tag:theconversation.com,2011:/uk/topics/social-stigma-20210/articlessocial stigma – The Conversation2024-02-14T13:23:10Ztag:theconversation.com,2011:article/1944332024-02-14T13:23:10Z2024-02-14T13:23:10ZReal-world experiments in messaging show that getting low-income people the help they need is more effective when stigma is reduced<figure><img src="https://images.theconversation.com/files/518833/original/file-20230401-14-crh8sz.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5168%2C2916&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Stigma tied to poverty can create a barrier to the very help people need. </span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/BUkU-VhzW-s">@felipepelaquim for Unsplash.com</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>There are pervasive stereotypes that Americans who are low income and access government assistance are lazy, lack a work ethic and are even morally inferior. This stigma has been <a href="https://doi.org/10.1016/j.ssmph.2022.101117">shown to have many negative consequences</a>. </p>
<p>But until now, there’s been little research on whether this stigma influences the willingness to use government assistance.</p>
<p>We studied the effect of stigma in the context of <a href="https://home.treasury.gov/policy-issues/coronavirus/assistance-for-state-local-and-tribal-governments/emergency-rental-assistance-program">Emergency Rental Assistance</a>. The purpose of rental assistance programs is to help low-income people avoid eviction by helping them pay overdue rent. While these programs have long existed, they received a large influx of new funds as part of the federal government’s response to the COVID-19 pandemic.</p>
<p>This offered an opportunity for our team at <a href="https://www.peoplelab.hks.harvard.edu/">The People Lab</a>, which is based at the Harvard Kennedy School, to examine some of the barriers that low-income populations face in accessing safety net programs.</p>
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<a href="https://images.theconversation.com/files/518832/original/file-20230401-28-bvpye4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A worn-out sign street advertising apartments for rent." src="https://images.theconversation.com/files/518832/original/file-20230401-28-bvpye4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/518832/original/file-20230401-28-bvpye4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/518832/original/file-20230401-28-bvpye4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/518832/original/file-20230401-28-bvpye4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/518832/original/file-20230401-28-bvpye4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1131&fit=crop&dpr=1 754w, https://images.theconversation.com/files/518832/original/file-20230401-28-bvpye4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1131&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/518832/original/file-20230401-28-bvpye4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1131&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">The federal government helped low-income Americans pay overdue rent during the pandemic – but they had to apply for this benefit.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/zZ2mUNET5DQ">Bethany Reeves for Unsplash.com</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
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<h2>A less stigmatizing message</h2>
<p>In a <a href="https://dx.doi.org/10.2139/ssrn.4040234">recently published paper</a>, we described the results of two large studies we conducted in collaboration with the Denver Department of Housing Stability, the Denver Office of Social Equity and Innovation, and the Austin Housing and Planning Department. </p>
<p>Our goal was to test the impact of different outreach messages on the likelihood that people eligible for rental assistance would apply for benefits.</p>
<p>In the first randomized experiment, about 25,000 presumed renters in 56 neighborhoods in Denver received a mailer with straightforward information about the rental assistance program. Another group of approximately 25,000 presumed renters received a mailer with subtle language changes that aimed to reduce the internalized shame and potentially expected discrimination associated with participation in rental assistance.</p>
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<a href="https://images.theconversation.com/files/575123/original/file-20240212-22-qg8aki.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A promotional message for help paying rent" src="https://images.theconversation.com/files/575123/original/file-20240212-22-qg8aki.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/575123/original/file-20240212-22-qg8aki.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=847&fit=crop&dpr=1 600w, https://images.theconversation.com/files/575123/original/file-20240212-22-qg8aki.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=847&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/575123/original/file-20240212-22-qg8aki.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=847&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/575123/original/file-20240212-22-qg8aki.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1064&fit=crop&dpr=1 754w, https://images.theconversation.com/files/575123/original/file-20240212-22-qg8aki.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1064&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/575123/original/file-20240212-22-qg8aki.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1064&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">A destigmatizing email from this experiment with some information redacted.</span>
<span class="attribution"><span class="source">The People Lab</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
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<p>This destigmatizing message emphasized, for instance, that “it’s not your fault” if you need rental assistance.</p>
<p>We found that people who received the destigmatizing mailer were 11% more likely to apply for rental assistance than people who received the mailer that only included basic information, and 37% more likely to apply than people who did not receive anything in the mail.</p>
<p>In the second randomized experiment, we tested similar messages delivered via email to approximately 50,000 residents in Austin, Texas. We found similar results: Sending people a destigmatizing email that emphasized “it’s not your fault” if you need rental assistance led to higher engagement than a purely informational email. </p>
<p>Our findings suggest that it is possible to reduce internalized shame in a way that makes people who are eligible for government benefits more likely to apply for them – despite the presence of pervasive societal stigma. </p>
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<a href="https://images.theconversation.com/files/518834/original/file-20230401-16-xrhwaf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="One person stops to give something to another person sitting on the ground in a tunnel." src="https://images.theconversation.com/files/518834/original/file-20230401-16-xrhwaf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/518834/original/file-20230401-16-xrhwaf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/518834/original/file-20230401-16-xrhwaf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/518834/original/file-20230401-16-xrhwaf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/518834/original/file-20230401-16-xrhwaf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/518834/original/file-20230401-16-xrhwaf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/518834/original/file-20230401-16-xrhwaf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">There should be no shame in getting assistance.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/kyeJW1zRH0I">Elyse Chia for Unsplash.com</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
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<h2>Overcoming stigma</h2>
<p>U.S. safety net programs are <a href="https://www.cbpp.org/research/poverty-and-inequality/safety-net-more-effective-against-poverty-than-previously-thought">highly effective</a>, but only if people who are eligible for benefits use them. Applying for <a href="https://www.nytimes.com/interactive/2020/01/28/upshot/administrative-burden-quiz.html">assistance can be onerous</a>.</p>
<p><a href="https://doi.org/10.1093/qje/qjz013">Research</a> demonstrates that simplifying processes and providing clear and simple information about program benefits can increase participation in some contexts. Yet, gaps remain: <a href="https://doi.org/10.1257/pol.20200603">Simply providing information about programs and benefits</a> doesn’t always increase participation, and it doesn’t necessarily reach those who need assistance the most.</p>
<p>We hope our research sheds light on the way in which stigma may affect people’s willingness to use government benefits. And we hope these findings encourage government agencies to reconsider their approach to providing information and assistance to avoid inadvertently reinforcing the stigma associated with benefits use.</p><img src="https://counter.theconversation.com/content/194433/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Elizabeth Linos receives funding for her research from many foundations, including the Russell Sage Foundation, the Hewlett Foundation, the Gates Foundation, J-PAL and others. She is a nonresident fellow at the Brookings Institution, and a Faculty Affiliate of J-PAL and the California Policy Lab. </span></em></p><p class="fine-print"><em><span>Jessica Lasky-Fink does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The stigma around poverty and government benefits can make those initiatives less effective.Jessica Lasky-Fink, Research Director of the People Lab, Harvard Kennedy SchoolElizabeth Linos, Associate Professor of Public Policy and Management, Harvard Kennedy SchoolLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1952452023-01-24T12:48:29Z2023-01-24T12:48:29ZSolving period poverty is about more than just making products free<figure><img src="https://images.theconversation.com/files/505623/original/file-20230120-16-dyu9td.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-caucasian-woman-reaches-top-shelf-2053114151">STEKLO</a></span></figcaption></figure><p>Upwards of <a href="https://www.unicef.org/press-releases/billions-people-will-lack-access-safe-water-sanitation-and-hygiene-2030-unless">2.8 billion people</a> do not have access to safe sanitation. <a href="https://www.theguardian.com/society/2015/jul/01/billions-have-no-access-to-toilets-says-world-health-organisation-report">A third</a> of the world’s population doesn’t have a toilet.</p>
<p>This broad, international issue links to poverty, destitution and environmental risk. It also provides the backdrop to the struggles women and girls the world over face in dealing with their period. At least <a href="https://www.worldbank.org/en/news/feature/2018/05/25/menstrual-hygiene-management">500 million</a> women and girls lack access to adequate facilities to manage menstruation. </p>
<p>“Period poverty” describes these <a href="https://theconversation.com/it-will-take-a-lot-more-than-free-menstrual-pads-to-end-period-poverty-120189">barriers</a>, from the cost of sanitary products and access to toilets to being excluded from activities ranging from the <a href="https://www.theguardian.com/commentisfree/2017/dec/19/british-girls-period-poverty-menstruation-sanitary-products">classroom</a> to <a href="https://www.globalcitizen.org/en/content/period-poverty-sports-study-uk/">sport</a>. But the challenges <a href="https://theconversation.com/it-will-take-a-lot-more-than-free-menstrual-pads-to-end-period-poverty-120189">don’t stop there</a>. </p>
<p>Research shows that in communities shaped by repressive <a href="https://link.springer.com/book/10.1007/978-1-349-21176-0">patriarchal</a> systems, menstruating is still seen as a <a href="https://theconversation.com/it-will-take-lot-more-than-free-period-products-to-end-stigma-around-menstruation-151711">taboo</a> subject. And with that comes shame and embarrassment. Further, when you’re young and just getting used to having a period in the first place, commercial advertising that, as Australian communication design expert Jane Connory <a href="https://researchbank.swinburne.edu.au/file/0d14c97b-4ad3-44c2-9462-053a15a7c01a/1/2021-connory-sanitary_secrets_exhibition.pdf">has shown</a>, sexualises or suggests needing to keep your period a secret, is damaging.</p>
<figure class="align-center ">
<img alt="Period products in containers on a bathroom shelf" src="https://images.theconversation.com/files/505116/original/file-20230118-22-4ignci.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/505116/original/file-20230118-22-4ignci.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/505116/original/file-20230118-22-4ignci.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/505116/original/file-20230118-22-4ignci.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/505116/original/file-20230118-22-4ignci.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/505116/original/file-20230118-22-4ignci.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/505116/original/file-20230118-22-4ignci.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Free period products are a big step forward.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/tampons-menstrual-pads-on-counter-bathroom-2069245310">New Africa</a></span>
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<h2>Why free products are only part of the solution</h2>
<p>In Britain, it is estimated that up to <a href="https://borgenproject.org/top-10-facts-about-period-poverty-in-the-uk/#:%7E:text=An%20estimated%2049%20percent%20of%20girls%20have%20missed,or%20discussing%20their%20period%20in%20an%20academic%20setting">49%</a> of girls have missed school due to their period. This appears to be primarily linked to the cost of period products. The simple solution, here, is to make these accessible and free. </p>
<p>Of the four UK nations, <a href="https://theconversation.com/ending-period-poverty-scotlands-plan-for-free-menstrual-products-shatters-taboos-and-leads-a-global-movement-103138">Scotland</a> in particular is taking steps towards this. Following a successful pilot scheme in Aberdeenshire, in 2018 the Scottish administration made <a href="https://www.gov.scot/news/providing-free-sanitary-products-1/">period products free</a> for people from low-income households across the nation.</p>
<p>Research shows, however, that money is only part of the problem. Many women and girls are <a href="https://www.proquest.com/docview/1987646421/30D311C7F210419FPQ/1?accountid=8630">socially disadvantaged</a>, with information and education about periods seriously lacking. </p>
<p>When shame is felt in relation to an issue, it results in people being reluctant to search out the information they need, to their own detriment. Embarrassment is compounded by a lack of adequate sex education, the latter often taught to girls only. </p>
<p><a href="https://plan-uk.org/media-centre/almost-half-of-girls-aged-14-21-are-embarrassed-by-their-periods">Research shows</a> that up to half of girls in the UK are embarrassed by their period and that support in school is lacking. According to the <a href="https://www.sexeducationforum.org.uk/news/blog/getting-timing-right-when-should-children-learn-about-periods">Sex Education Forum</a>, a charity focused on relationships and sex education, one in four young women did not learn about periods before they got theirs, a number which appears to be rising. <a href="https://theconversation.com/the-pandemic-made-period-poverty-worse-in-the-uk-but-also-led-to-new-ways-to-combat-it-175978">This may have</a> been <a href="https://plan-uk.org/sites/default/files/Documents/Policy/Reports%20and%20Briefs/plan-uk-state-of-girls-rights-coronavirus-report.pdf">further affected</a> by the <a href="https://theconversation.com/the-pandemic-made-period-poverty-worse-in-the-uk-but-also-led-to-new-ways-to-combat-it-175978">pandemic lockdowns</a> and resulting school closures. </p>
<p>Girls and women may be forced to lie about periods so as not to take part in certain activities, such as <a href="https://plan-uk.org/media-centre/almost-half-of-girls-aged-14-21-are-embarrassed-by-their-periods">physical education</a>, due to the <a href="https://www.ncbi.nlm.nih.gov/books/NBK565616/">taboo</a> and ingrained <a href="https://www.ncbi.nlm.nih.gov/books/NBK565666/">stigma</a> around periods that endure in wider society. This appears to stem from periods, historically, being framed as <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4463372/">a medical issue</a> rather than a positive indication of the natural workings of the reproductive system and body.</p>
<p>Opening up the dialogue across genders within relationships and improving sex education within schools is crucial. But business has a lot to answer for, too.</p>
<h2>How companies can make things worse</h2>
<p>Misguided advertising campaigns that seemingly aim to break down stigma often inadvertently feed into it instead. This compounds the feelings of shame that surround periods. </p>
