989). A seroepidemiologic survey of the prevalence of herpes simplex virus type 2 infection in the United States. New England Journal of Medicine, 321, 7-12. Laws, S. (1983)- The sexual politics of premenst~ualtension. Wotncn's Strtdies b l e r n a l i o ~ aF~o r m , 6(1), 19-3 1 . Mays. V . M., & Coelr,an, S. D. (1988). Issues in the perception of ALDS risk and risk reduction activities by Black and HispanicLatina women. American Psycllologisl, 43, 949-957. Nahrmias, S. (1989). A model of HIV diffusion from a single source. Journal of Sex Research, 26, 15-25. Nettina, S. L., & Kaufman, F. H. (1990). Diagnosis and treatment of sexually transmitted genital lesions. Nurse Praclitiotlcr, 15(1), 20-39. RasMsh. A. B. (April 23. 1991). Myths to die for. Village Voice, 34(17), 26. Rickert, V. I., Jay, M. S., Gotlieb. A., & Bridges, C. (1989). Adolescents and AIDS: Females' behaviors and attitudes toward condom purchase and use. Jourrral of Adolescet~lHcaltlr Care, 10, 313-316.
1.5
Downloaded by [University of Sydney] at 04:21 13 March 2015
Cecilia Leor~ardoa r ~ dJoan C. Chrisler
Stadlander, M., & Kok. 0, (1989). Prevention of sexually transmitted diseases: Relapse behavior o f visitors to the venereal disease clinic i n Amsterdam. Hcalflr Edrrcalional Research, 4, 267-271. Stone. K.M. (1989). Epidemiological aspects of genital HPV infection. Clinical Obstctrlcs and Gynecology, 32. 112-116. Travis, C. B. (1988). Worncrt and heal111psycl~ology:Biomedical issucs. Hillsdale; NJ: Lawrence Erlbaum. Wertz, D. C. (1983). What birth has done for doctors: A historical view. Woman & Hcalth, 8(1). 7-24. Worth, D. (1989). Sexual decision-making and AIDS: Why condom promotion among vulnerable women is likely to fail. Sludics i s Family Planning, 20,297-
307.
lor locully/prolessionals wilh journal subscriplion recommendallon eulhorily lor lheir inslilulionellibrery.
..
I1 you hew read a reprlnl or pholocopy 01 lhls alllcle, would you like lo make sure lhat your llbrery elso subscribes lo thls IournalP II you have the authority lo recommend sub. scrlptlons to your library, we will send you e lree sample copy lor revlaw wilh your librarian. Just till out the form below-end make sure lhet you lype or wrlte out clearly both the name of Ihe lournel snd your own name end eddrese. ( )
Yes, please send me a campllmenlary sample copy 01 lhis journal: (please wrile in complete journel lille hare-do not leave blank) Iwlll show thls journal lo our Instllullonal or agency library lor a possible subscrlpllon. The neme of my lnslitutloneVagency library Is:
INSTITUTION: ADDRESS: CITY:
STATE:
ZIP:
Relurn lo: Sample Copy Departmenl, The Haworth Press, Inc., 10 A k a Slreel, Binghamlon. NY 13904-1580
.
Women & Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wwah20
Women and Sexually Transmitted Diseases a
Cecilia Leonardo BA & Joan C. Chrisler PhD a
b
Connecticut College
b
Department of Psychology, Connecticut College Published online: 05 Nov 2010.
To cite this article: Cecilia Leonardo BA & Joan C. Chrisler PhD (1992) Women and Sexually Transmitted Diseases, Women & Health, 18:4, 1-15, DOI: 10.1300/J013v18n04_01 To link to this article: http://dx.doi.org/10.1300/J013v18n04_01
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden.
