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Keywords:

  • Douglas;
  • ethics;
  • feminist;
  • Foucault;
  • poststructural;
  • sexual health;
  • women’s health

Abstract

  1. Top of page
  2. Abstract
  3. Health, Lifestyle Choice and Moral Culpability
  4. Viral STIs and ‘Dirt’
  5. Methods
  6. Results
  7. Discussion
  8. Conclusion
  9. Acknowledgements
  10. References

Sexually transmitted infections (STIs) are socially constructed as more ‘dirty’ than other gynaecological conditions. This article analyses women’s accounts of interactions with clinicians, subsequent to a diagnosis of genital herpes simplex virus or human papilloma virus. Women conceptualised consultations as a ‘moral event,’ different from other consultations. This moral component is highlighted drawing on Foucault’s notion of ‘the confessional.’ Additionally, Douglas’ anthropological construction of ‘dirt’ is used to consider why these consultations are ‘confessional’ experiences. Email interviews were conducted with 26 women diagnosed with a viral STI and 12 sexual health clinicians. Data were analysed thematically using a feminist, poststructuralist approach. Findings indicated that discourses of morality shape sexual health consultations. Five themes were identified in relation to the moral ‘work’ in clinical consultations about a viral STI diagnosis: the particular ‘dirtiness’ of viral STIs, clinicians as moral agents, the ‘non-judgmental’ clinician, women juggling truth-telling and risk and clinicians prescribing moral work. Clinicians support and educate women more effectively if they recognise subjective, moral aspects of sexual health consultations rather than assuming that effective clinical teaching is rational, scientific and non-judgmental.

Clinicians working in sexual and women’s health act routinely, although most often unintentionally, as moral educators. The argument presented in this article is that moral ‘work’ is integral to clinical conversations, not reserved for overt ethical dilemmas. Morality talk is not necessarily detrimental and rather may be experienced as a desirable dimension of consultations. Discourses shaping the moral meaning of the two most common viral sexually transmitted infections (STIs), human papilloma virus (HPV) and herpes simplex virus (HSV) are explored. Both viruses are endemic internationally (Burchell et al. 2006; Looker et al. 2008). Considerable literature examines the social stigma associated with viral STIs that contrasts with the medical categorisation of these infections as endemic and predominantly relatively innocuous (cf. Bickford et al. 2007; Waller et al. 2007).

Given the burden of stigmatised conditions, sexual health clinicians attempt to counter stigma by proffering ‘truths’ from medical science to ‘normalise’ viral STIs (Cook 2012b). In effect, well-intentioned re-framing dismisses historical and contemporary social and medical links between STIs and morality. Lupton asserts that ‘[w]hile medicine is predicated on scientific principles of objectivity and the ethical tenet of altruism, moral values are suffused throughout the medical encounter’ (2003, 134). Although medical teaching ostensibly constitutes viral STIs in scientific, objective terms, sexual health education is shaped by a moral orientation (Galvin 2002).

Clinicians have a powerful role in shaping moral meaning. Foucault’s notion of ‘the confessional’ is used to examine how the morality of sexual health suffuses consultations, and yet for the most part goes unnoticed. Foucault described the confessor as ‘the authority who requires the confession, prescribes and appreciates it, and intervenes in order to judge, punish, forgive, console, and reconcile’ (1976, 61). Confession occurs within a power relation that may produce feelings of relief and well-being. Foucault emphasised that patients’ willingness to disclose is part of the western cultural obligation to tell the truth about matters considered private. ‘It is no longer a question of simply saying what was done – the sexual act – and how it was done; but of reconstructing, in and around the act’ (1976, 63). Engrained confessional practices are evident in the work of sexual health clinics (Pryce 2000). As these are normative behaviours within healthcare, they are most often invisible to clinicians and patients.

