DR. ADINA NACK: Hi.I'm Dr. Adina Nack.I'm a professor of sociology hereat California Lutheran University.I'm also the author of the book Damaged Goods:Women Living with Incurable Sexually Transmitted Diseases,and today I'm going to talk with youabout practitioner-patient medical interactions.

DR. ADINA NACK [continued]: A lot of times when people think about doctor-patientrelationships, it's in the context of Western medicine,which we have to remember was foundedon a paternalistic system of valuesthat has shaped medical norms.So in that system, doctors are presumedcapable of making decisions about whatis best for patients, and patients play little,if any role, in decision making.Ideally, patients have faith in their doctors' abilities

DR. ADINA NACK [continued]: and it all works out.However, medical practitioners arepeople living in a social world thatincludes biases and prejudices basedon traits like race and ethnicity, sex, age, gender,and socioeconomic status.So when we think about a particular type of disease,and we'll go into sexually transmitted diseasesas the focus for today, it's key to consider

DR. ADINA NACK [continued]: how practitioners' attitudes and values can affect patient care.And we want to try to understand that from the patient'spoint of view.So I'll share with you today whatI learned from an interview study of 43 womenliving with genital herpes and/orHPV, human papillomavirus, infections.

DR. ADINA NACK [continued]: In this talk, I'll share what female patients' descriptionsof medical care can tell us about how STD stigma impactshealth outcomes.I had several research questions going into this study.First, which type of practitioner-patientinteraction style do these women with STDs experience?Then, how can the specific study of women with STDs

DR. ADINA NACK [continued]: expand medical sociology models of practitioner-patientinteraction in general?And finally, what are the public health implicationsfor different styles of practitioner-patientinteraction on the variety of patientswith stigmatizing illnesses?Beyond STDs, we can look at obesity, smoking-relateddiseases, alcohol use-related diseases--things like that come with a social stigma as well.

DR. ADINA NACK [continued]: So women's STD medical encountersoccur at a very stigmatized crossroads of social controland sex-based norms of sexual behavior.So we need to ask ourselves, whatare the stereotypes that people have about women with STDs?And when I talk with students, or whenI interview women and men with STDs, the same words come up.Promiscuous, dirty, irresponsible.

DR. ADINA NACK [continued]: Those are the most common responses.In fact, 75% of the women I interview with STDsuse the word "dirty" to describe how they felt about themselvesafter receiving a diagnosis of genital herpesor genital warts.Exploring this question led me to theorizethat STDs evoke a level of social stigma for womenbecause of how women are seen as having membership in one

DR. ADINA NACK [continued]: of two tribes of femininity.So I theorized there was a small, exclusive tribeof women-- the good girls.You only got membership there by being a virgin or a good wifeand a good mother, and your membership statuswas revoked very quickly.You were demoted to a "bad girl" or fallen woman statusby being labeled a tease, a slut,

DR. ADINA NACK [continued]: and of course by certain professionslike being a sex worker, porn star, and exotic dancer.But in addition, that stigma of bad girlsapplied to girls and women with STDs as well asteen and unwed mothers.Any of those activities or labelscould get you demoted to "bad girl" status.

DR. ADINA NACK [continued]: So as we think about women with STDsgoing into their practitioner interactions,we want to think about that level of stigmathat these women have already experienced before theywalk in the clinic doors.Patients with less social power aregoing to experience high-status practitionersas morally judgmental.It's really easy to feel judged by your doctor or nursepractitioner and feel like you're

DR. ADINA NACK [continued]: under medical surveillance when you're sitting in that clinic.Medical practitioners serve as social control agents,in that they have the implicit authorityto assign moral statuses to different illnesses.So if female patients grow up understanding these twotribes and their connection with STD stigma, when they getdiagnosed with an STD, especially

DR. ADINA NACK [continued]: a medically incurable one, the way that practitionertreats them, that practitioner's demeanor,is going to have a very important impact on howthat female STD patient views not only her health but alsoher moral status-- how other people are going to view herin the world.

DR. ADINA NACK [continued]: So why does it matter?Well, from a public health perspective,practitioner-patient interactions impact healthattitudes and behaviors.It's also a determinant of patient satisfaction,and patient compliance is largely a resultof patient satisfaction.So if we put that together, if you have a disease thatcan be spread by skin-to-skin contactthat's highly contagious and you don't feel good about yourself,

DR. ADINA NACK [continued]: you are much less likely to do what your practitioner saysyou should do.Your practitioner might say, tell your partners,tell your current partners, tell your future partners.If you feel like your practitioner has alreadyjudged you to be dirty, promiscuous, irresponsible,or even stupid, how likely are youto go out there and tell your partner?And then if your practitioner recommends

DR. ADINA NACK [continued]: a particular medical treatment or medication to keep your STDsymptoms under control, again, if you feel judged and demeanedby that practitioner you are much less likely to go forwardwith that treatment plan.Going forward with your treatment plan,especially the act of disclosure of your STD status,is crucial in the case of chronic STDs.

