Bronwen Lichtenstein

Public tolerance, private pain: Stigma and sexually transmitted infections in the American Deep South

This pilot telephone survey sought to identify social barriers to treating sexually transmitted infections (STIs) in a socially conservative state (Alabama, USA). The sample consisted of 250 household residents aged 19–50 years, mostly African‐American and White, who were drawn from the general population. The participants reported that infected persons, per se, should not be stigmatized. However, almost half of respondents stated that they would seek revenge against a partner who infected them. Feelings of embarrassment negatively affected willingness to seek health care; almost half of the respondents stated that, if infected, they would delay treatment or not seek treatment at all. Differences in responses emerged in relation to ethnicity and religiosity, with African‐Americans and regular churchgoers being more likely than others to say they would delay or refuse treatment because of embarrassment. Gender differences also emerged: respondents reported that women would be more stigmatized than men if they were infected, even though men should be held responsible for spreading STIs. These findings suggest that stigma may be a compelling barrier to STI control in the American Deep South, and that ethnicity, gender and religiosity play an important role in attitudes toward treatment.

Caught at the Clinic African American Men, Stigma, and STI Treatment in the Deep South

The literature on gender and health typically addresses behavioral patterns when discussing men’s attitudes to health. Few of these studies explore men’s anxieties or presentations of self in relation to health problems, particularly for stigmatizing conditions such as sexually transmitted infections (STIs). Through direct observation and focus group interviews of health workers, clients, and students, this study explores African American men’s attitudes toward attending STI clinics in the Deep South. The men’s concerns about STI clinics center on realistic health or stigma-related concerns. Using a gender-relational analysis, three main sources of fear are identified in relation to attending the clinics: Gender anxiety (attacks on masculinity), social anxiety (damage to social reputation through stigma), and racial anxiety (AIDS as genocide). These fears present a barrier to STI care for African American men.

Drugs, Incarceration, and HIV/AIDS Among African American Men: A Critical Literature Review and Call to Action

Incarceration and HIV/AIDS disproportionately affect African American men compared to the U.S. population as a whole. Disparities in relation to crime and HIV/AIDS for Black men suggest that these phenomena have elements in common, particularly given the mediating role of illicit drug use or drug activities in both cases. A socioecological exploration of how and why these twin epidemics intersect (and the role of drug-related activities as mediating variables) is needed illicit drug use or to address the impact of these epidemics on the health and well-being of communities of color. This article critically reviews relevant articles, research reports, and official statistics, as well as conceptual frames of reference for information on the socioecological synergies between crime, drugs, and HIV/AIDS. The article recommends five calls for action for policies to mitigate the cumulative negative effects of these epidemics and for interventions to enhance the life chances of at-risk Black men.

Staff affirmations and client criticisms: staff and client perceptions of quality of care at sexually transmitted disease clinics.

Objectives: Public health sexually transmitted disease (STD) clinics play a central role in STD control efforts. This study addressed the perceived quality of client services at two STD clinics in Alabama. Goal: The goal of this study was to evaluate and develop tools for assessment of client satisfaction at STD clinics. Study: Four focus groups of staff (N = 16) and clients (N = 15) at the clinics were conducted between June and November 2003. Results: Staff and client assessments of respect, privacy protections, and friendliness at the clinics differed in substantial ways. Clients were concerned with visibility, being stigmatized or disrespected, and about a breach of confidentiality. Concerns about being stigmatized focused mainly on nonclinical staff. The staff did not perceive these concerns to be warranted. Quality of medical care was rated high by both groups. Conclusion: Staff–client interactions are an important element of STD care, and “front desk” actions set the tone at public STD clinics. Nonclinicians should receive training to improve body language and other behaviors to alleviate the stigma concerns of clients who are anxious, fearful, and sometimes distrustful of the health system.

Old Ways, New Impacts: Race, Residential Patterns, and the Home Foreclosure Crisis in the American South

The full impact of the U.S. housing crisis is still unfolding, with growing evidence that low-income groups and racial minorities have suffered the worst effects of foreclosure. This article addresses the spatial distribution of mortgage foreclosure in a Southern county that is residentially segregated in terms of race and wealth. We collected data manually from legal notices and public access property records between 2008 and 2011 and then used three basic approaches for analysis: visual identification, hot spot detection, and polygon-based spatial autocorrelation. We found that foreclosure activity followed the race–wealth divide by being heavily concentrated in older black neighborhoods, clustered in some white exurban developments, and largely absent from wealthy white areas. The results indicate that blacks and whites experience different patterns of foreclosure and that the housing crisis exacerbates geographical patterns of residential segregation.

