Abstract: HIV/AIDS has been documented as a stigmatizing condition due to its association with sickness, contagion, and bodily death. Still, further attention needs to be given to the role that the body plays in this process of stigmatization. Taking into consideration the visual dimension of the body, we examine the manner in which visual images of the body living with HIV/AIDS contribute to stigmatize those embodied in them. Through an analysis of bodily images presented in HIV/AIDS related articles published by Puerto Rico's major newspaper, we explain the manner in which they portray a stigmatized body. We examine how these images contrast with the current state of the epidemic in Puerto Rico and consequences that the messages presented by these bodily images may have on the stigmatization of people living with HIV/AIDS. The present study is a preliminary effort stemming from a larger research project that aims to qualitatively examine the stigmatization of HIV/AIDS through multiple media outlets including television, radio, printed press, and the Internet.

HIV/AIDS represents a worldwide pandemic that has influenced our understanding of multiple social dimensions of human life (UNAIDS, 2001). Traditionally held conceptions on sexuality, health, death, loss, survival, pleasure, and the body intertwine in this epidemic to foster different conceptualizations of all. The human body is at the center of discourses surrounding the epidemic since it is, in part, through our bodies that we experience sex, health, death, and pleasure. Still, among the many dimensions of HIV/AIDS that are intimately related to the body one remains to be fully explored: AIDS related stigma. [1]

The present study is part of an ongoing larger venture that aims to qualitatively examine the stigmatization of HIV/AIDS through multiple media outlets including television, radio, printed press, and the Internet in Puerto Rico. The aim of the research presented here was to explore the stigmatization of HIV/AIDS through images of the body in Puerto Rico's largest newspaper. In order to complete this objective let us start by defining the concept of stigma. [2]

The HIV/AIDS epidemic has severely impacted Puerto Rico. The numbers of reported AIDS cases on the island are alarming. Out of the more than 28,000 reported cases of AIDS, 17,000 have already died (OCASET, 2003). Men represent 77% of these cases and women 23%. The most common means of infection are injected drug use (51%), heterosexual transmission (24%) and transmission between men who have sex with men (17%). Along with Haiti, Puerto Rico accounts for the vast majority of AIDS cases in the Caribbean, which in turn is the second highest prevalence area in the world (PAHO, 2001; World Bank, 2001). To make this scenario even more worrisome, HIV cases were not reported until 1999 and no data is still available at the time. [3]

Just as in many other countries around the world these numbers are just one face of the epidemic. Research has shown that people living with HIV/AIDS face stigma on a daily basis (SANTIAGO, 1998; VARGAS DeLEÓN, 1996). Some of the research documenting this stigma is as recent as this decade documenting difficulties accessing health services, ostracism, and open discrimination even by families, friends, sexual partners, and employers (PORBÉN, TORRES BURGOS & BERNAL, 2000; TORRES BURGOS, PORBÉN & BERNAL, 2000; VARAZ-DÍAZ, 2002). In this context, stigma research addressing its manifestations and means of production are essential to address the epidemic. [4]

The concept of stigma dates to ancient Greece and was used to describe persons with bodily marks or tattoos which evidenced their involvement in a bad deed and were therefore to be avoided (CRAWFORD, 1996). The concept has also been defined as an unnatural mark in the bodies of saints, a mark made with a hot iron on the flesh of slaves, a bad reputation, and even a physical dysfunction (REAL ACADEMIA ESPAÑOLA, 1984). Other authors have described stigma as a social construction associated to the recognition of a difference, based on a specific characteristic which is used to devalue the person who possesses it (DOVIDO, MAJOR & CROCKER, 2000). All of these definitions share the idea that a stigma is the negative evaluation of a particular difference that may be identified in a person. [5]

