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Soc. Sci. Med. Vol. 42, No. 1, pp. 59-73, 1996

Key words--women, AIDS, media, inequity

INTRODUCTION

The seventeenth century.., was the beginning of an age

of repression emblematic of what we call the bourgeois

societies . . . . Without even having to pronounce the word,

modern prudishness was able to ensure that one did not

speak of sex . . . .

Yet when one looks back over these last three centuries

... things appear in a very different light: around and

apropos of sex, one sees a veritable discursive explosion . . . .

[1] (p. 17).

A massive amount of media attention has been

devoted to the subject of AIDS, to a degree rather

remarkable for what is really 'just' a disease. Why so

much talk about what is at essence a public health

issue, though admittedly a quite grave and frightening

one?

A number of writers have addressed this issue,

particularly in the context of the stigmatization of

homosexual men and, to a lesser degree, in response

to the demonization of the 'other': black Africans and

Haitians, both of whom have figured prominently in

Western scientists' search for the origin of the virus.

This literature has evaluated the ways in which

discourses on AIDS have further stigmatized these

groups, already construed as 'deviant' in some way.

Predominant themes have been the differentiation

among members of 'risk groups' and the 'general

public' [2]; assumptions about the 'deviant' sexual

practices of gay men, Haitians, or Africans [3, 4]; and

a demarcation of 'guilty' and 'innocent' victims of

AIDS. In this latter category, 'guilt' or 'innocence'

is associated with the means of infection, the identity

or risk-group affiliation of the sick person and the

attribution of personal responsibility for illness [5].

The underlying explanation given by those critical of

mainstream discourses about AIDS usually boils

down to explanations that account for the stigmatization

of homosexual men in the context of a generalized

homophobia, the stigmatization of people of

color in the context of a generalized racism, or a

general tendency for people to blame others for their

problems, particularly certain 'kinds' of others (see,

e.g. Refs [6-12]).

Such explanations are undoubtedly true as far as

they go. However, critics of popular and public

discourses in the West in general and in the U.S. in

particular who fail to place their observations in a

more meaningful or general context by emphasizing

one axis of stigma and inequality by itself neglect to

explain why homophobia and racism are such persistent

content of these discourses, but they fail to account

for the insistence with which certain stories or explanations

are put forth, take hold and shape images of

afflicted people or members of high-risk groups.

What function or more general purpose, that is, does

this effusion of discourses serve?

Foucault's work on sexuality, discourses and

power is enlightening in this context. In the first

volume of The History of Sexuality, Foucault contrasts

our stereotypical conception of Victorian discourses

on sexuality as repressive with the 'discursive

explosion' on the topic of sexuality that he observes

during this period. In the course of this volume, he

argues that it would be mistaken to construe these

59

60 Valerie Sacks

prolific discourses on sexuality as repressive; they can

more accurately be described as creative or productive

in that they establish and reiterate conceptions of

what is and is not 'normal'. In doing so, they form

important mechanisms for the social control of

bodies: "one had to speak of (sex) as of a thing to be

not simply condemned or tolerated but managed . . . . "

[1] (p. 24). Thus, argues Foucault, what has been

required since the seventeenth century is "[a] policing

of sex.., through useful and public discourses" [1]

(p. 25). Through such discourses, "legal sanctions

against minor perversions were multiplied; sexual

irregularity was annexed to mental illness; from childhood

to old age, a norm of sexual development was

defined and all the possible deviations were carefully

described" Ill (p. 36). While "[t]he legitimate couple,

with its regular sexuality.., tended to function as a

norm", there was a "setting apart of the 'unnatural'

as a specific dimension in the field of sexuality" [1]

(p. 39), a dimension which was regulated, stigmatized,

medicalized, criminalized and psychiatrized, and

which was integral to the propagation of embodied

relations of power.

While sexuality is by no means the only realm

subjected to this intense scrutiny, it is certainly an

important one. Bodies, as a "point of intersection

... between the biological and the social" [1] (p. 24),

constitute a region wherein notions of 'natural' and

'unnatural' are densely interwoven. Bodies clearly

have certain biological elements, but what these

elements are, and where the biological realm ends and

the social and cultural realms begin, is a question of

intense contestation and ambiguity. This ambiguity

makes it possible for hegemonic 'truths' to define

what is and is not natural, and in so doing, to

reinforce existing hierarchies.

As Foucault describes, discourses play a key role in

the creation and dissemination of 'truths' about

the world and about society, 'truths' that have a

normalizing and regulatory function [13]. Through

discourse--along with the extension of forms of

institutional power, another key mechanism--existing

modes of social control are created and perpetuated.

Power becomes internalized such that it

becomes no longer necessary for governments to

make overt shows of power in order to ensure a docile

populace; from every direction, we reproduce the

dominant paradigm ourselves, actively but usually

not consciously, and whether or not it would seem to

be in our own interest to do so. In other words,

relations of power are produced and reproduced from

every point, including through institutions of various

*The other main kind of deviant woman, the lesbian, does

not appear as such in these discourses, probably due to

the low likelihood of becoming infected through lesbian

sex. (Lesbians may, of course, become infected through

IV drug use, sex with infected men, blood transfusions,

alternative methods of fertilization [15] (p. 28) or oral sex

during menstruation [15, 16].)

kinds, through public discourses and through our

bodies. Sexuality is certainly not the only mode by

which this diffuse power is propagated; "lilt appears

rather as an especially dense transfer point for

relations of power" [1] (p. 103). In other words,

"Sexuality is not the most intractable element in

power relations, but rather one of those endowed

with the greatest instrumentality" [l] (p. 103).