Health, Lifestyle Choice and Moral Culpability

  1. Top of page
  2. Abstract
  3. Health, Lifestyle Choice and Moral Culpability
  4. Viral STIs and ‘Dirt’
  5. Methods
  6. Results
  7. Discussion
  8. Conclusion
  9. Acknowledgements
  10. References

Pairing of health and morality in western societies has relevance in the construction of beliefs about acquiring infection. This context shapes Foucault’s analysis of sex, morals and sexual health care. Although scientific medicine has displaced earlier beliefs about disease caused by corrupt morals, health policies and promotion serve to re-moralise illness (Hatty and Hatty 1999; Cheek 2008). Current public health interventions are focussed on risk factors linked to individuals’ behaviour and ‘lifestyle choices’ (Leichter 2003). Although risk factors attributable to conditions beyond individuals’ control are recognised, more credence is given to beliefs that ill-health is self-inflicted (Leichter 1997). The meaning people make of viral STIs readily links with beliefs about individuals’ morality rather than drawing from epidemiological explanations.

Viral STIs and ‘Dirt’

  1. Top of page
  2. Abstract
  3. Health, Lifestyle Choice and Moral Culpability
  4. Viral STIs and ‘Dirt’
  5. Methods
  6. Results
  7. Discussion
  8. Conclusion
  9. Acknowledgements
  10. References

Sexually transmitted infections are a special topic for confession. Although any medical consultation has aspects of a Foucauldian confessional process, STIs contravene discourses of individual responsibility for moral and physical purity (Pryce 2000). The anthropological notion of ‘dirt’ proposed by Douglas (1966) is useful for exploring cultural systems defining what is dirty. ‘Dirt’ is not neatly aligned with pathogenicity, even in societies where western medical discourses predominate. Douglas claimed that culture has a powerful role in determining what counts as dirt. Contamination is associated with boundary breaches and therefore is more symbolic than material. Pertinent to this study therefore, a herpes infection is socially constructed as dirtier when it occurs on the genitals than when it occurs on the lips as a ‘cold sore’. Warts are dirtier on genitals than on fingers and knees. These examples illustrate Douglas’ point that dirt is more about ‘matter out of place’ than an absolute measure of pollution. Douglas contended that orifices have taboo connotations associated more readily with vulnerability, dangerousness and dirt than other bodily parts. This article illustrates the workings of confessional practices and highlights the benefits for women when clinicians acknowledge this categorisation of ‘dirtiness’ along with epidemiological data used for reassurance.

Methods

  1. Top of page
  2. Abstract
  3. Health, Lifestyle Choice and Moral Culpability
  4. Viral STIs and ‘Dirt’
  5. Methods
  6. Results
  7. Discussion
  8. Conclusion
  9. Acknowledgements
  10. References

This study used data from in-depth qualitative email interviews conducted with 26 women with an HPV or HPV diagnosis and 12 sexual and women’s health clinicians. Most participants were from New Zealand. Women from USA, Canada and England also participated. The research study aims were to explore the effects of medical and social discourses on women’s experiences of a viral STI diagnosis and to consider the sexual health clinic as a pedagogical environment where ‘lessons’ are offered by clinicians about morality, femininity and sexuality. Poststructuralist feminist discourse theory was used to analyse the data. Within this theoretical context, women and clinicians were considered to be discursively positioned, ‘…described by the sum total of the subject positions in discourse they currently occupy’ (Burr 1995, 152). Clinicians’ and women’s accounts of consultations about viral STIs were understood to reflect pre-existing linguistic, cultural constructions of medicine, STIs, sex and femininities (Weedon 1997). Interviews were conducted by email (Cook 2012a). This method has been advocated by other researchers when investigating potentially ‘sensitive’ health-related topics, where participants might be vulnerable and marginalised (Kralik 2000; Illingworth 2001; Adler and Zarchin 2002; Beck 2005; Liamputtong 2006; McCoyd and Kerson 2006; Bjerke 2010). The method enables a level of rapport-building over an extended time. Participants value the control they have over time to reflect and the location and timing of responses.