GOFFMAN (1963) explored the subject further. He defined stigma as a profoundly discreditable attribute, which could lead a person to be deemed almost inhuman. He identified three types of stigma: abominations of the body, blemishes of individual character, and tribal stigmas. Abominations of the body are stigmas associated to physical deformations or deviations from a social norm such as people with physical challenges, missing limbs, or physical deformities, among others. Blemishes of individual character are stigmas associated to a person's character, identity, or simply their particular way of being. Some of these blemishes can be attributed to people in jail, drug users, alcoholics, and people with poor mental health, among others. Finally, tribal stigmas refer to the negative evaluation of particular persons due to their association with a group. Some of these stigmas are related to race, ethnicity, and sexual preference. All of these types of stigmas can contribute to devaluing people. [6]

Multiple dimensions have been attributed to stigma (JONES, FARINA, HASTORF, MARKUS, MILLER & SCOTT, 1984). These are: concealability, course (of the stigmatizing condition), disruptiveness, aesthetic qualities, origin, and peril. According to these dimensions a stigma will have more negative effects if it is not concealable (therefore evident to others), if it is deemed as advanced in its course (such as an illness in its final stages), if it disrupts or hinders social interaction, if it is not beautiful or aesthetically pleasing to the observer, if the stigmatized person or group is blamed for its origin, and if it is associated with death. GOFFMAN stressed the importance of the visibility element of stigma, and therefore its bodily dimension. According to him persons whose stigmatizing mark is clearly visible will be discredited by others, while those whose stigma is not visible are considered discreditable since the possibility of being identified as stigma bearers is always imminent (GOFFMAN, 1963). [7]

The importance of the visibility of a stigma evidences the key role of social interaction in this conceptual framework. Since stigmatized people are perceived as deviating from a social norm (LUCHETTA, 1999), it is in their social interaction with others that this difference is evident. Still, even though social interaction is important for the stigmatizing process, the presence of a non-stigmatized person is unnecessary for the negative effects of stigma to emerge. People may feel stigmatized even without the presence of others (CROCKER & QUINN, 2000) by experiencing rejection or feeling despised (HEBL, TICKLE & HEATHERTON, 2000). This social interaction between stigmatized and non-stigmatized is marked by power relations in which the stigmatized may be perceived as having less influence or power over the situation (JONES et al., 1984). [8]

These definitions and multiple insights into the concept of stigma provide us with central ideas on the subject: 1) a stigma is a negative mark which is attributed to a person, 2) stigma leads to a negative value judgment, 3) the process of stigmatization has negative effects for the stigmatized, and 4) there are socially shared ideas regarding specific attributes of a stigmatized person. Concepts such as visibility and abominations of the body evidence the body's underlying theme in stigma theory. Let us examine this bodily dimension of stigma. [9]

One of the most relevant aspects of the conceptual framework for stigma developed by GOFFMAN (1963) is the central role that the body plays in it. The body, as a biological and social entity, serves as a delimitator of particular types of stigmas. [10]

Although in some cases more evidently than others, the body plays a central role in all types of stigma identified by GOFFMAN. Probably the most obvious are the abominations of the body in which particular deformations or missing body parts elicit stigmatizing attitudes. Stigmas associated with blemishes of individual character also entail bodily dimensions. For example, this type of stigma can be found in an imprisoned person whose reality lies behind bars and whose bodily freedom is restricted due to a transgression of social norms. This transgression in turn may be interpreted as a fault of character or personal identity. The same can be said about drug users whose bodies evidence their addiction either by physical marks of drug injection or by lack of total bodily control once under the influence of drugs (CAPITANO & HEREK, 1999). Finally, tribal stigmas also evoke the subject of the body since it serves as an identifier of belonging to a particular group. This may be achieved through skin color, tattoos, body modification (FEATHERSTONE, 2000), or other types of marks such as those of a particular sickness. [11]

GOFFMAN's work on stigma incorporated the body into the subject in an explicit manner. Still, other theoretical contributions to the booming literature regarding the body contribute to further understand the implicit role of the body on stigma (BIRKE, 1999). One example is the literature on the body's role in consumer culture. In it the body plays a central role in the very process of consumption. According to FEATHERSTONE (1991, p.170) the body is a vehicle of pleasure that is socially presented and exposed and therefore must be preserved to "combat deterioration and decay." This evidences the role of the body as a mechanism through which the self or personal concept of identity is preserved in order to successfully consume. [12]