Downloaded by [University of Sydney] at 04:21 13 March 2015
Terms & Conditions of access and use can be found at http://www.tandfonline.com/ page/terms-and-conditions
Women and Sexually
Transmitted Diseases
Downloaded by [University of Sydney] at 04:21 13 March 2015
Cecilia Leonardo, BA Joan C. Chrisler, PhD
ABSTRACT. This paper presents a brief review of historical developments in women's heallh care. It describes lhe current campaign against sexually transmitted diseases (STDs) and assesses the camaign's success in light of its history and the reality of women's ives. The aulhors suggest that women are forced inlo a double-bid in which Uley are expected to take responsibility for Ule prevention of STDs although lhey may not have the ability to do so. Modifications are suggested which take into account gender-role socialization and social group norms.
P
Throughout the nineteenth and twentieth centuries, the treatment and prevention of sexually transmitted diseases (STDs) has been ieplete with moral judgments about those who suffered from them (Brandt, 1985). Medical treatment of women has, in general, been affected by sociocultural influences on their physicians ( E h r e ~ e i c h & English, 1973; Travis, 1988). Current campaigns against STDs which are aimed at women are infused with the same moral judgments found in earlier campaigns against STDs and against physical and intellectual activities which were once thought ,to harm women's reproductive health. The purpose of this paper is to briefly review historical developments in women's health care and to asCecilia Leonardo and Joan C, Chrislcr are affiliated with Connecticut College. Address correspondence to Joan C. Chrisler,Deparknent of Psychology, Connecticut College, New London, CT 06320. Women & Health, Vol. 18(4) 1992 Q 1992 by The Haworth Press, Inc. All rights resewed.
2
WOMEN & IIlMLTtI
sess the current campaign against STDs in light of its history and the reality of women's lives.
Downloaded by [University of Sydney] at 04:21 13 March 2015
HISTORICAL BACKGROUND
Feminist literature has criticized medicine as a major contributor to western sexist ideology (e.g., Delaney, Lupton. & Toth, 1988; Ehrenreich & English, 1973; Wertz, 1983). Writings about the differences between men and women have often relied on biological explanations and medicine has provided those explanations. Women have been viewed as weak and incomplete and men as strong and whole (Ehrenreich & English, 1973). Events in women's reproductive lives, such as pregnancy, menstruation, and menopause, have been perceived as both illnesses and justifications for devaluing a woman's worth (Delaney et al., 1988; Laws, 1983). A result of the perception that a woman is unclean, weak, and ill is the fear that she will infect men. Women have been seen as the source of sexually transmitted diseases, a view which served to validate the sociocultural image of woman as dangerous (Ehrenreich & English, 1973). The Judeo-Christian tradition has held that women are impure; Protestantism has implied that women could gain true spirituality if only they denied their sexuality. Thus, the age-old dichotomy of women as weak, pure, and good or powerful, tainted, and evil. At the turn of the century these two types of women were separated into the "delicate" upper classes and the "robust" lower classes. The upper class women received a surfeit of medical attention while the lower class women received almost none. Yet, the lower classes were viewed as transmitters of diseases, perils to their wealthier contemporaries (Ehrenreich & English, 1973). Today, availability of medical care is still unequally divided along class lines and blame for the transmission of diseases is frequently placed on outcast groups (e.g., the poor, the homosexual, the ethnic minority, the drug addict, the prostitute). Around the turn of the century, close medical attention came to be seen as essential for upper and middle class women, especially to safeguard their reproductive health. Illnesses of many types were traced to malfunctions of the reproductive organs and thought to be
Downloaded by [University of Sydney] at 04:21 13 March 2015
Cecilia Lconardo and Joan C. Cltrislcr
3
the result of "unfeminine activities." Sexual desires and behaviors in women were seen as capable of leading to both mental and physical stress (Ehrenreich & English, 1973). Although women were expected to deny their sexuality, they were encouraged to bear children. Women were warned to stay healthy so that they would be able to procreate successfully (Brandt, 1985). Venereal disease was pronounced the biggest threat to a woman's ability to bear healthy children. The stages of syphilis were understood by 1876; the bacteria which causes gonorrhea was identified in 1879. These two diseases were believed by physicians to contribute to the breakdown of the social order; it was feared they would result in the "fall of the race" and the "decline of the family." Thus began the campaign to protect the "good" women (the wives of the Anglo-Saxon elite) from the taint of STDs. The "bad" women (the unmarried, ethnic minority, poor) were seen as the carriers of these diseases. Men were urged not to have sexual intercourse with prostitutes, but it was the prostitutes, not their customers, who were punished (Brandt, 1985). In 1943 penicillin was discovered to be effective against both syphilis and gonorrhea. The prevalence rates of the diseases began a dramatic decrease which lasted until the late 1950s. Rates of STD infection have been steadily increasing since that time. Advances in birth control and the resultant "sexual revolution" have been the most frequent explanations for the rise in the STD infection rate. However, despite the increase in sexual activity, many Americans remained resistant to the discussion of STDs in classrooms and in the media. Funding for the prevention and treatment of STDs was not increased. Regardless of their prevalence, STDs were still equated with sin (Brandt, 1985).