Ethical considerations

Approval for the research was obtained from the University of Auckland Human Research Ethics Committee. Participants accessed the information sheet and consent form from a webpage, which was created on the University of Auckland website to establish researcher authenticity and provide study information. The participant information sheet alerted participants to possible psychological discomfort they might experience by participating in the study. Free local and international referral plans were in place, in case additional support was desired. The participant information sheet advised about the steps I would take to protect confidentiality and anonymity with regard to data security (Cook 2009).

Recruitment and participants

Participants were recruited using emailing lists established for sexual health professionals in Australasia, through a patient support group and via advertisements placed on two sexual health educational websites. Once ‘saturation’ in the data collected was reached, the advertisements were removed from the websites. Participants with a viral STI diagnosis were aged between 22 and 71 years of age and all identified as heterosexual. Time since diagnosis ranged from one week to more than 25 years. The clinician group was made up of seven doctors, four nurses and one clinical psychologist. Participants selected pseudonyms to be used in publications.

Data collection and analysis

Email interviews were conducted over six months. Participants completed the interview at their own pace, ranging from several weeks to six months. Interviews progressed through a series of questions; thirteen for clinicians and seventeen for women with HSV or HPV. Participants were emailed approximately four questions in each new email. The semi-structured process enabled the participants and I to gauge how far through the interview we were.

Questions to women with a viral STI diagnosis began by exploring the process of being diagnosed and subsequent experiences with clinicians. Opening questions were; ‘Can you tell me about when and how you came to find out about this diagnosis?’‘What do you recall about the initial process of consulting a health professional?’ Further questions investigated interactions with clinicians and then addressed personal, social and sexual effects of the diagnosis. Similarly, questions to clinicians addressed their understandings of the consultation process and possible effects of the diagnosis for women. For example; ‘Based on your clinical experiences, how do you think health professionals influence women’s experience of the diagnosis of HSV or HPV and its relevance to their lives?’‘When a woman has a diagnosis of HSV or HPV, how do you typically ‘frame up’ the way you talk about the implications of these diagnoses?’ Participants were encouraged to use the questions as prompts; some responded to each question and others wrote accounts incorporating points from questions.

Data were analysed using a qualitative method, thematic analysis (Braun and Clarke 2006), where repeated patterns are identified across the data set. The process began with initial line by line manual coding of the transcripts. Coding was inductive and deductive, using Foucault’s (1976) notion of the confessional and Douglas' (1966) argument about the cultural construction of dirt. Themes were critiqued with another researcher independent to the research, in the sexual health field, to address rigor and minimise bias (Liamputtong 2009).

Results

  1. Top of page
  2. Abstract
  3. Health, Lifestyle Choice and Moral Culpability
  4. Viral STIs and ‘Dirt’
  5. Methods
  6. Results
  7. Discussion
  8. Conclusion
  9. Acknowledgements
  10. References

Five themes were identified in relation to the moral ‘work’ in clinical consultations subsequent to a viral STI diagnosis: the particular ‘dirtiness’ of viral STIs, the clinician as a moral agent, the ‘non-judgmental’ clinician, women juggling truth-telling and risk and clinicians prescribing moral work.

The particular dirtiness of viral STIs

The social classification of STIs as ‘dirty’ is evident in the moral ‘weight’ applied to infections associated with sex. An STI is linked to connotations of choice and therefore culpability, as illustrated by the account of a 33-year-old participant, Dianne, about an HPV diagnosis:

I can walk into a general practitioner’s [GP’s] office and say, ‘I have depression, help me,’ or ‘I have endometriosis, help me,’ because these are somewhat beyond my control. People feel sorry for you. There’s no guilt… Vaginismus is difficult because you have to admit you are a sexual being and that what other people can do naturally you have difficulty with…. But with HPV it’s been different again. There’s an aura of sin around it, of uncleanliness.

Although margins of the body are culturally associated with danger, the dangers are unequal (Douglas 1966). The use of the descriptor, ‘sin,’ indicates a level of personal culpability not felt with endometriosis. The ‘sin’ and ‘uncleanliness’ associated with HPV echo Foucault’s (1976) point that historically, sex is the key theme of confessional practices, because sex, particularly sexual pleasure, causes sin.