The role of the body must not be assumed as a passive one. Through consumption and consumer culture a socially desirable body is promoted. This body is healthy looking, active, able to be dressed with the most current fashion trends that evidence an up to date body and therefore an appropriate individual. Bodies that deviate from these norms are subject to stigmatization due to negative conceptualizations attached to them. For example, bodies which are not subjected to self-preservationist regimes of exercise (fat bodies), visually unhealthy bodies, and unfashionable bodies are subject to negative interpretations under the standards set by consumer culture. [13]

Another contribution to the literature on the body that can be used to explain stigma is FOUCAULT's conceptualization of the bodies under regimes of discipline and punishment (FOUCAULT, 1995). According to FOUCAULT, the mechanisms of discipline and punishment in our society hold the body as an integral part of their agenda. Although public spectacles of punishment are less seen today, the body continues to be a site to be watched over and supervised. Epidemics are evidence of this phenomenon since in them the body is interpreted as a threat to social order, particularly public health. Through FOUCAULT's work it is clear that in epidemics we deal with meanings attached to health threats and to the bodies that incarnate them. These sick bodies, that must be disciplined into health by the medical establishment (VARGAS MOLINA, 1994), are subject to negative conceptualizations and therefore to stigmatization. [14]

TURNER's (1996) interpretation of the body as a personal possession can also be used to better understand stigmas associated to sickness. In his work, disease is interpreted as a loss of bodily ownership. Due to the fact that when one is sick, control over normal responses lies outside of our personal body. It is not totally up to a person to get well or be healthy, since this control exists elsewhere in different social dimensions associated to, for example, commercial medicine and local politics regarding the sick. These sickly bodies that threaten our sense of ownership can be held to negative interpretations of bodily control and therefore to the negative interpretation or stigmatization of the individual that has lost possession. [15]

For the purpose of this study we assume the body as a socially constructed entity through which people develop identity discourses. This is done through the constant interaction of personal and social meanings regarding what a desirable body should be. Therefore, the body must not be interpreted as just another social object, but as the vehicle through which people experience and constitute social discourses, and therefore social life itself. This perspective is vital to understand the role of the body in the HIV/AIDS epidemic. People living with HIV/AIDS have been subjected to negative interpretations of their bodies and consequently, their selves. These stigmatizing attitudes have been documented in research and are related to the social meanings that the epidemic evokes. [16]

The last decades of the HIV/AIDS epidemic have forced researchers to address the issue of stigma (HEREK, 1999). The HIV/AIDS epidemic has been embedded in myths and false notions about what HIV and people living with HIV are (CUNNINGHAM & RAMOS-BELLIDO, 1991). Among these we can identify misconceptions regarding the modes of transmission and the idea that this epidemic is only pertinent to some particular groups. Since epidemics have had social meanings attributed to them and to the people who are affected, it should not be surprising that HIV/AIDS has its own negative meanings. For example, seropositive people have been perceived as invasive agents in a healthy society (SONTAG, 1990). What is surprising is the magnitude of the stigma associated to HIV/AIDS and those affected, which is very different from other types of conditions. This is evident in the coining of the term "AIDS related stigma" (HEREK & GLUNT, 1988, p.886). [17]

AIDS related stigma has been defined as "all stigma directed at persons perceived to be infected with HIV, regardless of whether they are actually infected and whether they manifest symptoms of AIDS or AIDS-related complex" (HEREK & GLUNT, 1988, p.886). People who actually have HIV/AIDS or are associated to it can be stigmatized by the condition. This entails consequences for those who are directly affected by the disease and for those who work to deal with the epidemic such as health professionals or volunteers (SNYDER, OMOTO & CRAIN, 1999). AIDS related stigma has many causes including the association of HIV/AIDS with sickness and its combination with other types of stigmas. The association of HIV/AIDS with sickness has to do with: (a) the fact that it is an incurable, progressive, and deadly disease (MURPHY, 1995), (b) the notion that those who are affected got what they deserved because of their activities, and (c) the physical condition of HIV patients in advanced stages of the disease in which social interaction is particularly difficult (HEREK & GLUNT, 1988). On the other hand, AIDS related stigma has been associated with other types of stigmas related to sexual orientation, drug use, ethnic minority groups, and sexuality as a mode of transmission. [18]

