The impact of gendered scripts on chlamydia and safe-sex on young Australian men and women’s performance of gender and sexual responsibility

Abstract

Over the last decade, young Australian’s rates of chlamydia infection have been steadily increasing with notable differences between young men and women (Kirby Institute, 2018). We explore the impact of gendered scripts on chlamydia and safe-sex on young heterosexual men and women’s performance of gender and sexual responsibility. We examine findings from a Foucauldian discourse analysis (FDA) of key Australian public health websites, alongside in-depth interviews, and qualitative survey responses of students from an Australian university. The FDA identified gendered scripts in public health resources that generally avoided focussing on men in favour of encouraging women to take responsibility for couple’s safe-sex behaviour. Interviews revealed heteronormative gendered scripts framed many sexual practices with stronger focus on unwanted pregnancy than STIs, disproportionate targeting of women for STI testing by doctors and more open discussions on sexual health among women. Interviews also highlighted the absence of a normative ‘formula’ – or script – for safe-sex discussions.

Introduction

Chlamydia is a sexually transmissible infection (STI) caused by a bacterium (Chlamydia trachomatis). Chlamydia is usually transmitted through oral and penetrative sex and is best prevented via the use of latex condoms (Kirby Institute, 2018). According to recent media articles (Afshariyan, 2019; Han, 2018), public health information (Better Health Victoria, 2018; Health NSW, 2012), and statistics (Kirby Institute, 2018) chlamydia infection rates in Australia have been increasing over the last decade, particularly among young Australians.

However, prior research reveals a heterosexual gender gap within chlamydia infection, testing and diagnosis rates (Kirby Institute, 2018). Although testing and diagnosis rates are generally low across both young men and women, doctors are more likely to recommend testing to their female patients due to the nature of health and health-seeking behaviours (Smith et al., 2006; Su et al., 2016). Overall, women are more likely to attend doctor’s appointments and undergo opportunistic STI testing—when the primary reason for consultation is for sexual or reproductive health issues (Su et al., 2016), such as hormonal or menstrual abnormalities, seeking oral contraceptives, or undergoing routine pap-smear tests.

It has been argued that males and females access healthcare and public health information differently owing, in part, to social constructions of masculinity and femininity (Courtenay, 2000; Smith et al., 2006). Such constructions often depict women as holding responsibility not only for their interpersonal contraceptive use, but for the broader health of the community (i.e. preventing the spread of infection). However, it is unclear how public health policy– and the way in which it is translated through practice (i.e. doctors and sexual health education) and consumed (i.e. online resources such as websites)—reproduces this gendered bias.

Some researchers have acknowledged the gendering of scripts on STI prevention, testing and awareness (Chow et al. 2017; Flood 2003) but have not succeeded in changing the dominant rhetoric in sexual health and STI prevention campaigns, nor among heterosexual male discussions around sexual health. This article will therefore seek to examine whether there is a public health bias towards targeting heterosexual women in chlamydia treatment, most particularly in the information provided by their websites. It will examine how social constructions of femininity and masculinity impact upon young men and women’s health-seeking practices, as well as their understandings of safe-sex and safe-sex behaviours.

It will do so with reference to Gagnon and Simon’s (1973) scripting theory, whereby sex involves real and imagined audiences, judgements and views, which teach and reinforce attitudes about safe-sex. It will explore the idea that the rise of chlamydia in young people in Australia may reflect an incoherence between what is known as safe - sex practice, and what is done in sex practice.

This article examines the qualitative findings from a mixed-methods research project. Data was collected through a Foucauldian discourse analysis of key public health websites in Australia, and in-depth interviews with and a survey ¹ of students from the University of Wollongong.

Context

Missing men

In the past few years, there has been extensive media coverage reporting on rising rates of chlamydia among young people (Callander, 2017; Han, 2018). Public health data (Kirby Institute, 2018) also reflects an increase. The rapid spread of chlamydia among young people in Australia appears to suggest a gap in young people’s understanding and performance of effective prevention, early intervention and treatment strategies, such as using condoms to prevent the spread of infection. While this gap may be due to a general lack of chlamydia awareness in this demographic, we would suggest that it is likely due to a gendered bias that positions young women as morally responsible for ensuring their own and their partners’ sexual health.

