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Preliminary development of a scale to measure stigma relating to sexually transmitted infections among… Rusch, Melanie L; Shoveller, Jean A; Burgess, Susan; Stancer, Karen; Patrick, David M; Tyndall, Mark W Nov 20, 2008

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ralssBioMed CentBMC Women's HealthOpen AcceResearch articlePreliminary development of a scale to measure stigma relating to sexually transmitted infections among women in a high risk neighbourhoodMelanie LA Rusch*1, Jean A Shoveller2, Susan Burgess3, Karen Stancer4, David M Patrick2,5 and Mark W Tyndall6,7Address: 1Division of International Health and Cross Cultural Medicine, University of California San Diego, La Jolla, USA, 2Department of Health Care and Epidemiology, University of British Columbia, Vancouver, Canada, 3Department of Family Practice, University of British Columbia, Vancouver, Canada, 4Downtown Community Health Centre, Vancouver Coastal Health, Vancouver, Canada, 5British Columbia Centre for Disease Control, Vancouver, Canada, 6British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada and 7Department of Medicine, University of British Columbia, Vancouver, CanadaEmail: Melanie LA Rusch* - mrusch@ucsd.edu; Jean A Shoveller - jean.shoveller@ubc.ca; Susan Burgess - burgnesb@interchange.ubc.ca; Karen Stancer - karen.stancer@shaw.ca; David M Patrick - david.patrick@bccdc.ca; Mark W Tyndall - mtyndall@cfenet.ubc.ca* Corresponding author    AbstractBackground: As stigma is a socially constructed concept, it would follow that stigma related to sexualbehaviours and sexually transmitted infections would carry with it many of the gender-based morals that areentrenched in social constructs of sexuality. In many societies, women tend to be judged more harshly withrespect to sexual morals, and would therefore have a different experience of stigma related to sexual behavioursas compared to men. While a variety of stigma scales exist for sexually transmitted infections (STIs) in general;none incorporate these female-specific aspects. The objective of this study was to develop a scale to measure theunique experience of STI-related stigma among women.Methods: A pool of items was identified from qualitative and quantitative literature on sexual behaviour and STIsamong women. Women attending a social evening program at a local community health clinic in a low-incomeneighbourhood with high prevalence of substance use were passively recruited to take part in a cross-sectionalstructured interview, including questions on sexual behaviour, sexual health and STI-related stigma. Exploratoryfactor analysis was used to identify stigma scales, and descriptive statistics were used to assess the associationsof demographics, sexual and drug-related risk behaviours with the emerging scales.Results: Three scales emerged from exploratory factor analysis – female-specific moral stigma, social stigma(judgement by others) and internal stigma (self-judgement) – with alpha co-efficients of 0.737, 0.705 and 0.729,respectively. In this population of women, internal stigma and social stigma carried higher scores than female-specific moral stigma. Aboriginal ethnicity was associated with higher internal and female-specific moral stigmascores, while older age (>30 years) was associated with higher female-specific moral stigma scores.Conclusion: Descriptive statistics indicated an important influence of culture and age on specific types of stigma.Quantitative researchers examining STI-stigma should consider incorporating these female-specific factors inorder to tailor scales for women.Published: 20 November 2008BMC Women's Health 2008, 8:21 doi:10.1186/1472-6874-8-21Received: 2 April 2008Accepted: 20 November 2008This article is available from: http://www.biomedcentral.com/1472-6874/8/21© 2008 Rusch et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 10(page number not for citation purposes)BMC Women's Health 2008, 8:21 http://www.biomedcentral.com/1472-6874/8/21BackgroundStigma has long been a part of our social existence, withthe original Greek translation referring to a physical signexposing a moral imperfection[1]. While in today's soci-ety the physical mark need not be present, the moral asso-ciations have remained intact. The topic of sexuallytransmitted infections (STIs) presents a good example ofthe dynamic and socially fluid nature of stigma, asopposed to the stationary, objectified definition it issometimes given [2]. In relation to the categories ofstigma outlined in Goffman's (1963) foundational work,STIs could be argued to cross all three – stigma of thebody, of moral character and of tribe[1,3]. In addition, forany one individual, STIs could also blur the boundaries ofthe discredited – one who is overtly stigmatized – and thediscreditable – one who may be able to conceal their stig-matizing feature – depending on the nature of social inter-action at any particular time[1,4].Sexual morals have typically had a gender imbalance,leading to a stronger social stigmatization of women.Many societies and cultures view promiscuity among menfavourably (e.g., as a measure of virility or status), whilepromiscuity among women is viewed as undesirable andimmoral [3,5,6]. In the late 19th and early 20th centuries,the social and medical standpoints on the spread and pre-vention of STIs were influenced strongly by these genderstereotypes. For example, in World War I, STI preventionflyers were used to warn soldiers away from the 'dirty'women who would infect them with STIs, which theymight then pass on to their 'good' wives [7]. Prior to avail-able treatment, the impact of STI sequelae was so greatamong soldiers, some states enacted laws against 'promis-cuity', and many single women were arrested or detainedfor such things as being out at a bar or club on their own[7]. Today's views on sexual behaviours and STIs may notbe as overtly imbalanced, but there remains an underlyinggender bias in the stereotypes and the meanings associ-ated with STIs, resulting in different stigma experiencesand generally higher negative impacts among women[8,9].The continued impact of the good/bad dichotomy onwomen's perceptions of STIs is captured in the qualitativework of Nack (2002)[3]. In her work, discourse evolvedaround sexual behaviour norms and behaviour that wasdeemed appropriate for women evolved around themoral division of respectable or 'good girls' and disrepu-table or 'bad girls', leading to the development of the ideaof 'tribes of womanhood'. Membership in the 'good girltribe' or morally-correct category, whether through actualbehaviour, avoidance of STI or concealment of behavioursor diagnoses, was precarious, while membership in theIn addition to the potential psychological harms an indi-vidual might deal with when faced with a positive STI testresult, there may also be an impact on testing and treat-ment behaviours at the population level. In part, this maybe explained by the additional STI-related stigma that canarise within health care settings (e.g., patients must revealthe relevant details of their sexual behaviour in order toseek help from caregivers, thereby risking becoming dis-credited; patients may also fear being discredited to otherclinic staff who may have access to their charts). Patientcomfort, appropriate staff communication, confidential-ity and respect for the feelings of the women have beenidentified as key stigma-related factors that need to beaddressed in the provision of STI services[10]. A similarstudy in the southern U.S. outlined four important con-cepts of stigma that surfaced from qualitative focusgroups, including religious ideation of health care workersaffecting their views of 'promiscuous' women, privacyfears among men, racial attitudes and stigma transferenceor fear of being labelled [11]. Thus, the ability to presentsafely and comfortably in a clinic setting can be disturbedby actual or perceived discriminating attitudes of theother clinic attendees, the doctors and nurses, or otherclinic staff.Stigma scales exist for general disabilities, mental health,and more recently for HIV/AIDS [12-15]. There are, how-ever, few scales that examine stigma in relation to STIs(notably, Fortenberry's stigma and shame scales[16,17])and none that incorporate female stereotypes related tosexual morals, as well as the perceptions of both the com-munity in general and health care professionals in partic-ular. The purpose of this study was to develop a stigmascale specific to women, which encompassed a broaderrange of the stigma experience associated with sexualityand STIs. The present paper outlines the preliminarydevelopment of such a scale, and assesses the demo-graphic and behavioural characteristics associated withthe resulting scales.MethodsAn interviewer-administered structured survey was carriedout among 126 women attending a weekly programexclusive to women (including transgendered individu-als) held at a local community health clinic in Vancou-ver's Downtown Eastside. This region isdisproportionately impacted by issues including sub-stance use, mental illness, homelessness and poverty.Compared to the rest of the province, census data from2006 indicated higher levels of income assistance (4.1%vs. 0.6%), higher levels of low income households(23.9% vs. 12% of families earning < $20,000 CDN), andinferior health outcomes (life expectancy at birth 75 vs 81Page 2 of 10(page number not for citation purposes)'bad girl tribe', was easy to gain and often thought of asirreversible.years)[18]. Due to the concentration of injection drug useand sex work in this high risk neighbourhood, the regionBMC Women's Health 2008, 8:21 http://www.biomedcentral.com/1472-6874/8/21also exhibits high prevalence of HIV and other STIs[19-21].The women's program is open to all women, and sees any-where from 20 to 60 women in one evening (for moredetailed information on the program and population, seeRusch, et al. 2008 [22]). The weekly, three-hour programoffers women a safe place to access food and health care,as well as to socialize with other women, and take part invarious activities including free haircuts, foot baths, artprojects, and movie nights. There is also access to doctorsand nurses, counselling services and massage therapy. Theprogram is advertised through fliers at the clinic and othercommunity organizations frequented by women. Womenwere passively recruited through an announcement at thestart of each evening inviting women