<p>In November 2022, Tampax US <a href="https://twitter.com/tampax/status/1596512639332540417">deleted</a> a tweet from its official account, apologising for “messing up” and not being respectful while pledging to “do better”. The tweet, which <a href="https://www.msn.com/en-gb/news/newslondon/tampax-sparks-controversy-on-twitter-with-e2-80-98vulgar-e2-80-99-viral-tweet/ar-AA14sEYc">read</a>: “You’re in their DMs. We’re in them. We are not the same”, drew <a href="https://twitter.com/xjennaaaxo/status/1594846411497021441?ref_src=twsrc%5Etfw%7Ctwcamp%5Etweetembed%7Ctwterm%5E1594846411497021441%7Ctwgr%5E5afed50f119f9d6f37f8263eabe4be57449280e9%7Ctwcon%5Es1_&ref_url=https%3A%2F%2Fwww.standard.co.uk%2Fnews%2Fuk%2Ftampax-tampon-twitter-viral-tweet-controversy-b1042046.html">particular ire</a> for appearing to sexualise the use of a tampon, referencing the social media trope of “sliding” into someone’s DMs – direct messaging them as a flirting strategy. </p>
<p>This messaging harked back to the 1970s <a href="https://theconversation.com/friday-essay-i-looked-at-100-ads-for-menstrual-products-spanning-100-years-shame-and-secrecy-prevailed-152685#:%7E:text=Even%20during%20the%201970%20and%201980%E2%80%99s%2C%20sexist%20and,Weekly%20sexualises%20a%20prepubescent%20girl%20to%20sell%20tampons">adverts</a> for Dr White’s which showed women in bikinis and underwear to advertise sanitary products. In the 1980s, Tampax used scantily clad prepubescent girls to advertise its products. Decades on, in 2015, advertisers for Thinx period pants opted for pictures of halved grapefruit and runny eggs, <a href="https://www.thedrum.com/news/2020/10/12/gory-glory-the-evolution-period-advertising">imagery</a> suggestive of female anatomy. </p>
<p>Advertising that attempts to make sanitary products fun and edgy often links <a href="https://link.springer.com/chapter/10.1007/978-981-15-0614-7_24">periods to sex</a>. That’s because periods are profitable for those companies that make disposable products such as tampons and sanitary towels, and sex sells.</p>
<p>However, some girls start their periods as early as age nine, which makes such sexualisation of period products even more damaging. Research has shown that the common age for periods to start is indeed early, anywhere from <a href="https://pubmed.ncbi.nlm.nih.gov/12319855/">ten years old</a>. </p>
<p>What’s more, this type of advertising co-opts the language of empowerment for women and girls, thereby driving home the point about periods being something to be ashamed of. It can also be a subtle steer away from low-cost products such as menstrual cups, washable pads and period pants. </p>
<p>It is a common misconception that period poverty is only an issue for those who are menstruating. Many men and those who do not have periods also suffer as a result, either due to the financial impact of buying disposable products on a family’s budget, or the indirect impact that missed school and work days have on the wider class or workforce. </p>
<p>For many women and girls, menstruation can cause isolation and negatively affect their self-esteem and sense of dignity. Free period products and <a href="https://journals-sagepub-com.bham-ezproxy.idm.oclc.org/doi/full/10.1177/0095399713481601">being able to</a> deal with your period without shame or restrictions should be a basic human right.</p><img src="https://counter.theconversation.com/content/195245/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sophie King-Hill does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Free period products and being able to deal with your period without shame or restrictions should, however, be a basic human right.Sophie King-Hill, Senior Fellow at the Health Services Management Centre, University of BirminghamLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1896192022-09-22T12:40:05Z2022-09-22T12:40:05Z‘Men who have sex with men’ originated during the HIV pandemic to focus on behavior rather than identity – but not everyone thinks the term helps<figure><img src="https://images.theconversation.com/files/485710/original/file-20220920-14360-lngmmg.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2121%2C1412&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The monkeypox pandemic has seen an increase in the use of the term "men who have sex with men."</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/rear-view-of-gay-couple-on-lookout-above-the-city-royalty-free-image/1195433903">Westend61/Getty Images</a></span></figcaption></figure><p>Since the <a href="https://www.npr.org/2022/08/05/1116036167/talking-about-monkeypox-effectively-without-stigmatizing-men-who-have-sex-with-m">global monkeypox outbreak</a> started to spread this past spring, more people are seeing the term “men who have sex with men,” or MSM, in the news and public health messages. You may have also heard this term in places like HIV prevention campaigns or at the doctor’s office.</p>
<p>I am a <a href="https://cph.osu.edu/people/jricks">behavioral scientist</a> who focuses on reducing health disparities and improving health equity for sexual and gender minority populations at highest risk for poor outcomes. At the most basic level, <a href="https://doi.org/10.1080/00224499009551551">men who have sex with men</a> is a term that was originally intended to describe the risk of HIV transmission associated with sex between two men. But in reality, MSM describes a diverse group of behaviors and identities, bringing with it a complex web of social, political and cultural considerations about how it’s used.</p>
<h2>Why use MSM?</h2>
<p>HIV researchers have used the term “men who have sex with men” <a href="https://doi.org/10.1007/BF01326525">since at least 1988</a> as a way to describe a particular type of sexual behavior that may affect health.</p>
<p>The acronym MSM, however, was <a href="https://doi.org/10.1902/jop.1994.65.5.393">introduced in 1994 as a new concept</a> by some researchers and community advocates in response to public health research and prevention efforts early in the HIV/AIDS pandemic. These efforts almost exclusively targeted men based on their sexual identity as gay. Community advocates <a href="https://prideindex.com/in-touch-with-cleo-manago/">criticized this approach</a> for excluding Black and Latino men who have sex with men who were affected by the pandemic but did not identify as gay, homosexual or bisexual. MSM was considered to be a more inclusive, less stigmatizing term that could be used to reach a broader range of people.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/485707/original/file-20220920-11202-cf9dvv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Demonstrators holding signs protesting against AIDS discrimination" src="https://images.theconversation.com/files/485707/original/file-20220920-11202-cf9dvv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/485707/original/file-20220920-11202-cf9dvv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=839&fit=crop&dpr=1 600w, https://images.theconversation.com/files/485707/original/file-20220920-11202-cf9dvv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=839&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/485707/original/file-20220920-11202-cf9dvv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=839&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/485707/original/file-20220920-11202-cf9dvv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1055&fit=crop&dpr=1 754w, https://images.theconversation.com/files/485707/original/file-20220920-11202-cf9dvv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1055&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/485707/original/file-20220920-11202-cf9dvv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1055&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">During the AIDS epidemic, new terminology arose to focus research and public health interventions on behavior rather than identity.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/AIDSDiscriminationProtest/96ceaffa64224626b88eae3bd88e7503">AP Photo/Rick Maiman</a></span>
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<p>From a scientific perspective, using an identity-free term like MSM allows medical providers and public health practitioners to bypass the complexities of the social, cultural and political context of sexual orientation. Instead, they can then focus on the behavior that might put someone at risk for an infection such as HIV or monkeypox. This approach is <a href="https://pubmed.ncbi.nlm.nih.gov/16080458/">intended to help</a> increase the likelihood of screening, diagnosing and treating those at the greatest risk.</p>
<p>Prevention strategies that target people based on “what you do” rather than “who you are” reach more people who may be affected by a public health concern, including heterosexual men who have sex with men, rather than limiting outreach just to those who identify as gay or bisexual. They offer a larger number of men the opportunity to understand their risk and take the steps necessary for protection or treatment. They also help <a href="https://doi.org/10.2105/AJPH.2004.046714">decrease stigma</a> for those who identify as gay or bisexual.</p>
<h2>Limitations of MSM</h2>
<p>Despite its usefulness in some contexts, the term MSM has been hotly debated by scholars and community advocates since it was coined. <a href="https://doi.org/10.2105/AJPH.2004.046714">Disagreement</a> <a href="https://doi.org/10.2105/AJPH.2020.305870">on its use</a> is usually grounded in three arguments.</p>
<p>The first is that the term is ambiguous. Some researchers argue that distilling MSM down to “sex between two men” is too simplistic. For one, there are a number of nuances and factors that <a href="https://www.cdc.gov/hiv/group/msm/msm-content/prevention-challenges.html">influence the amount of risk</a> associated with sex between two men, such as how sex is performed and who and how many partners are in their sexual network. There is also confusion about how frequently or recently someone must have sex in order to be considered MSM. And there is <a href="https://doi.org/10.7448/IAS.19.3.20779">no consensus</a> about whether transgender men who have sex with men should be considered MSM. </p>
<p>The second critique is that the term <a href="https://doi.org/10.2105/AJPH.2004.046714">undermines the identities</a> of sexual minority group members, particularly people of color. Many public health researchers use MSM as a neutral term to push back against the idea that there is only one legitimate gay identity. However, some have criticized the term for erasing other sexual identities such as queer, two-spirited and same-gender loving by being the default term used in research, despite participants describing themselves as otherwise.</p>
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<figcaption><span class="caption">While HIV cases are largely decreasing across the U.S., high infection rates remain in Southern states.</span></figcaption>
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<p>Finally, the third argument is that the term conceals the social, political and cultural dimensions of health important for public health research and intervention. One of the greatest advantages of MSM is that it is grounded in tangible behaviors that researchers can target for health promotion and prevention efforts. But sexual health is influenced by a constellation of factors, and focusing on behavior alone is often not enough to completely protect against illness. </p>
<p>Beyond sexual behavior, <a href="https://doi.org/10.17226/25877">discrimination and social marginalization</a> put sexual minorities at significant risk of poor health outcomes. These can take the form of structural factors, such as anti-gay legislation, and community factors, such as discrimination and stigma. Interpersonal factors like relationship abuse and individual factors like internalized stigma also play a role. These factors <a href="https://doi.org/10.1016/j.mhp.2016.10.002">increase the risk of mental illness</a>, such as depression and suicidal thoughts, as well as risky health behaviors, such as sex without a condom or while under the influence of drugs.</p>
<p>Almost 30 years since it was introduced, the term MSM is becoming increasingly ubiquitous in both medical and public health spaces. But it does have limitations. Considering the sociopolitical context of whether MSM should be used, rather than using it by default, can help support the self-determination of those who belong to historically marginalized communities.</p><img src="https://counter.theconversation.com/content/189619/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>JaNelle Ricks does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The term ‘MSM’ allows public health interventions to gloss over the social, political and cultural complexities of identity. But it’s not without its limitations.JaNelle Ricks, Assistant Professor of Health Behavior and Health Promotion, The Ohio State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1886212022-08-31T16:56:31Z2022-08-31T16:56:31ZWaste pickers in Lagos tell their stories about a dangerous existence<figure><img src="https://images.theconversation.com/files/481014/original/file-20220825-20-y7xgw3.jpg?ixlib=rb-1.1.0&rect=3%2C3%2C2592%2C1677&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Waste pickers at the Olusosan landfill work in a hazardous environment. </span> <span class="attribution"><span class="source">Lionel Healing/AFP</span></span></figcaption></figure><p>Lagos, Nigeria’s economic hub, with a population of more than <a href="https://worldpopulationreview.com/world-cities/lagos-population">15 million</a>, generates an estimated <a href="https://www.scientific.net/JERA.35.11">12,000</a> metric tonnes of waste daily, which comes to about 4.3 million tonnes of waste annually. This ends up on the streets and in the city’s four officially designated landfills.</p>
<p>These sites support thousands of people who search through what’s discarded for materials with resale value. Our <a href="https://www.tandfonline.com/doi/full/10.1080/00207233.2022.2055344">survey</a> of two landfill sites discovered a total of about 2,800 waste pickers – men and women. </p>
<p>Most landfills have buy-back centres, where the waste pickers sell recyclables such as metal, glass, plastic and paper. We observed that the subsistence incomes of waste pickers fluctuated daily, depending on the volume of recyclable waste delivered to the landfill, its quality, and varying prices. The daily average income of the street waste pickers was N2,075 (US$4.99) while that of the landfill waste pickers was N5,530 (US$13.30). Though this average income is higher than the <a href="https://databankfiles.worldbank.org/data/download/poverty/987B9C90-CB9F-4D93-AE8C-750588BF00QA/AM2021/Global_POVEQ_NGA.pdf">poverty line</a>, the work and the environment are hazardous, and its value is not fully appreciated.</p>
<p>Waste pickers often work without protective gear, unassisted, and without access to primary care or first aid and employment regulations. They operate on the margins of or outside the formal process of managing solid waste, but play vital roles, especially in reuse, recycling and cost recovery. </p>
<p>They work in unsheltered environments and are unprotected from severe heat, sun, rain, and cold weather. These conditions have been linked with <a href="https://doi.org/10.1155/2021/5530064">cardiovascular disorders</a>. Likewise, exposure to dust, micro-organisms and microbial toxins can result in chronic respiratory diseases, <a href="https://pubmed.ncbi.nlm.nih.gov/7569875/">skin problems and gastrointestinal illnesses</a>. </p>
<p>Research on waste pickers has tended to focus on the health risks of their occupation. Our <a href="https://www.tandfonline.com/doi/abs/10.1080/00207233.2022.2055344?casa_token=PHnkskfO9ZIAAAAA:Y7PdgyDp5035bdZXV_0zHELhvZbD98vN9WUZGMDThwEHKpZEm0TfZfnQReqgqRZLAh4wM4DDSPeE">study</a> confirmed that Lagos waste pickers were exposed to occupational health hazards, but also aimed to reveal more about their well-being and their own perspectives. </p>
<p>The findings may help waste management authorities to make landfills a more dignified working environment that sustains waste pickers’ livelihoods without jeopardising their well-being.</p>
<h2>Occupational hazards of waste picking</h2>
<p>For our research, we interviewed 125 waste pickers in Olusosun landfill and 27 in Solous landfill. Olusosun is situated in Ojota, Kosofe Local Government Area and Solous in Egbeda, Alimosho Local Government Area of Lagos state.</p>
<p>We established that waste picking in landfills was mostly done by younger people: 88% of our respondents were aged between 18 and 45. The collection of recyclable materials and items was mostly done by men, while the sorting was mostly by women.</p>
<p>They operated at the landfill because of the abundance and concentration of waste there. In fact, 66% lived at the dumpsite. The majority worked seven days a week. The average number of years they had spent doing this work was seven.</p>
<p>Most of the waste pickers we spoke to had experienced illnesses or injuries. Body pain, bruises and fatigue were the most frequently mentioned conditions.