The idea that seropositive people place the rest of society (seronegatives) at risk for infection is important to understand AIDS related stigma (BUNTING, 1996; HEREK, 1999). This notion has fostered the social exclusion of those perceived as risk agents for the rest of society. This social exclusion is at the very heart of AIDS related stigma. When people are stigmatized they may be socially excluded for many reasons including being perceived as: a threat to the health and security of others, deviated from what society considers normal, and devoid of contributions for the development of society. They also, generate negative emotions in other people (LEARY & SCHREINDORFER, 1998). [19]

Interestingly, most theoretical and empirical contributions to the understanding of AIDS related stigma have not frequently addressed the subject of the body. Nevertheless, some studies regarding the body with HIV/AIDS and the stigma surrounding it allow us to develop a better understanding of the body with AIDS. [20]

Since the body is our vehicle for interaction with the world and others, it is through it that people experience the HIV epidemic. In this sense, the body cannot be separated from the experience of "living" with HIV/AIDS. It is through the body and its "fluids" that people are exposed to the epidemic. In social interactions, in which bodies are embedded, the consequences of infection are evidenced particularly in the case of stigmatization. [21]

The conceptual framework proposed by GOFFMAN (1963) generates understanding of the stigma that surrounds HIV/AIDS, and particularly of the role of the body in such stigma. For example, seropositive people can encompass all three types of stigma identified by GOFFMAN. They are perceived as having abominations of the body when they have visible marks associated to their condition, they suffer from blemishes of individual character when they are perceived as responsible for their HIV/AIDS status, and are victims of tribal stigmas when they are described as part of a risk group. The same can be said for the multiple dimensions of stigma defined by JONES et al. (1984). Since HIV/AIDS may not be concealable in some cases, it may disrupt social interactions with those who are afraid of contagion, and since it is associated with death, seropositive people are very likely to be stigmatized. [22]

The role of the body living with HIV/AIDS in the process of stigmatization can be a dual one. First, it can serve as evidence of the condition to other people. This is particularly evident when bodily marks of sickness are visible on the person living with the condition. Some of these marks include, but are not limited to, lesions, skin infections, and fungus (MURPHY, 1995). Other health complications such as lipodystrophy, condition in which fat is disproportionately accumulated throughout the body, can serve as markers of the disease (VELENTI, 2001). The same can be said of wasting in which the individual is physically debilitated due to loss of body fat and muscle tone (KALICHMAN, 1998). [23]

On the other hand, the body can work as a generator of self-stigmatizing attitudes even when the condition is not clearly visible. Even in asymptomatic bodies people can internalize negative perceptions widely held throughout society regarding infectious bodies. This is not surprising considering that the HIV/AIDS body has been conceptualized as a site of death and contagion, an instance of prejudice, an entity suspended between health and sickness, and as something that succumbs as it faces the epidemic (MURPHY, 1995; WALDBY, 1996). [24]

This stigmatized body living with HIV/AIDS must not be considered a natural or given phenomenon. On the contrary, it is a socially constructed body that lives within discourses of stigmatization collectively created. One manner in which this constructionist endeavor is carried out is through generalization of interpretations and meanings attached to this particular body through mass media. Visual images of the body living with HIV/AIDS are an integral part of this process. [25]

When exploring the important role that the body has on the process of stigmatization, one must examine its visual aspect. We cannot escape the fact that we socially display our bodies and that they are seen and interpreted by others. Therefore, it is a constant visual image in the process of social interaction and the manner in which our bodies look is directly associated to interpretations of who we are. This has been evidenced by FEATHERSTONE (1991) in his work regarding consumer culture and the importance placed on the appearance of a body that is cared for, looking to avoid its neglect and deterioration. Particular importance is given to the way the body is perceived by those that surround it, and therefore the way it looks. [26]