That the ‘dirty’ body is more about contravention of a social system than the presence of pathogenic agents is highlighted by another participant, Sophia, 51-year-old diagnosed with HSV. She compared experiences consulting clinicians about HSV compared with other conditions:

It was different for me because it was of such a personal nature, being an STI and my body. It was easier to go to the doctor about a bladder infection than it was to discuss herpes… to have a bladder infection was a different concept psychologically because it wasn’t to do with having sex, so I didn’t feel ‘dirty’ or ashamed of myself when I was asked to pee into a dish or had a swab taken.

Sophia distinguished between bladder infections and HSV. The latter impacted detrimentally on her self-construct, whereas bladder infections did not have burdensome connotations. Pathogens of bladder infections did not break a moral system and therefore were not as ‘dirty’ and the diagnosis did not have the same negative effect as the HSV diagnosis.

Clinicians as moral agents

Confession within a consultation can be experienced as a liberating relief. The power exercised by the clinician/confessor produces preferred thoughts and feelings and this relief obscures the ‘moral occasion’ of the consultation. Miranda, a 48-year-old woman with an HSV diagnosis indicated she wanted a clinician to take a moral position about the meaning of HSV:

I think for clinicians to emphasize that HSV is manageable would be helpful. The big bogey for me is that it’s not curable. It’s an alien thing inhabiting my body, and no amount of exercise and good nutrition will get rid of it. It’s a link to some unidentifiable shameful past. It feels like that and I’m not a promiscuous person, who wittingly has been in unsafe situations. I really needed reassurance from my doctor that I will manage, life will be normal.

Miranda’s description implied that she would have welcomed a clinician’s judgement to reconcile disparate beliefs and to reassure her about the question of responsibility. The shame of contracting a viral STI was constructed as evidence of risk-taking, and yet, this assessment did not make sense to her.

Invisibility of confessional practices is evident in the following quote, illustrating Foucault’s (1976) assertion that confession is experienced simply as a relief. Jane, a 71-year old, was diagnosed with HPV in her mid-60s, which led to her husband’s disclosure just before he died, of numerous extramarital sexual partners. She was devastated to find out about the diagnosis, primarily because of disruption to her marital memories, not because of the numerous monitoring procedures she had undergone to assess precancerous cervical changes:

I had the colposcopy yesterday and had such a good talk with my woman gynecologist. She gave me time and attention and asked the right questions – e.g. ‘would it have made a difference if your husband didn’t die and you had been able to talk it [the extra-marital liaisons and infection] through with him?’ There is no doubt that it would have helped. I said so little – at the time his dying became the main focus of everyone’s attention. That [the infidelity] is the issue I am currently dealing with.

From Jane’s perspective she and her doctor were just having ‘such a good talk.’ The benefit related to the doctor’s acknowledgement of the moral meaning of the diagnosis and associated grief. These experiences of relief and consolation illustrate the power of confessional practices.

‘Non-judgmental’ clinicians

Morality in clinical teaching is usually inconspicuous, merged with scientific education. Foucault (1985) described morality as values embedded within societal institutions to the extent that these prescriptions are not readily detected. This study identified that clinicians and women typically recognised health professionals’ moral judgements only when negative attitudes were expressed. For example, in the following comment by a sexual health nurse, Helen, she constituted an adverse judgmental comment as moralistic, whereas a positive judgment is not considered a judgment at all: ‘Health professionals definitely influence, although sadly not always positively. Any form of comment that could be taken as judgmental can have long term effects.’ In a similar vein, comments by Karen, a sexual health physician, overlooked the moral component of health professionals’ talk, whether or not the effects are considered positive or negative: ‘Of course, a professional, non-judgmental and respectful manner is extremely important in how patients perceive they are being treated and this can have lasting impact on their experience.’