AIDS discourses, because they are ostensibly about

disease, but equally about sexuality and power, reflect

this diffusion of power relations in their reproduction

of already existing mechanisms and patterns of social

control. Surely all these discourses on AIDS can be

seen in this light: so prolific, so fixated on 'perversions'

and irregularities in sexual behavior, and so

repetitive in their depictions of the practitioners of

these allegedly divergent forms of sexuality as members

of groups clearly distinct from the 'general

population', worthy of stigma, and needing to be

reached, controlled and subdued through the tentacles

of discourses and institutions. Discourses help

these behavioral norms to become internalized, and

in so doing to reinforce existing social, political and

economic hierarchies. They are patterned in systematic

ways, ways which perpetuate perceptions of

certain 'kinds' of behavior, and--because, according

to Foucault, sexual behavior is perceived as isomorphous

with identity--certain kinds of people as

deviant, less valuable, more prone to and deserving of

disease, and inexplicably intriguing in their apparent

perversity. Thus, for instance, mainstream media

represent Western prostitutes qua prostitutes (as in

contrast to qua IV-drug users) at rates quite disproportionate

to their actual importance as disease

vectors. This frequent depiction of prostitutes can be

explained not by their role as transmitters of HIV--

which is not very significant, as will be addressed

below--but by their obvious and public refusal to

attempt to conform to ideals of femininity. In this

way, the facts about the prevalence of seropositivity

among prostitutes is less important than the historical

association between prostitution and impurity [13] or

disease [14]. In this paper I will examine discourses on

women and AIDS in a context that recognizes Foucault's

contributions, and that seeks to understand

them in terms of a production and reproduction of

certain kinds of sexuality, of certain kinds of bodies,

A first set of themes concerns assumptions about

prostitution as a dangerous form of female pollution,

and prostitutes as a category of persons especially

likely to be diseased and contagious. A great deal of

attention both locally and internationally has focused

on the potential role of prostitutes as vectors of HIV.

This level of attention is remarkable given the inconclusive

findings regarding rates of seropositivity

among non-IV drug-using prostitutes in the U.S. and

other Western countries--and given the lower probability

of a man contracting the disease from a

woman than vice-versa since about one in three

women but only one in fifty men has contracted HIV

through heterosexual contact [17].*

These AIDS discourses nonetheless insist that

prostitutes are infecting the 'general population',

when in fact the evidence supporting this contention

is quite mixed. Part of the confusion stems from

media discussions' failure to distinguish between professional

prostitutes and those who engage in sex

*Two factors may account for this. First, more men than

women are HIV-positive in the first place, meaning that

heterosexual women have a larger pool of HIV-positive

potential sex partners than do heterosexual men. Second,

male-to-female transmission may be more efficient

[17].

tAmong prostitutes in developing countries, rates of

seropositivity may be quite a bit higher. I have encountered

no study that attempts to account for this but there

is reason to suggest that significant factors contributing

to high rates of seropositivity include the documented

prevalence of STDs among women in developing

countries [18, 19]. In Thailand and elsewhere, IV-drug

use among prostitutes or sex with IV-drug-using men

may be significant factors as well [20].

++European studies reiterate findings that infection rates

among IV-drug-using prostitutes are much higher than

among non-IV-drug-using prostitutes, among whom

infection rates are low [25]. In England, 80% of the

women in a cohort study of prostitutes contacted

through a clinic were tested for HIV. Of these women,

only 2% were found to be carrying the virus [26]. Studies

from the former West Germany found <1% of

the registered prostitutes to be HIV-positive [25].

Other studies in Europe also confirmed these findings

[24].

work to support their drug habits (usually IV-drugs

or crack). These categories are not discrete and

homogeneous, but in general non-IV-drug using and

IV-drug-using prostitutes do not face the same level

of risk for becoming infected or infecting others due

to their different patterns of condom use and different

clienteles. While Western, non-IV-drug-using prostitutes

harbor quite low rates of HIV infection, rates of

infection among IV-drug-using prostitutes are much

higher--but probably due mostly to needle-sharing

rather than to intercourse. Nonetheless, these categories

are routinely conflated in discourses on AIDS.t

Numerous studies in the West have examined the

presumed link between HIV and prostitution and,

over and over, have found that very few prostitutes

are seropositive; that rates of HIV infection among

prostitutes are similar to those among women who

are not prostitutes; and that of those women in either

category who are seropositive, almost all have a

history of IV-drug use or have been in intimate

relationships with men who are IV-drug users or

bisexual. For instance, as of 1988, no sex workers in

Nevada, where testing is mandatory, had been found

to be HIV-positive [21]. In New York City over a

ten-year period, only seven of 17,000 men with AIDS

reported "sex with women at risk" as their primary

risk factor [22] (p. 158). A survey of ten studies in

major U.S. urban centers also found no evidence

of prostitutes transmitting the AIDS virus to "the

public" [22].

IV-Drug use, however, is a frequent mode of

transmission, as is sex with IV-drug-using or bisexual

men. A San Francisco-based study found no difference

in HIV status for prostitute and non-prostitute

women; in either case, however, those who were

HIV-positive were either IV-drug users or involved

with IV-drug-using or bisexual men [23]. Another

study using both a control group of heterosexually

active women who were not prostitutes and a prostitute

group found that the incidence of infection,

4.5%, was the same in both categories [21]. All

of those infected had a history of IV-drug use,

while non-IV-drug-using prostitutes were free of infection.