Most waste pickers had bruises or scars on their hands, arms and feet, mainly from cuts or piercings during sorting. </p>
<p>Other illnesses and injuries were caused by inappropriate posture and prolonged work hours. Many had sore or itchy eyes caused by exposure to smoke from burning garbage and to other hazards like methane gas, sulphur dioxide and carbon monoxide.</p>
<p>The people in our study didn’t use personal protective equipment or go for regular medical checks. </p>
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Read more:
<a href="https://theconversation.com/nigerias-plastic-pollution-is-harming-the-environment-steps-to-combat-it-are-overdue-177839">Nigeria's plastic pollution is harming the environment: steps to combat it are overdue</a>
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<p>When we asked about their subjective feelings, we found that the waste pickers were very dissatisfied with their unhealthy working conditions, the extreme poverty they lived in, and the stigmatisation they experienced. Many used alcohol and drugs. Most said they were distressed by their work. </p>
<p>They experienced discrimination, prejudice and social rejection. </p>
<p>Yet with low education levels – 61% were illiterate – they could not find other work. They settled for waste picking as a last resort to earn a living.</p>
<h2>Value of waste pickers</h2>
<p>Nigerian authorities don’t fully appreciate the <a href="https://www.wiego.org/publications/feminizing-waste-waste-picking-empowerment-opportunity-women-children-impoverished-communities">beneficial role</a> of waste pickers. These workers contribute to environmental sustainability by reducing wastes in dumpsites and providing material for recycling and reuse. But they are never considered when waste management policies are designed.</p>
<p>Waste pickers should be recognised in waste management policies and their well-being should be taken seriously.</p>
<p>Waste management authorities, NGOs and multinational organisations must ensure that potable water, sanitary facilities and clinics are provided at landfills. Waste pickers must be allowed to use them free of charge, as is the case in Brazil.</p>
<p>In addition, waste pickers should be encouraged to develop workplace health frameworks to alleviate accidents and risks. </p>
<p>Training to build their capacity and expand their skills, giving them other work opportunities, could reduce their dissatisfaction. </p>
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<strong>
Read more:
<a href="https://theconversation.com/african-digital-innovators-are-turning-plastic-waste-into-value-but-there-are-gaps-188014">African digital innovators are turning plastic waste into value -- but there are gaps</a>
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<p>There is also a need for investment in regular occupational health and safety training through public/private partnerships. Waste pickers should be provided with personal protective equipment and monitored to ensure proper use. Non-compliance should be penalised.</p>
<p>Lastly, the rights of waste pickers must be protected. They should not be stigmatised but treated as essential to waste management.</p><img src="https://counter.theconversation.com/content/188621/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Olanrewaju Dada does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Lagos waste pickers were dissatisfied with their unhealthy working conditions, poverty and stigmatisation.Olanrewaju Dada, Lecturer, Department of Urban and Regional Planning, Olabisi Onabanjo University, Ago-Iwoye, Nigeria, Olabisi Onabanjo UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1347212020-04-01T11:56:05Z2020-04-01T11:56:05ZPatient zero: why it’s such a toxic term<figure><img src="https://images.theconversation.com/files/324267/original/file-20200331-65495-wi450.jpg?ixlib=rb-1.1.0&rect=0%2C213%2C4920%2C2854&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Stigma.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/red-human-figure-extends-influence-neighboring-1427728532">Andrii Yalanskyi/Shutterstock</a></span></figcaption></figure><p>Heightened fears surrounding COVID-19 have once again brought the idea of “patient zero” into public consciousness. Ever since it was coined by accident in the 1980s, this popular yet slippery term has regularly – and misguidedly – been applied to infectious disease outbreaks and public health efforts to control them.</p>
<p>Steve Wozniak, co-founder of Apple, <a href="https://twitter.com/stevewoz/status/1234575727678435328?s=21">tweeted earlier this month</a> that he and his wife might be “patient zero” for the epidemic of COVID-19 in the US after they returned from a trip to China with symptoms. He later described his use of the phrase as <a href="https://www.usatoday.com/story/tech/2020/03/02/not-coronavirus-steve-wozniaks-wife-has-sinus-infection/4933649002/">“kind of a joke”</a>.</p>
<p>Less frivolously, “the hunt for patient zero” formed part of a recent <a href="https://doi.org/10.1136/bmj.m799">BMJ headline</a> for an editorial examining the devastating epidemic unfolding in Italy. The piece described local attempts to find the country’s initial coronavirus cases, hypothesising that they might be a pair of visitors from China’s Wuhan region, where health authorities were confronting the world’s earliest recognised large-scale outbreak. </p>
<p>Amid heightened contact-tracing efforts to locate cases linked to a doctor in the UK who was displaying symptoms of the infection, the Daily Mail used similarly dramatic language. <a href="https://www.dailymail.co.uk/news/article-8059159/Health-officials-desperate-trace-contacts-20th-British-coronavirus-victim-Surrey.html">An article</a> described “the desperate hunt … for an unknown coronavirus spreader” who “gave” – note the implied volition of this word – “the deadly illness to the UK’s 20th victim – the first Briton to catch it in the country”.</p>
<p>And even more recently, the Mail on Sunday followed news of prime minister Boris Johnson’s positive COVID-19 test result by publishing a two-page spread asking its readers: <a href="https://www.dailymail.co.uk/news/article-8163427/Did-Michel-Barnier-infect-PM-EUs-Brexit-negotiator-Downing-Streets-Patient-Zero.html">“DID BARNIER INFECT BOJO?”</a> With little evidence, the authors intimated that Michel Barnier, the chief negotiator for the EU, “might be the ‘Patient Zero’ who brought [the] virus to No 10”, representing “the ultimate revenge for Brexit”.</p>
<p>With the words “patient zero”, you have a distinctly catchy phrase. This was the reason Randy Shilts, the American journalist <a href="https://books.google.co.uk/books?id=cGNetxKuLnMC&dq">whose work on the AIDS epidemic</a> initially amplified the term, <a href="https://www.readcube.com/articles/supplement?doi=10.1038%2Fnature19827&index=1">adopted it in the first place</a>. It sounds scientific, and as if it signifies the absolute beginning of an epidemic. It shares a linguistic link to 20th-century military expressions such as <a href="https://nyti.ms/39gTX1z">“zero hour”</a> (when an action begins) and <a href="https://nyti.ms/33OigTo">“ground zero”</a> (the point below where a bomb detonates), so it conveys a sense of excitement too.</p>
<p>But apart from its attention-grabbing tone, the phrase is hopelessly confusing. Its lack of precision and accidental formation disqualify it from formal usage, so most researchers will not touch it. And stories about unknown disease “spreaders” triggering a “desperate hunt”, whether or not they explicitly refer to a “patient zero”, are frequently giving expression to communal fears about dangerously reckless behaviour. On the surface, these stories seem motivated by science. Scratch a little deeper, though, and you will often uncover a desire to assign blame.</p>
<p>We should abandon the toxic phrase “patient zero” and discuss contact tracing – the process of locating individuals who have crossed paths with people who are infectious – with great care. Otherwise, we risk increased confusion, scapegoating and under-emphasising the significance of asymptomatic cases. These are all things which are deeply unhelpful for our collective response to COVID-19.</p>
<h2>Confusion</h2>
<p>First, let’s tackle the confusion raised by the term itself. “Patient zero” is often used interchangeably for three different scenarios: first case <em>noticed</em>, first case <em>here</em>, and first case <em>ever</em>. While there are legitimate reasons for discussing each of these situations, better terminology exists for doing so. </p>
<p>Speaking of “cases” instead of “patients” allows us to be more specific. By doing so we include those who may be infected and infectious but who don’t acquire official “patient” status by seeking treatment.</p>
<p>In terms of “first case noticed”, since at least the 1930s, health investigators engaging in contact-tracing work have used the phrase “index case” to mark the first person in a household or community whose symptoms grabbed their attention. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1562710/">Researchers studying tuberculosis</a> in Tennessee during the Great Depression defined “index case” as “that person through whom attention was drawn to the household”.</p>
<p>Crucially, these same researchers were quick to emphasise that this person might not be “the initial case in the household in point of time”. Turning our thoughts to COVID-19, there are many reasons why this might hold true. An initial case whose symptoms were so mild that she did not seek assistance. A child who picked up the infection first but took longer than his siblings to develop a fever. Or perhaps a grandparent with all the signs of infection, but without medical insurance and afraid to seek treatment. </p>
<p>The Tennessee tuberculosis researchers also pointed out that the index case might not be a true case of disease at all. Someone might appear to be ill, draw attention to a household, but ultimately test negative for tuberculosis.</p>
<p>To refer to “the initial case … in point of time”, epidemiologists coined the phrase <a href="https://books.google.co.uk/books?redir_esc=y&id=RPaQY8cG4N4C&q=primary+case#v=snippet&q=primary%20case&f=false">“primary case”</a>. In understanding how a disease might spread through a household or community, it can be useful to know who was the primary case <em>here</em>, in a particular location. By knowing when this person was infectious and by tracing their movements through a community, investigators can identify other people who might be at risk of infection and, ideally, test and treat them.</p>
<p>Where epidemiology lacks a good alternative phrase is for the first person <em>ever</em> to become infected. <a href="https://www.ccn.com/coronavirus-patient-zero-may-have-started-pandemic-in-november-or-earlier/">“Patient zero” often springs up</a> to fill this void in informal discussions. </p>
<p>There are many reasons why this person, the first human case ever in a particular outbreak, is seldom located: the absence of recognisable symptoms, gaps in disease surveillance, delays in recognising an outbreak, lack of effective testing. In some cases, the person <a href="https://www.bbc.co.uk/programmes/p004t2d7">popularly and arbitrarily crowned as “patient zero”</a> may simply be the person with a positive test result whose likely date of infection is the <a href="https://www.nytimes.com/2009/04/29/world/americas/29mexico.html">earliest on record</a>.</p>
<p>As such, any purported “first case ever” is largely figurative. Lacking a better phrase, we might choose to call this person the “alpha case” or “ur-case”, or, for infections such as HIV or COVID-19 where a virus transfers from an animal host to humans, the “crossover case”. “Crossover case” is readily understood. And “alpha” and “ur” are two words commonly used to describe absolute beginnings, each also hinting, appropriately, at a mythical realm (“In the beginning…”).</p>
<p>Each of these designations is meaningful. Index cases are helpful in terms of seeing how disease comes to authorities’ attention (“index” literally meaning “that which serves to point”). Primary cases are useful in terms of organising the key elements of epidemiology – <a href="https://doi.org/10.1215/9780822390572-006">time, place and person</a> – into a narrative chronology that helps bring order to the complexity of rapidly accumulating data during a health crisis.</p>
<p>Likewise, it can be important to talk of crossover cases – even if they are seldom directly identifiable. Understanding their habits and living conditions might reveal risks that can be avoided in the future. Studying how a virus has evolved over time from its first interactions with humans can offer insight into its past trajectory as well as possible future points of intervention for treatment and vaccine research.</p>
<p>In short, each of these situations is worth discussing with precision. With its many possible meanings, “patient zero” is simply not up to the task.</p>
<h2>Blame and scapegoating</h2>
<p>Identifying a “patient zero” is also rife with potential to incite blame and scapegoating. To understand how, it’s useful to think historically about the overlapping but divergent interests of two different groups keenly following the spread of infection during an epidemic: members of the public and public health workers. </p>
<p><a href="https://books.google.co.uk/books?id=IaRBDwAAQBAJ&pg=PA42&source=gbs_toc_r&cad=2#v=onepage&q&f=false">Long before</a> they had the ability to test for specific germs, those studying epidemics – whether religious, civic or medical authorities – found value in locating the first cases. Like now, they were keen to work out what identifiable factors might have led to ill health in the community. </p>
<p>Many medieval Europeans believed that disease could spring up from dangerous miasmatic air. From the 14th century onward, conspiracies also circulated about specific minorities – lepers, Jews, heretics and sodomites – causing the plague, either directly by poisoning wells, or more generally by provoking God’s punishment with their behaviour. Members of minority groups who were judged to have disobeyed community standards often faced isolation, banishment and sometimes death in the aim of seeking atonement.</p>
<p>Humans are storytellers, and through several centuries of epidemics in Europe and North America (where my research has focused) they have told stories of how outbreaks started and spread. These included tales of how foreign travellers brought non-native disease (the malady from X country) – a phenomenon later aptly described in relation to AIDS as a <a href="https://books.google.co.uk/books?id=fbBg41hs9vsC&printsec=frontcover">“geography of blame”</a>. </p>
<p>On a more local level, observers also described real and fictional chains of disease transmission between named people (“Our town was free from infection until so-and-so came”; or “A infected B with the pox, who infected C and D”). With their similarity to family trees, I call this second kind of story a <a href="https://books.google.co.uk/books?id=Iro7DwAAQBAJ&printsec=frontcover">“genealogy of blame”</a>. </p>
<p>Both types of stories tend to feature people behaving inappropriately, immorally or wickedly, especially by transgressing important boundaries. These might be natural, religious or geographic divides. One finds examples of proposed “ur-cases” of the pox generated by crossed celestial bodies, crossed species or crossed borders. </p>
<p>These ancient and widespread stories that explain disease and misfortune link to the popular stories of a “patient zero” still told today. They trace real or perceived connections between different people to understand how illness spreads. But unlike the main motivation of public-health contact tracing, a much more recent practice, these stories enact personal distancing through words, aiming to provide reassurance by locating the responsibility for disease elsewhere. </p>
<p>Contact tracing as we now define it <a href="https://books.google.co.uk/books?id=ocEo899r3ZkC">developed in the late 19th and early 20th centuries</a> when investigators and health departments drew upon the remarkable discoveries of bacteriological researchers and applied them to public health problems. Scientists had developed new techniques that allowed them to identify specific germs as the cause of specific diseases. This powerful breakthrough in studying infection, in turn, gave health authorities a much better understanding of how a specific germ was moving through a population and where to allocate resources for prevention.</p>
<p>For diseases such as typhoid fever, tuberculosis, syphilis and gonorrhoea, investigators could now identify potential cases with more confidence. Increasingly, public health workers tested these cases to see if they were carrying specific germs, followed up their contacts, and then applied measures such as treatment, quarantine or isolation to prevent further spread. </p>
