Gender and HIV/AIDS

Critical Perspectives from the Developing World

Nana K. Poku, Jelke Boesten

• Publisher: Routledge
• Year: 2016
• Print ISBN:
  9780754672692
• eBook ISBN:
  9781317130628
• Topic: Social Sciences
• Subtopic: Politics
• Index: Social Sciences

Gender issues are central to the causes and impact of the ongoing AIDS epidemic. The editors bring together cutting edge contemporary scholarship on gender and AIDS in one volume. They address questions related to gender and sexuality, how women and men live the epidemic differently and how such differences lead to different outcomes. The volume joins research on Africa, Asia and Latin America and illustrates how the epidemic has different gendered characteristics, causes and consequences in different regions. Collectively, the chapters demonstrate the fundamental ways that gender influences the spread of the disease, its impact and the success of prevention efforts. This scholarly, interdisciplinary volume provides a comprehensive introduction to the themes and issues of gender, AIDS and global public health and informs students, policy makers and practitioners of the complexity of the gendered nature of AIDS.

1 Gendered Vulnerabilities

1 Stigma, Gender and HIV: Case Studies of Inter-sectionality

Catherine Campbell and Andrew Gibbs

DOI: 10.4324/9781315583907-2

In this chapter we use the theoretical lens of “intersectionality” to examine the complex relationship between gender and stigma, and to consider the implications of this relationship for HIV/AIDS programs. Our focus on HIV/AIDS, gender and stigma lies at the interface of two related interests. First, we believe that an understanding of stigma is required to deepen our analysis of facilitators and barriers for effective participatory HIV/AIDS programs. Participation in HIV/ AIDS prevention, treatment and care programs has become somewhat of a mantra. HIV-related stigma serves to deprive people with AIDS of the confidence and agency they need to access treatment, participate in programs and increase self-efficacy, all of which have positive health outcomes. Currently, much research into HIV-related stigma remains at the descriptive level, emphasizing the impact of stigma on agency, rather than exploring the complex psychosocial roots of stigma.

Our second interest in the relationship between HIV/AIDS, gender and stigma relates to the way in which the HIV/AIDS pandemic is driven by gender inequality and exacerbates gender inequality (UNIFEM 2004). We recognize gender as a socially constructed relationship that limits women's access to material and symbolic resources compared to men's access to these. The role of HIV-related stigma in supporting gender inequality is under-theorized—but as we hope to make clear, this needs to be at the center of any understanding of HIV-related stigma. Understanding the relationships between stigma, gender inequality and the continuing HIV/AIDS pandemic is crucial if this cycle it to be broken.

In this chapter we develop a social psychological reading of HIV-related stigma, which focuses on the relationship between the individual and society. The aim of social psychology is to understand how social imperatives become sedimented in the individual psyche (Joffe 1999) and how this might best be resisted (Howarth 2006). In relation to the social dimension of the individual—society interface, we are particularly interested in the interrelationship between the symbolic and material dimensions of human life in shaping peoples’ experiences of HIV/AIDS (Campbell et al. 2005a; Cornish 2006). In relation to the individual psychological dimension of this interface, we are concerned with the way in which this social world shapes and sets the context for the construction of social identities and agency, which are central to the ways in which stigma is internalized or resisted. Stigmatized people often have highly marginalized social identities and limited agency, because of poverty and symbolic forms of chronic marginalization. Key to the process of resisting stigma is that people start to view themselves as competent social actors, capable of withstanding some of the impacts of marginalization, if not actually able to change the underlying causes.

In order to illustrate our argument, three interventions involving female sex workers will be explored. Women engaged in sex work (visible and invisible) often have higher prevalence levels of HIV/AIDS than other population groups (UNAIDS 2002; Cote et al. 2004; Dunkle et al. 2004; Chen et al. 2007). A focus on female sex workers is particularly illustrative of our argument, because this group of women sit at the intersection of multiple forms of symbolic marginalization or stigmatization—HIV/AIDS, gender, occupation—and material marginalization—poverty, limited access to healthcare and so on. All these shape the contexts in which sex workers construct their social identities and their ability to assert agency in ways that protect their health.