It has already been noted that much social research into chlamydia targets women (Bowden et al., 2008) and disadvantaged or minority groups (McMichael and Gifford, 2010; Senior et al., 2014; Su et al., 2016). This trend is mirrored within public health discourse, which predominantly targets women and non-heterosexual men by using gendered language and graphics. This aligns with gendered health awareness and practices (Courtenay, 2000; Smith et al., 2006) and the social and historical construction of STIs as other ² (Flood, 2003; Shovellor and Johnson 2006).

According to the Kirby Institute (2018, p.15), there is a higher estimated amount of new infections in males aged 15–29 than females, but the rate of diagnosing – and consequently reporting on – these new infections is twice as low among males (20%) as females (42%). The absence of young heterosexual males in chlamydia research does not provide sufficient evidence towards an absence of chlamydia in this demographic. However, it may contribute to a lack of testing and preventative behaviours. The under-testing of young heterosexual males for STIs has been linked by Flood (2003) to a ‘boundary of imagined safety’, characterised by three key elements. Firstly, the HIV-driven protective fallacy that heterosexuality and heterosexual sex is understood as safe compared to sex between men (Flood, 2003: p. 364). Secondly, the historical representation of anal sex and homosexuality as unclean and dangerous, compared to vaginal sex as a clean sex act (Flood, 2003: p. 364). Thirdly, the stereotyped heterosexual male distinction between ‘“nice girls” and “sluts” … [requires] precautions only with the latter on the basis that “unclean” women are sexually active and thus potentially infected’ (Flood, 2003: p.365). Further, Shovellor & Johnson (2006, p.6) describe a shift in public health discourse following the spread of HIV/AIDS in the heterosexual community in the mid-1980s, from focussing on risky individuals (i.e. the ‘other’) to risky behaviour (i.e. un-protected sex). Arguably, the discourse on ‘risky behaviour’ and its underlying emphasis on shame still lingers in Australian public health websites.

Masculinity, health awareness and health-seeking behaviour

Health discourse has become synonymous with women, and thus health policy and practice seeks to target women (Hankivsky, 2012; Smith et al., 2006). Men often lack their own specifically male health discourse, and health promotion messages often only access men through the women they interact with (Hankivsky, 2012) and have sex with (Su et al., 2016).

Such discursive strategies can impact policies aimed at improving sexual health. They place undue emphasis on heterosexual women and their responsibility as carers, managing both their own sexual health and their male partners’ (Doull et al., 2013). This is both inequitable and less likely to help prevent the spread of disease (Hocking et al., 2008), and health policy in turn reflects these biases. Regan et al. (2008) demonstrate how effective coverage and screening of males and females can reduce chlamydia prevalence in the general young adult population, but the increase in chlamydia rates among young Australians (Kirby Institute, 2018) suggests this approach has not been realised. Certain strategies have been suggested to indirectly involve infected men.

This gendered approach to health policy is reflected in Bowden et al., (2008) suggestion that women be offered opportunistic testing at the time of their pap smear appointment. This would include contact tracing of sexual partners of chlamydia positive women, aimed at increasing the targeting of men (Bowden et al., 2008: p.79). However, this approach may not be cognisant of power dynamics within male–female relationships, requiring a woman to disclose the number of recent sexual partners she has had, provide accurate contact details for each of them, feel comfortable disclosing her chlamydia diagnosis to each of them (knowing she may be judged/stigmatised), and finally for each male partner to act and be tested themselves. This scenario draws attention to the multitude of social, cultural and political factors that influence testing and health policy application.

Social constructions of masculinity not only impact a young male’s willingness to be tested and to take preventative measures – such as using condoms – but also on a doctor’s openness to discussing sexual health and chlamydia testing with their male patients. Doull et al. (2013 p. 331) state, ‘masculine ideals can […] serve to affirm young men as poor communicators about sexual health issues, and reticent to seek professional healthcare for fear of being seen as weak or sexually vulnerable’. Other researchers have demonstrated that once prompted men will openly engage in sexual health discussions with doctors and accept STI tests (Su et al., 2016). However, doctors tend to spend less time with male than female patients, provide them with fewer health services and offer less detailed medical advice. This pattern is reflected in fewer online information and interactive resources that are targeted towards men. Masculinity also negatively impacts a male’s access to healthcare by perpetuating the myth of the invulnerable male body (Himmelstein and Sanchez, 2016). These masculine ideals exist as part of broader gender regimes that position young men and women in particular roles or identities in relation to their sexuality and sexual health, contributing to both positive, sexual satisfaction and self-esteem, and negative, STI transmission and sexual aggression/violence and sexual health outcomes within heterosexual relationships (Doull et al., 2013: p. 331).