Omitting critique of power relations is significant because clinical conversations are value-laden. Only one sexual health physician, Kate, described the purposeful use of her medical authority to offer an alternative discourse of health and morality:

This [when women experience the diagnosis as negative] is one of the few times that I consciously use my power as a doctor – employing that almost-bordering-on ‘doctors are God-like myth’ and the power of the doctor–patient relationship, to make a very clear statement…I am aiming for even the most distressed person to at least be able to leave this appointment with a clear message that no matter what they are believing (‘my life is over, I’ll never have sex again, I am a bad, damaged person’) that the doctor knows otherwise and therefore they presumably have at least one piece of information that holds hope and a way forward. I do not expect them to be OK now as am very aware that their current reaction should not be dismissed or minimised – I just let them hear that I know they will be OK.

The above description aptly illustrates the power relations of the confessional, where the clinician’s authority is used to prescribe moral meaning, offering consolation, forgiveness and liberation.

Clinicians emphasised medical objectivity in their interventions as if it was ideal, free from subjective judgment. This point is illustrated in the following quote by Karen, a sexual health physician:

…by this [clinical objectivity] I mean the ability to maintain a friendly detachment, provide professional unbiased advice to the patient without being influenced by their distress, domestic situation or agendas…it is important, as clinicians, not to become too involved in the patients’ personal difficulties or decision-making processes such that you end up colluding with them so-to-speak in order to help them extricate themselves from a potentially difficult situation. It is the clinician’s job to provide the patient with information which is correct, up-to-date and to help the patient put the information in context or in perspective…it helps…to be able verbalize concerns and have a conversation with someone [clinician] who helps you put issues in perspective.

In Foucauldian terms, the apparent objectivity of the clinical consultation is a subjective, ritualistic practice occurring within a power relationship. In the quote below, Karen went on to describe standard routines of sexual history taking and risk assessment. These customary practices extract and give information according to the clinician’s assessment of what is significant:

I try to follow a fairly standard routine with patients: usual medical history, full sexual history and risk assessment, examination, do tests, explain diagnosis and plan of management. I then deal with the specific issues or questions that are troubling them, educate the patient so that they understand the reasons why infections behave in certain ways and the rationale for management.

The patient’s ‘turn’ follows the clinician’s ‘interrogation’. The clinician’s questions determine the hierarchy of important ‘facts’. Given the power relations of the clinical encounter, it is more difficult to ‘confess’ troubling questions if the topic has not been raised in the clinician’s assessment; a point discussed in the following section.

Women juggling truthfulness and risk

In consultations, women had problems asking questions outside areas already raised by clinicians. Questions give information that affect power relations: ‘…if I tell the truth about myself …in part it is that I am constituted as a subject across a number of power relations which are exerted over me and which I exert over others’ (Foucault 1988, 39). This problem is illustrated by Jeannie, a 37-year old with an HPV diagnosis who described the worry about being judged by a doctor for being a sexually active, sexually interested woman:

Iin a situation with a health professional, I get worried that they will …either judge me for being so open or will be uncomfortable and will bluster their way through it and give me bad information…. It would be much easier for me…if the questions were brought up by the health professional so that the patient knows it’s okay – to say something like, ‘this diagnosis or condition can have some effects on your sex life and your partner or partners. Most women who have this have some concerns about that. Are there any questions you have that you’d like to talk about?’

The account highlights the tension in deciding whether to withhold questions. Foucault (1976) argued that providing detailed accounts of anything related to sex is normalised. Assumptions of clinicians’ right to know sexual history details mean that withholding information can bring unease. Victoria, a 37-year old diagnosed with HSV noted tension between a perceived a moral obligation to tell and competing desire to withhold information:

My most recent consultation with a new primary care doctor was for another problem but I happened to be a new patient so she took a medical history. I was really not going to confide that I had been diagnosed with HSV, yet I told her I had terminated a pregnancy… She absolutely did not ask me if I had a history of STIs even though she does vaginal examinations. I just didn’t want to tell her because I have a gynaecologist and I feel that’s his area. I had this feeling that somehow it would be found out, or that I was withholding information. It [telling the new doctor] would be another place where I felt I was ‘labelled.’