<p>The most famous instance of these tools being put to use was with typhoid fever and the <a href="https://books.google.co.uk/books?id=cgDHAgAAQBAJ&printsec=frontcover">case of Mary Mallon in early 20th-century New York</a>. Authorities found this Irish American cook to be a “healthy carrier” – capable of infecting others while remaining symptom-free herself – and they advised her against continuing to work as a cook. When they later traced numerous infections and two deaths to a maternity hospital where Mallon had resumed cooking, she was forcibly confined to North Brother Island for more than two decades until her death in 1938. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/324279/original/file-20200331-65509-7mfd02.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/324279/original/file-20200331-65509-7mfd02.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=445&fit=crop&dpr=1 600w, https://images.theconversation.com/files/324279/original/file-20200331-65509-7mfd02.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=445&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/324279/original/file-20200331-65509-7mfd02.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=445&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/324279/original/file-20200331-65509-7mfd02.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=559&fit=crop&dpr=1 754w, https://images.theconversation.com/files/324279/original/file-20200331-65509-7mfd02.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=559&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/324279/original/file-20200331-65509-7mfd02.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=559&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Mary Mallon, a ‘healthy carrier’ for typhoid fever, in hospital, 1909.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/w/index.php?curid=689801">Wikimedia Commons</a></span>
</figcaption>
</figure>
<p>In carrying out their responsibilities, public health workers have long benefited from media stories that borrowed heavily from crime fiction, portraying them as tireless <a href="https://doi.org/10.1215/9780822390572-001">“disease detectives”</a>. Alexander Langmuir, the godfather of the Epidemic Intelligence Service at the US Centers for Disease Control, <a href="https://books.google.co.uk/books?id=ocEo899r3ZkC">actively cultivated such media accounts</a> of his organisation’s epidemiologists from the mid-20th century onward. </p>
<p>One downside, however, to this popular public image is the overlap in word choices and story conventions drawn from crime fiction. Describing public health workers as “disease detectives” opens the door to characterising the contact-tracing process as a “hunt” for guilty “suspects”, people who choose to “give” their infections to innocent “victims” (another harmful story formula with a long history). This is especially troubling if the people in question are going about their lives without the knowledge that they are infected.</p>
<p>It is obvious that a public health method that investigates the same person-to-person connections that have long fascinated members of the public will be particularly vulnerable to mixed messages like these. As a result, writing about contact tracing in relation to a public health emergency must always be done with extreme care. Word choice matters. </p>
<p>Journalists focusing on a “patient zero” risk invoking widespread and historically rooted social impulses to attribute responsibility and blame to the people linked to chains of infection. On their side, public health workers might think twice about using the term “superspreader”. This evocative and stigmatising phrase, still in relatively wide use, describes an infected person who transmits an infection to many others, and <a href="https://books.google.co.uk/books?id=rX0iH0tAH28C&pg=PA358&dq=gaetan+dugas+superspreader&hl=en&sa=X&ved=0ahUKEwikqejhocLoAhVOXhUIHe3bBCIQ6AEIMzAB#v=onepage&q=gaetan%20dugas%20superspreader&f=false">has often been applied</a> to the first-ever “patient zero”: Gaétan Dugas.</p>
<h2>What we don’t see</h2>
<p>Many people will know the story of Gaétan Dugas, the French-Canadian flight attendant <a href="https://www.nytimes.com/2016/10/27/health/hiv-patient-zero-genetic-analysis.html">wrongly accused</a> of being “patient zero” of the North American AIDS epidemic. Briefly, this man emerged as a person of interest in 1982 when American public health investigators received reports that a number of gay men with AIDS in California had had sex with one another. This was before a virus was known to be the cause and before a test was available to determine who was sick.</p>
<p>In the absence of a definitive test for AIDS, this sexual network of cases, all of which fit the narrowly defined official case definition for the new syndrome, offered an opportunity to study whether the syndrome was caused by a sexually transmissible agent. The Canadian appeared to provide the sexual link to several Californian cases that otherwise did not have any apparent connection. He was labelled the “out of California” case because he lived outside of the state, and “case O” or “patient O” for short.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/324351/original/file-20200331-65537-1mn49pk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/324351/original/file-20200331-65537-1mn49pk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=602&fit=crop&dpr=1 600w, https://images.theconversation.com/files/324351/original/file-20200331-65537-1mn49pk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=602&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/324351/original/file-20200331-65537-1mn49pk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=602&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/324351/original/file-20200331-65537-1mn49pk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=757&fit=crop&dpr=1 754w, https://images.theconversation.com/files/324351/original/file-20200331-65537-1mn49pk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=757&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/324351/original/file-20200331-65537-1mn49pk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=757&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Gaétan Dugas, photographed by Ray Redford in Vancouver, 1972, before becoming the prototypical ‘patient zero’.</span>
<span class="attribution"><span class="source">Richard McKay</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>The investigators’ detailed contact-tracing work revealed a web of sexual connections, eventually linking cases in California with others in New York and cities in other states. The <a href="https://doi.org/10.1016/0002-9343(84)90668-5">investigators initially represented this network</a> with “patient O” at the centre. After other researchers later misread the letter O for the numeral 0, many began to misinterpret the person at the centre of the diagram <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4046389/">as “patient zero”</a>, the “primary case” for the North American epidemic.</p>
<p>This example has <a href="https://www.fadoo.com/killingpatientzero">received more attention recently</a> for the personal consequences it had for Dugas’s memory and the pain it brought his loved ones, as well as for the stigmatising story frame that it set up for subsequent “patients zero”. Initially, Randy Shilts’s popularising account, And the Band Played On, even emphasised – using dubious evidence – that Dugas’s refusal to heed public health guidance demonstrated that he was intent on deliberately infecting others.</p>
<p>However, this historical example also offers a useful cautionary tale for thinking about identifiable individuals linked to a cluster of infections, and about asymptomatic cases more generally.</p>
<p>Dugas, the prototypical “patient zero”, did have a very large number of sexual contacts, and some of the connections depicted took place before his symptoms became apparent. But several other men with AIDS represented in the same diagram had as many or more sexual partners. The main difference was that they could not, or would not, share the contact details for their partners in the way that the cooperative Dugas did. The result was that while Dugas’s identified sexual partners radiated out from him in the diagram like spokes on a wheel, these other men were surrounded by empty space.</p>
<p>In this way, the limits of a contact-tracing model focusing on identifiable cases become clear. When we represent something visually, it becomes much easier to focus on what is depicted instead of what might be missing. Similarly, by representing the known connections between people with symptoms, we risk overlooking the just-as-important connections between those who are infectious but symptom free, and who are less likely to be linked to a chain of infection.</p>
<p>There is another way we can now understand the cluster diagram to direct our attention away from what is important. In 1982, it was reasonable to hypothesise that it might only be a few months between someone being exposed to whatever caused AIDS and subsequently displaying signs of the disease. Representing these men’s sexual connections in a diagram made sense because it seemed likely that these depicted exposures were the ones that had permitted a transmissible agent to infect them.</p>
<p>But it became increasingly apparent that it took much longer for people to display symptoms after they were infected, a process which we now understand to be in the order of eight to ten years, in the absence of other health issues. And we now know that by the time that investigations into AIDS began in earnest in 1981, many thousands of Americans were already infected, going about their lives without realising they had acquired a virus that they were transmitting to other people. </p>
<p>So, <a href="https://www.nybooks.com/articles/1988/12/08/aids-without-end-2/">by the late 1980s</a>, and certainly from our current viewpoint, it is clear that most if not all of the sexual connections depicted in the cluster diagram were <em>not</em> the acts of sexual activity that led to these men becoming HIV-positive. Those exposures would have occurred years earlier, in the early to mid-1970s, beyond the focus of the investigation and therefore left out of the diagram. Not only does this further remove any particular significance attributable to Dugas, but it also importantly reminds us of what we too may be failing to see from our own limited present-day perspective.</p>
<p>In short, by focusing too much of our attention on a “patient zero” or the cases uncovered in a contact-tracing investigation, we risk diverting our attention from the hazards posed by infectious people without symptoms. Also, if we spend too much time thinking about individuals, we risk overlooking steps we can undertake together in our communities.</p>
<p>In other words, the more we can do to think of infection being <em>here</em> among <em>us</em>, instead of <em>over there</em> among <em>them</em>, the more it will allow us to focus on behaviours – things like hand-washing, self-isolation and physical distancing – that can collectively reduce our risk of infection <em>now</em>.</p>
<p>Contact tracing will, and should, remain a vital part of the response to COVID-19 for many months to come.</p>
<p>Since public health responses to a global pandemic generally fall within national jurisdictions, it makes sense that a country’s health authorities will give heightened attention to the first cases of a disease recognised within its borders. Yet authorities should remember that some will interpret this attention as an encouragement to blame outsiders for the disease, feeding into long histories of <a href="https://theconversation.com/calling-covid-19-a-chinese-virus-is-wrong-and-dangerous-the-pandemic-is-global-134307">viewing other parts of the world as disease incubators</a>.</p>
<p>In locations where the virus has not yet become apparent, vigorous tracing of new cases and testing their contacts in a bid for “containment” can help prevent a shift to undetected “community spread”. And in areas where the virus is widespread and the population has been subjected to restrictive measures, any relaxing of controls will also require the careful investigation of new cases to avoid a re-escalation of infections.</p>
<p>Regardless, there should be no more “patient zero” in our stories of COVID-19. We must be conscious of the stories we tell and the connections we trace, remaining mindful of the ripple effects these can have. Writing of a “patient zero” is a damaging red herring that distracts from constructive efforts to contain the epidemic. Let’s wash our hands of this toxic phrase. Our general health, and our ability to understand epidemics now and in the future, will be stronger as a result.</p><img src="https://counter.theconversation.com/content/134721/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Richard McKay receives funding from the Wellcome Trust, a politically and financially independent foundation dedicated to improving health. </span></em></p>Why we should wash our hands of this unhealthy phrase.Richard McKay, Wellcome Trust Research Fellow, Department of History and Philosophy of Science, University of CambridgeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1202982019-07-15T08:47:48Z2019-07-15T08:47:48ZYoung South Africans want to farm. But the system isn’t ready for them<figure><img src="https://images.theconversation.com/files/284061/original/file-20190715-173334-13bn9i2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">There's a perception among young South Africans that farm jobs are back-breaking and financially unappealing.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Persistent unemployment has become <a href="https://www.youthpolicy.org/factsheets/country/south-africa/">synonymous with the youth experience</a> across South Africa. Youth unemployment rates are almost <a href="https://www.ilo.org/empent/whatsnew/WCMS_459490/lang--en/index.htm">four times higher</a> than the regional average – 62% of South Africans between 15 and 35 years are <a href="https://www.ilo.org/empent/whatsnew/WCMS_459490/lang--en/index.htm">unemployed</a> and of these 60% have <a href="https://www.section27.org.za/wp-content/uploads/2013/10/Spaull-2013-CDE-report-South-Africas-Education-Crisis.pdf">never been employed</a>. </p>
<p>Add to this the fact that even those who have jobs are earning below what is considered to be a <a href="https://tradingeconomics.com/south-africa/living-wage-individual">monthly living wage</a> and what emerges is youth employment crisis.</p>
<p>The agricultural sector could be a key source of job creation for young people. But conventional opinion has it that they are turning their backs on the sector despite high levels of unemployment. So what gives? </p>
<p>Drawing on personal narratives collected from 573 young people across three provinces in South Africa, <a href="https://www.tandfonline.com/doi/full/10.1080/03031853.2018.1564680">recent research</a> has begun building a picture what young people think and feel about work in agriculture. </p>
<p>Overall, the prevailing notion that they are turning their backs on the sector seems to hold true. Over 60% of respondents felt that it was harder to make career decisions relating to agriculture than other careers. </p>
<p>But our research dispels the view that this is because of a lack of interest. Based on our interviews, more than half of those surveyed suggested that they saw a place for agriculture in the long-term visions for their lives. This was either as a useful stepping stone, or as an exciting option in its own right. </p>
<p>The problem wasn’t a lack of interest: rather it had to do with the fact that jobs in agriculture were either back-breaking and financially unappealing – at the subsistence level – or they were in large agri-businesses where workers are often treated appallingly. </p>
<p>These voices present a clear mandate to those interested in the future of youth, land and employment in South Africa: open up an economic space for viable family farming in South Africa and young people will throw their energy into the sector.</p>
<h2>Stigma, risk and reward</h2>
<p>Unsurprisingly, agriculture appears to carry a stronger set of negative stigmas than other careers. Examples included themes around agriculture being for poor and elderly people, on the one hand, or, on the other, for wealthier white people. </p>
<p>Agriculture was also perceived by many as a risky career path that involved a lot of hard work for little financial reward. </p>
<p>One 27-year-old put it this way:</p>
<blockquote>
<p>I was 17 and had to put through my university application. I sat my parents down and told them that I wanted to do farming as one of my career choices. They said no, farming was for old people and they didn’t put me {through} school to get dirty running after pigs. They wanted me to do an office job. I had to choose between my parents funding and career. </p>