Gender and contraceptive responsibility

The undue emphasis on women to manage both their own and their partners’ sexual health is manifested in depictions and perceptions of contraceptive responsibilities (Brown, 2015; McMichael and Gifford, 2010). Even in national studies, contraceptive data is measured through women’s reports of contraceptive behaviours (Family Planning NSW, 2020). It is unclear what proportion of men use contraception, and what effect presenting female-centred contraceptive data has on social and cultural – and medical – attitudes and perceptions towards contraceptive responsibility. Brown (2015) found that many young men and women perceived contraception as the female’s responsibility, as unplanned pregnancy impacts women more than men. Additionally, Flood (2003) notes that many men fail to ask their female partners if they are using contraception, assuming that if a woman does not wish to get pregnant then she will be on oral contraception. Similar attitudes applied to condoms, though women were also subjected to expectations of wanting or expecting sex if they carried condoms (Brown, 2015; Flood, 2003; McMichael and Gifford, 2010). Doull et al. (2013, p.331) highlight the negative impacts of gender regimes on young women’s sexual health, stating that ‘gender regimes that idealise emphasised femininities position young women as submissive within sexual encounters yet responsible for their own sexual health and that of their male partners’. Consequently, young women’s opportunities to negotiate protective behaviours within their heterosexual relationships are limited, positioning them at risk of negative sexual health outcomes such as unplanned pregnancies and STIs (Doull et al., 2013: p. 331). Other studies examining men’s perceptions of contraceptive responsibility identified a perceived unnaturalness to condom use and ‘skin on skin as sexier’ (Downing et al., 2018; Flood, 2003), as well as a desire not to spoil the ‘heat of the moment’ by drawing attention away from the sexual act and towards a chore-like task (Flood 2003). Condom use thus becomes part of sexual labour, or ‘…the work that women undertake to become, remain or refuse to be sexually active’ (McClelland, 2017 in Dutcher and McClelland, 2019: p.402).

Overall, these studies suggest that public health responses that target women feed into social constructions of femininity that position women within the caring and nurturing role. They do not consider the impact of gendered cultural scripts on the negotiation of safe-sex practices, and ultimately of power and responsibility, within heterosexual relationships.

This article will therefore seek to explore whether there is evidence of a public health bias in online chlamydia prevention initiatives that targets heterosexual women rather than heterosexual men and how this influences gendered awareness of chlamydia. It will also examine how constructions of masculinity impact on young heterosexual men’s chlamydia awareness, public health-seeking behaviours (seeking information and getting tested) and responsibility/empathy for others regarding chlamydia. Finally, it will seek to understand how social constructions of femininity and masculinity shape attitudes towards condom usage and contraceptive responsibility.

Methodology

This study examines heterosexual ³ men and women’s interpersonal and intrapsychic scripts in relation to the performance of gender and sexual responsibility within their sexual relationships, as well as in discussions among friends and general attitudes towards chlamydia prevention and testing. To understand the impact of gender on sexual health, the study analyses data derived from a Foucauldian discourse anlysis (FDA) of chlamydia help websites, and a series of in-depth interviews – augmented by open-ended qualitative data from a small-scale survey of under-graduate students from the University of Wollongong. These methods produce data in accordance with Simon and Gagnon’s scripting theory (Gagnon, 1990; Simon & Gagnon, 1986, 2003), which identifies three levels of scripting; cultural scenarios, interpersonal scripts and intrapsychic scripts. Cultural scenarios are ‘… the instructional guides that exist at the level of collective life’ (Gagnon, 1990: p.10) and were examined via an FDA of chlamydia help website(s). Interpersonal scripts ‘operate at the level of social interaction’ (Gagnon, 1990: p.11), such as between heterosexual men and women negotiating sexual activity, while intrapsychic scripts are the internal cognitions connecting ‘meaning (culture) and action (social interaction)’ (Gagnon, 1990: pp.10-11). The interpersonal and intrapsychic scripts have been explored through qualitative survey and interview data.