to take part in thestudy. Although there was no overt advertising for thestudy, snowball sampling through word-of-mouth wasused to recruit women, including those women who maynot have been accessing the evening program on a regularbasis.The 27-item structured interview was used to gather datato describe the socio-demographic characteristics of thestudy participants, their use of and contact with servicesavailable in their community (including their contactwith outreach programs, outreach workers and streetnurses), as well as their self-reported patterns of sexualbehaviour and drug use. We also asked questions abouttheir use of sexual health care services such as annual papsmears and testing or treatment for STIs. The purpose ofthe larger study was to determine the characteristics andrisk levels of the women attending the program in orderto help inform program planners and to help tailor out-reach initiatives for those women missing from the demo-graphic, as well as to assess potential barriers to sexualhealth care among this population of women.Participants were given a copy of the consent form, andstudy coordinators read through the details of participa-tion before asking for their consent. Regular clinic staffand doctors were not actively involved in the recruitmentor interviewing, and the consent included a statementreassuring participants that if they chose not to partici-pate, there would be no consequences to their involve-ment with the clinic or the women's night program, northeir normal receipt of care at the clinic. As part of thelarger study, participants had the option of providing aurine sample for Chlamydia and gonorrhoea screening;however, this was not a requirement for taking part in thestudy. The clinic provided follow-up care for participantstesting positive. Participants received $10 remunerationfor completing the structured interview. This study wasWhile transgendered individuals were not excluded fromparticipating in the study, they were not included in thepresent analysis, as STI-stigma perceptions may be verydifferent in this population and there were insufficientnumbers (N = 4) to allow for comparison.An 18-item pool was created building on Goffman's(1963) basic three categories, drawing on previous con-structs from a general STI stigma and shame scale byFortenberry et al (2002), and incorporating the idea of thetribes of womanhood introduced by Nack(2002)[1,3,17]. In addition, based on other discoursearound stigma and sexual health care seeking behaviours,items relating to Goffman's category of 'moral' stigmaincluded both internal feelings of guilt or shame, as wellas the perceived views of others in the community, includ-ing health care workers and intimate partners [10,23].Items were also included to encompass concerns over dis-cretion, confidentiality and gossip. While the items weredeveloped and selected based on the pre-existing theoriesand literature mentioned above, the analysis was explora-tory rather than theory-driven and therefore did not pre-suppose any categories or groupings of the items.Items were assessed for endorsement using a discrimina-tion index, and for internal consistency within subgroupsusing Pearson's correlations. Problematic items werehighlighted and taken into account during exploratoryfactor analysis.Exploratory principal component factor analysis wasdone using promax (oblique) rotation to explore the cat-egories present in the responses. An iterative process wasused, discarding one item at a time based on factor load-ings as well as on discretion and internal consistencyresults, where applicable. From the original 18 items, fourwere discarded due to poor discrimination or poor factorloading. For each of the remaining 14 items, non-responders were compared to responders in order toassess variability.For the three resulting scales (female-specific moralstigma, social stigma and internal stigma), item-total cor-relation and alpha scores were calculated. Means andstandard deviations are also presented. Associations of thethree final scales with demographic and behavioural char-acteristics were assessed using the Wilcoxon rank-sumtest.ResultsDemographics of the 126 participants are shown in Table1. The median age was 42 years, approximately 40% iden-tified as Aboriginal, Inuit or Métis, and approximatelyPage 3 of 10(page number not for citation purposes)approved by the University of British Columbia Behav-ioural Ethics Review Board.40% reported having completed high school. Unemploy-ment was high (95%), as was substance use (injectionBMC Women's Health 2008, 8:21 http://www.biomedcentral.com/1472-6874/8/21drugs: 40%, non-injection drugs: 80%). Thirty-eight per-cent of the women were currently involved in sex trade.Table 2 outlines the STI-related stigma items included inthe structured interview. Items included feeling dirty, feel-ing violated, knowing (and conversely, not knowing) thatan STI was present, being able to hide an STI from others,feeling guilty, feeling embarrassed, perceiving those withan STI as having low intelligence, bad character and spe-cifically, bad character as judged by clinic staff. Four itemsincorporated concepts introduced by Nack (2000, 2002)elucidating what women perceived to be