The Centers for Diseased Control (CDC)

confirmed that the incidence of HIV infection among

prostitutes is about the same as among women

in general, that IV-drug use is overwhelmingly

the cause of transmission, and that IV-drug-using

prostitutes are about four times more likely to be

HIV-positive than are non-IV-drug-using prostitutes

[17, 24].~:

Contributing to the misapprehension that prostitutes

are reservoirs of disease are ill-executed studies

so designed as to increase the likelihood of finding

high rates of seropositivity. Such methodological

problems include failing to use control groups of

non-prostitute women, using outdated and inaccurate

testing methods likely to generate many false positives,

and choosing a population of prostitutes more

likely to be IV-drug users [21]. One notably bad study

62 Valerie Sacks

Table 1. Coverage of prostitutes and AIDS in the Washington Post and The New York Times from

5 15

2 3

3 0

i0 18

c The Hayworth Press, Inc. All rights reserved. Reproduced with permission. For copies of this work,

contact Laura Stevens'-a.t The Hayworth Document Delivery Service (Telephone 1-800-3-

HAWORTH; 10 Alice Street, Binghamton, NY 13904). For other questions concerning rights and

permissions contact Wanda Latour at the above address.

forced women who had been arrested for prostitution

in Seattle to be tested using an inaccurate method.

The researchers found seropositivity rates of 4.5%, a

percentage which, as Priscilla Alexander, co-director

of the U.S.-based prostitutes rights organization

COYOTE (Call Off Your Old Tired Ethics) put it,

"was widely publicized and was used as documentation

for those wishing to blame prostitutes for the

spread of AIDS" [21] (p. 170). When the women in

the original study group were tested again with a

more accurate test, none were found to be seropositive.

These later results, unfortunately, were never

publicized. In other studies, women have been selected

for testing at jail, in drug rehabilitation programs

[27], and at STD clinics [21], the same places

one might look to find women who used IV drugs or

who did not practice safe sex.

Not only are non-IV-drug-using prostitutes unlikely

to be HIV-positive, they are not particularly

likely to be transmitters of the virus since, as studies

in a number of centers have found, most non-IVdrug-

using prostitutes use condoms as a matter of

course [28], and in general to a much greater degree

than women who are not prostitutes [29-31]. Informal

networks of prostitutes who encourage the use of

condoms as protection from sexually transmitted

diseases [29] may account for the much higher level

*One study cited in Ms. found very low rates of condom

use among prostitutes. However, this reference does not

elaborate on the study's methodology nor give any

information about the study population beyond stating

that they are prostitutes [15].

of awareness found by a Project AWARE study

comparing condom use among prostitutes and nonprostitutes

[21]. COYOTE also emphasizes that use

of condoms is part of prostitutes' professional code

[21].*

Concern about health and a network promoting

safe sex are important reasons for condom use among

prostitutes, but may only be part of the story. In her

ethnography of a group of London sex workers,

Sophie Day found that condoms serve as important

ideological tools for creating and maintaining boundaries

between public and private sexual contacts. The

'unnaturalness' of condoms and their presence as a

physical barrier between the client and the prostitute

are regarded by Day's informants as positive characteristics

because of their utility in helping maintain

the separation between work and non-work contexts

[26]. Another study reports similar patterns among

U.S. prostitutes [29].

The connection between HIV and prostitution has

lingered in the public's mind and in press reports

despite the weak evidence linking them. Donna

King's study of coverage of prostitutes in the context

of AIDS in the Washington Post and New York Times

from September 1985 through April 1988 found that

There is a continuing misrepresentation in the media of

women prostitutes as "transmitters" of AIDS to men

through sexual intercourse, despite the fact that the data has

pointed to male-to-female transmission as... the overwhelming

mode of sexual infection. There is also little

concern with the health of the prostitutes themselves, but

only with their role as possible disease vectors [22] (p. 175).

The results of her study are summarized in Table 1.

Women and AIDS 63

Also perpetuating such notions are reports of

AIDS abroad in popular news and business

magazines, which consistently emphasize the risks to

men of becoming infected by prostitutes rather than,

as far more frequently occurs, the reverse. In a series

of articles on AIDS in Asia in the Far Eastern

Economic Review, a Hong-Kong-based international

into the "broad population" [32] (p. 28). Elsewhere,

the writer declares that "The Thai male's penchant

for visiting brothels has been the main engine of

transmission throughout the country and across

social classes. From the men, the disease passes

to girlfriends, wives and children" (emphasis added)

[32] (p. 29). Another writer for the Far Eastern

Economic Review states that "Although the prevalence

among pregnant women is still low, heterosexual

transmission from prostitutes to male customers

Even where rates of seropositivity among prostitutes

justify media attention, mostly in developing

countries, the focus is still overwhelmingly upon the

prostitutes as the infectors, rather than as the infected.

In this depiction, the actual power relations

between prostitute and client are reversed, and notions

of female sexuality as dangerous and unclean,

and of prostitute as essence, "perceived and responded

to primarily in terms of (her) category

membership", are perpetuated [36] (pp. 6-7). Such

discourses also reassert a conception of (heterosexual)

maleness as normative and of male experience

and suffering as primary. At the same time, they seem

to suggest that men are in particular danger of being

polluted by women while they undermine recognition

of the fact that, in this context, men 'pollute' women

far more often then women 'pollute' men [17].

Despite this fact, there has been a conspicuous lack

of attention to men's roles, particularly as clients.

Those studies that do exist suggest that this population

of men is very much in need of AIDS education

to teach them that they are vulnerable to infection but

can protect themselves and their partners (see, e.g.

Refs [35, 37]). As noted above, clients often are

willing to pay more for unprotected sex, often assume

they 'can tell' if a woman is 'clean' or not, and often

underestimate the danger of their becoming infected,

being infected, or infecting others [35, 38].