Recruitment and sampling

Survey and interview participants were recruited through convenience and snowball sampling (Walter, 2013: p.110). Flyers containing information about the study were distributed on campus at the University of Wollongong in addition to being advertised on Facebook. The online survey received 58 complete responses. Online survey participants were provided the opportunity to volunteer for an interview by providing an email address. Only those who provided an email address were contacted to confirm their interview participation. In total, seven interviewees were recruited, three males and four females. ⁴

Analysis – Foucauldian discourse analysis, interviews and qualitative survey

Using Willig’s (2013) six-stage model, FDA analysis was undertaken on three public health (Better Health Victoria, 2018; Health Direct, 2017; Health NSW, 2012) ⁵ and two youth-specific sexual health websites (Frank, n.d.; Play Safe, 2019) ⁶ on chlamydia. In accordance with other researchers who have applied this model (Ness et al., 2017), these data are presented around themes identified from analysis. Discourses may be understood, in the Foucauldian sense, as ‘sets of statements that construct objects and an array of subject positions’ (Willig 2013: p. 130). Willig’s (2013) six-stage model of FDA is outlined as follows: Discursive Construction (how is the discursive object constructed within the text?); Discourses (what discourses does the text draw upon?); Action Orientation (what is the function of these constructions?); Positionings (what subject positions are made available?); Practice (what can be said or done within these subject positions?) and Subjectivity (what can be felt or thought within this subject positions?). The first three of these FDA stages pertain to analysing Simon and Gagnon’s (1990) cultural scenario. They are useful for analysing how the discourses around help and support on these websites employ culturally gendered constructions of chlamydia and its treatment. The latter three FDA stages are more relevant to the interpersonal and intrapsychic scripts, as they reveal the (interpersonal) positions and practices that males and females should take, and the subjective (intrapsychic) thoughts and feelings that are encouraged (and allowable).

In addition to the FDA analysis, seven in-depth interviews were undertaken with three males and four females aged 18–25. While it is unlikely that complete saturation was reached from this number of interviews (Walter, 2013), some degree of saturation was achieved where themes became coherent and started to repeat. Interviews were semi-structured (Blackstone, 2012) and included questions regarding chlamydia knowledge/awareness, chlamydia testing, contraceptive behaviours and sexual relationships, in random order. No identifying information was recorded, aside from gender and age. Interview data was supplemented with qualitative open-ended survey responses obtained from 16 (3 x male; 13 x female) ⁷ respondents. ⁸ The research was approved by the Social Sciences Human Research Ethics Committee of the affiliated institution.

Rather than reporting on each analysis separately, results from the FDA, interview and survey data have been organised thematically below to accord with the three research questions outlined in this study. Themes were inductively (Walter 2013; Lamb et al., 2018) identified from each method and triangulated to form cross-referencing meta-themes (or themes that transcend one method and encapsulate them all).

Limitations

Possible limitations to this research include the impact of social desirability bias on both survey and interview participant responses. The larger proportion of female survey and interview participants may also impact results by creating a gender bias in results. Additionally, participants were all university-educated and from middle-class backgrounds and thus may have held more positive attitudes towards chlamydia, sex, gender and health.

Findings

The gender bias in online health resources and public awareness of chlamydia

Health is synonymous with women

The FDA analysis revealed the underlying gendering of sexual health responsibility within public health discourse. Through their use of language, Health Direct (2017), Health NSW (2012) and Better Health Victoria (2018) construct gendered positionings in relation to chlamydia preventative and testing behaviours, placing undue emphasis on females having responsibility over maintaining healthy sexual relationships and young bodies. When discussing chlamydia symptoms, for example, Health NSW (2012) personalises women’s experience of chlamydia, ‘[a woman may experience] a change in her vaginal discharge’, contrasted to ‘[a man may experience] a discharge in the penis’. In another example, Health Direct’s (2017) chlamydia website features a video with a female reproductive and sexual health expert, who when asked ‘how do you treat chlamydia?’ states, ‘for most women diagnosed with chlamydia, it’s just a single dose of antibiotics […] That’s the same for the male partner as well’.

In this video, the male is not portrayed as an active agent but the male partner of the active female who has undergone testing and been diagnosed. Similarly, when asked ‘should I tell my partner?’ the expert responds: ‘… communication [between both partners] is key [to chlamydia prevention and treatment] …what we don’t want to do is treat the female partner, [and then find] the male partner was not treated…’. This heteronormative response situates the female partner as a proxy for male testing and treatment, and the webpage within a wider medical discourse of female-centred public health solutions (Bowden et al., 2008; Hocking et al., 2008; Regan et al., 2008).