</blockquote>
<p>Other themes that emerged included peer pressure, shaming, racism and substantial family pressure when considering agriculture as a career choice.</p>
<p>A 20-year-old from Limpopo said: </p>
<blockquote>
<p>I once went to a certain farm to buy tomatoes, while I was there, there was a huge argument between the white boss and a worker who put wrong grades of tomatoes, she was kicked and fell on tomatoes in front of the customers, I started to have questions about working in agriculture.</p>
</blockquote>
<p>Nevertheless, over a third of the young people we spoke to expressed positive vies about working in agriculture. </p>
<p>Many want to work in agriculture. But they said they battled to navigate the spaces between their own vocational motivations, the available work opportunities and the pressures they encountered from friends and family. </p>
<p>A 25-year-old from Kwa-Zulu Natal put it this way:</p>
<blockquote>
<p>I studied agriculture at university. It was a very good career path. I enjoy doing it a lot while my friends were against it, but I carried on {to} finish my year. But the problem came when I have to apply for a job. I didn’t get any job and that was painful to me and it felt like it {was} a waste of time because my parent have faith in me now I’m sitting home with my degree. But I still have hope. </p>
</blockquote>
<h2>Context</h2>
<p>Stepping back to look to contextualise youth narratives within the broader food system presents good news and bad. </p>
<p>The bad news is that there aren’t enough farmers who fill the space between subsistence agriculture and large-scale agri-businesses. This “missing middle” leaves young people feeling trapped.</p>
<p>They either feel trapped by the poverty, isolation and backbreaking drudgery associated with rural subsistence agriculture. Or they face the unappealing prospects of unskilled minimum wage jobs on increasingly industrialised (and often racialised) commercial farming operations. </p>
<p>Seen in this light, it’s not surprising that young people are turning away from agriculture. The choices they are making simply reflect the fact that they are avoiding work that is demeaning. </p>
<p>There is some good news: many young people see potential. They aspire to entrepreneurial work with a deeper social purpose. Encouragingly, many believe that the act of working on the land to produce food is meaningful work.</p><img src="https://counter.theconversation.com/content/120298/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Luke Metelerkamp received funding for this research from The National Research Foundation of South Africa and the Southern Africa Food Lab. He is currently affiliated with the Environmental Learning Research Center and the Center For Complex Systems in Transition.</span></em></p>Agriculture appears to carry a stronger set of negative stigmas than other careers, but this is only half the story.Luke Metelerkamp, Post-doctoral research fellow, Rhodes UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1171212019-05-19T07:43:31Z2019-05-19T07:43:31ZHow do Nigerian gay and bisexual men cope? This is what they told us<figure><img src="https://images.theconversation.com/files/274950/original/file-20190516-69189-1lm0hpw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Many Africans who are not gay or bisexual – sexually attracted only to people of the same sex or of both sexes – claim that being gay or bisexual is <a href="https://www.theguardian.com/global-development/2018/mar/30/blackmail-prejudice-persecution-gay-rights-nigeria">not acceptable</a> for <a href="https://www.notizieprovita.it/wp-content/uploads/2015/12/Global_Divide_on_Homosexuality-Pew_Research_Center.pdf">religious and cultural reasons</a>. Laws in numerous African countries – as is <a href="https://journals.sagepub.com/doi/full/10.1177/1358229115591403">the case</a> in Nigeria – also reflect this by criminalising same-sex sexual activities and same-sex marriage.</p>
<p>This cultural and legal environment increases the chances that gay and bisexual individuals <a href="https://psycnet.apa.org/record/2013-25652-002">will be discriminated against</a>. They can also face threats and physical violence. Gay and bisexual people are aware of this, and often anticipate discriminatory acts even when they are not immediately present. This may include going to great lengths to conceal their sexual orientation. </p>
<p>Taken to the extreme, gay and bisexual people can imbibe these negative attitudes and direct them towards themselves – what’s known as internalised stigma or self-hatred. Collectively, these stressful factors increase the likelihood of mental health problems and low life-satisfaction among gay and bisexual relative to heterosexual individuals. </p>
<p>Research has been done on how people – generally speaking – <a href="https://psycnet.apa.org/record/2012-04677-005">cope with stress </a>. The studies show that some people use helpful strategies such as seeking support. This, in turn, improves their mental health and overall wellbeing. But others take up unhelpful strategies, like drinking, which can worsen their mental health. </p>
<p>Few African studies have investigated how gay and bisexual men manage minority stress. Based on this, my colleagues and I decided <a href="https://www.tandfonline.com/doi/full/10.1080/00918369.2019.1600899">to look into what the situation was among Nigerian gay and bisexual men</a>. Specifically, we set out to find out whether self-stigma affected their quality of life. We also investigated what coping strategies they adopted – both positive and negative – and how these affected them. </p>
<h2>The findings</h2>
<p>We asked 89 gay and bisexual Nigerian men to fill in questionnaires that asked them about self-stigma due to being gay and bisexual, quality of life and the coping strategies they used.</p>
<p>We found that the men in our study were more likely to use positive – or helpful – coping strategies rather than negative ones. These included accepting things as they were – in other words they accepted their sexual orientation and adopted a positive attitude towards it. Strategies like this were also associated with better quality of life.</p>
<p>But there were also those in our study who had adopted unhelpful strategies. These included smoking and drinking. These, in turn, were associated with poorer quality of life.</p>
<p>Other studies <a href="https://www.tandfonline.com/doi/abs/10.1080/00377317.2013.746920">have shown</a> that higher levels of stress in situations like this were often associated with more mental health problems and poor quality of life.</p>
<p>Our findings, however, weren’t as straightforward. Overall, self-stigma was associated with poor quality of life, but when the level of self-stigma was low, its effects were offset by using positive strategies. However, when the levels of self-stigma were high, the positive strategies could not offset the associated poor quality of life. </p>
<h2>Implications</h2>
<p>These findings tell us that gay and bisexual men in Nigeria who have low levels of self-stigma and have adopted positive coping strategies can maintain a good quality of life. This means that one way of helping gay and bisexual men – in Nigeria as well as in other African countries – is to teach them positive strategies. These include accepting themselves for who they are and seeing the positive aspects of being gay or bisexual. This can be done by counsellors, therapists, psychologists, psychiatrists or other medical specialists. </p>
<p>However, these strategies don’t work when the levels of self-stigma are high. This highlights the need to identify factors that can increase self-stigma. These are likely to be connected to the negative attitudes that predominate in many African societies. </p>
<p>This calls for a positive change in the attitude towards gay and bisexual individuals. It also calls for a change in punitive legislation, and positive additions such as laws to protect gay and bisexual individuals from being discriminated against.</p><img src="https://counter.theconversation.com/content/117121/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Olakunle Oginni does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The negative effects of lower levels of self-stigma can be offset by positive coping strategies.Olakunle Oginni, PhD candidate, King's College LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1098212019-01-21T13:30:42Z2019-01-21T13:30:42ZHalf of employers say they are less inclined to recruit obese candidates – it’s not OK<figure><img src="https://images.theconversation.com/files/254125/original/file-20190116-163268-mcmhpn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Women in customer facing roles often suffer most.
</span> <span class="attribution"><a class="source" href="https://www.worldobesity.org/resources/image-bank">World Obesity Image Bank</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>Obesity is one of the most pressing and controversial public health challenges. It has the distinction of being a crisis about which most people have an opinion – often based on a simple diagnosis – but for which nobody has found a correspondingly neat solution. </p>
<p>It’s still very common to hear even clinically trained experts, as well as ordinary folk, trot out tired old certainties about a <a href="https://www.womenshealth.northwestern.edu/blog/obesity-it-disease-or-choice">lack of willpower</a>, or that it is a lifestyle choice for which people should take more responsibility. Even in some modern businesses, it seems that it’s still OK to target discriminatory practices against those living with obesity. </p>
<p>Only recently, Pakistan International Airlines was reported to have told <a href="https://www.independent.co.uk/travel/news-and-advice/pakistan-international-airlines-cabin-crew-weight-loss-flight-fat-weight-limit-a8715166.html">overweight cabin crew</a> that they must lose weight or be grounded. “No one would like to have shabby crew in the aircraft,” <a href="https://edition.cnn.com/travel/article/pakistan-international-airlines-cabin-crew-weight-memo-intl/index.html">a spokesperson reportedly said</a> in mitigation. </p>
<p>So is it time to get tougher on obese or overweight workers and the “burden” they have become, or would a more empathetic and supportive approach work better?</p>
<h2>Obesity: the facts</h2>
<p>In England, <a href="https://www.gov.uk/government/news/dame-carol-black-publishes-review-on-links-between-work-and-addiction">60% of men and 50% women are overweight or obese</a>. A quarter of men and women are obese and this has been increasing over the last 30 years. For comparison, in 1980 only 7% of adults were obese. In 2014-2015 treating obesity and its consequences cost the NHS in England £5.1 billion. </p>
<p>Evidence shows the causes of obesity are devilishly complex. The 2007 UK government’s Foresight report on <a href="https://www.gov.uk/government/publications/reducing-obesity-future-choices">the science of obesity</a> remains one of the most comprehensive dismantling of the “lack of willpower” argument. It showed dozens of medical, psychological and societal contributors to the problem.</p>
<p><a href="https://www.gov.uk/government/news/dame-carol-black-publishes-review-on-links-between-work-and-addiction">Dame Carol Black’s review</a> into the impact on employment outcomes of drug or alcohol addiction, and obesity – to which I was an adviser – found there are many social determinants of obesity. <a href="http://www.euro.who.int/__data/assets/pdf_file/0003/247638/obesity-090514.pdf">A major review by the World Health Organisation</a> found that over 33% of those not in work, and those who are either obese or severely obese, were from the most deprived areas. </p>
<p>This means that obese people in lower socioeconomic groups are getting heavier at a faster rate than people in higher socioeconomic groups. This is illustrated in the graph below from France where, between 1997 and 2012, the lowest income group became obese more than three times faster than those in the two highest income groups.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/254118/original/file-20190116-163265-1kqkbn9.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/254118/original/file-20190116-163265-1kqkbn9.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=425&fit=crop&dpr=1 600w, https://images.theconversation.com/files/254118/original/file-20190116-163265-1kqkbn9.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=425&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/254118/original/file-20190116-163265-1kqkbn9.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=425&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/254118/original/file-20190116-163265-1kqkbn9.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=534&fit=crop&dpr=1 754w, https://images.theconversation.com/files/254118/original/file-20190116-163265-1kqkbn9.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=534&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/254118/original/file-20190116-163265-1kqkbn9.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=534&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="attribution"><span class="source">2014/ World Health Organisation.</span></span>
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Read more:
<a href="https://theconversation.com/your-parents-lifestyles-can-determine-your-health-even-as-an-adult-86879">Your parents’ lifestyles can determine your health – even as an adult</a>
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</em>
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<h2>Weight stigma</h2>
<p>Obesity in the workforce is something we still hear less about, but which is also increasing. <a href="https://publications.parliament.uk/pa/cm200304/cmselect/cmhealth/23/2309.htm">Public Health England estimates</a> that up to a third of working people are obese and that there are 16m days of sickness absence each year due to obesity. The cost of lost productivity in the US attributable to obesity has been <a href="https://bmjopen.bmj.com/content/7/10/e014632">estimated at $15.1 billion</a>. <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/obr.12621">Shift workers</a> also have an elevated risk of obesity too.</p>
<p>What is clear is that negative stereotypes about obese people at work persist. They are often seen as lazy, lacking in self-discipline, less competent, less conscientious and unmotivated. <a href="https://www.hrmagazine.co.uk/article-details/obesity-at-work-fighting-fat-or-fighting-stigma">Obese</a> workers often have lower starting pay and less hiring success – <a href="https://www.crosslandsolicitors.com/site/crossland_news/Employer_survey_obese_candidates_2015_html">45% of employers</a> say they are less inclined to recruit obese candidates. They are less likely to be regarded as able leaders or to have career potential, are more likely to experience bullying and harassment, and obese women are less likely to get customer-facing jobs. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/254126/original/file-20190116-163265-nlljbo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/254126/original/file-20190116-163265-nlljbo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/254126/original/file-20190116-163265-nlljbo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/254126/original/file-20190116-163265-nlljbo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/254126/original/file-20190116-163265-nlljbo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/254126/original/file-20190116-163265-nlljbo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/254126/original/file-20190116-163265-nlljbo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The workplace can be a difficult place for people with obesity.</span>
<span class="attribution"><span class="source">World Obesity Federation</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p><a href="https://onlinelibrary.wiley.com/doi/full/10.1038/oby.2008.636">One study on employment discrimination</a> found the more overweight a person is, the more the likely they are to report discrimination in the workplace. Overweight workers were 12 times more likely, obese respondents were 37 times more likely, and severely obese respondents were 100 times more likely than normal weight respondents to report employment discrimination. </p>
<p>Women are also 16 times more likely to report weight related employment discrimination than men. This is because parts of our service sector have an “<a href="https://www.theguardian.com/society/2016/dec/02/dorchester-hotel-could-be-sued-over-grooming-rules-for-female-staff">aesthetic labour</a>” market where body image and grooming are at least as important as competence. </p>