Older African American Women and Barriers to Reporting Domestic Violence to Law Enforcement in the Rural Deep South

Victims of domestic violence are legally entitled to police protection, but multiple barriers exist in contacting law enforcement. In this study, we used Federal Bureau of Investigation data, key informant interviews, and focus groups to examine barriers to reporting domestic violence among older African American women in the rural Deep South. Three primary barriers were identified: gender roles, age dependency, and mistrust of law enforcement. The main finding was that reports of domestic violence were deterred by fears of being stigmatized by church, family, and community. The one compelling and feasible resolution is for law enforcement to take a leadership role in educating clergy and other community leaders about domestic violence as a crime against older women.

Illicit Drug Use and the Social Context of HIV/AIDS in Alabama's Black Belt.

CONTEXT The rural Black Belt of Alabama is among the poorest areas of the nation. Poverty, lack of health infrastructure, and health disparities involving HIV/AIDS and other diseases reflect the lower life expectancy of people in the region. The Black Belt region has the highest HIV rates in rural America. PURPOSE Using Alabama as a case example, the paper describes the role of illicit drug use in pathways to HIV transmission in the Black Belt and examines the relationship between drug use and social context with respect to HIV/AIDS disparities in the region. METHODS Published research and national and state data were triangulated for information on interactions between illicit drug use, social context, and HIV/AIDS. FINDINGS Illicit drug use is implicated in HIV risk in Alabamas Black Belt, but less so than in other parts of the nation. Published research suggests that the impetus for drug use involves status seeking in the context of heterosexual contact and economic disparities. HIV transmission in Alabamas Black Belt speaks to the tyranny of small places; that is, the risk of HIV/AIDS occurs in geographically bounded areas with a history of racial homogeneity, historically high rates of sexually transmitted infections, and clustered sexual networks in this isolated region. CONCLUSIONS Social context is an important correlate of HIV risk in the Black Belt. The role of drug use in HIV risk is secondary to social-contextual factors involving rural isolation, racial homogeneity, and the racial disparities of the region.

Health Inequity The Plight of Uninsured Children in a Rural Alabama County and the Plan to Cure It

Many children in the United States do not have access to health insurance. Providing health insurance for children has been particularly challenging in rural America. This article describes and evaluates a local plan to provide access to health care for school children in a rural Alabama county. A triangulated methodology (personal interviews, ad hoc survey focus groups, US census and health fair data) was used in the evaluation. Gains were made in enrolling children despite some limitations, especially in rural outreach. The most successful aspect of the program was a partnership between local leaders, health providers, and educators to provide impetus for a coordinated plan. The stability of the program is uncertain because of diminishing resources and the negative effects of economic recession.

Notify your partners--it's the law: HIV providers and mandatory disclosure.

HIV care providers in the United States must counsel clients about disclosure to sexual partners and report anyone who is suspected of noncompliance. This study compared provider attitudes and practices in relation to counseling clients about mandatory disclosure in North Carolina and Alabama, the 2 states with similar HIV epidemiology but different laws for HIV control. Personal interviews were conducted with 20 providers in each state (n = 40). The results were analyzed in a qualitative, cross-comparison method to identify patterns of convergence or difference. Providers in both states believed that clients often failed to notify sexual partners and were secretive if questioned about disclosure. Differences in counseling styles and procedures for each state were noteworthy. Compared to Alabama, North Carolina had harsher penalties for nondisclosure, stricter and more standardized procedures for counseling, and providers expressed greater support for HIV criminalization. Although most North Carolina providers viewed the stricter standards as beneficial for HIV care and control, Alabama providers were likely to view such standards as a barrier to patient care. These results indicated a direct relation between state HIV law, provider attitudes, and counseling procedures for mandatory disclosure.

Women foreclosed: a gender analysis of housing loss in the US Deep South

Women were a focus of subprime lending during the housing boom, increasing their risk of mortgage foreclosure during the Great Recession of 2007–2011. Following Valentines (2007) call for a feminist geography on interactions between social categories and geographic patterns, this article investigates housing loss among women foreclosees in a southern US county with a history of residential segregation. We collected foreclosure data manually from legal notices and municipal property records, compared foreclosures with home mortgage rates for couples, sole men, and sole women homeowners between 2008 and 2012, and then combined the information with census tract data for GIS analysis. Women homeowners typically foreclosed within five years of buying modestly priced homes, which were mostly concentrated in African-American neighborhoods close to the county seat. Women were significantly more likely to foreclose than other homebuyers, a new twist on gender and race inequalities in US homeownership that increased during a recessionary economy. This foreclosure activity followed historical patterns of residential segregation, with privilege and disadvantage in juxtaposition with social hierarchies of race and class. We conclude that housing loss in the US South is complicated by racial history and the subordinate status of ‘women alone’ in the residential mortgage market.