When viewing these sites as symbolic representations of the cultural scenario of sexual health and responsibility, such messaging communicates an underlying assumption within medical health discourse that chlamydia is a feminine health issue, which young women may then assimilate into their interpersonal and intrapsychic scripts. The qualitative survey data demonstrates a coherence among all three levels of scripting, with one respondent stating; ‘I feel like most people think chlamydia is a thing girls get from having a lot of sex. While I know both males and females can get it, I just think it’s interesting that chlamydia connotes with female’. Additionally, both female and male interviewees reported assumptions to the effect that chlamydia was a female issue. The websites thus create subjectivities (Willig, 2013) of active-female and passive-male through their over-emphasis on women, which translates into and reproduces a discursive truth that connects women to health, and in turn encourages female health-seeking practice while discouraging male health-seeking practice.

Women seem more likely to get tested

While the interview data revealed no clear differences in personal chlamydia testing behaviours among genders, there was a common perception that females were tested more frequently and were generally more concerned for their sexual health:

“I feel like women are more prone to go and get checked than guys. Guys … I think they’re sort of too chill at times, they’re just like “oh, you know it’s fine” (Louise, 18, female, in-a-relationship).

Norms regarding masculinity and health were seen as negatively impacting male testing behaviours:

“[M]asculinity …. creates this blind spot as if “not to worry, I’m made of stone didn’t you know?” [But] if you truly are made of stone, let’s test, right?” (Kyle, 25, male, single).

Interviewees attributed these gender disparities to a gendered stigma associated with STIs and sex, whereby the social and physical consequences of having an STI (i.e. severity of symptoms) were harsher for females than males, thus encouraging them to test more:

“I feel like the stigma is always harsher on females than on males … where … some people might … think of her as like unclean or like a slut … Whereas I think that society in general is just more accepting of guys having more sexual partners” (Michael, 25, male, in-a-relationship).

Male awareness

A key finding of the present analysis was the absence or omission of the male voice within public health discussions around chlamydia. The FDA reveals a clear gap between knowledge translation and understanding regarding the effects of chlamydia on men. Health NSW (2012), for example, provides detailed explanations for female chlamydia symptoms translating medical terminology, such as pelvic inflammatory disease (PID) and ectopic pregnancy. In contrast, complications in men are scant and provided in unexplained medical terms, (e.g. recurrent urethritis and epididymitis). In accordance with this, the interview findings revealed that young males are generally less likely to receive or recall relevant health information. Female interviewees – but not males –referenced high school sex-education and chlamydia knowledge. One female interviewee noted that:

“[I]n school, P.E. classes are separated. … [and] even then ... [Boys] would make jokes and just be silly. Whereas, girls would … actually learn and take down notes and whatever” (Louise, 18, female, in-a-relationship).

In general, all female interviewees expressed a strong desire towards acquiring further information and felt that schools had a responsibility towards educating young people about chlamydia, sexual health and contraception. Many felt that schools and teachers were biased in their attitudes towards sex and their portrayal of sexual health information, often due to generational sociocultural stigma surrounding sex and sex-education. One female interviewee (Sofia, 20, female, in-a-relationship) described her PE (physical education) teacher as ‘like pressuring abstinence because he kept talking about like just not doing it at all’. Similarly, another female interviewee (Natalie, 21, female, in-a-relationship) described her high school sex-education as ‘very clinical … It’s just like you make babies and here’s how to stop it’. Male interviewees were more likely to have heard of and discussed chlamydia in informal settings, such as between friends, or when prompted to seek information about chlamydia themselves following their engagement in risky behaviour or due to experiencing unusual symptoms.

None of the interviewees (male or female) felt particularly satisfied or confident with their knowledge and understanding of chlamydia, and few had heard of Health NSW (2012), Better Health Victoria (2018) and Health Direct (2017). The lack of awareness of these sites among young participants may be due to an orientation in these sites towards treatment rather than prevention; only one male had accessed them when prompted by the onset of unusual symptoms. Nonetheless, these sites are reflective of the broader cultural scenario of safe-sex and gendered practice, as is demonstrated by the prevalence of gendered sexual discourses within young people’s sexual scripts.

Getting tested and condom use difficult conversations

Doctors versus sexual health clinics

The interview findings provide further evidence of a perceived gendered bias in health practitioner’s approach to caring for male and female patients. Although most participants had been tested for chlamydia before, females were more likely to have been offered testing by doctors, in association with ongoing health issues, while males were more likely to have had to request a chlamydia test from doctors/sexual health clinicians. Nearly all participants who had tested for chlamydia had gone to their local/family doctor with the exception of one male interviewee – who underwent regular chlamydia testing at an SHC and was strongly opposed to seeing a doctor, viewing them as unskilled and sexually conservative.