<p>The relationship between obesity and mental health is also important. <a href="https://onlinelibrary.wiley.com/doi/full/10.1002/oby.21052">One study</a> found that discrimination on the basis of weight explains much of the link between obesity and psychological well-being and there is clear evidence that <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5561038/">anti-psychotic drugs</a> and obesity are linked. Despite all this complexity, for some it’s still easier to blame the obese. </p>
<h2>Supportive help</h2>
<p>In Europe, <a href="https://europeanlawblog.eu/tag/case-c-35413-kaltoft/">the law is catching up</a> with the need to make sure that employers understand that functional impairment – such as reduced mobility – resulting from extreme obesity can be considered as coming under the scope of equalities legislation as a “protected characteristic” and require workplace adjustments to be made. This at least points the way towards supportive rather than punitive approaches in workplaces. </p>
<p>Offering support is not about absolution but it is about helping people living and working with obesity and overweight to take more control and to make changes to their diets and lifestyles which gradually rebuild self-esteem and agency. </p>
<p>Workplaces can be great arenas within which this support can be offered without prejudice and where small successes can be built upon. I’m old-fashioned enough to believe that kindness and empathy are, in the end, more powerful forces than derision and contempt. Let’s give them a try.</p><img src="https://counter.theconversation.com/content/109821/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stephen Bevan receives funding from bodies such as the Department of Work and Pensions, the Engineering Employer's Federation and the European Occupational Safety and Health Agency to conduct research on workforce health policy and practice.</span></em></p>People with obesity earn less and have a harder time finding work.Stephen Bevan, Head of HR Research Development, Institute for Employment Studies, Lancaster UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1015512018-09-17T14:53:31Z2018-09-17T14:53:31ZEx-offenders in South Africa should get a resettlement grant. Here’s why<figure><img src="https://images.theconversation.com/files/236460/original/file-20180914-177941-1a8dv28.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Stigmatising and shaming ex-offenders hampers efforts to reintegrate them into society.</span> <span class="attribution"><span class="source">shutterstock</span></span></figcaption></figure><p>South Africa’s prison authorities <a href="https://www.news24.com/SouthAfrica/News/mps-reject-social-grants-for-ex-convicts-20170201">have proposed paying unemployed ex-offenders</a> a social grant for a transitional period after serving their sentences. The grant would provide thousands who re-enter society every year with some income while they try to put their lives back together. </p>
<p>Ex-offenders with a criminal record find it hard to reintegrate into society when they’re released. More often than not, they are returned to prison because they can’t make it on the outside. Most ex-offenders are stigmatised and find it impossible to find a job. <a href="https://acjr.org.za/resource-centre/Ex-prisoners%20Views%20on%20Imprisonment%20and%20Re-Entry.pdf">Research on former prisoners shows that</a> finding employment is perhaps the most daunting obstacle facing released ex-offenders in South Africa. </p>
<p>The grant proposal by the Department of Correctional Services is an innovative idea and should be taken seriously. But the department has met with a lot of opposition. Members of parliament from the country’s biggest parties have rejected it outright. Many argued that a grant would be <a href="https://www.news24.com/SouthAfrica/News/mps-reject-social-grants-for-ex-convicts-20170201">equavalent</a> to “rewarding” ex-offenders for their crimes.</p>
<p>The rejection of DCS’s proposal is a pity. <a href="http://hdl.handle.net/11660/9289">My own research</a> found that ex-offenders in South Africa suffer from being stigmatised and shamed. This has meant that all previous integration efforts have failed. Accepting the grant proposal would ease the transition and go some way to alleviating the problem.</p>
<h2>Stigma and shame</h2>
<p>Criminologists see the reintegration of returning ex-offenders as important to helping curb the tendency of criminals to re-offend. Reintegration strategies need to address the shame inherent in stigmatisation. </p>
<p>The Australian criminologist John Braithwaite made <a href="http://genup.net/connect/action-portal?id=101">the valuable distinction</a> between two kinds of societal responses to crime and, by extension, ex-offenders.</p>
<p>The first is a culture in which offenders are stigmatised and driven away from mainstream culture. Most Western countries (including the US and the UK, as well as South Africa) fall into this category.</p>
<p>In the second – what he called integrative shaming cultures – offenders are also shamed but once the punishment has run its course, they’re accepted back as a full member of that society. What’s notably absent from this response is stigma. China and Japan take this approach. </p>
<p>Research shows that in these cultures, recividism is much lower. Re-offending rates in China at the turn of the century stood at 6%-8% compared to 86%-94% in post-apartheid South Africa.</p>
<p>Based on Braithwaite’s insights it’s clear that in South Africa stigma drives ex-offenders into the arms of criminal subcultures. Given this, what should South Africa do?</p>
<h2>Reintegration?</h2>
<p>South Africa’s <a href="http://www.crimestatssa.com/">runaway crime rates</a> and unsustainable rates of re-offending are the direct result of the country’s inability to successfully integrate ex-offenders. </p>
<p>Given the prevailing culture it’s no surprise that past reintegration programmes have failed. As my research points out, cultures that stigmatise ex-offenders are by definition “selfish” and not “caring”. This makes reintegration close to impossible. </p>
<p>Every effort must be made to ease the impact of stigma, including the marginalisation and discrimination of ex-offenders.</p>
<p>Research in China found that ex-offenders in communities in which <a href="https://www.researchgate.net/publication/248967367_Crime_prevention_in_a_communitarian_society_Bang-jiao_and_Tiao-jie_in_the_People's_Republic_of_China">‘<em>bang-jiao</em>’ (re-integration) neighbourhood committees</a> are active are at least 50% less likely to re-offend than in areas without them. The mandate of ‘bang-jiao’ committees is to <a href="https://www.researchgate.net/publication/248967367_Crime_prevention_in_a_communitarian_society_Bang-jiao_and_Tiao-jie_in_the_People's_Republic_of_China">“assist and guide those who have misbehaved”</a> and actively contribute to their constructive resettlement with warmth, love and acceptance.</p>
<p>In the US, research by criminologist <a href="https://nypost.com/2016/04/04/statistical-proof-that-america-doesnt-care-about-ex-cons/">Christopher Uggen and his group of co-workers</a> has shown that ex-offenders are almost obsessed with rejoining society as responsible citizens. For the most part, however, their efforts are rebuffed.</p>
<p>If ex-offenders have served their time and have shown genuine remorse and a willingness to reform their ways, they should be lent a helping hand in making a renewed effort at living an honest and honourable life. This is not a plea to “reward” criminals. It’s about designing an intervention that encourages ex-offenders to get back on track. </p>
<p>And to stop any potential abuse of the system, the initiative should arguably be extended only to <a href="http://users.soc.umn.edu/%7Euggen/Uggen_Wakefield_Chap_05.pdf">first time and elderly offenders</a>.</p>
<h2>Tackling recidivism</h2>
<p>If South Africa is serious about curbing the country’s unsustainably high and rising rate of recidivism, it should seriously consider sensible suggestions about integrating ex-offenders. </p>
<p>The proposal to provide newly released ex-offenders with some bridging income is one such idea.</p>
<p>Politicians should refrain from knee-jerk, politically expedient and for the most part ignorant reactions. Integration is a tall order in a country where ex-offenders are routinely stigmatised and shamed. This applies equally to the challenges that face both returning ex-offenders and the communities that have to absorb them.</p>
<p>Integration will remain a pipe dream unless a more broad-based approach – one that moves away from punitive stigma as the sole response to crime – is considered and implemented.</p><img src="https://counter.theconversation.com/content/101551/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Casper Lӧtter does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Politicians’ knee jerk dismissal of an idea that could help rehabilitate ex-offenders is
unhelpful.Casper Lӧtter, PhD candidate in Social Philosophy, University of the Free StateLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/796552017-08-03T01:03:21Z2017-08-03T01:03:21ZStigma and stereotypes about sex work hinder regulatory reform<figure><img src="https://images.theconversation.com/files/178601/original/file-20170718-22052-1s4kh60.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">In 2016, a UK Home Affairs Committee report highlighted that street-based sex work has diminished significantly over the last two to three decades.</span> <span class="attribution"><span class="source">shutterstock</span></span></figcaption></figure><p><em>Although sex workers around the world lobby for decriminalisation, sex work law remains controversial. This article is part of a <a href="https://theconversation.com/au/topics/sex-work-series-41416">series</a> exploring sex work and regulatory reform.</em></p>
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<p>Mention the word “prostitution” and there’s more than a fair chance that most people will automatically think of a drug-dependent female in high heels and a mini-skirt shivering on a cold and darkened street in a dodgy part of the city.</p>
<p>This stereotypical image is largely informed by popular cultural and media representations of sex workers and red-light districts. Socially conservative politicians, religious organisations, and certain branches of radical feminism also <a href="http://journals.sagepub.com/doi/abs/10.1177/0042098016674903">play an instrumental role</a> in perpetuating this stereotype and reinforcing the stigma endured by sex workers.</p>
<p>However, sex work is much <a href="https://us.sagepub.com/en-us/nam/prostitution/book232295">more complex and nuanced</a> in terms of the types of people who offer commercial sexual services, the types of sex work they perform, where sex work takes place, and why people engage in it.</p>
<p>To be clear, “sex work” is used here to refer to consensual sexual encounters between two or more adults for some form of payment. Sex work includes different types of erotic labour such as street work, brothel work, in-calls, lap-dancing, web-camming and pornography. Sex work may involve direct and indirect sexualised interactions between provider and client.</p>
<p>People forced or coerced into providing commercial sex against their will by a third party can in no way be viewed as performing sex work. Such acts constitute labour/sexual explotiation and even, depending on the circumstances, <a href="https://www.amnesty.org/en/latest/news/2015/08/sex-workers-rights-are-human-rights/">human trafficking</a>. </p>
<p>Consensual sex work and human trafficking for sexual exploitation are wrongly conflated, by certain <a href="http://journals.sagepub.com/doi/pdf/10.1177/0002716214521562">political, religious and feminist groups</a>, as being one and the same thing.</p>
<h2>Why people engage in sex work</h2>
<p>It is important to acknowledge that people do in fact <a href="https://www.nytimes.com/2016/05/07/insider/the-everyday-faces-of-sex-workers.html">choose to do sex work</a>. This is not to say that these decisions are easy or without challenges to the individual because of wider social taboos and stigma that surround sex and sex work.</p>
<p>For many people, economic expediency or necessity is a key factor. For example, <a href="http://www.smh.com.au/federal-politics/political-news/brothels-say-welfare-cuts-push-mums-to-sex-work-20130120-2d19x.html">The Sydney Morning Herald</a> reported in 2013 that an increasing number of single mothers were turning to sex work and lap-dancing in order to make ends meet, due to cuts in parenting welfare payments.</p>
<p>People in other <a href="https://nyupress.org/books/9780814794630/">vulnerable or precarious situations</a> such as drug or alcohol dependency, abusive relationships, homelessness, unemployment, or coming to terms with their sexual and gender identity may also engage in sex work for <a href="https://cup.columbia.edu/book/male-sex-work-and-society/9781939594013">survival, experimental and/or lifestyle purposes</a>.</p>
<p><a href="http://www.thestudentsexworkproject.co.uk/wp-content/uploads/2015/03/TSSWP-Research-Summary-English.pdf">A 2015 study</a> in the UK found that one in 20 students were involved in sex work. As students find themselves facing increased debt burdens by the time they graduate, sex work has become a means of mitigating this issue and also covering costs while living away from home and attending university.</p>
<p>Other people <a href="https://www.nytimes.com/2016/05/07/insider/the-everyday-faces-of-sex-workers.html">choose sex work</a> because it offers them economic opportunity. It is seen as a form of labour they can exploit for material gain because they have a certain mix of attributes in terms of sexuality, looks, skills, personality and attitude.</p>
<p>Sex work also offers flexible working hours that suit peoples’ lifestyles. </p>
<h2>Sex work spaces</h2>
<p>It is often assumed that only women are sex workers. While it is the case that the majority of sex workers are women, <a href="https://cup.columbia.edu/book/male-sex-work-and-society/9781939594013">men</a> plus <a href="https://cup.columbia.edu/book/transgender-sex-work-and-society/9781939594228">trans and gender-diverse</a> individuals also engage in sex work. </p>
<p>The complex legal arrangements and stigma that surround sex work means it is impossible to ascertain the number of sex workers in Australia. Estimates put the overall number at around <a href="http://www.aic.gov.au/publications/current%20series/rpp/121-140/rpp131/05_aus_industry.html">20,000 people</a>. The gender profile of sex workers varies across different sex work scenes. </p>
<p>Street-based sex work tends mainly to comprise women with a predominantly male client base. For some, this mode of sex work offers greater labour flexibility, autonomy, and lower overheads compared to indoor work.</p>
<p>There are small street-based scenes in cities like <a href="http://pure.qub.ac.uk/portal/files/100681556/Ellison_ARTC_172.pdf">Manchester, London, Dublin and Berlin</a> involving young queer-identifying males who often have older heterosexual-identifying male clients. There is also an <a href="http://www.aboutmaleescorting.com/women-who-buy-sex/">emerging body of research</a> showing that an increasing number of women are now booking the services of male and female sex workers. </p>
<p>Street-based sex work is often imagined to be the most visible and prominent form of sex work. This is far from true. It is estimated that the street-based scene in Australia accounts for between <a href="http://www.aic.gov.au/publications/current%20series/rpp/121-140/rpp131/05_aus_industry.html">5-10%</a> of sex work. Street-based sex work is illegal in all states and territories with the <a href="http://www.scarletalliance.org.au/laws/nsw/">exception of New South Wales</a>, where it is:</p>
<blockquote>
<p>… lawful as long as it is not near or within the view of a school, church, hospital or dwelling.</p>
</blockquote>
<p>In 2016, the <a href="https://www.publications.parliament.uk/pa/cm201617/cmselect/cmhaff/26/26.pdf">UK Home Affairs Committee</a> highlighted that street-based sex work had diminished significantly over the last two to three decades, with research suggesting it accounts for less than 5% of all sex work.</p>
<p>The majority of sex work in Australia now takes place off-street and/or online. Off-street sex work spaces include brothels, saunas, massage parlours, private apartments or homes, BDSM dungeons, strip clubs and lap-dance bars. Most of these tend to be female-dominated work spaces. The vast majority of male, trans and gender diverse sex workers offer their services online. </p>
<p>Online sex work generally refers to websites or social media platforms that sex workers use to advertise their services, where clients can make bookings, and where some form of live or recorded sexual performance can be viewed. <a href="https://theconversation.com/webcamming-the-sex-work-revolution-that-no-one-is-willing-to-talk-about-69834#comment_1170010">Webcam performers</a> can market anything from conversation to explicit sex acts. </p>