THE SITUATION TODAY How frequently do STDs occur today? See Table 1 for approximate prevalence rates of the most common STDs in the U.S. The figures presented were chosen in consultation with the Center for Disease Control. Comparison between populations is difficult because private physicians tend to under-report cases whereas public clinics tend to be more thorough in their reporting (Goldsmith,
Downloaded by [University of Sydney] at 04:21 13 March 2015
4
WOMEN & HEALTH
1989). Thus, a bias occurs which makes it appear that women from the lower socio-economic classes, have a higher rate of STDs than do older, wealthier women. Despite knowledge of this reporting bias, it is not uncommon for experts to conclude that "STDs occur disproportionately among lower socio-economic groups, primarily among Blacks and Hispanics" (Goldsmith, 1989; p. 3509). The turn of the century division of women into the "good/clean" (those who can afford to visit private physicians) and the "badldirty" (the urban, minority, poor) apparently stillhfluences medical personnel to believe that "routine gonorrhea and chlamydia cultures, Pap smears to detect condylomaacuminata, and serologic syphilis screening are appropriate in large, urban populations of low socio-economic status"' (Nettina & Kaufman, 1980; p. 39). Prostitutes (the prototypical "bad/dirtyH women) are still frequently blamed for the spread of STDs. One researcher recently developed a mathematical model of the spread of the human immunodeficiency virus (HIV) through an infected prostitute, concluding that "in five years a single prostitute could be expected to infect about 20 men and about 0.8 unborn children" (Nahmias. 1989; p. 24). Yet, when researchers abstracted and analyzed records of syphilis patients, they found prostitution to be relatively unimportant in its epidemiology (Goldsmith, 1989). Little concern has been expressed about how many prostitutes a client withan STD might infect. Women visit physicians more often than men (Travis, 1988), are more likely than men to read magazine articles on health and physical fitness (Chrisler & Kaufman, 1988), are: routinely screened for STDs during gynecological examinations, and have thus been given the responsibility for prevention and treatment of STDs. Yet, many women are not able to take up that responsibility. THE CURRENT CAMPAIGN
The current campaign against the spread of STDs is deceptively straightforward. People are asked to (1) limit the number of sexual partners, (2) talk to their partners about STDs, and (3) use condoms. Such a campaign aimed at women is unlikely to be successful be-
Downloaded by [University of Sydney] at 04:21 13 March 2015
Cecilia Leorlardo and Joan C. Chrisler
5
cause it ignores gender-role socialization and the lack of power many women have in their intimate relationships. It is not that women are ignorant about STDs. Television talk shows and magazine health columns have presented much valuable information about AIDS and herpes. Ads urging condom use appear on television and billboards and in magazines. HIV education is taught in 50% of the schools in large, urban districts and a recent study (Brooks-Gunn, Boyer, & Hein, 1988) found that 94% of parents supported it. Sixty-two percent of women in a recent survey (Ricken, Jay, Gotlieb, & Bridges, 1989) admitted that the fear of AIDS had influenced their sexual behavior, yet only 17% reported that they had used or purchased condoms to prevent AIDS. Knowledge appears to be increasing faster than behavior is changing.
Table I APPROXIMATE PREVALENCE OF SELECTED SEXUALLY TRANSMITTED DISEASE IN THE U.S.