Condom use and negotiation

All interviewee responses surrounding condom use and negotiation ⁹ reflect an incoherence between cultural scenarios - what is prescribed as good/healthy sexual behaviour through public health policy and the wider sociocultural context - and interpersonal scripts - what is practiced within sexual interactions. Most scripting occurred internally (intrapsychic), as the participants negotiated between lust, safety and sexual responsibility. The interview findings demonstrate that McClelland’s sexual labour theory (2017 in Dutcher and McClelland, 2019) may apply to both males and females, as both expressed concerns regarding how to negotiate condom use without spoiling the ‘hot moment’ (Flood, 2003), or as one male participant stated:

“[I]n the same moment whereby there exists this … ethereal chaos of … romance and lust … you’re asking someone to drop the rains of the fiery chariot and ... make this decision [where] they have to make all these various calculations about like what the risk of STIs are ... ”(Kyle, 25, male, single).

Various methods were used to make condom negotiation easier, with some participants – both male and female – using humour (Francis, 1994) or technology (texting) as a mediator of possible tension:

“I try to make light-hearted jokes about it … I’ll say something like “oh, there’s going to be like no little gingers running around any time soon, is there?” and they’re like “what?” and I’m like “are you on the pill?” (Greg, 27, male, single).

Interestingly, females emphasised the difficulties of negotiating condom use in their past and present relationships – referencing both their own experiences and those of friends. When reflecting upon their current/recent sexual relationships, four key attitudes/approaches to condom use emerged within the females’ responses; (1) condom use assumed – with no presence of interpersonal scripting – by both partners without conflict; (2) female initiates condom use/non-use and male accepts without resistance; (3) female initiates condom use/non-use and male accepts with resistance and (4) male initiates condom non-use and female accepts. The fourth attitude/approach can be further broken down, where (a) conflict ensues and the female accepts to avoid further conflict or (b) female accepts to avoid conflict. Yet the concept of adequate condom use and negotiation as a preventative measure is absent in the FDA data. The multitude of attitudes/approaches to condom use, evidenced in the interview data, reflect a lack of scripting within the cultural scenario of safe-sex. Interviewees negotiated their condom use at the interpersonal and intrapsychic levels, creating inconsistencies and uncertainties within and across sexual relationships.

These attitudes/approaches can shift throughout the course of a females’ sexual life and depending on their partner, differing from Grunseit’s (2004) study, which suggests current and future contraceptive behaviours are influenced by first intercourse. As summarised in one female interviewee’s response below:

‘In my first relationship, he didn’t want to use [condoms] at all … It was ... always his way of how things went. I did ask him to wear condoms and he just wouldn’t do it … second sexual relationship, he was very okay with whatever I wanted … and I wanted all forms of protection [After that …] it changed person to person.’ (Zara, 24, female, single).

Condom use was moderate and highly contextual, depending on the type of sexual relationship and perceived level of risk. Female interviewees were more likely to undertake a dual method approach, using both condoms and oral contraceptives. All male interviewees reported different contraceptive methods, including condoms, withdrawal and rhythm method. As demonstrated in other studies (Swan and Thompson, 2016; Flood, 2003), trust was a key factor influencing condom use/non-use. Participants were less likely to use condoms if they knew a person well, unless that person was known to engage in a lot of sexual activity. The main reasons for condom non-use were trust (such as knowing the person beforehand or being in a committed/monogamous relationship), reliance on other contraceptive methods (such as the pill or the rhythm method) and an association between condomless sex and stronger sensation and intimacy. This was apparent among both males and females in the study.

Friends as discussants

Both males and females discussed chlamydia, contraception and health in more depth with their female friends. Humour was more commonly used in discussions with male friends and was emphasised as a way of regulating possible tensions, as stated by Francis (1994, p. 147):

‘…humor as emotion management is an expert cultural performance; which strengthens or restores the feeling norms of the situation and creates amusement in the self and others; generating positive sentiments among members of an interacting group by bonding them and/or reducing an external threat…’.

When asked how she would discuss chlamydia testing with friends, one female interviewee stated, ‘I’ll probably take a softer approach to my girlfriends and tell them, “oh, maybe you should get tested.” While I’d probably laugh at my guy friends in the face’ (Zara, 24, female, single). While the males in this study were more empathic and open to discussing sexual health and contraception with friends – often initiating these discussions – they acknowledged these views were not shared by other males. Similar to the young male participants in Doull et al.’s study (2013), the young men in the present study distanced themselves from these other men who appeared to reflect a stereotypically masculine indifference to one’s sexual health and a lack of compassion towards their female partners, demonstrating their ‘agentic capacity to resist or align with expectations about their sexual relationships behaviour’ (Doull et al., 2013: p.335).