Victoria justified not telling by positioning the clinician as responsible for extracting the confession. The decision to withhold information because of the risk of being ‘labelled’ is a useful point for further illustrating Foucault’s (1988) contention that telling the truth constitutes people within power relations. Victoria resisted the possibility of being constituted as a woman with a diagnosis she associated with a more problematic subject position than that of a woman with a termination history. Although clinicians might believe that their consultations are objective, women make distinctions about the ‘moral work’ entailed related to specific health topics.

Clinicians prescribe moral work

The confessional activity of advice-giving is an ordinary aspect of clinicians’ interactions with patients. Comments by clinicians point to their taken-for-granted role as expert interpreters of the ‘true’ meaning of a diagnosis and its (moral) implications. The patient has partial knowledge, transformed into full understanding through confessional practices (Foucault 1976). This transformational process is apparent in the following comments by Helen, a sexual health nurse:

Many people I have worked with have handled the diagnosis, worked through their fears, met fabulous partners, and learnt to communicate well early in a relationship because of the diagnosis… I have heard from partners who have been devastated that they haven’t been told [about a partner having genital herpes], had believed that they had an open, honest trusting relationship, and the damage from not telling has been huge; in some cases catastrophic, leading to the end of the relationship. This [level of upset] in comparison to perhaps telling a new partner, and then rejecting them at an early stage in the relationship – if a partner can’t handle a ‘cold sore’ in the wrong place how would they handle BIG issues in life. I have had people tell me of potential partners that have bailed [out], but overall once the pain of rejection is over, relief that they didn’t spend years with that person. So yes I explain options, but overall my approach is to tell if there is potential for a future in it. I also use the tack of, ‘what would you want someone to do if they knew?’ All of this is of course tempered with the statistics of the numbers of people with HSV that are unaware.

Helen’s description of options, pitfalls and metaphorical salvation for those who disclose a viral STI diagnosis to partners ‘correctly’ illustrates Foucault’s (1976) notion of the confessional.

Although Helen indicated that epidemiological data ‘temper’ the preceding situations she outlined, the moral obligation to be truthful and to self-regulate prevailed. Helen emphasised the importance of telling the truth that the benefits and responsibility to tell outweigh possible detrimental effects of disclosure. Potentially unpleasant effects of disclosure are reframed, positing beneficial outcomes.

The following example demonstrates the clinician’s position as confessor interpreting meaning. Jessica, a nurse in general practice, described her typical intervention when women were newly diagnosed. Jessica held the idea that, as a clinician, she was best placed to interpret appropriately the meaning of the diagnosis:

The worst thing for them [women adjusting to a diagnosis of HSV/HPV] is always trying to tell their partner – usually because of preconceptions and attitudes toward STDs in the past. I offer to see their partner with them to be the messenger if they want, so that I can answer any questions the partner may have, and try to make it all matter-of-fact rather than emotional.

The ability to assist the confessional process by relaying information matter-of-factly rather than emotionally gives the former more weight. An emotional explanation by a woman is, in Foucauldian terms ‘… incomplete, blind to itself…’ (Foucault 1976, 66). The clinician’s ability to present information with an absence of emotion is conceptualised as a process of completion by scientific means.

The confessor as a conduit of verification, enabling people to move from incomplete to complete understanding (Foucault 1976) is illustrated in the consultation description below by Annalise, a sexual health nurse as she recalled the following:

I remember a female client in her 40s … who had been courageous enough to commence a new relationship after a separation and divorce from a long-term marriage. She had contracted genital herpes in the marriage and had in recent months been coming to terms with the possibilities of how that might have occurred! She was tearful about this [possibility of ex-husband’s infidelity] during our conversation even though she was ostensibly just attending for a sexual ‘WOF’ [warrant of fitness] before having sex for the first time with her new partner. She tried to describe to me how confused she was about her emotional connection with the virus and how difficult she had found it to tell this new man. At one point she said the tears were about how grateful she was that he had taken the news so well and was so supportive. She had obviously ‘educated’ him well so he was able to be realistic about managing the virus and I was able to give her good feedback about how this open, honest communication boded well for a healthy start to their time together.

