Introduction

The twin factors of stigma and discrimination are a significant cause for the denial of human rights and access to services in the area of sexuality, gender and sexual health.

The Webster's Dictionary defines stigma as 'a mark of shame or discredit'. To stigmatize means 'to regard with opprobrium; censure, denounce, identify with disfavour, designate'.

Discriminate or discrimination is defined as 'to make a difference in treatment or favour on a class or categorical basis in disregard of individual merit'.

Thus stigma is more of an attitudinal issue while discrimination can be identified in practice. Though the two are different phenomena, they are inextricably linked because stigma is usually a primary cause for an act of discrimination and has its origin in the way human society developed.

Stigma and discrimination are particularly noticeable in issues around sexuality and gender. They are present within individuals, families, communities and institutions, and can be measured in numerous cases of violence, abuse, denial of care, shelter and employment, harassment of family and children, and social ostracism.

Strategies that address discrimination may need to be different from those that address stigma because discrimination is often a concrete action, this can be confronted head on. Political representations, legal interventions, public hearings and demonstrations, and sensitivity training for specific stakeholders are important strategies to combat discrimination.

Stigma on the other hand is more subtle and more pervasive. It is often cultural and its effects can be diffused. In our experience, strategies to address stigma are relatively long-term. Building access to non-discriminatory services in public institutions, influencing supportive policies, building enabling supportive environments among local people and encouraging capacity-building of affected people are some effective strategies.

These are not peculiar to India, and have been well documented around the world. At Siaap, we have been dealing with several manifestations of this phenomenon among the people we have worked with.

Women Doubly Discriminated

Summary Report of Police Violence

To understand the nature and extent of police violence among women in prostitution, Siaap talked with 172 women from 13 districts of Tamil Nadu, in October 2000. The results are a shocking indictment of the way we allow the state to treat a significant number of its women citizens. Nearly 70% of the women reported that they had been beaten with lathis (police batons) and logs of wood, as well as kicked by booted policemen. Some had their hand and legs broken and their sex organs mutilated. Others reported incidents of slapping, twisting of hands and ears, pulling of hair, spitting on the face, etc.

More than 80% of the women said they had been arrested without evidence i.e., based on the assumption that the woman was soliciting in a public place at the time of her arrest. This, they said, was only to meet the monthly 'targets' of each police station. Had the woman fought the case in court, chances are she would have been let off for lack of sufficient evidence.

Nearly 15% said they were arrested because they questioned the policemen's right to beat them or verbally abuse them. A small percentage (2%) said they were picked up while distributing condoms and talking to women about protecting themselves from HIV. Most women (70%) said they preferred to pay a fine and get away from the police. Those unable to do so (11%) said they underwent imprisonment after pleading guilty because they did not know how to fight a case and prove their innocence. Nearly 12% of the women reported that they had been forced to vacate their homes due to harassment by the police.

All women said they routinely parted with gold or silver ornament such as nose studs, earrings, bangles, anklets, etc., as part of the fine or 'bail' amount. Women also said that each time they were arrested - usually once every two or three months - they spent close to Rs. 1,000 to pay the lawyer, court fees, transport, etc. This was in addition to the expenses they incurred on medical care in case of injury due to assault by the police.

Women selling sex

In Siaap's experience, women bear the brunt of stigma and discrimination in the context of HIV. The phenomenon cuts across class, caste, and religion. Only the contexts are different. Among women in sex work, one of the most visible symptoms is the increase in police violence since the identification of HIV among them. Identified by national and international policy experts as a primary source of HIV infection in India, the women now bear the twin brunt of being the targets of both 'HIV-prevention workers' as well as the police. The former have, perhaps unwittingly, succeeded in visibilising a hitherto 'invisible' community. This has led, inevitably, to increased levels of repression through measurable increase in violence, arrests, foisting of false cases, imprisonment, etc. A more benign face of the repression is seen in the proliferation of and the support to 'anti-trafficking' activities which have removed all distinction between trafficking and voluntary sex work.

Married women

One of the largest rates of increase in new infections in Tamil Nadu currently is among monogamously married women from rural areas. In some cases, this is as high as 8% among women attending antenatal clinics. This is not surprising given the traditionally high incidence of reproductive tract infections among rural women in India - 40% by some estimates. Stigma around issues of sexuality and sexual health has ensured that women do not access treatments for related problems. This is reflected in the large numbers of deaths due to cervical cancer among women in India.

With the advent of HIV, this has further impacted the lives of women. Marriage today is a major risk factor among women in India. And most don't even know it. Even among those who may be aware of the implications of HIV spread among general populations, there is no climate that can encourage them to articulate their concerns and help identify possible strategies to address these issues. In many cases women testing positive after marriage have been deserted by their husbands and have returned to their maternal homes. Where the husband has died due to AIDS, the wife is denied a share in the family property, and often has no resources to fight the matter.

The current promotion of a national programme to prevent parent-to-child transmission of HIV has had unexpected fallouts for women. The programme targets pregnant women attending antenatal clinics, encourage them to test for HIV, and offers anti-retroviral therapy to reduce risk of HIV transmission to the baby. Though an excellent strategy to reduce mother-to-child transmission of HIV, the programme has actually led to further stigmatizing and discrimination of women. A situational analysis in four districts of Tamil Nadu conducted by Siaap in 2001-2002 showed that the programme targets women as the primary target of intervention and tests are done on women. If she tests positive, the onus is upon her to convince her partner to seek testing. Meanwhile, the husband himself often rejects the notion that he has been the source of transmission to his wife and questions her behaviour.

Another problem is with the advice being given to women to not breast-feed. Quite apart from the community stigma and suspicions and the cost implications that arise from such behaviour, the woman unwittingly adds to the risk of HIV transmission to the baby because her guilt and physical discomfort as well as lack of finance often persuade her to supplement the substitute feed with occasional breast-feeding. This intermixing of both breast-feeding and alternate feeding increases the chance of HIV infection in the child, because of the higher risk of inflammation of the intestinal wall.

Sexual minorities

On the one hand, HIV has provided sexual minorities, homosexual and bisexual men, a forum to spotlight sexuality issues. On the other, the discrimination against them is reflected in the official response to their demands for (a) adequate self-protection measures (b) decriminalization of homosexuality. Nearly 20 years into HIV, appropriate condoms for anal intercourse are still not available. Nor is it on the list of priorities for policy makers. Neither is there any move to examine the law against homosexual behaviour. Thus, homosexual and bisexual men continue to be doubly vulnerable to sexually transmitted infections including HIV and AIDS.

People Living with HIV and AIDS

An investigative study by Siaap in 1996, on the quality of care for PLHAs in Tamil Nadu, highlighted the discrimination they faced from healthcare providers as well as the cavalier attitude of the government in addressing these issues. Though the situation has improved considerably, on the policy front these have not translated into practice particularly around treatment and support issues. Doctors and other healthcare personnel around Tamil Nadu continue to be reluctant to treat PLHAs. The biggest source of their reluctance is the fear of infection on the one hand and the lack of adequate provisions for following universal precautions on the other. This is compounded by a strong element of judgement around sexual behaviour. Currently, there are only a handful of hospitals in the state that provide a reasonable degree of care. Others continue to refuse adequate treatment to PLHAs on some pretext.

Often stigma, and its more concrete form of discrimination, is rooted in both personal fears as well as societal values. Since sexual behaviour, disease, perhaps death as a consequence, is so fundamental to our understanding of reproductive health and HIV and AIDS, these factors assume greater potency. It is in this context that Siaap has worked towards building supportive policies and environment, both within the communities as well as within institutions.