Fertility, responsibility and emotion

(Unsafe) sex and shame

Many of the websites take a conservative stance in their approach towards chlamydia prevention, employing the deliberate evocation of negative emotions. Play Safe (2019) appeals to audiences’ moral and legal responsibilities as well as emotions of fear, shame and regret; ‘[t]elling someone they’re at risk [of chlamydia] is the legal and right thing to do’. Similarly, Better Health Victoria (2018) notes undetected chlamydia may lead to infertility and ectopic pregnancy, negatively impact the health of any future children or prevent future enjoyment of sex. The language describing female symptoms implies a sense of urgency and action, referring to burning, bleeding and pain, while male symptoms are more muted, describing discomfort, soreness and swelling. These constructions thereby use negative emotional compulsion – particularly fear, shame and guilt – to mobilise women into testing and treatment, for their own health, their partner’s health and for their future children.

Threats to women as mothers and carers

Some websites emphasise the risks chlamydia poses for motherhood and a woman’s future child. For example, Health NSW (2012) states that ‘[i]f a mother has chlamydia, her baby can become infected during birth’. Health Direct (2017) – assuming a female audience – states that: ‘[i]f [chlamydia] isn’t treated, [it] can sometimes spread to other parts of your body and lead to serious long-term health problems such as pelvic inflammatory disease and infertility (not being able to have children)’.

The language used by these sites assists in the creation of fear, anxiety and regret, emphasising chlamydia’s impact on female reproductive choice, while implicitly evoking women’s assumed moral responsibility towards their selves as a potential mothers and (unborn, future) others. The absence of information regarding the impact of chlamydia on men’s future fatherhood draws attention to the normative function of discourses that position women within mothering/caring subjectivities (Willig, 2013).

Alternative websites, such as Frank (n.d.) and Play Safe (2019), aim to provide a counter discourse to the active-female/passive-male subjectivity commonly constructed by most public health discourse. They refer to people, rather than genders, and discuss symptoms in relation to their effect on reproductive organs. However, when drawing upon the dominant discourses within the cultural scenario of STIs and contraceptive responsibility, as well as general health-seeking behaviour and practice, it appears that women are still more likely to access these websites due to their normative relationship to health and care (Hankivsky, 2012; Su et al., 2016).

The stigma of promiscuous women

The interview and survey data uncovered a perception of females being more concerned about judgement around testing and sexual activity than males. Participants attributed this perception to social stigmatisation of female sexuality whereby STIs symbolise ‘improper’ female sexual desire. One survey respondent emphasised, ‘STIs are highly stigmatised, especially among women, who are often judged for being more promiscuous’. Similarly, another survey respondent stated:

“… It was only after I got chlamydia that I began to realise how common it was and spoke openly about it with friends … but it took me a long time to not see myself as dirty and I think the stigma with the infection is the worst part of getting it…”

This quote emphasises how dominant discourses surrounding sex negatively impact young women’s understandings of themselves and their bodies, particularly in relation to STIs. Additionally, it communicates how the cultural scenario – impacted by dominant discourses – manifests within both interpersonal scripts (between the female respondent and her partner) and the intrapsychic (the feelings of shame and seeing oneself as dirty).

Conclusion

This study demonstrated the presence of gendered discourses in public health media and information sources, as evidenced through chlamydia public health websites. These gendered discourses are communicated through language and reinforce traditional values and attitudes around feminine caring subjectivity that position women as socially and morally responsible for health, motherhood and fertility. Similar to George, Weaver, Higginson and Chartier’s (2015) study on youth-specific public health websites in Canada, this study found that public health websites in Australia lack discourses on sexual pleasure and intimacy and focus largely on the negative consequences of sex. Counter discourses are emerging in alternate ‘youth-centred’ websites, such as Play Safe (2019) and Frank (n.d.), which aim to reclaim women’s sexuality and position sex as a means of enjoyment and not simply for reproduction. However, their current scope appears limited.