the "type ofwoman" who gets an STI: 1) being 'damaged goods', 2)enough"[3,4]. Lastly, four items were included to encom-pass discretion of clinic setting and clinic staff, concernregarding community gossip, and fear of repercussionsfrom partner disclosure. It was felt that including itemsregarding discretion and disclosure would build on theconcept of social judgement, potentially allowing a subtledistinction between women who perceived others to bejudgemental and women who were concerned aboutbeing judged, or becoming, even in a hypothetical setting,discredited.Using the discrimination index, four items were flagged,including items 4 and 6 (being able to hide an STI and notknowing an STI was present), item 10 (staff discretion)and item 16 (staff morals). Using p < 0.20 as the cut-pointfor internal consistency, another two items were initiallyflagged, including item 3 (knowing an STI was present)and item 17 (partner disclosure). Internal consistency wasalso re-evaluated within the sub-groups emerging duringexploratory analysis.Principal component factor analysis using all items wasfirst assessed, and the resulting eigenvalues were plotted,revealing three distinct factors arising from the item pool.Iterative factor analysis was done, omitting items one at atime. Item 4 and 17 were the first two deleted, as their fac-tor loadings were low and both had been flagged as hav-ing low discrimination or internal consistency. Item 6 wasthen deleted, due to multiple factor loading, low discrim-ination and consistency. Finally, item 3 was dropped, as itcontinued to load poorly and had low internal consist-ency. Correlation between the final three factors (factors 1and 2: -0.18; factors 1 and 3: 0.23; factors 2 and 3: -0.21)was not high enough to warrant combining the three sub-scales into one larger scale.The remaining 14-items factored together in three finalscales – female-specific moral stigma, social stigma andinternal stigma – shown in Table 3. The four items thatfactored together in the first scale were derived from thework by Nack[3,4], surrounding the 'tribes of woman-hood' and included moral judgement statements typicallyimposed on women as opposed to men, resulting in thename 'female-specific moral stigma'. All the items that fac-tored together in the second scale referred to how the par-ticipants felt others perceived someone with an STI,prompting the name 'social stigma'. Finally, both moraland physical stigma items factored together in the thirdscale; however, in examining the wording of these items,all four were directed at how participants would feel aboutthemselves if they were diagnosed with an STI, thusprompting the name 'internal stigma'.Table 1: Demographics of 126 participants attending a women's program in a community clinic located in a low-income, high risk neighbourhoodTotal(N = 126)GenderFemale 96.8 (122)Transgender 3.2 (4)Median age (IQR) 42 (36, 49)EthnicityWhite 52.4 (66)Aboriginal 39.7 (51)Education<High school 59.5 (75)High school 40.5 (51)EmploymentAny 5.6 (7)None 94.4 (119)Drug UseInjection 39.7 (48)Non-injection 81.8 (99)Alcohol 41.6 (52)Sexual partners (past 6 mos)Regular partner 57.9 (73)Casual partner 20.6 (26)>1 partner 45.6 (57)Commercial Sex Work statusNon- 30.2 (38)Former 26.2 (33)Current 38.1 (48)Attendance at Weekly Women's ProgramNever 23.8 (30)Sometimes/Regularly 76.2 (96)Page 4 of 10(page number not for citation purposes)being promiscuous, 3) being at fault as "women should'know better"' and 4) being at fault for not being "carefulIn Table 3, item-total item correlations and alpha co-effi-cients if deleted for the three emergent factors are shown,BMC Women's Health 2008, 8:21 http://www.biomedcentral.com/1472-6874/8/21along with scale statistics and cronbach's alpha. The alphaco-efficients for each scale were 0.737, 0.705 and 0.729for female-specific moral stigma, social stigma and inter-nal stigma, respectively. It is possible that two of the items(items #9 and #10) addressing women's perceptions ofstaff and clinic discretion may be measuring characteris-tics of this particular clinic, rather than of women's gen-eral perceptions, and may not be warranted in a stigmascale for wider use. Thus, an alternative analysis was runeliminating these items. The results were identical, withthe exception of the social stigma scale, which now con-sisted of only four items and had a Cronbach's alpha scoreof 0.647.Assessing each item for response and non-response char-acteristics, there was no large variation found; however,overall injection drug users and current sex workers wereless likely to complete the stigma section of the question-naire. As the stigma-related items were positioned at theexcluded due to incomplete answers in the stigma sectionof the structured interview. However, subsequent to thefactor analysis and determination that the three scales didnot correlate sufficiently to combine into one large scale,women who answered at least all of the stigma items rep-resented in any one scale were included in the final calcu-lation of Cronbach's alpha-scores shown in Table 3.In Table 4, the associations of demographic and behav-ioural characteristics with the three stigma scales areshown. Higher female-specific moral stigma scores