An indirect focus on heterosexual men appears in

AIDS discourses in ways quite different from those

used to depict prostitutes. Men appear, for instance,

emaciated and languishing in hospital beds from the

ravages of AIDS. A Newsweek article, for instance,

Medicine at the Crossroads focussing on AIDS internationally

follows this pattern despite generally quite

matter-of-fact portrayals of some of the stigmatized

groups at high risk. In this episode, men suffering

from AIDS in the U.S. and elsewhere are depicted at

several points, while women are only depicted in the

context of AIDS-prevention interventions. Young

Thai women working in a brothel in which 70% were

HIV-positive were chosen as focal points. In this

segment, the focus shifts back and forth between men

hospitalized with AIDS and brothel prostitutes. "Initially

being picked up by men from visiting brothels,"

64 Valerie Sacks

the narrator tells us, "the AIDS virus is increasingly

being spread to their partners and to unborn children"

(emphasis added) [40].* Certainly transmission

from this group is a legitimate concern. However,

juxtaposing dying men with seemingly healthy

women in the context of their potential to infect

others deflects the viewers' concern away from the

women's suffering and toward their potential to

transmit the disease, while it does just the opposite

with men--even though the converse would present

a more accurate depiction of reality. Along the same

lines, a US News & World Report article goes on at

only to focus on women as infectors fails to

*Characteristically, pictures of babies also appear rather

frequently in AIDS discourses. See below.

in the Phillipines [5] (p. 82). As one former 'hospitality

worker' put it:

Very few of the guys take this seriously, or will use

condoms . . . . They are warned about getting VD and are

told not to take too much money with them once they go

off the base. It's all to protect the guys. They protect the

servicemen, but not the working women [49] (p. 168).

This is particularly glaring given the only-illusory

effectiveness of screening out HIV-positive men, and

the fact that the U.S. army's own study revealed "a

significant amount of 'unsafe and indiscriminate'

sexual behavior" on the part of its enlisted men [34]

(p. 10)--meaning that men who are seronegative now

may not be so for long. Typically though, "rather

than focusing on the danger that these men might

pose to others, media accounts emphasized the 'vulnerability'

of soldiers to AIDS" [34] (p. 10).

Mandatory testing of prostitutes or other 'risk

groups' would be no more effective. First, testing

would not address the 'vector' of transmission between

prostitutes and other women or men. Second,

testing laws would make those prostitutes who did

test positive even more economically and socially

vulnerable, more desperate to make money, and less

able to protect themselves from their clients [48].

Those women who felt compelled by their economic

circumstances to engage in sex work in the first place

are unlikely to have equally lucrative economic

alternatives available to them to replace sex work if

unable to continue in their profession. Increased

expenses due to health problems and the need to save

money for the point when the syndrome becomes

debilitating might also compel such women to continue

working. Absent explicit provision for alternative

resources to make it possible for sex workers to

stop working, it is uncertain how effective mandatory

testing plans could be.

From a public health perspective, then, this persistent

focus of public discourses on prostitutes as transmitters

of HIV, rather than recipients or victims of it,

is inexplicable. From the standpoint of Foucault,

who would see this scrutiny as an important mechanism

for shaping both the normal and the deviant, this

focus makes more sense. Prostitutes are almost by

definition beyond the bounds of 'respectable' society.

AIDS discourses reproduce and perpetuate notions

of their deviance, a notion of deviance closely linked

to notions of female as polluting. These views of

prostitutes as deviant or polluting emerge unscathed

by the lack of evidence that in Western countries they

have been playing the role assigned them in the

epidemic.

The lack of interest in prostitutes suffering from

AIDS is not surprising either. As Edwin Schur states

in Labelling Women Deviant, "Individuals often are

This 'essential character' of prostitutes in particular

and, to a certain extent, women in general, is also

reflected in AIDS discourses which assume that the

category of 'prostitute' is a homogenous one defined

by essentialized characteristics. This assumption

directs attention away from the fuzzy boundary

between 'normal' women and prostitutes, away from

the context of poverty and disempowerment underlying

many women's decision to engage in sex work,

and away from the variation within the field of

prostitution in terms of working conditions and risk

for transmission of HIV.

One implicit assumption is that there is a clear

boundary between women who will exchange sexual

services for money or other material goods and

women who will not. This assumption, aside from

being quite false at all levels of society, directs attention

away from the various ways in which women

may perceive the need to use sex as a strategy to gain

access to men's resources, and away from structural

inequalities along gender, race and class lines.

Poor women in the U.S. often find themselves

unable to fulfill their basic material needs. For such

women, lack of economic opportunities and perhaps

lack of work skills means that "sex becomes an

economic commodity" [50] (p. 301). Such circumstances

increase "the chances that they will turn to

prostitution to support themselves, their partners,

and their children" [50] (p. 301). Many women in

situations of poverty and disempowerment

rely on sex as a source of employment, as a means to

establish ownership or proprietary rights in relationships,

or as a means of simply getting tangible supports, generally

short in supply [51] (p. 27).

The boundaries between engaging or not engaging in

sex work are permeable, as Shayne and Kaplan note

[511.

There is a great deal more research detailing the

variety of ways in which poor women in developing

countries may use sex to survive, research which may

shed light on the diverse ways in which sex becomes

a medium of exchange for those who lack access to

other means. Thailand's infamous sex industry has

fueled the emphasis placed on prostitutes' alleged role

in spreading HIV in their country, but this emphasis

rests on assumptions about the incommensurability

of 'good' women and prostitutes. Susan Thorbek's

study of women's roles and experiences in Bangkok's

urban slums depicts a scenario in which women not

infrequently exchange sexual services for economic

assistance---whether formally through prostitution or

informally through their dependent relationships

with husbands orfeens (boyfriends/lovers) [52]. This

illustrates "the interplay between women's difficult

economic situation, their economic dependence on

men, their sexual subjugation and the social definition

of women's sexuality" [52] (p. 79). Thorbek

found that "[t]hese factors are mutually reinforcing,"

and that

[a]lmost all women in the slum were economically and

socially dependent on men and on the sexual services they

provided for men. This was true whether they were wives or

minor wives; if they were, as often, dependent on a protector

in the economic sphere, or if they were prostitutes [52]

(p. 79).