STD
Year
Total Cases
Chlamydia
1986
4,400,000
Gonorrhea
1988
750,000
Hepatitis B
1987
300,000 '
HPV
1987
12,200,000 "
HSV 2
1980
25,000,000 "*
Sy~hilis
1988
Celcs & Toomcy (1990)
** Stone (1989) ++*Johnson et al (1989)
35,000
6
WOMEN & HEALTH
Downloaded by [University of Sydney] at 04:21 13 March 2015
Seeing STDs as a Threat
In order to attempt to follow the suggested steps to prevent STDs, a woman has to see STDs as a threat to herself. For some women, STDs are just one of many risks they face daily. These women may be more directly concerned with the threat of physical violence or the search for adequate food and shelter. Typically, such women feel powerless to change their iives (Mays & Cochran, 1988) and cannot be expected to feel entitled to change their sexual patterns. Furthermore, to see AIDS as a threat to herself, a woman has to accept the fact that she is sexually active. This may be particularly difficult for young women in a society that has traditionally divided good women and sexual women into different groups. Women who are taught to feel ashamed of their sexuality may also be likely to deny it. As with birth control, a woman will not take precautions against STDs if she views sex as an event that happens to her rather than one she can control. Finally, many modem Americans still hold onto romantic notions about love and sex which make it difficult for them to believe that their partner could transmit an STD to them. This refusal to assume that anyone, even the nice person with whom one is in love, could have an STD is problematic in a society in which sex has become a means to intimacy, rather than its result (Rashish, 1991). Just as smokers believe that cancer is something that happens to others, many patients receiving treatment for STDs simply did not believe that they were at risk. Taking Precautions
I. Limit the number of partners. In a recent study of over 1,000 women's attitudes toward AIDS, Worth (1989) discovered that many of the subjects did not understand what was meant by the advice to "limit the number of partners." It meant different things to different women. Some thought that it meant one should avoid one-night stands, although serial monogamy was safe. Others thought it meant to limit the number of partners in one day or at one time. The campaign is thus hindered by the use of terms which
Downloaded by [University of Sydney] at 04:21 13 March 2015
Cecilia Leoitarrlo at~dJoan C. Clrrisler
7
are not explained because it is assumed that certain background knowledge is available. It takes only one person to infect another. More partners increase the risk of being exposed to STDs. When experts state that "the incidence of infection increases with frequent, casual, sexual intercourse," (Enterline & Leonardo, 1989; p. 10) others may infer that it is the action of having many partners that leads to STDs. Such an inference reflects the societal 'ideal of monogamy, an ideal which is not attained or even desired by everyone. Many of the women in Worth's (1989) study had long term, primary relationships in which they often relinquished control, and sometimes sexual satisfaction, to uphold the ideal of the happy couple. Women in such relationships will sometimes engage in sex with other partners for various reasons. For economically deprived women, especially those with drug habits, sex is an economic commodity, a way "to earn a good living." More commonly, due to sexual dissatisfaction with their primary partner, women reported that they would seek "affection" from others. Sex in the primary relationship was dictated by the man. T o limit one's partners would mean giving up income or enjoyable sex (Worth, 1989), which they were not likely to decide to do, 11. Discuss STDs with partners. People are encouraged to discuss their sexual histories and their experience with STDs with their partners prior to sexual activity. The purpose is to allow the partners to estimate the relative risk of infection. It is an unrealistic expectation for several reasons. First, the advice assumes sexual equality in intimate relationships, which is often not the case. If a woman begins to ask a man about his sexual history, it may appear that she is trying to question his authority and cause conflict. To maintain peace and protect herself from his anger and possible physical violence, she may prefer to suppress her questions (Worth, 1988). Second, the advice is based on the assumption that the couple is both comfortable enough and intimate enough to discuss sex. Cultural norms still dictate that discussion of sex with casual acquaintances is taboo (Fisher, 1988). Sexual partners can be casual acquaintances or even strangers, and couples who have known each other for some time may still not be comfortable frankly discussing sexual experiences. Third, it takes
