Who Bears the Brunt of STI Stigma?
The stigma surrounding sexually transmitted infections (STIs) is pervasive, so much so that shame and discriminatory attitudes about STIs seep through pop culture, sex ed courses and healthcare systems.
Although anyone with a sexually transmitted infection may face stigma, already marginalized people bear the brunt of STI stigma on a deeper, more complex level. These groups can include women, teenagers and young adults, Black people and other minorities, and anyone without adequate healthcare access.
Alongside causing emotional distress, the stigma of a sexually transmitted infection can get in the way of obtaining timely treatment, leading to poorer health outcomes.
Does every STI carry the same stigma?
Stigma around curable infections, which should be temporary, usually stems from discriminatory attitudes from healthcare providers or partners. It can otherwise come from a breach of trust, said Shana Singleton, co-founder of Herpes Could Never, an organization that is reframing the narratives around herpes.
"People with curable STIs feel the social stigma when they have been outed by a confidant," Singleton explained.
While people and pop culture may apply stigma to all sexually transmitted infections, STIs that are treatable but not curable, such as herpes or HPV, may carry an increased burden.
"People who test positive for chronic STIs bear the brunt of STI stigma," said Courtney Brame, the founder and executive director of Something Positive for Positive People, an STI harm reduction and resource platform based in St. Louis. "People's identities are often very much interconnected with their sexuality."
"Even with all the advancements of medications that can make a person living with HIV undetectable with little to no chance of passing their virus on to their partners, they are still dismantling the stigma from the AIDS era," Singleton added.
Women and STI stigma
The Centers for Disease Control and Prevention (CDC) estimates 1 in 5 people has an STI.
"Even though it's now more statistically normal for adults to have been infected with at least one STI, like HPV, than to not be infected, there's still a myth that only promiscuous people contract STIs," said Adina Nack, Ph.D., professor of sociology, director of the public health program at California Lutheran University and author of "Damaged Goods? Women Living With Incurable STDs."
In turn, the label of promiscuity disproportionately impacts women.
"The root of STI stigma is the gender-based double standard of sexual morality," Nack continued. "Male social status typically increases as their number of sexual partners increases, whereas female social status typically decreases."
"Unfortunately, many societies still place high value on female virginity/chastity and on male sexual conquests," she added. "There is more 'slut-shaming' of those assigned female at birth. My research found that infected patients who identified as women most often used the word 'dirty' to describe how they felt after receiving an STI diagnosis."
Men still encounter related stigma, but the effects across genders are different, Nack explained.
"Infected women were most afraid that others who found out would judge them to be a 'slut' and that they might be rejected by current or future sexual partners," she said.
Youth and STI stigma
According to the CDC's 2020 STD surveillance data, more than half (53 percent) of reported STDs were diagnosed among adolescents and young adults ages 15 to 24 years. The data sounds the alarm on how STI stigma may exist in partnership with high rates of STIs.
"Children lack resources," Singleton said. "I have several 13- to 17-year-olds a month in my direct messages asking for my help because they are too afraid to talk to their parents. How can we make a safe place for teenagers more accessible?"
Racial disparities and STI stigma
A 2014 survey published in AIDS Patient Care and STDs and conducted among 108 young, low-income Black men in San Francisco found STI stigma heavily equated to lower rates of STI testing, treatment and partner notification. The highest shame and stigma scores were among participants who had never been tested.
According to the CDC's 2020 data, 32 percent of all cases of chlamydia, gonorrhea and primary and secondary syphilis were among Black patients, even though they made up only about 12 percent of the U.S. population. The CDC noted these rates are unlikely explained by sexual behavior but rather by a lack of access to quality care.
STI rates are highest in Southern states. A 2003 study published in Social Science & Medicine sought to explore the stigma-related barriers to treatment and screening in the South, namely, Louisiana, Mississippi, Alabama, Georgia and South Carolina. The study pinpointed differences in stigma across gender, age and race. Women were seen as either "good" or "bad" in correlation to their behavior or STI status. Healthcare workers had poor perceptions of sexually active younger women who "flaunted their sexuality."
For men in the study, sexual behavior was considered acceptable, but going to a clinic or getting treatment was seen as embarrassing; a lack of treatment was a consistent theme. Mistrust in health systems was significant for Black male individuals, with one participant naming the Tuskegee Study as a reason for distrust.
The Tuskegee Study began in 1932 and continued for more than 40 years. During this time, the U.S. Public Health Service and CDC tracked the health of 600 Black men in Alabama as an experiment to study the effects and full progression of untreated syphilis. The men were given a placebo, allowing the disease to run its course unchecked. In the early 1970s, after many of the original 600 men, their spouses and, in some cases, their children had died, the study was shut down and the scandal was reported in the press.
The 2003 study concluded that punitive attitudes from healthcare providers have detrimental impacts on patients seeking care.
"Medical practitioners who judge STI patients as immoral make it less likely that those patients will comply with their doctor's recommendations for treatment, either because they are in denial or because their self-esteem is so damaged that they don't feel they deserve to get well," Nack explained.
STI rates reached an all-time low in 2010. However, they're on the rise again in the United States. Cases of gonorrhea are up 10 percent and syphilis cases are up 7 percent. While testing, treatment and more resources are needed to combat the public health crisis, destigmatizing efforts may go hand in hand with curbing cases.
"In addition to the need for a public health campaign to promote STI vaccination, testing and treatment, public health will benefit from destigmatizing STIs," Nack said. "That begins by making medically accurate, age-appropriate sexual health education more accessible."