Although the relevant variables differ from place to

place, in many parts of Africa a variety of indigenous

patterns in concert with importations of the colonial

system, the impoverishing effects of capitalism, and

the spread of AIDS have created a situation in which

African women's health may be compromised in a

variety of overlapping and mutually exacerbating

ways which ultimately make them more vulnerable to

HIV. In a context of acute poverty, chronic overwork,

malnutrition and illness [18, 53], women in a

variety of contexts may need to exchange sexual

services for access to men's resources. Such arrangements

range from outside wives, in which married

men seek out sexual services in exchange for lending

material support [54] (p. 478), temporary marriages,

by which a man may contract with a woman to

provide conjugal services in exchange for a salary [55]

(p. 207), boyfriends, who may be expected to provide

their girlfriends with regular gifts, and the kind of

brief and limited exchange we normally think of as

prostitution [55].

Poor women dependent on such arrangements for

part or all of their survival needs may have very little

power to insist upon their sexual partners' monogamy

or condom use. Monogamously married

women economically dependent on their husbands

may also have little control over their husband's

behavior [18]. In contrast, the fact that at least some

prostitutes in urban areas have been able to organize

collectively and mobilize for safer sexual practices

[54] means that, contrary to what one might expect,

professional sex workers in some circumstances may

have more power to protect themselves from AIDS

than do monogamously married wives faithful to

their husbands and conforming to the gender role

norms expected of them.

This exchange of sex for support may be more

overt among poor women, and the market price of

their sexuality may be lower. However, the notion of

sex as a medium of exchange is by no means restricted

to poor women, but is pervasive in U.S. culture. It is

implicit, for instance, in the legal definition of rape in

many states, which defines it as "sexual intercourse

by a male with a female, other than his wife, without

66 Valerie Sacks

the consent of the woman and effected by force . . . . "

(emphasis in original) [56] (p. 22). Because the key

issue is not "violent, unwanted sex" but "sexual

assault by a man who has no legal rights over that

woman" [56] (p. 22), rape becomes not a violation of

a basic moral principle by which a woman should

have the right to decide with whom she wants to have

sex, but instead a property issue. Thus, "Society's

view of rape was purely a matter of economics--of

assets and liabilities . . . . [T]he monetary value of a

woman determined the gravity of the crime" [56]

(p. 22).

This notion of women's sexuality as a medium of

exchange is also apparent in many people's perceptions

of date rape. An Association of American

Colleges study found that many men feel that spending

money on a date entitles them to have sex with

her [57]. As Herman argues,

The American dating system...places female in the

position of sexual objects purchased by men .... [M]en are

socialized to expect sexual reward (or at least to try for that

reward) for their attention to women .... If a man.., has

provided (a woman) with certain attention and gifts, then he

has a right to expect sexual payment [56] (pp. 26-27).

This kind of exchange, then, is very much within

the realm of the 'normal'. It is much more explicit

among prostitutes, but there is a great deal of variation

among this group as well--in terms of experiences,

working conditions, power to turn down

work--and risk for HIV. Class, race, regional and

work-context differences among prostitutes may

affect their level of exposure to HIV. The fact that

rates of HIV infection among U.S. sex workers are

generally low but may vary "from 0% in a number

of studies to above 80% in a few" can be explained

by pointing out that prostitutes do not all face the

Unspoken assumptions about the abnormal sexuality

of the prostitute become more explicit when the

subject of discourses turns to non-Western prostitutes.

Such women, doubly or even triply removed

from the normative ideal--as prostitutes, as poor

women and as women of color--appear as exotic

fantasy objects. The particular shape this fantasy

takes on varies from place to place according to the

Western stereotype attached to the specific 'kind' of

'other'. African women, for instance, are depicted as

promiscuous but not necessarily as attractive to

Western men, unlike Southeast Asian, particularly

Thai, women. The Thai woman is

presented in the Western media as an exotic beauty, an

Aphrodite in comparison to the Western sex worker, who is

presented as a "whore".... [F]arang* see Thai sex workers

in a different light to sex workers in their home land. (qtd

in Ref. [35] p. 8).

Discourses on Thai prostitutes may acknowledge

their poverty but talk about them in the context of

their enjoyment of their work, in keeping with the

stereotype of the "exotic, enigmatic, submissive, and

Women

erotic" Asian woman described in Ara Wilson's

"American Catalogues of Asian Brides" [59] (p. I 16).

Catalogues of Asian mail-order brides, like brochures

aimed at Western men promoting sex tours to Thailand

or the Philippines, "construct imagined Oriental

ladies that draw upon traditional representations of

Asian women" [59] (p. 116). This text of an advertisement

for mail-order brides--"Faithful Oriental girls

make the best wives--by far . . . . Many feel its just

about the only way left to find someone who is sweet

and unspoiled" [59] (p. l l5)--does not differ greatly

in tone or substance from the text of a pamphlet

from a Swiss travel agency specializing in Southeast

Asian sex tours: "Holidays with the most beautiful

women of the world... Slim, sunburnt and sweet,

they love the white man in an erotic devoted way.

They are masters in the art of making love by

nature . . . . " (qtd in Ref. [60] p. 100). Another

brochure from a Dutch agency describes the sex

workers as "little slaves who give real Thai warmth"

(qtd in Ref. [61] p. 496).