Downloaded by [University of Sydney] at 04:21 13 March 2015
8
WOMEN & HEALTH
considerable self-esteem and courage for some women to assert themselves in an, intimate relationship; women "have to ask themselves if they are important enough to themselves to risk rejection by a man" (Cochran & Mays, 1989) who may not want to wear a condom. Women have been socialized to put the needs and desires of others before their own. Fourth, many STDs do not have external symptoms, so infected partners may be unaware of their medical condition. Men are not routinely screened for STDs and may not know they ale infected until the disease progresses. Fifth, people may lie about their medical condition (Cochran & Mays, 1989) if they think it will lead to rejection. 111. Use a condom. Condoms form a barrier between partners which prevents the exchange of fluids. They are currently the only form of prophylactic available which effectively prevents the spread of STDs and, therefore, their use should be encouraged. The prevention of AIDS has become a major selling point for condom manufacturers and advertisements for the products have become common. Condoms are fairly easy to obtain and relatively inexpensive, yet for poor women the cost may be too high. Condoms are free at many birth control clinics, but utilization of clinic services is typically low (Cochran & Mays, 1989). Cost and availability are factors in condom use, but other factors play a more significant role. Condom use, like talking to one's partner about STDs, is dependent on a woman's ability to be assertive in an intimate relationship. Traditional gender-roles require women to follow the lead of their partners in romantic and sexual situations. To ask a man to use a condom upsets these expectations. Because condom use has to be renegotiated with each sexual encounter, the issue of control is brought up repeatedly. Each time the "women are vulnerable to the emotional, sexual, physical, or economic vicissitudes of their relationship at the moment" (Worth, 1989; p. 304). To ask a p'artner to use a condom for STD prevention is to suggest the existence of other sexual partners, which violates the romantic monogamy ideal and can threaten the relationship. Fears of threatening the relationship may take precedence over fears of STD infection as partners are often more willing to risk infection than to risk ruining a relationship (Cochran & Mays, 1989; Worth, 1989). Worth (1989) found that women were more assertive about the
Downloaded by [University of Sydney] at 04:21 13 March 2015
Cecilia Leonardo and Joan C. Cl~risler
9
types of sexual activities in which they would engage than they were about requesting condom use. In our society, a man's sexual needs are believed to take precedence over a woman's. Sex with a condom is thought to be less comfortable or exciting for men and so women are often reluctant to insist that one be used. Similarly, "suggesting condom use means that a woman is sexually active, that she is available for sex, and that she is seeking sex" (Worth, 1989; p. 303). Such a frank admission of sexual desire violates the sexual double standard; this is not an e k y thing for many women to do. Prostitutes have been found to use condoms more often than other women (Cochran & Mays, 1989; Stadlander & Kok, 1989). Prostitutes have more power over their clients than they do over their other partners; they have the ability to deny their services or to charge more for them if the men refuse to use condoms. In their primary relationships, women prostitutes are less likely to insist on condom use than they are with their clients. Research suggests that HIV infected prostitutes were generally infected by their primary sex partner or drug use rather than by their clients (Mays & Cochran, 1988).