A similar interpretation of the body as a visual image has been made with regards to GOFFMAN's work on the body (SCHILLING, 1993). Since the body plays an integral part of social interaction, it must be properly controlled and managed in order to avoid portraying inappropriate non-verbal messages. The body's appearance, or the way that it looks, is of importance to this type of social interaction. Both of these instances evidence the central aspect of the body's visibility. Therefore, they signal a path for research endeavors related to the body and foster the use of its visual images as a means of analysis. [27]

Debate on the use of visual images in research efforts is ongoing. Some of the main concerns with their use include: 1) the idea that in a media dominated society spectators tend to take images for granted, 2) that they are methodologically more difficult than words to transcribe, and 3) that attention to the image alone distracts the researcher from the social process that has produced it (SILVERMAN, 1999). Despite these limitations, other researchers have pointed out the importance of image analysis due to the fact that in our current historical moment "visual literacy" is replacing traditional "print literacy" (DENZIN & LINCOLN, 1998, p.33). [28]

Although the important role of the image analysis has been evidenced (HARPER, 1998), debate still exists as to what is to be done with them. Traditional content analysis done with literary texts has been implemented with visual images such as photographs (BALL & SMITH 1992), leaving much to be desired since they concentrate on the quantification of explicit content of the images or pictures. On the other hand, researchers exploring visual data in newspapers have stressed the need to understand images in a wider context. Particularly the manner in which they are "reflexive" of a production process of those who create them and therefore the meanings that they seek to convey through them (ALTHEIDE, 1996, p.56). [29]

It is important to note that one image can evoke multiple interpretations (PEARCE, 1999). These can vary among people that see them on an every day basis and, particularly, among researchers interpreting them. Even when some people could consider this a limitation for analysis, qualitative researchers have dealt with this issue extensively when addressing the reliability and validity of their data (MEADOWS & MORSE, 2001). Even when some people may see this as an unsurpassable obstacle, some researchers have developed steps to carry out these analyses. [30]

For example, PHILLIPS and HARDY (2002) have implemented image analysis with newspaper cartoons taking into consideration the limitation of a non-existing standardized method for such an analysis. They recommend the implementation of three steps when carrying out such an analysis: 1) examining the represented objects in the images, 2) coding the images in accordance to the themes (or subjects) they addressed, and finally 3) carrying out this coding process separately, and afterwards in conjunction, to elaborate on the meanings and themes analysts understood were portrayed in the images. This third step has been described in the literature as analyzing the "higher levels of signification" of the images (PENN, 2000, p.233). That is, asking oneself what is the message of the image, and the person/s who created it, is/are trying to disseminate. BELL (2001) has recommended similar steps as a potential mechanism for image analysis. [31]

Although some of the limitations of image analysis can not be easily surpassed, as researchers we feel as that the steps proposed by the previously mentioned authors serve as an initial guide to carry out such an analysis. The possibility that researchers can implement their analysis beyond the manifest content of the images, and undergo a critical interpretation of the meanings they understand it intends to portray, is an important venture in this type of research. It is in this conceptual framework that we engaged in the image analysis presented here. That is, images as portrayers of messages that incarnate opinions and positions of those who create them and their possibility, once included in means of mass communication, of shaping opinions of those who are exposed to them. With this in mind, the main objective of this study was to explore the stigmatization of the body with HIV/AIDS through visual images collected from 1995 to 2000 in Puerto Rico's most popular newspaper. Let us examine the process by which the images were selected and analyzed. [32]

Images were selected from Puerto Rico's most popular and widely read newspaper, El Nuevo Día ("The New Day" in English). More than 69 million copies of this newspaper are sold every year in Puerto Rico (approximately 189,041 daily copies), an impressive quantity considering that the Island's population does not surpass 4 million inhabitants (AUDIT BUREAUS OF CIRCULATIONS, 2001). This ensured that a vast majority of people in Puerto Rico had the possibility of accessing them. Images were selected from articles that addressed AIDS related topics and which included a visual design or picture to accompany it. The articles selected for pictorial analysis were published between 1995 and 2000. [33]