In keeping with this image, Western media frequently

represent Southeast Asian prostitutes as

happy to greet soldiers or tourists, shy, girlish, giggly

and submissive. An article in In Health describes

Mechai Viravaidya, the driving force behind Thailand's

efforts to stem the epidemic, as talking to "the

girls" about condoms: "the girls would shrug, giggle

shyly, and tease him a bit" [62]. According to this

article, "Thais do not take offence at much of anything;

sanook is the work they use--fun, better to

keep things fun" [62]. A Far Eastern Economic Review

article describes Thailand along these lines as well:

"Patpong and sex are an indelible facet of the

country's exotic image . . . . It all looks so wholesome,

so acceptable, like a walk in the park" [63] (p. 44).

Thailand is described elsewhere as a place "Where

they don't lock up their daughters" [64], "The lust

frontier" [63], and "The land of smiles and sex" [63]

(p. 44). Media reports create the impression that it is

not, for instance, economic necessity but this supposed

'fun'-loving quality of Thai women, Or 'Thai

seductresses' [65] (p. 48), that is the driving force

behind their entrance into the sex industry. According

to Newsweek, "Many provincial women want a

taste of big-city life, and they are often tempted by the

fancy clothes, gifts and gadgets they see other women

bring back from their jobs in the city" [39] (p. 51). A

newsletter from the International Campaign to End

Child Prostitution in Asian Tourism (ECPAT) says

that

Historically, it was poverty.., that caused rural folk to sell

their daughters to brothel owners. More recently, ambitious

*Most prostitutes come from the poorest regions of

Thailand [20].

tExacerbating this rise in incidence rates is the fact that the

nineteen-week average life expectancy after diagnosis of

a person of color with AIDS is less than one-fifth the two

I kept imagining...was that suddenly, instead of

nurturing and nourishing my baby girl, I might be

poisoning her, infecting her, betraying her" [74]

(p. 24). Another mother in the same situation apparently

feels the same way: about her the writer comments,

"I could not take away the power of her fear,

of her sense that she is herself the source of the

shadow hanging over her infant" [74] (p. 25).

'Good' HIV-positive mothers, then, are characterized

by self-denigration for having transmitted the

virus to their children, and by selflessness regarding

their own fates. Such depictions, while sympathetic in

some respects, are nonetheless one-sided. Why, that

is, has it so consistently been the case that, as Devitt

put it, "If news accounts dealing with Hie-infected

women did not discuss prostitution, they usually

focused on the plight of HIV-positive women's children,

emphasizing the transmission of the virus from

mother to fetus" [34] (p. 10). For most HIV-positive

women only appear through indirect references to

them in the context of what they may have 'done to'

their babies or what may happen to their children as

a result of their illness. As one writer notes in

reference to a baby's mother, described as "a crack

addict," "[w]here she is now, or whether she's even

alive, (the baby's father) no longer knows or, he says,

cares" [75] (p. 29). Along the same lines, Rolling

Stone features a photograph of an eight-month-old

baby "'infected with the virus by his mother, a

prostitute" [76] (p. 70); and the Far Eastern Economic

Review features a picture of an "AIDS-infected child:

ultimate victim of ignorance" alongside photos of

Thai prostitutes doing their hair and make-up [32]

(p. 28). As one writer critical of these asymmetries

remarked, "[w]omen continue to get the attention of

most AIDS researchers only as possible infectors of

children and men. It's as if HIV-infected women are

viewed solely as carriers of disease" [15] (p. 24).

'Bad' mothers--those who have become infected

through IV-drug use, sex with multiple partners, or

sex with IV-drug using, bisexual or Haitian men--

rarely appear in AIDS discourses as individuals.

Their stigmatization and marginalization becomes

apparent in debates such as that over a proposed New

York State measure which would mean involuntary

testing and identification of infants, and thus indirectly

their mothers. As one typical article on the

debate put is, the controversy is between two groups.

On the one side is "an array of powerful special

interest groups" for whom "the confidentiality law is

untouchable, a piece of politically correct doctrine"

[75] (p. 28). On the other is a "much less organized

group of doctors" who emphasize the important

implications of early identification of HIV-positive

infants in terms of their care and the prolongation of

their lives [75] (p. 28). While no one would question

the importance of attempting to help these children,

it is not at all apparent why their health must come

at the expense of their mother's civil rights. At least

one study has indicated that "[e]nforced newborn

HIV testing...wouldn't be necessary in the vast

majority of cases if effective HIV counseling were

available to every pregnant woman" [75] (p. 30).

Many women who have reasons for not wanting to

take the test, for example, might be willing to do so

if they were told that it might help their child. One

article, entitled "AIDS Babies Pay the Price", recognizes

this but nonetheless argues that "[t]bese dangers"

are

hypothetical and pale compared with the concrete fact that

hundreds of babies are being neglected for whom something

useful might be done . . . . It seems cruel and misguided to

Women and AIDS 69

protect parental privacy when the welfare of tiny babies is

at stake [77] (p. A26).

The negative consequences for the mother---or even

the possibility that knowledge of her serostatus might

help her as well--are not seen as pertinent issues.

The threat of interventions such as mandatory

testing of pregnant women or involuntary testing of

babies plays upon normative notions of who are and

who are not appropriate maternal figures.* Pivnick

attributes calls for mandatory testing, sterilization

and prosecution to public discourses which, "reflecting

middle-class values and sensibilities, ha(ve) focused

almost exclusively on an assumed opposition

between potentially infected infants and their

mothers, portraying the latter as selfish drug users

who lack moral scruples" [47] (p. 153).