DR. ADINA NACK [continued]: Any incurable, contagious infection,you really need patients to leave that clinic officefeeling like "I'm a good person, I deserve to get well."And you want to feel like you can assume people outthere in the world are not going to judge you as bad for havingthat particular illness.

DR. ADINA NACK [continued]: So when I was studying these women's interactions,I looked at the literature, and therewere two models that were very clearabout patient-practitioner interaction.There was the traditional biomedical style and the newerpatient-centered style, and when I looked at my datathose models described two of the three patterns.For that third pattern, I had to conceptualizea new third practitioner interaction style,

DR. ADINA NACK [continued]: and it came through from my data analysis.I saw that there was what I would call a moral surveillancemodel, a practitioner-patient interaction.And these practitioners-- they surpassedeven the most authoritative model in the literature.You can think about that as exemplifyingFoucault's conceptualization of professionals as social controlagents.

DR. ADINA NACK [continued]: Focus on the surveillance of deviant behavior.These moral surveillance practitioners,they saw themselves like that.They believed in all the sex-based stereotypes.Through their actions, words, tone of voice,interactions with patients, they showedthat they were labeling these STD patients as immoral,and they saw them having earned their infections.

DR. ADINA NACK [continued]: Now, as a patient, those patientssaid, I see them as judgmental and condemning.They felt like they were being judged and condemnedby their medical practitioners, and the women in my studydescribed about 24% of their practitioner interactionsas fitting the style of moral surveillance.I want to give you a few of their quotesto kind of paint a really clear picture of whatthey were seeing.

DR. ADINA NACK [continued]: The first one came from Diana, and I should point outI use pseudonyms, I use fake names,to protect the identity of all the women in my papersin my book.Diana was a 45-year-old, single, African-American professional,and in her case and other cases that practitionerdirectly attacked the moral character and sexual conductof her as a patient.And I would say they revealed that they believed,

DR. ADINA NACK [continued]: in her case, in some race-based sexual stereotypes,if we think about the socio-historicalconceptualization of African-American womenas sexual objects.So Diana told me, quote, "At first I didn't knowexactly what was wrong with me.I just knew that I was having some pain in my vagina.So I went to the gynecologist, and he said, 'Well,

DR. ADINA NACK [continued]: you know, it looks like you've had some really rough sex.Did you have rough sex?' And I said, well,I didn't think it was rough.It was passionate.I thought I was going to die, literally die.And I think that it's probably beenone of the most devastating moments of my life ever."So Diana was telling me that she felt his accusation about her

DR. ADINA NACK [continued]: having some type of deviant rough sexwas implying that she therefore deservedto be infected with herpes.And for Diana in particular to saythis was the most devastating moment of her life ever,this is a woman who had already survived a heart transplant.So if you talk about the level of ability for a practitionerto impact that patient's sense of self and senseof health, huge-- just his words, his tone, his look.

DR. ADINA NACK [continued]: Another example of the moral surveillance practitionercame from Chris.Now she was a 40-year-old, divorced, white professionalat the time I interviewed her, and she represents a variationwhere the doctor was displaying kind of general disgustand revulsion towards his patients--in particular the women who had herpes and HPVthat he felt deserved it.So Chris talks to me and she says this,

DR. ADINA NACK [continued]: "He just sort of looked at my crotch and said,'Yep, that's herpes,' and sort of slammed my knees backtogether."Now, if you haven't been up in stirrups,you have to understand that your knees kind of swivel.So literally he smacked the sides of her legsafter saying, "yep, that's herpes,"and I asked her as the interviewer-- I said,how did you feel at that point in time?And she says, "Shitty.

DR. ADINA NACK [continued]: Yeah.I felt like, let's close this back up, like a car.Slam the hood down.I don't want to see any more of this one."So she felt like her doctor had viewed heras some type of messed up car enginethat he did not want to see anymore.Talk about dehumanizing.Moral surveillance practitioners are pretty distasteful whenyou hear them described.

DR. ADINA NACK [continued]: But the second type that has been well-documented literatureare biomedical style practitioners,and they have some big problems as well.So you know you're dealing with a biomedical style practitionerwhen they treat the disease and not the patient.So they try to practice medicine as neutral and scientific.They are perceived by their patientsas being very matter-of-fact and aloof,

DR. ADINA NACK [continued]: and the woman I interviewed described about 42%of their practitioner interactionsas fitting this style.So let's start off with Summer.She was a 20-year-old, working-class Native-American,and her case really is emblematic of practitionerswho are reductionist.They focus on the infected body part,and they totally separate it from the social and emotionalhuman being that's there in front of them.