The woman was constituted as ‘courageous,’ showing moral responsibility by coming in for a sexual health check-up as a ‘warrant of fitness’. The moral prescription of sexual self-denial until a clear set of sexual health test results is a standard public health message. The nurse guided the woman to consider transformative possibilities of her actions. Through appropriate moral conduct, disclosure exemplifying ‘open, honest communication,’ the woman was reassured of the likely reward; a ‘healthy’ relationship. The account demonstrates the integral and usually invisible relationship between scientific ‘objectivity’ and moral prescriptiveness in clinical encounters. In the commentary on her clinical work, she is the confessor, helping the woman to decipher how to make sense of the situation, shaping the meaning of the conversation: ‘I was able to give her good feedback.’ The account demonstrates the integral and usually invisible links between scientific ‘objectivity’ and moral prescriptiveness in consultations.

Discussion

  1. Top of page
  2. Abstract
  3. Health, Lifestyle Choice and Moral Culpability
  4. Viral STIs and ‘Dirt’
  5. Methods
  6. Results
  7. Discussion
  8. Conclusion
  9. Acknowledgements
  10. References

The belief that ideal consultations are based on scientific rationality means that clinicians are relatively unaware of, or underplay powerful moral components in clinical situations where diagnoses impact detrimentally on a person’s self-construct. Such diagnoses are usually associated with culturally determined assumptions about ‘lifestyle choices’ and individual responsibility and symbolise some form of contamination. Aspirations to empower and de-stigmatise mask clinicians’ moral judgements and attempts to extract confession. Notions of being a non-judgmental practitioner conceal the moral ‘work’ undertaken by clinicians and their patients in efforts to produce a preferred subject position.

Certain diagnoses, treatments and their effects are more disruptive to women’s self-constructs and social interactions than clinicians believe are medically warranted. This perception results in efforts to use scientific rationality to cancel out the effects of (irrational) stigma (Cook 2012b). Other studies have similar findings. For example, Gagnon and Holmes (2010) highlight that the development of lipodystrophy syndrome, the abnormal redistribution of adipose tissue associated with highly active antiretroviral therapy (HAART), can be associated with levels of disgust greater than beliefs about the ‘pollution’ of HIV infection. The detrimental impact is such that women may choose to forego HAART in an attempt to reclaim a familiar body. A high viral load may be preferred to disfigurement from HAART. Several studies assert that clinicians typically deflect lipodystrophy-related distress, focussing on treatment benefits. Participants indicated that they want clinicians discuss moral concerns, about what it means to live with bodily disfigurement that in effect discloses an HIV diagnosis (Reynolds et al. 2006; Gagnon and Holmes 2010). These studies are used here also to illustrate Douglas' (1966) claim that what counts as dirt is a sociocultural construction of matter out of place. In the case of lipodystrophy the redistribution of fat becomes such matter, reshaping discursive positioning, social functioning and transforming embodiment.

Clinicians’ limited awareness of confessional components within consultations means the personal negotiation of subject positioning that impacts on disclosure decisions may go unnoticed. A study of nurses who followed up mothers after the occurrence of intimate partner violence analysed how discourses of befriending and empowering obscured home-visiting nurses’ regulatory role (Peckover 2001). Findings identified that nurses’ non-coercive pastoral care practices enabled surveillance. Peckover notes the repositioning work for women, who resisted being labelled ‘bad’ mothers, hiding evidence of depression and recurrent abuse in order to produce themselves discursively as good mothers. Peckover concludes that healthcare is potentially enhanced when clinicians appreciate that their roles in welfare and surveillance are ‘double-edged’ for women. Strategies to resist the confessional power of clinicians can lead to women risking safety in attempts to produce themselves in preferred ways.