Having an STD When an STD is diagnosed, the patient is asked by the clinician
to inform their sexual partners in order that the partners may seek immediate treatment. During the treatment, the partners must abstain from sexual intercourse or use a condom. Again, this is deceptively simple. STD patients will only inform their partners if they care about them and know where to find them. In her experience counseling women with STDs, the first author has found them unwilling to inform their partners when they are no longer involved in the relationship or when they did not get the infection from their primary partner. Reaction to the diagnosis of an STD is sometimes guilt; more often it is anger at the partner who transmitted the infection. Informing a partner about the diagnosis is likely to result in the end of the relationship as it makes clear that one or both have had other sexual partners. If a woman does not have the power to ask her partner to take
Downloaded by [University of Sydney] at 04:21 13 March 2015
10
WOMEN & HEALTH
precautions against STDs, it is unlikely that she has the power to insist that he seek treatment and comply with the treatment regimen. It may also be difficult for her to comply. Some STDs, such as gonorrhea and chlamydia, do not produce obvious symptoms in women, but the medicalions given to cure them produce side effects. If a woman who isn't feeling ill is given medication which makes her feel ill, her compliance with the treatment regimen is likely to be low (Enterline & Leonardo, 1989). Other STDs, such as herpes and venereal warts, require a lengthy series of treatments. Many follow up visits are necessary and patient motivation must be high (Enterline & Leonardo, 1989). The instruction to abstain from sex or use a condom during treatment is not as serious a problem for diseases such as gonorrhea and chlamydia which can be cured in a few weeks as it is for diseases such as venereal warts which can take up to six months to eradicate (Enterline & Leonardo. 1989). Changes in sexual behavior must be lifelong for those diagnosed with herpes or AIDS. Again, women who do not feel that they can exercise control in their relationships cannot initiate the required changes. For women who rely on sexual activity for income, an STD is, at the very least, a financial strain. SOCIAL INFLUENCE AND BEHAVIOR CHANGE
Fisher (1988) has developed a social influence model to explain how social networks and reference groups affect an individual's HIV risk-taking decisions. This model seems to us to be equally valid for other STDs. When the values underlying AIDS preventive behaviors are inconsistent with group norms, the group will engage in normative processes which will inhibit AIDS preventive behaviors and increase risk. When the values are consistent with group norms, the group processes will be supportive of AIDS preventive behaviors. The aim of any group is to maintain the status quo. When the status quo is threatened, sanctions are imposed on the offending individuals (Fisher, 1988). Examples of such sanctions are abuse from a partner, ostracization due to promiscuity, and curt treatment from medical personnel. Such sanctions are very real to many women who may not have the emotional or economic resources to cope
Cecilia Leonardo and Joart C. Cltrisler
II
Downloaded by [University of Sydney] at 04:21 13 March 2015
effectively with them. Fisher (1988) has also pointed out that members of a social network or reference group are especially effective in influencing change in their peers. A woman is more likely to listen to her friends than to the Surgeon General. Therefore, to influence behavior change effectively, (1) the behaviors need to be consistent with group values and (2) the influence may need to come from someone who appears to be a member of one's peer group.
Effectively Combatting the Spread of STDs The current campaign against the spread of STDs is too limited in its scope. It focuses on select populations and does not take into account variations within and between the populations. Women do not have the same resources as men and the campaign needs to become more comprehensivein order to account for these differences. This can be accomplished by (1) increasing and adjusting funding levels, (2) increasing awareness of STDs, and (3) eliminating the double bind of traditional gender-roles. I. Increasing and adjusting funding levels. In 1989 the National Institute of Health allocated $604 million for AIDS research; the other STDs were allotted $60 million (Goldsmith, 1989). The fact that AIDS is the newest and most deadly of the STDs is a major reason why its funding is ten times higher than the others put together. One thud of the budget for the other STDs is spent for research on herpes, a disease which can be contained, but not cured. Of the remaining $40 million, first priority is given to gonorrhea research, second to chlamydia, third to HPV (human papilloma vhslvenereal warts). The most prevalent STD among women is chlamydia, which affects 15-20% of young women (Goldsmith, 1989). Venereal warts is the second most common STD among women and is believed to be a principal cause of genital cancers (Goldsmith. 1989). One cannot help but notice that government funds are spent primarily on those STDs which affect men more frequently than women. Aside from the AIDS budget, funding for STD research has not significantly increased over the last decade. More funds are urgently needed for STD programs. Willard Cates, Director of the Center for Disease Control's Division of STDs, has recommended a creative
