Social Theory and Public Health

Introduction

Aboriginal and Torres Strait Islander people (hereafter referred to as Indigenous Australians) have substantially higher notification rates of sexually transmitted infections (STIs), such as gonorrhoea, infectious syphilis and chlamydia compared to non-Indigenous Australians (1–9). In 2017, notification rates among Indigenous Australians compared to non-Indigenous Australians were six times greater for gonorrhoea, six times greater for infectious syphilis and 2.8 times greater for chlamydia (2). These STIs can be transmitted through sexual contact, blood contact, oral contact, and through vaginal childbirth (1). Although these STIs are easily diagnosed and treated, infections can go undetected and cause serious complications (1). Gonorrhoea and chlamydia can lead to pelvic inflammatory disease and infertility, whereas syphilis can damage the cardiovascular and nervous system (1, 5). Indigenous Australians also face a range of barriers and challenges which contribute to the significantly high rates of STIs (1, 4, 5, 8). This essay draws upon three sociological theories to better understand how Indigenous Australians have substantially higher rates of STIs. This essay will first discuss how Marxism can advance our understanding of how Indigenous Australians face a greater risk of contracting STIs. The essay then discusses how the theoretical framework of Intersectionality can be used to better understand how Indigenous Australian women experience converging forms of oppression that increase their risk of STIs. Lastly, this essay explores how Erving Goffman’s theoretical insights can enhance our understanding of how the stigma attached to STIs prevents Indigenous Australians from accessing STI testing. Based on these claims, this essay argues that health interventions addressing STIs among Indigenous Australians need to take a multifaceted and holistic approach in order to achieve better health outcomes.

Theory and STIs

Marxism can advance our understanding of how Indigenous Australians, who experience significant economic inequality and are overrepresented in the lower social classes, face a greater risk to contracting STIs. Marxism is a conflict theory developed by Karl Marx and Friedrich Engels, which focuses on the social stratification that occurs in capitalist societies (10–14). In their seminal work, Manifesto of the Community Party, published in 1848, Marx and Engels describe how capitalism produces inegalitarian social structures due to the conflict between the bourgeoisie (the ruling class) and the proletariat (the working class) (10, 14, 15). Marxist discourse illustrates how economic inequality can contribute to poor health outcomes for those in the lowest social classes (10, 12–14, 16). Engels used the term ‘social murder’ to describe the poor health status of those in the lower social classes (10) and this analysis can be applied to better understanding the health inequalities among Indigenous Australians. Empirical evidence indicates that there is an overrepresentation of Indigenous Australians in the lower socio-economic status (SES) groups (17–19). On average, Indigenous Australians have lower levels of education, higher unemployment rates and lower household incomes than non-Indigenous Australians (17–19). All of these factors contribute to higher rates of STIs among Indigenous Australians (9, 20, 21). One particular study conducted in Northern Queensland, highlighted the increased prevalence of STIs among Indigenous Australians living in low SES groups (22). Having a lower income is associated with increased STI risk because individuals have less access to healthcare services and preventative health information (23). Multiple studies have also reported that young Indigenous Australians from remote communities have low engagement with education and as a result were at an increased risk of not practicing safe sex behaviours such as wearing a condom (21, 22). Engels research, which mapped out disease incidence among social classes, emphasises the important relationship between socio-economic structure and peoples experience with illness (10, 16). By adopting a Marxist perspective, public health officials should implement interventions that improve the social standing of Indigenous Australians, such as increasing opportunities for employment and education (1, 5). This will provide Indigenous Australians the opportunity to have better access to healthcare and understand the importance of practicing safe sex, which would reduce the risk of STIs (1, 5).