We define stigma as any negative thoughts, feelings or actions against people infected with or affected by HIV/AIDS (Campbell et al. 2007) HIV/AIDS stigma is increasingly described as a major driver of the HIV/AIDS pandemic through limiting peoples’ access to prevention, formal and informal care and more recently anti-retroviral treatment (Deacon, Stephney and Prosalendis 2005; Ogden and Nyblade 2005; Rankin et al. 2005). Stigma inhibits many women from learning their HIV status, for fear of abandonment or violence by their partners (Gaillard et al. 2002; Medley et al. 2004). Men—who associate their ability to conceive children as a central and prized dimension of their masculinity—may also deny or hide their status, for fear that this will hinder the likelihood of them conceiving children, leaving them to die without having fulfilled their masculine life destiny of “leaving behind people who bear their names” (Steinberg 2007).

It is important, however, to move away from the common tendency to describe the effects of stigma, and to seek to explain its underlying drivers in order to inform stigma reduction interventions (Campbell and Deacon 2006). In the following section a theoretical model of stigma will be outlined, leading on to a discussion of the possibility of effective interventions.

Stigma, Gender and Power

Sociologists and anthropologists highlight the role played by stigma in maintaining social inequalities (Link and Phelan 2001; Parker and Aggleton 2003) through the way in which it perpetuates existing patterns of social inclusion and exclusion in a given society. Various studies have examined the links between the stigmatization of HIV/AIDS and the stigmatization of women, and more particularly the stigmatization of female desire, with these interlocking stigmas serving to perpetuate a more general devaluation of women in many societies (Joffe and Begetta 2003; Campbell et al. 2005b). According to psychoanalytic psychologists, the stigmatization of identifiable out-groups serves as a way in which people cope with the fear and uncertainty at the heart of the human condition. Individuals project their fear of the randomness of illness and death onto out-groups, as a way of distancing themselves from such threats (Joffe 1999; Campbell and Deacon 2006). The choice of out-groups is not random, but shaped by the already existing symbolic and material contexts of a society.

The material contexts of HIV/AIDS stigma revolve around issues of poverty, lack of access to adequate health services and the crippling burden of care faced by many people caring for someone living with HIV/AIDS (Castro and Farmer 2005; Ogden and Nyblade 2005; Campbell et al. 2007). Closely tied to the material context of HIV/AIDS stigma is the symbolic context—relating the way in which HIV/AIDS is represented in many social settings. Pryor and Reeder (1993) suggest HIV-related stigma is supported by an associative network of symbolic links (sometimes logical and sometimes arbitrary) between AIDS-affected individuals and other negatively valued groups. In the US context in which their research is conducted, these include youth, the poor, ethnic minorities, sex workers, gay men, injecting drug users and so forth. Recent literature refers to the way in which different sources of stigma overlap and reinforce one another as the “layering” of stigma (Deacon et al. 2005). While the concept of layering makes us aware of the multiple interlocking representations that form HIV-related stigma, it remains too descriptive a concept. Rather, we draw upon the concept of intersectionality to deepen understandings of HIV-related stigma and its relationships to gender and how such stigma impacts on individuals.

The concept of intersectionality was initially evoked by feminists to challenge singular categories of oppression, especially the unitary concept of “women”. More specifically it was argued that black women were oppressed quite differently to white women, because of their race, and to speak of a homogenous group called “women” who all faced the same issues marginalized other categories and lines of oppression (Crenshaw 1993; Phoenix and Pattynama 2006). Intersectionality allows a focus on the multiple lines of power and exclusion that circulate in everyday life—class, race, sexuality, gender etc.—and importantly how these intersect through the multiple representations they invoke to shape people's identities and experiences of everyday living. The concept of intersectionality “aims to make visible the multiple positioning that constitutes everyday life and the power relations that are central to it” (Phoenix and Pattynama 2006, p.187).