<p>All manner of people, in terms of gender, age, sexuality, socioeconomic status, ethnicity and body shape can be found on cam websites. For some sex workers, web-camming might be their primary form of erotic labour and source of income. For others, such as adult performers, web-camming may be an additional or supplementary form of income.</p>
<h2>Time to decriminalise consensual sex work</h2>
<p>Consensual sex work takes multiple forms and takes place in a variety of spaces. The actual practice of sex work, like non-commercial sex, predominantly takes place behind closed doors; it is discreet, private and out of view.</p>
<p>When sex workers experience exploitation or violence at the hands of clients, employers, the police or others, these crimes must be be dealt with promptly and justly. </p>
<p>For Australian sex workers and peer-led sex work organisations, decriminalisation is seen as the only model of regulation because it affords protection of their human and labour rights. </p>
<p>Decriminalisation is supported by a number of highly respected international organisations including: <a href="https://www.amnesty.org/en/documents/pol30/4062/2016/en/">Amnesty International</a>, <a href="https://www.hrw.org/sites/default/files/wr2014_web_0.pdf">Human Rights Watch</a>, the <a href="http://www.who.int/hiv/topics/sex_work/en/">World Health Organization</a>, and <a href="http://www.unaids.org/en/resources/presscentre/featurestories/2017/june/20170602_sexwork">UNAIDS</a>.</p>
<p>The Legislative Council in the South Australian parliament recently passed a bill <a href="http://www.abc.net.au/news/2017-07-06/sa-sex-work-decriminalisation-marathon-debate/8682738">supporting the decriminalisation</a> of sex work. If the Legislative Assembly passes the bill then South Australia will be the second state to do so, after NSW which decriminalised sex work in 1995.</p>
<hr>
<p><em>Read the rest of the articles in this series <a href="https://theconversation.com/au/topics/sex-work-series-41416">here</a>.</em></p><img src="https://counter.theconversation.com/content/79655/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span> Nothing to disclose</span></em></p><p class="fine-print"><em><span>Emily Cooper does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Consensual sex work, like non-commercial sex, mostly happens behind closed doors. Yet stigma toward and ignorance about sex workers makes people panic when we try to talk about reform.Paul J. Maginn, Associate Professor of Urban/Regional Planning, The University of Western AustraliaEmily Cooper, Lecturer in Human Geography, University of Central LancashireLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/761382017-06-02T20:00:28Z2017-06-02T20:00:28ZDoes changing style of hair or dress help black people avoid stigma?<p>On the eve of the NBA Finals, superstar LeBron James found the “N-word” spray painted on his home. Not even <a href="http://www.espn.com/nba/story/_/id/19505341/police-looking-racial-slur-sprayed-front-gate-lebron-james-home-los-angeles">James</a>, with all his wealth, fame and success, is exempt from being <a href="https://theconversation.com/uncovering-the-roots-of-racist-ideas-in-america-71467">attacked with classic racist slurs</a>.</p>
<p>In the United States, blackness is stamped with centuries-old <a href="http://www.publicaffairsbooks.com/book/hardcover/stamped-from-the-beginning/9781568584638">images and ideas</a> that assign it to <a href="http://press.uchicago.edu/ucp/books/book/chicago/S/bo21386376.html">perpetual “last place</a>.”</p>
<p>One way blacks have historically responded to stigma – a discredited or disgraced identity – is by displaying what they understand as mainstream values associated with white elites. This strategy, often referred to as “respectability,” is intended to put on display black people’s fitness for full cultural and social citizenship, thereby protecting them from stigma or lowering their exposure to it.</p>
<p>We know from prior research that consumption has been an important <a href="http://www.springer.com/us/book/9780306460890">part of this strategy</a> since a full-fledged mass market emerged in the U.S. in the late 1800s. The mass market brought with it standard product quality, package sizes and prices. Before that, <a href="https://www.uncpress.org/book/9780807848067/american-dreams-in-mississippi/">as historian Ted Ownby has detailed</a>, blacks had little chance to escape discrimination and stigmatized treatment at local general stores. The mass market, at least in principle, provided an opportunity to express equality with whites in a very tangible way.</p>
<p>These everyday acts of consumption may seem simple, but they gave birth to the Montgomery bus boycott and other acts of anti-racist resistance. Rosa Parks and Montgomery’s riders protested more than the indignity of “back of the bus” treatment. They protested paying full fare for less than full service. Likewise, the student sit-ins at lunch counters throughout the Jim Crow South, as well as protests at leisure places in the North <a href="http://www.upenn.edu/pennpress/book/15035.html">like swimming pools, golf courses and amusement parks</a>, protested for the rights of blacks to engage fully as consumers.</p>
<p>As a researcher who studies sociological aspects of consumption, <a href="https://www.researchgate.net/profile/David_Crockett2/publications">including racial inequality</a>, I examine the question of how well consumption works to manage everyday anti-black stigma in a forthcoming study in the <a href="http://academic.oup.com/jcr/article/doi/10.1093/jcr/ucx049/3064204/Paths-to-Respectability-Consumption-and-Stigma?guestAccessKey=04bdd54a-31c8-47b4-b394-972286268627">Journal of Consumer Research</a>.</p>
<p>Here’s what I found.</p>
<h2>Two approaches</h2>
<p>My analysis shows that members of the contemporary black middle class continue to use consumption to combat stigma. However, after the end of the civil rights movement by 1970, the strategy splintered into two approaches.</p>
<p>The most traditional approach involves avoiding stigmatized objects and practices. The other approach, which emerged after 1970, uses cultural features of blackness to destigmatize objects and practices.</p>
<p>People at times use both strategies to combat “[Fill in the blank] while black” treatment at <a href="http://scholarship.sha.cornell.edu/articles/587/">restaurants</a>, <a href="http://www.ebony.com/news-views/black-bank-profiling-lawsuit">banks</a>, in <a href="http://losangeles.cbslocal.com/2016/02/02/city-council-oks-airport-ban-on-cab-drivers-who-refuse-customers-based-on-race/">taxis</a> or <a href="https://www.bloomberg.com/news/articles/2016-10-31/study-finds-racial-discrimination-by-uber-and-lyft-drivers">using a ride-hailing app</a> like Uber or Lyft. </p>
<h2>How well do these strategies work?</h2>
<p><em>Note: To protect the anonymity of study participants, I do not identify specific locations. I also use pseudonyms.</em></p>
<p><strong>Case 1: When avoiding stigmatized things or actions works</strong>. No one better embodies this than former President Barack Obama and First Lady Michelle Obama (not participants in my study, unfortunately). Their entire public persona <a href="https://www.theatlantic.com/politics/archive/2013/05/how-the-obama-administration-talks-to-black-america/276015/">scrupulously avoids anti-black stigma</a>. </p>
<p>Many study participants likewise reported an emphasis on avoiding stigmatized objects and practices. For example, one person was critical of “sagging” pants or shorts as a style because it invites stigmatized treatment. They feel that this vigilance in avoiding stigma helps them “fit in” in predominantly white settings. </p>
<p><strong>Case 2: When avoiding stigmatized things or actions fails</strong>. Rather than 1950s-style discrimination or open racial hostility, participants emphasized seeing fewer benefits from middle-class status than their white counterparts. For instance, a group of participants who each migrated to a small, rural southern town from more cosmopolitan settings found that avoiding stigmatized objects and practices did not help them or their children fit in with white middle-class peers. They felt they were not granted the status that presumably comes with middle-class occupations, accomplishments and households. </p>
<p>A participant spoke about coming to terms with this in the context of his daughters’ experience at school. In a story I heard repeated, he said:</p>
<blockquote>
<p>“You know when it hit me? Prom. That’s when it finally – when my daughter had to go to prom with her girlfriends… I was like how tough is this for you to be an A student, an athlete, doing the right thing, and you can’t even date these knuckleheads because they want certain things that you’re not ready to compromise?”</p>
</blockquote>
<p>Prom, with its formal dresses and tuxedos, bouquets and boutonnieres, hair, makeup and limousines, is the quintessential consumption event of adolescence. It is also where the politics of race, class and gender became crystal clear to this dad. His daughter refused to accept last-place stigma, which for black girls means the <a href="http://www.npr.org/templates/story/story.php?storyId=10057104">presumption of openness to sexual advances</a>. Although she conformed to the classic “good girl” norms of achievement and chastity, this did not shield her from last place stigma. It also left her dateless on prom night. </p>
<p><strong>Case 3: When “oppositional respectability” succeeds</strong>. My study is the first to identify this approach to combating stigma, which emerged after 1970. Rather than avoid stigmatized things and actions, it seeks to remove stigma using features of black culture. For instance, one participant, Adam, does this by cultivating an identity as a cosmopolitan consumer of fine arts who especially loves African-American and African art.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/165153/original/image-20170412-25898-1j88v7x.PNG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/165153/original/image-20170412-25898-1j88v7x.PNG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=487&fit=crop&dpr=1 600w, https://images.theconversation.com/files/165153/original/image-20170412-25898-1j88v7x.PNG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=487&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/165153/original/image-20170412-25898-1j88v7x.PNG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=487&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/165153/original/image-20170412-25898-1j88v7x.PNG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=612&fit=crop&dpr=1 754w, https://images.theconversation.com/files/165153/original/image-20170412-25898-1j88v7x.PNG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=612&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/165153/original/image-20170412-25898-1j88v7x.PNG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=612&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Pieces from Adam’s art collection.</span>
<span class="attribution"><span class="source">Author provided</span></span>
</figcaption>
</figure>
<p>His extensive art collection is an expression of pride in his cultural heritage, although black art is historically stigmatized as <a href="http://www.journals.uchicago.edu/doi/abs/10.1086/496153?journalCode=wp">“low-brow” and unrefined</a>. So how does he destigmatize these objects?</p>
<p>In my interview with him, his extensive knowledge of pieces with slave themes allow him to craft a story that centers (rather than minimizes) slavery as an ordeal that forged great strength of character. In his telling, that character – and in effect, the art – is part of his cultural heritage.</p>
<p><strong>Case 4: when “oppositional respectability” fails</strong>. Cynthia, a young, single, corporate attorney, lives in a midsized southern city. She migrated there, the city of her childhood, after law school. It’s a traditional black working-class and poor neighborhood derisively known as “Black Bottom.” She was one of few blacks to be part of a wave of gentrification in the neighborhood. Like Adam, she sought to combat last-place stigma by removing stigma from the neighborhood. The ways <a href="https://newsone.com/3114333/gentrification-is-racist-brooklyn-landlord/">gentrification exacerbates racial inequality</a> are well-documented, yet has also <a href="http://press.uchicago.edu/ucp/books/book/chicago/H/bo3643926.html">helped remove last-place stigma</a> attached to certain neighborhoods.</p>
<p>The market reinforced her efforts, as it did Adam’s. Builders renovated older homes and buildings in anticipation of newcomers. But many of the first wave of gentrifiers moved away for fear of crime. When perceptions of neighborhood disorder become widespread they almost invariably exceed reality, but they are very <a href="http://myweb.fsu.edu/bstults/ccj5625/readings/sampson_raudenbush-spq-2004.pdf">difficult to change</a>.</p>
<p>Cynthia did not see her move to combat stigma as successful. When I interviewed her, she was contemplating leaving the area, as life there became less tolerable. Many traditional residents saw her as just another gentrifying intruder. And without any real change in the neighborhood stigma, Cynthia felt navigating crime in the neighborhood wasn’t worth it, even if it wasn’t as bad as its reputation suggested.</p>
<h2>Shaking stigma</h2>
<p>Avoiding stigmatized things and actions is the classic approach for many African-Americans. For them, “Pull up your pants!” has an unassailable logic. But my research suggests that, whatever other benefits may come from hiking up one’s britches, that won’t always effectively combat stigma. </p>
<p>Many participants shared instances of their refusal to internalize anti-black stigma, and how they expressed that through things like art collections, home displays, and personal hair and clothing styles. This approach works best when people can craft stories that disavow stigma and the marketplace reinforces their stories.</p>
<p>Yet for many, stigma still attaches more strongly to black identity than to <a href="http://www.apa.org/news/press/releases/2014/03/black-boys-older.aspx">specific behaviors or objects</a>. Once attached, it can <a href="https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2538616">survive for a long time</a>.</p><img src="https://counter.theconversation.com/content/76138/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>David Crockett received funding for this study from the Institute for African American Research at the University of South Carolina. </span></em></p>Research on how black people try to avoid racism in their daily lives shows that following white, mainstream standards can have mixed results.David Crockett, Associate Professor of Marketing, University of South CarolinaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/564812016-04-01T10:19:50Z2016-04-01T10:19:50ZHow can we help young adults with autism thrive in the workplace?<figure><img src="https://images.theconversation.com/files/117036/original/image-20160401-31093-ltpmkt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Navigating work and stress can be hard for anyone, but especially so if you have ASD.</span> <span class="attribution"><span class="source">Woman at work via www.shutterstock.com</span></span></figcaption></figure><p>The outlook is often bleak for young adults with autism spectrum disorders (ASD). Even when they manage to graduate from high school or college, it’s very difficult for them to find a full-time job.</p>
<p>While there are many programs that help them interact with society when they’re young, those services are typically cut off by the time they graduate, leaving them with few options if they’re unable to navigate the work world on their own. </p>
<p>As a result, just 58 percent of young adults in their late teens and early 20’s with ASD worked for pay outside the home after high school, a far lower share than those with other types of disabilities, according to the <a href="https://nevadaautism.com/national-autism-indicators-report-transition-into-young-adulthood/">2015 National Autism Indicators Report</a>. Those who were employed tended to work part-time in low-wage jobs. </p>
<p>Currently the primary services intended to help young adults with autism are so-called sheltered programs that start them in a segregated work environment with the hope that they will be able to become employed with a regular company down the road. But because they are narrowly focused and usually don’t include training in social cognition, they rarely succeed in this goal. </p>
<p>Frustrated by the lack of transition programs available, I worked with Autism Services and Resources Connecticut (ASRC) to see if there was a better way to help these individuals learn the social and cognitive skills necessary to thrive in the workplace. The results, which involved help people with ASD work in demanding jobs processing patent applications, were encouraging.</p>