Downloaded by [University of Sydney] at 04:21 13 March 2015
12
WOMEN & HEALTH
approach to the use of government funds to combat STDs. He has called for the integration of STD prevention into education programs in such diverse areas as ren natal care and mental health in order to reach more people. He believes that it is essential to bring the information to the public rather than wait for them to come to the clinic to get it (Goldsmith, 1989). The integration of STD information into other educational programs is a good idea, but it will not work unless these other programs, which are also struggling for increased funding, have the economic support that they need to be successful. 11. Increasing awareness of STDs. Since the onset of the AIDS prevention campaign in the mid 1980s, the American public has become much more aware of STDs. Condoms are now openly advextised and clinics routinely screen for more kinds of STDs. If we can continue to encourage open discussion of STDs, we can create an atmosphere in which victims are less likely to be thought deserving of their illness and less likely to be blamed for bringing it on themselves. We must also strive to make the values underlying STD preventive behaviors acceptable to the general public. Fisher (1988) has suggested that STD preventive behaviors should be promoted in much the same way as fads, so that to change one's behavior would have implied rewards such as increased popularity and social acceptance. The campaigns to reduce smoking and alcohol use have had such results for some segments of the population in recent years. Another approach is to incorporate the group values into STD preventive behavion. For example, the campaign might suggest that it is "macho" to "protect your woman" by using a condom (Fisher, 1988). Furthermore, there must be an increased awareness of STDs among medical personnel. As pointed out earlier, only about 10% of p r i ~ n a care r ~ physicians "even ask their patients questions that might reveal their risk for STDs" (Goldsmith, 1989). Decisions about whether or not to screen patients for STDs are often based on inaccurate assumptions resulting from stereotypes. III. Eliminating the double-bind of tradirional gender-roles. Women are in a double-bind because they are expected to be responsible for the sexual health of the couple, yet they do not have the power to take the necessary action. One way to eliminate this
Downloaded by [University of Sydney] at 04:21 13 March 2015
Cecilia Leonardo and Joan C . Cl~risler
13
double-bind is to increase men's responsibility through more screening. In some cases it is actually easier to test men for STDs than to test women. For example, the male test for chlamydia involves only a urine sample which costs about 20 cents to analyze; the female test involves taking a vaginal culture and its analysis is more expensive (Goldsmith, 1989). However, increasing the man's sense of responsibility without increasing the woman's sense of control can have negative effects on the psychology of women. Women must be helped to achieve equal power in their intimate relationships. This can be done by increasing the social status of women economically and politically, by presenting as role models peers who are happy and equal in their intimate relationships, and through both group (community and school based programs) and individual (medical and psychotherapeutic) educational efforts.
CONCLUSION
It is time to break away from the historical trend of using women's physiology to subjugate them. Sexually transmitted diseases should no longer be thought of as if they were punishment for women's sexual activity. The high incidence rates presented earlier clearly demonstrate that STDs are a problem for our entire society and cannot be relegated to any particular segment. Blaming the victims will not help to eradicate these diseases. The current campaign against STDs needs to be altered to take into account the unequal power distribution in intimate relationships. Women should no longer be expected to shoulder the entire responsibility for the couple's sexual health. However, until women achieve equal status with men in their personal relationships, as well as economically and politically, they will not have the power or the resources they need to protect themselves against STDs. NOTE 1. This is also the population most likely to be studied by researcl~crsworking on STDs. Most of the literature we reviewed for this paper was primarily concerned with the urban, minority poor. A broader range of populations should be studied.
WOMEN & HEALTII
Downloaded by [University of Sydney] at 04:21 13 March 2015
REFERENCES Brandt, A. (1985). No magic bullel: A social lrisrory of vcncreal diseases in the United Slates since 1880. New York: Oxford University Press. Brooks-Gum, J., Boyer, C. B., & Hein, K. (1988). Preventing HIV infection in children and adolescents: Behavioral research and intervention strategies. American Psycltologist, 43, 958-964. Cates, W., & Toomey, K. E. (1990). Sexually transmitted diseases: Overview of the situation. Primary Care, 17, 1-27. Cluisler, J. C., & Kaufman, S. G. (1988, April). Health autonomy: An exploration of licallh promoling attitudes and behaviors in college slude~ts.Paper presented at the meeting of the Eastern Psychological Association, Buffalo, NY. Coehran, S. D., &Mays, V. M. (1989). Women and ADS-rclated concerns: Roles for psychologists in helping the worried well. American Psyclrologisl, 44,529535.