weremarginally associated with being over 30 years of age,identifying as Aboriginal, Inuit or Métis and not reportingany use of injection drugs in the past six months. Amongactive CSW, higher social stigma scores were associatedwith having been working in the sex trade for less than 10years, while among all the women, there was a marginalassociation of higher social stigma among women whodid not report use of any non-injection drugs in the pastTable 2: Items developed for STI-related stigma scale, measured on a 10-point scale (1 = strongly disagree, 10 = strongly agree)If you had an STI, you would feel: Mean (std) Median (IQR)1. Dirty 7.11 (3.42) 8 (5, 10)2. Violated 7.58 (3.24) 10 (5.5, 10)Someone with an STI:3. Would know it 5.72 (3.71) 5.5 (1, 10)4. Could hide it 7.13 (3.31) 9 (5.5, 10)5. Is damaged goods 3.25 (3.10) 1 (1, 5.5)6. May not know 8.04 (2.99) 10 (6, 10)If you had an STI, you would feel:7. Guilty 5.46 (3.88) 5.5 (1, 10)8. Embarrassed 6.25 (3.86) 8 (1, 10)At the clinic:9. Everyone would know if you were being tested for an STI 2.43 (2.82) 1 (1, 2)10. Staff are discreet 9.43 (1.62) 10 (10, 10)(Only) women .......... get STIs:11. Who have slept around 2.94 (3.09) 1 (1, 5.5)12. Should know better than 4.69 (3.73) 3 (1, 9)13. Who aren't careful 4.19 (3.58) 3 (1, 7)If someone has an STI:14. People will think she is a bad person 4.27 (3.28) 3.5 (1, 6)15. People will gossip 5.31 (3.41) 5.5 (1, 8)16. Health workers will think poorly of her 2.86 (2.74) 1 (1, 5.5)If you had an STI:17. Your partner would be angry with you7.28 (3.47) 10 (5, 10)If someone has an STI:18. People will think she is stupid3.58 (3.04) 1.75 (1, 5.5)Page 5 of 10(page number not for citation purposes)end of the 27-item structured interview, a few women didnot complete all of the questions and nine women weresix months. Higher internal stigma scores were associatedwith not having completed high school and identifying asBMC Women's Health 2008, 8:21 http://www.biomedcentral.com/1472-6874/8/21Aboriginal, Inuit or Métis ethnicity. In a multivariable lin-ear regression model, Aboriginal ethnicity (β = -1.63; p =0.002) and less than a high school education (β = -1.27; p= 0.010) remained significantly associated with internalstigma score, adjusting for age, commercial sex work andinjection drug use (N = 110, R-squared = 0.180). Therewere no significant associations in multivariable modelsfor either the female-specific moral stigma or social stigmascales.Discussion and ConclusionWhile qualitative studies can help us develop a deeperunderstanding of women's experiences of stigma; quanti-tative measures can be useful for comparing the magni-tude and prevalence of stigma-related experiences acrossor within populations. In this paper, three distinct STI-related stigma scales emerged from a pool of itemsaddressing STI issues including physical stigma, moralstigma, judgment by community and by healthcare work-ers in particular, as well as female-specific sexual categori-zations of 'good' and 'bad' girls. The resulting female-specific moral stigma scale was not found to be signifi-cantly different among participants; however, there weremarginally higher scores among Aboriginal women, IDUsand women with lower education levels. Social stigmawas found to be higher among more recent initiates intothose with lower education as well as among womenreporting Aboriginal, Inuit or Métis ethnicity.The perception of any stigma will invariably be affected byboth the previous experiences of an individual as well astheir current situation. Nack (2002) found that womenwho had higher perceptions of stigma prior to their ownexperiences with STIs (being tested and/or testing posi-tive) and those women who identified as 'good' girls weremore affected by the notion of being identified as a 'badgirl' [3]. Others who had previously received educationabout STIs as well as those who felt they already belongedin the 'bad' girl category were less concerned with thesefemale-specific moral categories and social forms ofstigma. In our study, while female-specific moral andsocial stigma did not vary significantly by demographic orbehavioural characteristics, those with higher female-spe-cific moral stigma scores were less likely to be active injec-tion drug users.In contrast, those women in our study with higher socialstigma scores were less likely to be active non-injectiondrug users, and, among active sex workers, were morelikely to have been working for less than 10 years. Thismay reflect an 'accommodating' phenomenon wherebywomen who already view themselves as 'bad' girls (i.e.Table 3: Item-total item correlation and alpha-coefficients if deleted and scale statistics for three factors identified in factor analysisItem Factor 1:Female-specific Moral StigmaFactor 2:Social StigmaFactor 3:Internal stigmar(i-t) α(d) r(i-t) α(d) r(i-t) α(d)1. Dirty 0.547 0.6522. Violated 0.457 0.7035. Damaged goods 0.459 0.7197. Guilty 0.473 0.6928. Embarrassed 0.591 0.6239. Clinic discretion* 0.432 0.66710. Staff discretion* 0.413 0.67311. Sleeps around 0.598 0.63212. Should know better 0.563 0.65813. Isn't careful 0.478 0.69714. Bad person 0.398 0.67615. Community gossip 0.443 0.66416. Staff morals 0.519 0.63918. Stupid 0.404 0.675N 120 116 122Alpha