The stigmatization of HIV-positive mothers can be

intense. Among poor women, even asymptomatic

HIV-positive mothers "can experience discrimination,

shunning, and abuse both from within and

without the health care system" [78] (p. 196). Such

women may not pursue services available to them

because "they don't want to risk losing their jobs, or

risk the stigmatization of their kids if their status is

known," and because they may recognize the lack of

social support available to HIV-positive women [79]

(p. 43). Expectant mothers with HIV may fear that

disclosure of information about their HIV status will

lead to "abandonment by their mates" [75] (p. 31),t

"deportation (in the case of Haitians), or loss of their

children... Medicaid benefits, or even jail (if the

mother is a prostitute)" [78] (p. 196). Compounding

these problems is the fact that such women are

already stigmatized and disempowered in a number

of respects; their pregnancy and serostatus may only

add to their layers of problems. IV-drug-using

women, for instance, may "be stigmatized more than

their male counterparts", particularly when their

drug use seems to interfere with their "fulfillment

o f . . . nurturant role obligations" [51] (p. 31). The

stereotypic association between female IV-drug use

and prostitution also reinforces their stigmatized

status [51]. IV-drug-using women are also less likely

than their male counterparts to be able to maintain

supportive family ties, thus increasing their isolation

and perhaps reinforcing their ties to IV-drug-using

colleagues [80, 81].

Because almost three-quarters of HIV-positive

mothers in the U.S. receive public assistance, and the

mean income of those who are employed is about

$10,000 a year [51], HIV-positive pregnant women

*It also reflects the primacy of the fetus over the mother in

the eyes of many, perhaps a reflection of the prolife

movement's success in insisting upon the inviolable

personhood of fetuses. (I owe this insight to Myra

Dinnerstein.)

tConcerns which are not unrealistic--nine out of ten ill or

disabled women are abandoned by their mates [79]

(p. 43).

are particularly vulnerable to mechanisms of control

deployed through contact with public health and

other governmental institutions. Studies of such

interactions reveal many ways in which micro-level

forms of control--either institutional protocols or

interactions between hospital workers and patients--

perpetuate such women's stigmatization and disempowerment,

and discourage or prevent them from

accessing badly needed assistance.

Women who are IV-drug users or prostitutes tend

to be already suspicious of institutions and unwilling

to acknowledge "illegal or socially unacceptable behavior"

because of bad past experiences [51] (p. 30).

African Americans share a long history of distrust of

public health services and other institutions, particularly

those that involve giving whites personal information

[80]. Latinos have been noted to avoid test

sites and clinics as well [51]. This distrust may contribute

to delay and avoidance in seeking preventive

or timely health care services [79]. One study of

HIV-positive expectant mothers and the levels of

confidentiality afforded them in one hospital setting

found that the consequences of public knowledge of

women's serostatus can vary in severity according to

the class affiliation of the woman seeking care. For

one HIV-positive mother, "the daughter of a respective

physician in the community," the hospital cooperated

in "spreading a cloak of secrecy over her"

[78] (p. 198). There are no records of her HIV status

in the hospital, and because the research project

funds the cost of her care, there is no need for such

records for insurance reasons [78]. In contrast,

"those...who are already disempowered" because

they are poor, black, Latino, or otherwise affiliated

with a stigmatized group (e.g. IV-drug-users or prostitutes)

may have less control over who knows what

about them at the same time that they are more

dependent upon public services [78] (p. 199). This is

also the group harboring the highest rates of maternal

HIV [51, 73].

Another important theme in U.S. culture that is

implicit in AIDS discourses about both prostitutes

and HIV-positive mothers is that of self-control and

self-discipline. AIDS discourses imply that HIV can

be prevented through disciplined behavior, and that

therefore those who become infected with it are

responsible for their illness. In the context of AIDS,

'promiscuous' or 'indiscriminate' sex as well as IVdrug

addiction or 'inappropriate' pregnancy become

powerful indices for loss of control. The properly

disciplined body uses sex and intoxicants in controlled

and socially acceptable ways. Prostitutes, seen

as "ostentatiously overconsumptive of sexual partners"

(after Ref. [82] p. 72) and often associated with

the use of addictive drugs, are seen as undisciplined

and worthy of censure. Pregnant, HIV-positive

mothers, as 'unfit mothers,' are also seen as out of

70 Valerie Sacks

control--having failed to protect themselves from

HIV, having failed to prevent themselves from getting

pregnant, and having often engaged in activities

deemed inappropriate for would-be mothers. Thus,

these notions of individual responsibility for health

and self-control are reflected in AIDS discourses

through the stigmatization of those perceived as

incapable of controlling what goes into and comes

out of their bodies.

It is also perhaps this notion of individual responsibility

for health that is behind the categorization of

some people with AIDS as 'guilty' and others as

'innocent'. HIV-positive women appear 'guilty', their

infected offspring do not. Men who acquire the HIV

virus through homosexual sex appear 'guilty', those

who acquire it through heterosexual sex do not. In

this way, media images reflect and perpetuate a much

greater level of anxiety regarding women's and homosexual

men's sexual activity than they do for heterosexual

men's sexual activity, a sensitivity not related

to actual levels of sexual activity.

Another implication of these notions of individual

responsibility for health and self-control is that, if

you are responsible for your health, you are responsible

for your illness. The ideology of personal responsibility

thus works to focus blame on those who

are 'guilty' for their illness, and to deflect attention

away from the social context of the spread of disease.

This process serves to "mystif(y) the social production

of disease and undermine demands for rights

and entitlements to medical care" [83] (p. 75). As

Worth put it,

implicit in the idea that AIDS or other diseases are the result

of 'bad personal behavior', such as IV-drug use, is the

assumption that the government or society cannot address

the roots of IV-drug use in poverty, racism, and sexism [80]

(p. 126).

It thus deflects attention away from the consistently

demonstrated links between poverty and a host of

social and biological illnesses [81, 84].

A focus on the social context in which many poor

women of color live may illustrate how difficult it can

be for such women to take control of certain aspects

of their lives. Poor women of color may find it

difficult to protect themselves from AIDS if they live

in areas where a significant proportion of the available

sex partners use drugs--which is in turn in part

a response to poverty, hopelessness and chronically

high rates of unemployment and underemployment.