The criteria for an image to be included in the analysis were: 1) that the image had some reference to the human body, be it in an explicit manner or metaphorically, 2) that the image accompanied an article addressing news about HIV/AIDS, and 3) that the article and the image were published during the past 5 years previously mentioned. Although a vast array of images accompanied HIV/AIDS related articles in this 5-year period, only 14 of them met these criteria. Many other articles, and their respective images, addressed the subject of HIV/AIDS during this period of time. Nevertheless, only 14 of these presented images of the body and therefore were used for our analysis of the bodily dimensions of stigma. During the analysis process, the judges agreed that out of the 14 images six made explicit reference to the body with HIV/AIDS in a more stigmatizing manner than the other images (ex: with distorted and fragmented bodies). Other images not presented in this article included depictions of: body parts bound to a chain, bodies in sexual interactions, and bodies on the verge of death.¹⁾ [34]

The amount of images that met our criteria, and the subset presented in this paper, may seem a small amount of instances of stigmatization through the media in Puerto Rico. Still, this stigmatization process is not confined to images in the newspaper we analyzed. It encompasses radio and television programs, informational posters from the Department of Health, and magazine articles, among others. Even though some of these instances are a part of our ongoing analysis, we concentrate on images of the body in a particular newspaper for this article. Still, the stigmatization process through the media is a larger venture that must be continuously addressed by researchers. This research is one piece of that venture. [35]

The analysis was done taking into consideration ALTHEIDE'S (1996) previously mentioned challenges on visual image analysis, and the process outlined by PENN (2000) and PHILLIPS and HARDY (2002). That is, exploring the meanings researchers felt the image intended to portray to the person who saw it. Therefore the question that researchers posed themselves while facing the image was: what meaning(s) is this image trying to portray? [36]

A panel of three judges, the two investigators and a third party, was established to discuss the perceived meanings portrayed in the images. Each judge elaborated on the meanings or themes they perceived the image to portray. Analyses were done independently and compared at a later time. Only meanings and interpretations in which judges agreed upon were included in the final results and in this article. [37]

As researchers we are aware that these images can elicit a vast array of interpretations (PEARCE, 1999). These multiple interpretations could emerge from the reader of this research article and from the same judges of the analysis. It is important to understand that the interpretations included in this article are only one of potential many. We understand this as a manifestation of the complexity of image analysis and the subjective implications of qualitative research in this area. In this manner, we invite the reader to embark with us in our analysis of the images, while at the same time elaborating his/her own. [38]

Published on July 27, 1997 it is the oldest of the images presented in this paper. It accompanied an article delineating the difficulties of implementing effective prevention campaigns in Latin American countries due to the existing conservative social environment; particularly influenced by the Catholic Church. In it a dim silhouette of a kissing man and a woman can be seen. Although the face of the male is completely evident, the face of the female seems to fade into inconclusiveness. Instead of a finished female complexion, the presence of death finalizes the image incarnated in the bodily presence of the grim reaper.

The presence of bodies is clearly evident in this image in the lovers bonded in a passionate kiss and the reaper's body symbolizing death. Further associations can be made in accordance to the actions of these bodies. The man and the woman are engaging in what could be considered an act of sexual nature and therefore associated to a mode of HIV transmission. The presence of a woman is particularly important since they have been traditionally portrayed as vectors of infection in the HIV/AIDS epidemic (WOLFE, 1996). The link is established between sexuality, transmission of HIV, and therefore bodily death. [39]

Although sexual intercourse is not the most common means of HIV transmission in Puerto Rico, it is one of the most stigmatized due to traditional taboos regarding sexuality. This image incarnates the stigmatization of sexuality and HIV through its association with the seemingly unavoidable possibility of infection through sex and death. [40]

Published on June 6, 1995 this image depicts a hand in the process of using a needle for what can be interpreted as intramuscular or intravenous drug use. The image accompanied an advertisement for a television movie on HIV infected youth and the positive role that community based organizations played in their lives. Furthermore, the hand seems to transform into a serpent-like animal that coils around a symbol ascribed to the medical practice. Finally, a singe drop emerging from the needle reflects the image of a skull.