Co-efficient 0.737 0.705 0.729Mean 3.77 5.16 6.59SD 2.52 1.81 2.68*As these items may refer to perceptions of a specific clinic, an alternative Cronbach's alpha score for the social stigma scale, eliminating these two items would be 0.647; other factors were not affected by removal of these items. Note: item 10 score was reversed for factor analysis.Page 6 of 10(page number not for citation purposes)the sex trade, while internal stigma was higher among active drug users, highly active sex workers) are less con-cerned with societal views and stigma. Societal norms,BMC Women's Health 2008, 8:21 http://www.biomedcentral.com/1472-6874/8/21Page 7 of 10(page number not for citation purposes)Table 4: Characteristics associated with standardized scales for female-specific moral stigma, social stigma and internal stigma, with higher scores indicating higher stigmaFemale-specific Moral Stigma Social Stigma Internal StigmaN Median p-value Median p-value Median p-valueDemographicsAge > 30≤ 30111103.252.120.085† 4.003.500.536 5.376.750.813High School (HS)No HS50733.373.250.928 3.374.000.464 5.507.500.008*Aboriginial, Inuit, MetisOther49744.373.250.072 † 3.504.120.340 7.755.500.001*Substance UseInjection Drug useNo IDU45733.003.620.076 † 3.374.000.584 6.507.250.960Non-Injection Drug useNo NIDU96223.254.750.216 3.254.560.061 † 7.195.500.346High Alcohol(> 6 drinks, >1 a week)Low Alcohol111093.624.000.916 4.753.500.743 7.258.870.150Sexual BehaviourAny partnerNo partner96273.253.250.435 3.754.000.628 6.695.620.643Regular partnerNo regular partner72243.253.250.570 4.253.250.164 7.375.500.292Casual partnerNo casual partner25713.253.250.418 3.254.000.773 6.006.620.880> 1 partner (non-client)≤ 1 partner25693.373.250.185 4.004.000.614 7.126.250.702CSW – NeverFormerCurrent3833463.373.003.250.816 4.313.253.500.178 5.567.376.690.841Among active CSW:Years working≥ 10 years<10 years29193.003.250.864 3.255.000.007* 6.626.750.891Clients (past 6 mos)≥ 50 clients< 50 clients33132.253.250.592 3.254.000.427 5.507.500.611STI CommunicationWith Partner – Yes 91 3.25 0.275 3.50 0.467 6.50 0.485No 31 4.37 4.00 6.62With Friend – Yes 74 3.25 0.926 3.37 0.594 6.00 0.497No 48 3.37 4.37 7.00With HC worker – Yes 110 3.25 0.640 4.00 0.705 6.66 0.966No 12 2.50 3.25 6.12*p < 0.05; † p < 0.10BMC Women's Health 2008, 8:21 http://www.biomedcentral.com/1472-6874/8/21which are intrinsically tied to the social constructions ofstigma, thus play a powerful role in self-identity and cate-gorization into these predefined groups. The impact iseven greater among marginalised communities, who arealready separated from 'mainstream' society, generallydue to a combination of factors including poverty, ethnic-ity, or other non-conforming behaviours (substance use,sex work). Within a marginalised community, the conceptof female-specific moral stigma may serve to deepen thedivide between women who are identified or self-identifyas 'bad' girls, and those who self-identify as 'good' girlsbut who feel potentially labelled incorrectly because oftheir affiliation with the larger community. This mayengender an intensified stigma between these groups inan effort to explicitly remove the 'community' level stigmafrom individual 'good' girls within the community.High levels of female-specific moral stigma and internalstigma were found among Aboriginal women in ourstudy. Given that minority women have historically beensingled out as 'vectors and vessels' of STI transmission, thehigher STI-stigma scores among Aboriginal women mayrepresent a compounding of cultural stigma felt by thesewomen [24-26]. And, while public health and researchefforts (e.g., targeted testing and treatment of Aboriginalwomen in the community; numerous studies that reportvery high rates of HIV and STIs in this population) aremeant to assist this population in accessing testing, it ispossible that Aboriginal women in our study feel 'cultur-ally targeted' – resulting in high levels of stigma and STI-stigma in particular.Aside from this, there are other cultural factors which maybe influencing the way in which the stigma scale is inter-preted. The traditional meanings of female sexual moral-ity in Aboriginal cultures may shape the way these specificstigma items, most which reflect a Western definition offeminine morality rooted in Christianity, are felt. Forexample, in many Aboriginal cultures, sex and sexualityare taught as being a gift, although a powerful one whichneeds to be respected[27]. The central idea of balance andthe holistic views of health are also important and theo-retically cultivate a healthy view of sexuality, as opposedto Western views which tend to stress the associationbetween sexuality and sin[27]. In addition, in matrilinealclans female gender did not reflect lower status, and manyancient stories venerated strong, powerful female fig-ures[28]. Despite these traditional meanings, the rise ofresidential schools which removed Aboriginal childrenfrom their families in order to 'educate' them in Westernand Christian ways, introduced, or forced, these ways ofthinking onto their existing cultures. This, coupled withWestern perceptions of Aboriginal women as either "theence the present interpretation of stigma items. Neverthe-less, the increased internal