These gendered discourses on women’s responsibility for sexual health frame the cultural scenario which is reinforced through young people’s interpersonal scripts – interactions with friends and sexual partners (Gagnon, 1990: p.10) – about testing and condom usage. In order for young people to continuously use condoms, engage in healthy pre-sex discussions and undergo frequent chlamydia testing, they must exhibit a shared acceptance, or ‘normalisation’, of these behaviours within their own levels of scripting. While the majority of young people who participated in this study held fairly sex positive attitudes and beliefs, they felt that these views were not common among peers and that gendered scripts still framed discussions about condom use for many women. As emphasised by Montemurro & Riehman-Murphy (2019, p. 876), it is still commonly ‘critical to interpret heterosexual sexual interactions as dyadic interactions with two actors, stereotypically expected to play out a binary scenario with masculine and feminine parts’.

Similar to previous research (Breny and Lombardi, 2019; Brown, 2015; Flood, 2003), young people in this study were more concerned about unwanted pregnancy than STIs and their largely oral/non-barrier contraceptive patterns reflected this. While most interviewees were in relationships and had little difficulty discussing and instantiating contraceptive use – or perhaps non-use – female interviewees emphasised that these discussions were varied and largely dependent on each individual male partner, some males agreeing to use condoms and others not. However, discussions on condom use and STI testing were largely played out in the intrapsychic realm – where the individual had to negotiate between pleasure/lust and trust/safety.

The majority of interviewees had close relationships with their doctors and preferred them to SHCs. There was a stigma associated with SHCs that prevented young people from accessing them, not wishing to identify with such places. Females were more likely to have received STI testing upon a doctor’s recommendation, while males were more likely to have requested STI testing – either due to increased sexual activity or experiencing unusual symptoms.

Additionally, men and women’s feelings and experience of sexual health and STIs differed. Although the males in this study were quite empathic – demonstrating care and understanding for others – there was a clear distinction between their use of emotive language and expression whereby they used humour and reason to create distance. This relates to other literature which suggests humour is used to affirm masculine identities (Swain, 2004) and that men are rationally concerned about STIs only if there is a calculated risk involved (deBoise, 2017). Females spoke more openly about fears associated with having STIs and of caring about oneself and others. In keeping with the need to be reflexive (Clough and Nutbrown, 2012), I understand this may also have been subject to the fact that, I – as the researcher/interviewer – am a female and discussions with other females may have been viewed as ‘girly chat’ (Natalie, 21, female, in-a-relationship).

This study has demonstrated that young people’s sexual health-seeking and preventative behaviours are impacted by a multitude of factors, such as sexual health education, relationships with doctors and gendered social and cultural expectations of behaviour. Additionally, there are various layers of stigma – relating to gender, health and sexuality – impacting young people’s attitudes and behaviours towards chlamydia prevention and testing. These factors all contribute to the formation of gendered scripts on young people’s performance of safe-sex and sexual responsibility within a cultural scenario around chlamydia and safe-sex. This study has demonstrated that while Simon and Gagnon’s scripting theory may provide useful insights into the social and cultural context of this issue, it appears inadequate in understanding the performance of safe-sex among young people. As summarised by a male interviewee below:

‘…there’s no formula that's set on any type of social practice before sex … There doesn’t seem to be a clear social norm that supports healthy pre-sex behaviour … I’m talking about specifically for STIs … [and even just asking your sexual partner] ‘Hey, have you checked? Do you think we should check [for STIs]?’ (Kyle, 25, male, single)

The above quote highlights the issue that most young people appear to be facing – there is a formula (culturally defined script) but there is no clear social norm that supports healthy pre-sex behaviour. As a consequence, healthy pre-sex behaviour is left to be negotiated within the interpersonal (what do you and I [as sexual partners] want to do/should we do?) and intrapsychic (how should I ask these questions and how will they be received?) scripting realms. These script-disparities require further research in order to influence positive change.

Young people have a right to healthy and respectful sexual relationships as well as adequate access to sexual health information, testing and treatment that is free from shame and stigma. Although there have been positive developments in Australian education initiatives promoting respectful relationships and healthy sexual behaviours, such as Love Bites (2022). Public health practitioners, educators and policy-makers should consider including messaging on safe-sex in these initiatives, noting that conversations around safe-sex, STIs and condom use are part of respectful relationships. The young people in this study highlighted the difficulty of initiating/negotiating condom use. Further the female participants emphasised the negative aspects of these negotiations, often resulting in shame, anxiety and even conflict. Public health initiatives seeking to encourage chlamydia testing and safe-sex practices should engage with young people to develop information that is free from shame and stigma and ultimately create safe spaces, both in-person and online.