This situation may be exacerbated by the relative

shortage of young men in such communities due to

high death and imprisonment rates. The scarcity of

men in turn may mean women have less leverage over

or ability to make demands upon male sexual partners.

Furthermore, the lack of economic alternatives

available to poor minority women means they may

need to rely on exchanging sex for access to economic

goods, whether through prostitution or through a

variety of less explicit exchanges. The fact that physical

abuse was extremely common among women

in Worth's sample--three-quarters of interviewed

women said they had been physically abused as

adults, usually by their sex partner [50]---is also likely

to be a great disincentive for those who wish to make

demands on fidelity, insist upon condom use or make

other potentially threatening changes in their relationships.

Since use of condoms may connote

promiscuity, a lack of trust regarding the partners'

behavior, one's own infidelity, or lack of commitment

[49, 79, 80], the idea of suggesting condom use may be

quite daunting. The fact that those under 25, blacks

and Latinos, lower-income people and those with less

education are likely to be less well-informed about

AIDS [85] also makes it harder to insist upon behavioral

changes. All of these factors make it more

difficult for poor women of color to protect themselves

than discourses exhorting them to 'just' use

condoms indicate. For many women of color, "being

assertive and getting their men to wear condoms is a

ludicrous idea" [15] (p. 29).

The ideology of individual responsibility thus bolsters

the fiction that all members of society are

equally capable of 'controlling' their health, and if

disproportionately high numbers of some 'kinds' of

people are manifestly less able to do so, then it must

somehow be their fault. Attention is deflected away

from the systematic inequalities that make it objectively

more difficult for women, the poor, and people

of color to control certain aspects of their lives.

CONCLUSION

That the enormous amount of media attention

given to the AIDS epidemic goes far beyond the level

of coverage that would seem necessary for public

health reasons is illustrated by themes revealed

through a close reading of discourses pertaining to

AIDS. These discourses exhibit certain patterns--

patterns that could be accurately construed as, for

example, racist, sexist or homophobic, but that are

more inclusively described as attempts to produce

and reiterate notions of normative and deviant sexuality.

AIDS discourses, ostensibly about disease but

equally about sexuality, reproduce relations of power

by exhorting us to embody norms that reflect these

hierarchical relations, and thereby to reproduce

power relations ourselves.

AIDS discourses on women focus on normative

notions of sexuality, notions which are often conveyed

through stigmatizing discourses about deviant

women. Prostitutes are depicted as indiscriminate in

their sexuality and dangerous and polluting to men,

although their rates of HIV infection are generally

much exaggerated, and although most sex workers

are in much greater danger of becoming infected than

they are of infecting others. Their vulnerability to

infection and the suffering they may endure are

downplayed--heterosexual men with AIDS are much

more likely to be depicted as victims. Prostitutes are

Women and AIDS 71

also essentialized in the sense that they are rarely

depicted as individuals, they are perceived as being

somehow categorically different from 'normal'

women, and their experiences are implicitly assumed

to be much more homogeneous than they really are.

Asian prostitutes are depicted in particularly distorted

ways, and some of the more subtly communicated

assumptions about Western prostitutes become

amplified and distorted according to racist and sexist

stereotypes when discussion turns to them. Essentializing

assumptions about prostitutes deflect attention

away from the context of poverty and disempowerment

that precipitates many women's decision to

engage in sex work, away from the heterogeneity of

sex workers' working conditions and risk for HIV,

and away from the ambiguous boundary between

women who will and will not exchange sexual services

for money or other material support.

When women other than prostitutes are depicted

in AIDS discourses, they are almost always HIVpositive

mothers or HIV-positive pregnant women.

Just as prostitutes are largely of concern in AIDS

discourses insofar as they may infect heterosexual

men, mothers are largely of concern insofar as they

may infect their babies. Children are overwhelmingly-

if not exclusively--the focus of these discourses.

Women depicted as 'good' mothers obsess

about what will happen to their children, dwell on

their role in transmitting the virus to their babies,

and never think of themselves. 'Bad' mothers are

less visible, appearing only collectively in the context

of involuntary testing of infants or mandatory testing

of pregnant women. In these cases in particular,

arguments tend to be framed in dichotomous terms

of either prolonging the lives of helpless 'tiny' babies

or insisting upon maintaining 'politically correct

doctrines' that worry about minor issues such as

women's civil rights. Although there are good medical

and ethical reasons for encouraging women to be

tested or to allow their babies to be tested, the other

side of the story--the good reasons women may have

for not wanting to be tested--is rarely mentioned.

In fact, HIV-positive mothers whose serostatus is

known may face a variety of difficulties, such as

intense stigmatization and the loss of tangible, badly

needed supports.

Finally, the themes of self-control and self-discipline

so pervasive in U.S. culture may also be used to

stigmatize women. First, AIDS discourses concerned

with responsibility suggest that because there are

ways to avoid becoming infected, those who have

AIDS are responsible for their own illness, 'guilty',

and not deserving much sympathy. Second, AIDS

discourses concerned with self-control depict prostitutes,

because of their 'uncontrolled' sexuality, and

HIV-positive mothers, because of the combination

of seropositivity and pregnancy, as out of control and

worthy more of censure than of sympathy. Finally,

AIDS discourses that emphasize personal responsibility

deflect attention away from the social and economic

contexts which may make it more difficult for

some to avoid infection--by telling women to 'just'

use condoms when women are not the ones who wear

Acknowledgements--I thank Marcia Inhorn, Myra Dinnerstein,

Mark Nichter, Joel Post and two anonymous referees

for their comments on previous drafts of this paper.

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