Delaney, J., Lupton, M. J., & Tolli, E. (1988). The curse: A cultural history of mcnstrualion. Chicago: University of Illinois Press. Eluenrcich, B., & English, D. (1973). Complaints aand disorders: The sexual politics ofsickness. Old Westbury, NY: Feminist Press. Enterline, J. A,, & Leonardo, J. P. (1989). Condylomata acuminata (venereal warts). Nurse Practitioner, 14(40), 8-16. Fisher. J. D. (1988). Possible effects of reference group-based social influence on AIDS risk behavior and AIDS prevention. American Psycltologisl, 43.914-920. Goldsmith, M. (1989). "Silent epidemic" of "social disease" makes STD experts raise their voices. Journal of the Americati Medical Association, 261, 35093510.
Jolmson, R. E., Nd~arnias,A. J., Magder. L. S., Lee. F. K., Brooks, C. A., & Snowden, C. B. (1989). A seroepidemiologic survey of the prevalence of herpes simplex virus type 2 infection in the United States. New England Journal of Medicine, 321, 7-12. Laws, S. (1983)- The sexual politics of premenst~ualtension. Wotncn's Strtdies b l e r n a l i o ~ aF~o r m , 6(1), 19-3 1 . Mays. V . M., & Coelr,an, S. D. (1988). Issues in the perception of ALDS risk and risk reduction activities by Black and HispanicLatina women. American Psycllologisl, 43, 949-957. Nahrmias, S. (1989). A model of HIV diffusion from a single source. Journal of Sex Research, 26, 15-25. Nettina, S. L., & Kaufman, F. H. (1990). Diagnosis and treatment of sexually transmitted genital lesions. Nurse Praclitiotlcr, 15(1), 20-39. RasMsh. A. B. (April 23. 1991). Myths to die for. Village Voice, 34(17), 26. Rickert, V. I., Jay, M. S., Gotlieb. A., & Bridges, C. (1989). Adolescents and AIDS: Females' behaviors and attitudes toward condom purchase and use. Jourrral of Adolescet~lHcaltlr Care, 10, 313-316.
1.5
Downloaded by [University of Sydney] at 04:21 13 March 2015
Cecilia Leor~ardoa r ~ dJoan C. Chrisler
Stadlander, M., & Kok. 0, (1989). Prevention of sexually transmitted diseases: Relapse behavior o f visitors to the venereal disease clinic i n Amsterdam. Hcalflr Edrrcalional Research, 4, 267-271. Stone. K.M. (1989). Epidemiological aspects of genital HPV infection. Clinical Obstctrlcs and Gynecology, 32. 112-116. Travis, C. B. (1988). Worncrt and heal111psycl~ology:Biomedical issucs. Hillsdale; NJ: Lawrence Erlbaum. Wertz, D. C. (1983). What birth has done for doctors: A historical view. Woman & Hcalth, 8(1). 7-24. Worth, D. (1989). Sexual decision-making and AIDS: Why condom promotion among vulnerable women is likely to fail. Sludics i s Family Planning, 20,297-
307.
lor locully/prolessionals wilh journal subscriplion recommendallon eulhorily lor lheir inslilulionellibrery.
..
I1 you hew read a reprlnl or pholocopy 01 lhls alllcle, would you like lo make sure lhat your llbrery elso subscribes lo thls IournalP II you have the authority lo recommend sub. scrlptlons to your library, we will send you e lree sample copy lor revlaw wilh your librarian. Just till out the form below-end make sure lhet you lype or wrlte out clearly both the name of Ihe lournel snd your own name end eddrese. ( )
Yes, please send me a campllmenlary sample copy 01 lhis journal: (please wrile in complete journel lille hare-do not leave blank) Iwlll show thls journal lo our Instllullonal or agency library lor a possible subscrlpllon. The neme of my lnslitutloneVagency library Is:
INSTITUTION: ADDRESS: CITY:
STATE:
ZIP:
Relurn lo: Sample Copy Departmenl, The Haworth Press, Inc., 10 A k a Slreel, Binghamlon. NY 13904-1580
.