Clinicians’ positioning in extracting confession through the consultation and via bodily surveillance, does not ensure that patients passively adopt medical moral authority. There is fluidity in acquiescence and resistance to medical social control. In a study that examined confessional practices in healthcare, Wheatley’s (2005) account of patients in cardiac rehabilitation settings highlighted the contingency of the ‘truthfulness’ or otherwise of patients’ confessions. Endeavouring to constitute themselves as ‘good’ patients, self-reports about diet, smoking and exercise were routinely evasive. This example echoes others in the current study, demonstrating Foucault’s (1980) point that power is exercised by all, subject to ongoing negotiation, struggle and resistance.

Discussion of statistical risk obscures clinicians’ awareness of efforts to regulate moral choices, because of beliefs that scientific objectivity informs rational choices. Ruhl’s (1999) exploration of the relative invisibility of moral judgment in the medical surveillance of pregnancy traced links that blur science and morality:

Responsibility is equated with the capacity to behave rationally … a decision to follow the path with the greatest possibility of benefit with the least risk. In this sense, responsibility talk within liberal regimes is also morality talk; behaving responsibly is a moral act (Ruhl 1999, p. 96).

When clinicians convey that their advice is informed by rational, objective data, patients’ digressions from clinicians’ assumptions of moral choices and concerns are readily positioned as non-rational and irresponsible (Ruhl 1999).

The current study demonstrates that clinicians use the concept of non-judgmental communication to describe efforts to cultivate permissive responses. Clinicians detailed intricate conversations aimed at improving women’s well-being, offering alternative moral discourses to the stigma of STIs. Evidence of the moral ‘work’ undertaken by clinicians indicates that the term, non-judgmental, does not capture the complexity of their confessional practices. Awareness of the confessional nature of sexual health consultations better enables clinicians to recognise that these conversations are not value-free (Holmes and O’Byrne 2006). Public health efforts are shaped by power relations inherent in clinicians’ extraction of particular information and recommendations that promote population-based values.

Conclusion

  1. Top of page
  2. Abstract
  3. Health, Lifestyle Choice and Moral Culpability
  4. Viral STIs and ‘Dirt’
  5. Methods
  6. Results
  7. Discussion
  8. Conclusion
  9. Acknowledgements
  10. References

Clinicians assert that they draw from rationality and science, rendering routine consultations free from moral judgment. Clinicians consider that judgmental clinicians are those who convey overtly negative moral assessments. This study’s analysis is that discourses of morality shape all sexual health consultations, although assumptions of rationality obscure moral agendas. Foucault’s notion of the confessional is useful for analysing the relative invisibility of clinical interrogation practices. The confession is an integral part of the consultation process, extracted without force. In women’s assessment, a sexual health consultation involves ‘moral work;’ they account for sexual health problems in ways that differ substantially from non-STI-related health diagnoses. Women bring to consultations considerable knowledge about morality, health, sex and ‘dirt.’ Clinicians might be better able to support and educate women if they are able to acknowledge the inevitably subjective, moral terrain of STIs; that there are multiple discourses shaping the potential social implications of contracting, transmitting and living with the knowledge of a viral STI.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Health, Lifestyle Choice and Moral Culpability
  4. Viral STIs and ‘Dirt’
  5. Methods
  6. Results
  7. Discussion
  8. Conclusion
  9. Acknowledgements
  10. References

I am appreciative of the women and clinicians who participated so generously in this study. I am grateful to Professor Alison Jones and Associate Professor Louisa Allen from The University of Auckland for their guidance with this research. Special thanks to Associate Professor Annette Huntington, from Massey University, for her comments on the early draft. Funding for this research was received from The University of Auckland New Zealand Doctoral Scholarship Fund.

References

  1. Top of page
  2. Abstract
  3. Health, Lifestyle Choice and Moral Culpability
  4. Viral STIs and ‘Dirt’
  5. Methods
  6. Results
  7. Discussion
  8. Conclusion
  9. Acknowledgements
  10. References
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