DR. ADINA NACK [continued]: So this is Summer talking."My doctor walks in and she's telling meI have a tonsil infection or something.'Oh, I think you have genital warts.' And I'm like,'OK, so what's that?Are you going to give me some pills?' And she explains to methat it's not curable.And then she gets me this mirror,and she's like showing me what they look like."And I ask her, "She didn't ask you if you wanted to see them?"

DR. ADINA NACK [continued]: So then Summer replies, "Well, I wanted to know,but it didn't feel very good.Because the moment I saw them I knew that I'd seen them before,and I remembered exactly who I'd seen them on.And then she just walked out of the roomand left me crying and thinking that I have this disease thatwill never go away."

DR. ADINA NACK [continued]: And when Summer described that to me,I realized that it was not just thatforcing the mirror and the viewing of the wartsthat had upset her and seeing her bodyas this kind of deviant and stigmatizedand, at that point in her mind, disgusting body parts.But she also realized that her boyfriend had lied to her.

DR. ADINA NACK [continued]: Because she had seen genital warts on him,and he had told her he had an allergic reactionto laundry soap and that he didn'tneed to wear a condom because it wasn't actually an STD.So that practitioner, by being biomedical and beingso distant and scientific, completely missedthe emotional devastation that shewas leaving that patient in, and she walks out of the room.

DR. ADINA NACK [continued]: So now I want to tell you about Rhonda.At the time I interviewed her, shewas a 23-year-old, working-class Latina.And in other cases of biomedical practitioners,it was that they were extremely efficient and impersonal,leaving patients feeling confusedand too intimidated to ask for clarification.So Rhonda tells me, "It was very sterilethroughout the entire experience.

DR. ADINA NACK [continued]: I went in and the doctor looked at me, and she said,'You have herpes.'"And I as the interviewer ask her,"When you were still in the stirrups?" "Yeah.She just gave me a pamphlet and told methat I could not have unprotected sex.And I asked about oral sex, and she said,'No, because even when you don't have an outbreak,you can still transmit it.' She made it seem like I could neverreceive oral sex again, and it felt horrible."

DR. ADINA NACK [continued]: So now we're going to leave behind the moral surveillancepractitioners and the biomedical practitionersand focus on my personal favorite-- and probably yours,too-- the patient-centered style practitioners.These are the people, the doctors and nursepractitioners, who treat that patient as a whole person,not just an infected body part.And they are especially sensitiveto the emotional implications of STDs

DR. ADINA NACK [continued]: on a patient's sense of herself andon her interpersonal relationships.Not surprising.These are the ones that were perceived by their patientsas being most compassionate, and in my researchthe women described about 34% of their practitioner interactionsas fitting this style.So we'll start with Lily.She was a 40-year-old, white graduate student,and she described her doctor as showing a lot of compassion.

DR. ADINA NACK [continued]: She told me, "My doctor gained my confidence,was really respectful to me.The nurses that worked there called you by your first name.It was warm, but there was also a lot of privacy.I'm not afraid of asking questions,and I made him explain everything to me.My doctor preferred that I was involved in my own careand that I understood what was going on.The doctor told me when I could expect to get the news.

DR. ADINA NACK [continued]: He called me himself at home, and he told me the results."Now, that may not sound too special to you,but as an STD researcher, I can tell yousome of these practitioners, theywould leave a message on an answering machine,on an answering machine that back in the daycould be overheard by anybody in the house who came homeand pressed "listen to messages."Some patients these days are receiving their STD diagnoses

DR. ADINA NACK [continued]: by text.Talk about potentially shocking if youhappen to look at your text in the middle of a businessmeeting or a class.So that level of respect of making surethat he was talking directly to herand giving her a diagnosis-- in this case, thatcould potentially affect her healthand her reproductive fertility.So I want to tell you about Gita,a 23-year-old, middle-class Persian-American,

DR. ADINA NACK [continued]: and she shared how her practitioner was empatheticallyholistic, showing concern for allthe implications of an incurable sexually transmitted disease.This is Gita."My doctor didn't talk to me about HPVwith my legs spread open.She put me in her office in a comfortable chairand talked to me.She asked, 'How are you feeling?What's going on?' She really got deep with me.

DR. ADINA NACK [continued]: She took the time.She didn't just say, 'We'll freeze the genital warts off,you'll be fine.'"She explained that at least 70% of the population have itand how some people don't even know they have it.She sat there with me, and she went over everything.And then she said to me, 'I give youpermission to not look at your vagina for three weeks.I give you permission to feel OK,

DR. ADINA NACK [continued]: because you're going to be OK.'" Now,that may sound kind of strange for a practitioner to say that,but when you're dealing with a person who's just receiveda diagnosis of an incurable STD, to let her experience her firsttreatment and not focus on how the area looks can actuallygive a lot of healing and comfort to that person.