stigma seen in this studyamong Aboriginal women remained in a regressionmodel controlling for age, education, injection drug useand sex work status indicating that a culturally-specificinfluence was present.Unfortunately, it is difficult to tease out the historicallygendered and socially moral underpinnings of sexualityfrom sexual and sexual health education. We may be moreaware today of the double-standards that exist in society'sview of how men and women should behave sexually;however, there remains an ingrained social double-stand-ard which can, consciously or subconsciously, alter one'sperceptions even among those who do not prescribe tothese views. An example of this was reported by Nack(2000), where women diagnosed with an STI describedtheir diagnosis as either 'deserved' or 'undeserved' basedon their perceptions of what society viewed as acceptablebehaviour and how this fit in with their own past histo-ries[4]. In the present study, the items making up thefemale-specific moral stigma scale included statementswith a moral tone placing the responsibility, or insinuat-ing the fault, of STIs on women. Although the responseswere skewed towards low stigma levels, a quarter of thewomen had moderate to high overall agreement withthese items.There are several limitations to this study. First, as thestigma scales were developed as a preliminary analysis ofperceptions in this population of women, there was noinclusion of an external tool for validation. In this partic-ular setting, it was felt that including several scales for thispurpose would unduly increase respondent burden. Sec-ond, the sample was a convenience sample of womenalready connected with community services – therefore,we cannot generalize findings to the broader communityof women in this area who may not be accessing servicesin any capacity. In addition, the scale categories (female-specific moral stigma, internal stigma, social stigma) thatemerged from this exploratory analysis should be tested ina larger population using an hypothesis driven factoranalysis (i.e. comparing the pre-supposed categories tothe data). Thus, the present scales, while providing valua-ble insight, should undergo further development and test-ing to assess its usefulness on a larger scale. This is alsotrue as the study sample size presents a limitation withrespect to the ability to detect differences of less than 2.0units in the scale scores. It is difficult to say whether themarginal results seen with differences of only 1.0 unitwould become significant in a larger sample; however, thepotential implications of these differences are presentedand discussed as theories requiring further evaluation.Page 8 of 10(page number not for citation purposes)glorified 'princess' or the denigrated 'squaw"'[28], make itdifficult to predict how this entangled history may influ-BMC Women's Health 2008, 8:21 http://www.biomedcentral.com/1472-6874/8/21With few significant differences in stigma scores amongsub-groups of women, the question of the practical use ofsuch scales arises. Comparisons beyond demographicsand behaviors, such as contact with health care providers,access of testing and treatment programs would provide abetter picture of how these stigma measures may influ-ence sexual health. Further, although the findings pre-sented here lacked sufficient power to detect smallerdifferences, the suggested increased levels of female-spe-cific moral stigma, social stigma and internal stigmaamong sub-groups of women is theoretically plausibleand should be further evaluated in a larger population. Asmentioned above, the presence of cultural differencesindicates the necessary evaluation of the potentially differ-ent meanings and interpretations of STI-stigma, femalesexual morals, and social perceptions held by differentcultures. Importantly, the interpretations given here canonly be seen as suppositions, and are limited by the lackof a priori investigation into these cultural influences andmeanings.A final limitation is that the current study only sampledwomen. While we developed our female-specific itemsfrom an extensive literature outlining the unique sexualcategorization of women, we did not directly compare theendorsement of the items among women to similar itemsamong men. Of note, STIs and barriers to care, includingSTI-related stigma, are just as important among men, andwhile the measure may be very different, scales that assessthese experiences among men should also be developed.The study was nevertheless able to sample a diverse groupof women from a high-risk neighbourhood. In addition,while the sample was recruited from a clinic site, theevening program serves as a drop in for many services,including dinner, clothing and other aspects not directlyrelated to seeing a health care professional. Despite theneutral setting of the evening, it is a clinic and, even withinthe context of a safe evening for women, perceptions ofSTI-related stigma and moral categories of 'bad' versus'good' girls were recorded.As public health practitioners continue to work to preventand reduce the impact of STIs in highly marginalised pop-ulations, it will be important to consider the roles of STI-related stigma. Prevention or screening programs that are'tailored' (rather