<p>First let’s consider why it’s so difficult for individuals with autism to cope in social and work environments in the first place. </p>
<h2>Background on ASD</h2>
<p>Individuals with ASD <a href="https://www.researchgate.net/publication/262178232_Using_Handheld_Applications_to_Improve_the_Transitions_of_Students_with_Autism_Spectrum_Disorders">tend to have difficulties with social interactions</a> and social communication. They may feel lost or anxious if an assigned task isn’t clearly explained or if a sequence of events is not fully understood. </p>
<p>They also struggle with the rapid comprehension required for spoken communication. The fleeting nature of verbal language (once spoken, words disappear) is <a href="http://www.iidc.indiana.edu/styles/iidc/defiles/IRCA/Structured%20Teaching%20Strategies%20Article%202.pdf">especially problematic</a> when the information is complex or lengthy. </p>
<p>The <a href="http://rstb.royalsocietypublishing.org/content/358/1430/345">so-called enactive mind theory</a> was articulated in the early 2000s by researchers at the Yale Child Study Center to try to explain why ASD causes these social deficits. The theory is based on the emerging field of embodied cognitive neuroscience. It posits that the social deficit in autism arises from an atypical developmental trajectory beginning in the first months of life that precludes an individual from having the experiences necessary for normal social development. </p>
<p>When entering new or unfamiliar social and physical environments, individuals with ASD often experience a high level of anxiety that may result in inappropriate behavioral manifestations, such as tantrums or crying, or social withdrawal. This makes it difficult for them to independently enter the workforce. </p>
<h2>Sheltered programs</h2>
<p>Unfortunately, <a href="http://www.socialworktoday.com/archive/090208p12.shtml">few programs exist</a> for helping young adults with ASD to transition effectively to college and the workplace. </p>
<p>There are quite a few programs across the country that provide job coaching or employment opportunities for individuals with ASD, but they tend to be sheltered. That is, the employees start in a segregated work environment with the hope that they will be able to become employed with mainstream employers at a later point. </p>
<p>Sheltered workplaces also tend to focus on a specific skill set and do not provide a curriculum in social cognition. Since they are often subsidized, they are constantly seeking more financial support. They also tend to lack transition planning to help employees find competitive jobs elsewhere.</p>
<p>While they play an invaluable role in helping individuals with ASD, they rarely achieve the goal of true independence.</p>
<h2>‘Falling off a cliff’</h2>
<p>Hoping to find a better solution, Lois Rosenwald, executive director of ASRC, and Julie Hipp, its board president, in 2014 created a for-profit startup called Open Options Partnership to figure out what might better integrate young adults with ASD into the workforce. </p>
<p>The idea was to see if people with ASD could develop and improve crucial social skills while working at a task they might be particularly well-suited for: researching patents. </p>
<p>I was the independent evaluator of the project. Rosenwald and I served together on Connecticut’s Autism Spectrum Disorder Advisory Council’s subcommittee to improve and expand access to training, consultation and learning opportunities for providers, professionals and families. I also <a href="https://www.researchgate.net/publication/262178232_Using_Handheld_Applications_to_Improve_the_Transitions_of_Students_with_Autism_Spectrum_Disorders">recently coauthored</a> a book chapter on using a high-tech application to improve the transitions of students with ASD. I am a community faculty member with the Yale Child Study Center and a researcher with the Center of Excellence on Autism Spectrum Disorders at Southern Connecticut State University. </p>
<p>Rosenwald likened the bleak outlook of young adults with ADS to “falling off a cliff,” a phrase that captures the frustration felt by families who watch their children graduate from college but unable to find a job and soon after reach the cutoff point for after-school ASD services. </p>
<p>At the time of the project, a client was having trouble finding employees who demonstrated competency in patent application reviews, which require manipulating and analyzing large data sets and performing what many would consider tedious work. Some people who are on the high-functioning side of the autism spectrum are particularly well-suited for such tasks because of their comfort with repetitive work tasks, attention to very small details and ability for sustained attention. </p>
<p>Rosenwald and Hipp believed that with the right framework and planning, the barriers to employment could be overcome and that people with ASD would be able to not only survive but thrive in professional, highly competitive work environments. </p>
<p>The project began by selecting four young adults (in their 20’s or early 30’s) who lived in the area served by ASRC. They were deemed able to successfully deal with workplace situations and managers – according to a predictive index used by ASRC’s board president in her executive search and <a href="http://www.impactpartners.com/philosophy/">consulting firm</a> – and assigned them to work with the patent company on an as-needed, contract basis. The availability of contracts was not continuous or guaranteed, nor was a steady paycheck, making it more closely resemble real-world conditions rather than a sheltered program. Not only did the four employees need to learn the high-tech aspects of the work, but also they needed to learn how to work together as a team. </p>
<p>Open Options, funded by grants from the <a href="http://www.jhnapierfdn.org/index.html">Napier Foundation of Meriden</a> and Wallingford, provided the employees with social cognition training, including social skills in the workplace, pragmatic language skills, behavioral regulation and executive functioning. A social cognition specialist worked with the employees to develop an employee handbook governing proper workplace behavior and establish goals to help them learn to self-regulate their emotions and handle stress on the job. </p>
<h2>The results</h2>
<p>The study ran for about a year and used the <a href="http://www.jecei.org/pdf_impact/16%20Comerfulltext.pdf">CEDAR Social Cognition Scale</a> – which uses a point system to measure cognition and self-regulation – and employer evaluations to demonstrate progress. </p>
<p>The CEDAR scale includes 51 items or statements, scored from 1-9, such as: </p>
<blockquote>
<p>Expresses needs and feelings in a way that is likely to result in good outcomes, and</p>
<p>When receiving feedback, tends to respond with arguments and explanations rather than acceptance.</p>
</blockquote>
<p>All four employees saw steady growth on the scale, particularly in terms of openness to new ideas and experiences, ability to transition from one activity to another and willingness to accept feedback. </p>
<p>Their evaluations by the employer also showed improvement. For example, one employee started off at “meets minimum requirements” and finished the program at “exceeds requirements.” He is now working at least 20 hours a week in an internship in a related field, and is being considered for a competitive position with the company. </p>
<h2>The need for predictable schedules</h2>
<p>One important finding of the project, and the reason it ended earlier than planned, was that the key to supporting individuals with ASD in a workplace setting involves some degree of predictability. Consistent work schedules are one of the most important certainties that employees with ASD need for their success in the world of work. But this was often not the case. </p>
<p>The client was unable to determine in advance how many hours it needed the employees to work on a day to day basis. On some weeks, the employees would work eight hours on the first day, have two days off, and then be notified a couple hours ahead of time that they were needed on the fourth day. </p>
<p>Overall, the study underlined the importance of providing social cognition training for the business environment in order for individuals with ASD to succeed in competitive workplaces. In this project, ASRC’s role as its backbone was critical to making it work. </p>
<p>With the proper training and accommodations, people with ASD could become productive and indeed sought-after employees in the workplace, making them truly independent. </p>
<p><em>Lois Rosenwald, executive director of Autism Services and Resources Connecticut, Renee DePastino, a social cognition specialist at Autism Services & Resources Connecticut, and Patrick Iben, a senior research assistant at Southern Connecticut State University, coauthored this article.</em></p><img src="https://counter.theconversation.com/content/56481/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The evaluation was funded by the Connecticut Developmental Disabilities Council.</span></em></p>The outlook can be bleak for people with ASD who have difficulty navigating the stressful work world. A trial project in Connecticut sought to find a new way to help them become truly independent.Michael Ben-Avie, Director of the Office of Assessment and Planning, Southern Connecticut State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/472762015-09-10T07:23:13Z2015-09-10T07:23:13ZEpilepsy: sorting the myths from the facts of a common disorder<figure><img src="https://images.theconversation.com/files/94367/original/image-20150910-27304-it1ffl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Epilepsy is one of the most common neurological conditions in the world.
</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>One of AFL’s biggest stars, Lance Franklin, was briefly hospitalised for a mild epileptic seizure last week. He was also <a href="http://www.sydneyswans.com.au/news/2015-09-08/club-statement-lance-franklin">ruled out of</a> Saturday’s qualifying final, as he is reportedly suffering from an “ongoing mental health condition”. </p>
<p>Although they may coexist, epilepsy is a neurological disorder that doesn’t fall under the umbrella of mental or mood disorders. But the likelihood of mood disorders, such as depression and anxiety, <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181864/">increases with chronic brain illnesses</a>. And there may be a slight further increase if you have epilepsy.</p>
<p>People with epilepsy need treatment, but also understanding they are normal, capable people. Unless someone has a noticeable seizure in a public place, you won’t know they have epilepsy. There’s no abnormality, as such, springing from the illness. Nor is there a limit to what someone with the condition can accomplish. </p>
<h2>Understanding epilepsy</h2>
<p>Globally, epilepsy is one of the <a href="http://www.who.int/mediacentre/factsheets/fs999/en/">most common neurological diseases</a>, particularly <a href="http://www.rch.org.au/neurology/patient_information/about_epilepsy/">among children</a>.
Epilepsy is not a single disorder; it has many causes that share the hallmark of a seizure, when brain function is disrupted, often dramatically. When seizures remain isolated in just one part of the brain, they can be very small and can even pass by unnoticed.</p>
<p>But when seizures involve large parts of the brain, the consequent event is what people typically associate with an “epileptic fit”. The person’s muscles stiffen, they lose consciousness and fall to the floor, and their body starts jerking rhythmically. These types of seizures are called <a href="http://www.epilepsy.com/learn/types-seizures/tonic-clonic-seizures">“tonic-clonic” seizures</a> - because the body is first stiff all over (tonic) and then has rhythmic jerking (clonic). </p>
<p>Seizures can be frightening for those who have never witnessed one before. Historically, the loss of control of the body and brain that came with having an epileptic seizure was often <a href="http://onlinelibrary.wiley.com/store/10.1046/j.1528-1157.44.s.6.2.x/asset/j.1528-1157.44.s.6.2.x.pdf;jsessionid=FE40B159FCC219C2F51D6E8E7DDD9AE5.f02t04?v=1&t=iedru2p8&s=4bf1d1073f3657454fb7b4b4c3c75e8c9ca5fabe&systemMessage=Wiley+Online+Library+and+related+systems+will+have+3+hours+of+downtime+on+Saturday+12th+September+2015+from+10%3A00-13%3A00+BST+%2F+05%3A00-08%3A00+EDT+%2F+17%3A00-20%3A00+SGT+for+essential+maintenance.++Apologies+for+the+inconvenience.">misunderstood</a>. The biblical story of Jesus performing an exorcism on a young boy having a seizure, for instance, led some to believe they were a result of <a href="http://brain.oxfordjournals.org/content/125/2/441">demonic possession</a>. Only in modern times has epilepsy been <a href="http://www.who.int/mediacentre/factsheets/fs999/en/">truly recognised</a> as a disease of the brain. </p>
<p>There are still misunderstandings, though. It’s wrong to think, for instance, something should be put into the mouth when someone is in the middle of a seizure; it’s not true that the tongue can be “swallowed”. First aid is applied to prevent injury while the person is stiff and jerking, but when they go limp at the end of the seizure, they should be put on their side to prevent the floppy tongue obstructing breathing. After a seizure, it may take some time for behaviour to return to normal and sleepiness is common.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/94366/original/image-20150910-27304-1ed3gz6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/94366/original/image-20150910-27304-1ed3gz6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/94366/original/image-20150910-27304-1ed3gz6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/94366/original/image-20150910-27304-1ed3gz6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/94366/original/image-20150910-27304-1ed3gz6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/94366/original/image-20150910-27304-1ed3gz6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/94366/original/image-20150910-27304-1ed3gz6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Epilepsy is a diverse condition that can have many, different causes.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
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<h2>Treatment options</h2>
<p>Saying someone has epilepsy is a little like saying that they’re ill. Its cause is diverse and can be anything from a brain tumour to an inherited genetic condition, the consequence of injury, or any other disorder that affects the brain. In some cases, epilepsy is associated with other brain problems and intellectual disability. But mostly, people with epilepsy are normal between seizures and can participate in normal activities. If seizures are not controlled, then operating dangerous machines, like cars, or swimming unsupervised must be avoided. </p>
<p>Most epilepsy is well controlled with medications. Options for treatment have expanded with new drugs available, more precise diagnosis based on sophisticated imaging, and better understanding of the mechanism of epilepsy in each individual patient. In some cases, very precise detection of brain lesions can allow for a surgical cure of epilepsy. Even devices used as brain implants have been developed that can <a href="http://www.hindawi.com/journals/ert/2014/582039/">control severe epilepsy</a>. </p>
<p>It’s common for some mood disorders also to <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181864/">be present in people with epilepsy</a>. Naturally, the fear of having an unexpected seizure can directly lead to an anxiety disorder, while the stress of coping with chronic illness can contribute to depression. In some types of epilepsy, the brain networks that give rise to the illness may also make people more vulnerable to these co-morbidities. It is important that both problems are properly assessed and diagnosed. </p>
<p>For someone like Lance Franklin, simply “carrying on” if there is a mental or neurological problem would be as bad as “playing on” with a muscle problem that was not recognised and treated. Like the physical side of sport, where an optimised musculoskeletal system is important, so it’s important to recognise that the brain needs just as much care, effort and medical attention.</p><img src="https://counter.theconversation.com/content/47276/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Graeme Jackson receives funding from the National Health and Medical Council Australia</span></em></p>Saying someone has epilepsy is a little like saying they’re ill. Its cause can vary from a brain tumour to an inherited genetic condition, the consequence of injury or a disorder affecting the brain.Graeme Jackson, Senior Deputy Director, Florey, Neurologist Austin Health, Florey Institute of Neuroscience and Mental HealthLicensed as Creative Commons – attribution, no derivatives.