Such is the intersectional nature of health-related social identities that HIV-related stigma is best thought of as the “nexus in a web of ostracised groups and threatening images” (Pryor and Reeder 1993, p.269). People living with HIV/ AIDS can be thought of as living with multiple forms of stigma, rather than one, that serve to marginalize them in different ways. Without recognizing that there are likely to be multiple layers of stigma at work and how they interact and support on another, Reidpath and Chan (2005) argue it will be difficult to challenge HIV-related stigma.

People construct and reconstruct their social identities in material and symbolic contexts not of their choosing. Social identities are crucial in understanding people's agency (and lack of agency) especially in relation to health and health behaviors (Campbell and Jovchelovitch 2000). Because of the intersectional nature of social identities, based on class, gender, race and so forth there are multiple, overlapping representations that inform social identities and representations of these issues “provide the building blocks of identity” (Howarth 2001, p.231).

Focusing now on female sex workers in a time of HIV/AIDS it is possible to locate sex workers at the intersection of a number of stigmatized identities—as women, as poor and as sex workers. These intersecting negative identities reinforce the stereotyping of sex workers as “vectors of HIV/AIDS.” Given the fact that such women are often poor, and socially excluded, they often lack the confidence and/or power to resist this layered stigmatization (Farrimond and Joffe 2006). It is these layers of stigma that form the backdrop and resources in which female sex workers construct and reconstruct their social identities, which in turn limit their agency to protect their health.

Closely linked to the stigmatization of female sex workers is the idea of “out of control” women, especially women living with HIV/AIDS who are often labeled as promiscuous or immoral. As Mary Douglas (1966) emphasized, when societies are threatened, they expand the range of social controls they exert over people. For male society, HIV/AIDS is a threat on two accounts. First, HIV/AIDS threatens to undermine male-dominated institutions of society and government (de Waal 2003). Second, and more relevant to our interests, HIV/AIDS demonstrates the failure of male, patriarchal society to enforce patterns of women's behavior—while these were always tenuous—the rapid spread of HIV/AIDS and its visible nature highlight this failure. In addition, a similar point has been made about sex workers, whose “existence challenges the standard family and reproduction-oriented sexual morality found in most societies” (UNAIDS 2002, p.9), which is also a challenge to male authority to control women.

Stigmatizing women with HIV/AIDS and female sex workers becomes a way of policing women for challenging traditional norms and is an attempt to overcome the anxieties associated with declining power. The stigmatization of HIV/AIDS needs to be understood within a framework which centralizes the role of gender inequality and recognizes the stigmatization of people living with HIV/ AIDS and sex workers as part of wider attempts by men to reassert their authority over women who transgress male norms. And this partially helps explain the high levels of violence against women that is associated with HIV/AIDS stigma and sex work (Farley and Barkan 1998; Gaillard et al. 2002; Medley et al. 2004), which can be understood as attempts by men to reassert their authority over women's bodies in direct and violent ways.

Indeed HIV/AIDS has been used as a way for men to reassert their authority and control over women's bodies in a wide variety of ways. Other ways in which this has become apparent include the re-emergence of “traditional” practices, seeking to control the sexuality of young women and girls. One such practice is virginity testing for females that has seen a resurgence in South Africa recently. Leclerc-Madlala (2001) identifies this as another way in which men seek to exert greater control over women and their sexuality.

Intersectionality provides a framework for understanding how layers of stigma can be transcribed from the social to the individual realm through the production of intersecting social identities. In addition, it highlights the centrality of power relations in structuring unequal social identities.

Stigma Interventions

A key challenge facing anti-stigma interventions is that of increasing the agency of those who are subject to marginalization (Cornish 2006), as part of the process through which they can start to view themselves as competent social actors, capable of resisting the impacts of marginalization. Many interventions to challenge stigma have been based on social cognition approaches which have focused on providing people with infor...

Table of contents

• Cover
• Half-Title Page
• Title Page
• Copyright Page
• Table of Contents
• List of Figures and Table
• List of Contributors
• Introduction: Gender, Inequalities, And HIV/AIDS
• PART 1: GENDERED VULNERABILITIES
• PART 2: TARGETED INTERVENTIONS
• PART 3: HIV/AIDS AND CHANGING GENDER RELATIONS
• Index