than 'targeted') for particular high-riskgroups may be less likely to add to perceptions of discrim-ination or stigma. In addition, in highly marginalisedcommunities, where the population at risk represents abroad group of women, the preconceived notions of 'badgirl' membership may supersede participation in other-wise beneficial programs (e.g., a more general women'sment that is less desirable for another group, such asactive sex workers). Thus, in the creation of new sexualhealth interventions and prevention messages, particularattention should be paid to the language used and thepotentially subtle ways in which programs may isolaterather than integrate members of the community. Forexample, messages that highlight good sexual health prac-tices and the benefits of treatment, rather than those thatadvertise the consequences of bad behaviour (and therebycondemn those that practice them) could help encourageindividuals to seek sexual health care instead of avoidingtesting for fear of a potentially stigmatizing label. In addi-tion, efforts to assess the importance of stigma as a barrierto sexual health care should attempt to incorporate thesebroader aspects of the stigma experience. Sexual stigma isa deeply rooted construct in our society; however, thisshould not be seen as an insurmountable barrier to creat-ing programs and policies that work to change the damag-ing and disproportionate impact of STI-related stigma onwomen.Competing interestsDrs. Rusch, Burgess and Stancer were involved with theweekly women's clinic program. Drs. Burgess and Stancerwork at the clinic, and provide medical care during theevening program. Dr. Rusch volunteered, helping to co-ordinate activities. The doctors and clinic staff involvedwith the women's program did not actively participate inrecruitment or data collection and women were informedthat participation or refusal of participation in this studywould in no way affect their normal standard of care at theclinic, nor their regular participation in the woman's pro-gram. This research was carried out as part of Dr. Rusch'sgraduate thesis work. The other authors have no compet-ing interests to declare.Authors' contributionsMLAR, JAS, DMP and MWT were involved in the conecp-tualization of the study. All authors were involved in thedevelopment of the survey items. MLAR was responsiblefor the analysis and writing of the manuscript. All authorscontributed to the editing and gave final approval on themanuscript.AcknowledgementsFunding support was provided through the Michael Smith Foundation for Health Research and through the Canadian Institutes for Health Research – Partnerships for Community Health Research program. Authors would also like to acknowledge the help of the clinic staff, and the participation and support of the women.References1. Goffman E: Stigma: Notes on the Management of Spoiled Identity NewYork: Simon & Schuster Inc; 1963. 2. Parker R, Aggleton P: HIV and AIDS-related stigma and dis-Page 9 of 10(page number not for citation purposes)program may draw participation from a certain group ofwomen, such as non-sex workers, creating an environ-crimination: a conceptual framework and implications foraction.  Social Science and Medicine 2003, 57:13-24.Publish with BioMed Central   and  every scientist can read your work free of charge"BioMed Central will be the most significant development for disseminating the results of biomedical research in our lifetime."Sir Paul Nurse, Cancer Research UKYour research papers will be:available free of charge to the entire biomedical communitypeer reviewed and published immediately upon acceptancecited in PubMed and archived on PubMed Central BMC Women's Health 2008, 8:21 http://www.biomedcentral.com/1472-6874/8/213. Nack A: Bad Girls and Fallen Women: Chronic STD Diag-noses as Gateways to Tribal Stigma.  Symbolic Interaction 2002,25:463-485.4. Nack A: Damaged goods: women managing the stigma ofSTDs.  Deviant Behavior: An Interdisciplinary Journal 2000, 21:95-121.5. Campbell CA: Male gender roles and sexuality: Implicationsfor women's AIDS risk and prevention.  Social Science & Medicine1995, 41:197-210.6. 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Tyndall M, Patrick D, Spittal P, Li K, O'Shaughnessy MV, SchechterMT: Risky sexual behaviours among injection drug users withhigh HIV prevalence: implications for STD control.  SexuallyTransmitted Infections 2002, 78:i170-i175.22. Rusch M, Shoveller J, Burgess S, Stancer K, Patrick D, Tyndall M:Demographics, Sexual Health Care and Uptake of Screeningfor Sexually Transmitted Infections (STIs) among Attendeesof a weekly Women-only Community Clinic Program.  Cana-dian Journal of Public Health 2008, 99:257-261.23. Lichtenstein B, Bachmann LH: Staff affirmations and client criti-cisms: staff and client perceptions of quality of care at sexu-ally transmitted disease clinics.  Sex Transm Dis 2005,32:281-285.24. Davidson R: Venereal Disease, Sexual Morality, and Public25. Luker K: Sex, Social Hygiene, and the State: The Double-edged Sword of Social Reform.  Theory and Society 1998,27:601-634.26. Mahood L: The Magdalene's Friend: Prostitution and SocialControl in Glasgow, 1869–1890.  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