DR. ADINA NACK [continued]: So there are several recommendations thatcome out of this case study.If we just focus on the example of women with STDs,we can expand current medical sociological modelsof practitioner-patient interactionand highlight the public health implicationsfor different styles of practitioner-patientinteraction on the variety of patientswith stigmatizing illnesses.So when we talk about public health costs,

DR. ADINA NACK [continued]: we're looking at how moral surveillanceand biomedical interaction styles can actuallycause us more harm.If patients leave the office confused, intimidated,feeling undeserving of their health,they're not going to comply with practitioner recommendations.In contrast, there are actually public health benefitsfor patient-centered interaction style,

DR. ADINA NACK [continued]: where the person feels respected,they feel like they deserve to get well,and they feel like they can ask all the questions they wantto know about how to understand their illnessand their treatment plan.So the patient-centered model of interactioncan produce patients who will be morelikely to follow medical treatment plansand to actually modify their risky behaviors,because they will not only understand

DR. ADINA NACK [continued]: their medical pathways towards healing,but they will also believe that they deserve to get well.If we look at this from a public policy perspective, giventhe public health costs of moral surveillanceand biomedical interaction styles,we have to understand that these patients often leftwith diagnosable levels of anxiety, depression,and noncompliance with their medical treatment

DR. ADINA NACK [continued]: plans-- also noncompliance with disclosingto their sexual partners.We must promote patient-centered interaction styleamong practitioners, because it bestallows practitioners to safeguardthe moral identity of patients and to empowerthem to ask questions.Well, how are we going to do this?I would say, we need to change the waywe train health practitioners.

DR. ADINA NACK [continued]: And we can't expect one practitioner to do it all,so we should consider adding professional health educatorsto the medical team.That way, a patient might be examined and diagnosedby a doctor in one.When they're brought into the officeand get out of the stirrups, fully dressed,with their dignity and composure,they're given their diagnosis, which

DR. ADINA NACK [continued]: can lead to diagnostic shock.So it's fine to give some pamphlets,but it's not fine to stop with pamphlets.We need to actually make sure we introduce themto somebody who has the social skillsand professional knowledge to help that person understand--a health educator who can really walk them through what is lifegoing to be like living with HPV,living with general herpes.

DR. ADINA NACK [continued]: So in summary, we talked about models of practitionerinteraction style.I introduced you to moral surveillance stylepractitioners.Those are the doctors and nurse practitionerswho believe in some or all illness stereotypes.They're the ones who label patients as immoral,and they view patients as having earned their illnesses.Not surprisingly, patients see those practitioners

DR. ADINA NACK [continued]: as judgmental and condemning.Biomedical style practitioners, well-documentedin the literature-- they're the ones who treat the disease, notthe patient.So they're reductionist, not holistic.They practice medicine as neutral and scientific.Therefore, patients do see them as matter-of-fact and aloof,but they also see them as unreachable-- not somebody

DR. ADINA NACK [continued]: they can ask questions to and not somebody who'sgoing to care about the social and psychological implicationsof the diagnosis they've just received.In contrast to the negatives of those two styles,we also talked about patient-centered stylepractitioners.Those practitioners treat that patientas a whole person, not as an infected body part.Those practitioners are sensitive

DR. ADINA NACK [continued]: to the emotional implications of stigmatizing illnesseson patients with regard to their sense of self and alsothe interpersonal relationships they'regoing to have outside of that doctor's office.Those are people who are perceived by their patientsas being compassionate.They give the best quality patient care.They make sure their patients leavewith no question unanswered and without feeling

DR. ADINA NACK [continued]: judged or stigmatized by that practitioner.As we wrap things up, there are a couple questionsI think are good to reflect on.The first one, how does the material in this presentationmatch or contrast with what you knew about sociallyconstructed STD stigma?Second, what are typical sources of knowledge about STD stigma?

DR. ADINA NACK [continued]: Where do we learn about this?Where do we learn what STDs mean for men versus women?An STD affected man does not alwaysreceive the same stigmatizing treatmentas an STD infected woman.And what do we learn from the stigmaabout the types of people, the negative stereotypeswe associate with those most likely to contract an STD?

DR. ADINA NACK [continued]: And third, how might health care practitionersreact to my policy recommendationsabout adding a health educator to their team?And finally, switching the focus from health care practitioners,what can lay people do to help protectthe mental health and physical health of our loved oneswho are living with chronic STDs?