The theoretical framework of Intersectionality can be used to better understand how Indigenous Australian women experience intersecting axes of oppression, which consequently increases their risk of STIs. Intersectionality was coined by Kimberlé Crenshaw, a legal scholar and critical race theorist in 1989 (24–30). Intersectionality is a theoretical framework for understanding how different social identities, such as gender, race, Indigeneity, class, sex and geography, intersect to create compounding experiences of oppression and privilege (24–31). These interlocking systems of privilege and oppression occur within a context of varying power structures and include different forms of discrimination such as colonialism, sexism, ableism, and racism (24–30). Intersectionality can be used as a lens for understanding how race — which is impacted by a history of colonisation — intersects with gender, sex and geography to make Indigenous Australian women (32–39) vulnerable to STIs. There is extensive literature linking STIs with gender inequalities experienced by Indigenous Australian women (22). Studies have highlighted the power imbalances that exist between Indigenous Australian men and women, with many young women unable to negotiate safe sex practices because of men’s dislike of condoms (22). This places women in a vulnerable state and increases their risk of STIs (22). Studies have also highlighted the gendered violence Indigenous Australian women experience, with one study conducted in the Northern Territory evidencing a strong association between a woman’s experience of assault and being diagnosed with an STI (22). Along with gender inequality, Indigenous Australian women simultaneously face structural barriers to healthcare services, which prevents them from receiving early diagnosis and treatment of STIs (40–42). Barriers that Indigenous Australian women face include racism, particularly from healthcare professionals who can be culturally insensitive (40, 41). They also face practical barriers such as distance to healthcare services in rural and remote communities, which makes it challenging for women to receive appropriate care for STIs and increases their risk of further complications (40–42). Intersecting axes of race, gender, sex and geography disempowers Indigenous Australian women to a degree not experienced by non-Indigenous Australians and cannot be understood through a single identity analysis (32–39). This suggests that health interventions need to have a multifaceted approach when addressing the high rates of STIs among Indigenous Australian women (1, 5). Interventions need to recognise and address the multiple intersecting identities that can create health inequities for women from historically oppressed groups (26).

Erving Goffman’s theoretical insights can enhance our understanding of how the stigma associated with STIs prevents Indigenous Australians from accessing STI testing. In his seminal work, Stigma: Notes on the Management of Spoiled Identity, published in 1963, Erving Goffman uses symbolic interactionism to provide an insight into the nature of stigma (43). Goffman contends that society classifies and ascribes people by their ‘social identity’, and individuals who possess a stigmatising attribute are restricted from gaining social acceptance (43, 44). According to Goffman, individuals who possess a stigmatised attribute that is concealed — such as an STI — are referred to as the ‘discreditable’ (43–45). Goffman’s writings on the ‘discreditable’ stigma can be used to better understand how the stigma attached to STIs discourages Indigenous Australians from accessing STI testing (4, 44, 46–48). One study conducted in the Northern Territory evidenced that young Indigenous Australians felt that attending STI testing would lead to stigmatisation among their peers, cause damage to their reputation and lead to name calling (49). Literature also indicates that irresponsible reporting of sensitive issues such as STIs can cause Indigenous Australians living in remote communities to experience societal ridicule (50). STIs in young Indigenous Australians is often portrayed as a consequence of child sex abuse and this inaccurate reporting can be stigmatising and further discourage young Indigenous Australians from attending STI screening (50). Studies suggest that the stigma and negative societal perceptions attached to STIs are so strong that even if an individual experiences pain from an STI, they may still abstain from testing and treatment (44). This process of concealing one’s stigmatised attribute to avoid societal ridicule, no matter the risk, is what Goffman refers to as ‘passing’ (43, 44). Goffman’s theory illustrates how individuals who possess an undesirable attribute or trait that deviates from societal norms, such as those with STIs, are negatively judged for having a ‘spoiled identity’ (43, 44). However, health interventions should strive to break down the notion of the ‘spoiled identity’, so that individuals with STIs do not avoid or delay treatment (4). Health interventions need to empower individuals and address social stigma, as this will allow people with STIs to have better health outcomes (1).

Conclusion

Through applying sociological theories to better understand how Indigenous Australians experience high rates of STIs, it becomes evident that health interventions need to take a multifaceted and holistic approach to prevention and care.

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