Injection drug use represents the most common means of HIV transmission in Puerto Rico (51% of 27,451 reported AIDS cases). Even though needle exchange programs exist as HIV prevention efforts, they are scarce and cannot attend to the large amount of existing drug users. This image links drug use with infection and consequent death. A hand, which entails the bodily dimension of the image, transforms into a serpent that represents a biblical connotation of evil. In turn it twists itself around the symbol of medical profession which has been unable to stop the spread of HIV through needle exchange and drug use, as if to evidence the failure of modern medicine to attend to the matter and force its control upon the bodies that incarnate it. The image associated drug use with infection, evilness, and death. It evidences existing notions of drug users as evil people whose bodies are closely linked to death due to a negative vice. Furthermore it presents people with HIV/AIDS as drug users and therefore evildoers. [41]

This image was published on August 10, 1997. It accompanied an article describing an increase in the reported HIV/AIDS cases on the island of Cuba, in light of a conference on the subject of health held in the same country. In it a clearly fragmented body is presented. This body, while being broken in two pieces, seems to float in the picture between what could be considered strands of a virus or DNA. The image presents a body that is torn between objects traditionally ascribed to science.

As if confessing science's impossibility of totally deciphering the body living with HIV/AIDS, the man in the picture seems torn apart without possibility of being reconnected. Science, with its knowledge of HIV, viral loads, antiviral drugs, and protease inhibitors is still unable to completely understand the phenomenon. The expected control that biomedicine should exert upon the body is questioned as if pointing to the difficulty of understanding the body as a machine with specific and constant operating rules (GROZ, 1994; SCHILLING, 1993). The human body infected with HIV/AIDS seems fragmented and incomplete, just as its understanding of the virus that afflicts it. An association is made between science's incomplete agenda and the lack of control over the body. These bodies can be interpreted in a stigmatizing manner when compared to those who are not sick, integral, or under control. [42]

This image was published on October 16, 1998. It accompanied an article describing the approval of a bill by the Puerto Rican senate to ensure the rights of people living with HIV/AIDS in the Island. In it a body in decay is presented. A man is dressed in what can be interpreted as a hospital gown and sits looking gloomy in a chair. In the distance, others also sit and seem to wait. Meanwhile their bodies fragment and drift away, all this set on a desolate setting in which no clear place can be identified.

This is one of the most impressive images published in recent years. It is stigmatizing in several manners. For example, it incarnates people living with HIV/AIDS as patients passively waiting, instead of doing so as active agents who engage in health regimens. It presents those living with HIV/AIDS as desolate and solitary people who are distanced from others, maybe to avoid infection. Finally, the image presents bodies that fade. It portrays the HIV/AIDS body as one that will eventually decay into nothingness. Bodily death is clearly linked with HIV/AIDS and to a passive body that is distanced from others and fading constantly. [43]

This image was published on September 2, 2000, which makes it one of the most recent included in this paper. It accompanied an article describing epidemiological data in Puerto Rico. With the presented data it was argued that women were the fastest growing affected group by the epidemic, and that few cases exist among children and adolescents. In it an office scenario is presented in which people are either working or walking through a common work area. One body is singled out as it has been encapsulated in some sort of bubble. This bubble seems to make sure that the body inside does not come in contact with the outside environment and its inhabitants. This is important since past research has evidenced fear of contact with people living with HIV (HEREK & CAPITANO, 1997).

This image must be interpreted in light of the vast amount of people living with HIV/AIDS that have rejoined work scenarios due to the positive effect that antiviral drugs have had on their health. Still, fear of infection has been documented in coworkers (GARCÍA VARGAS, 2001). In the image a person living with HIV/AIDS is working inside a bubble that represents a form of distancing himself from the rest of the present bodies and therefore avoiding infection. This image portrays ongoing beliefs about the possibility of being infected with HIV by casual contact in the work scenario and the stigma and isolation that people living with the condition face at work. To some these bodies must be contained (EPSTEIN, 1992) and distanced (LEIKER, TAUB & GAST, 1995) in scenarios that make social interaction, and therefore infection, impossible. An association is made between the need to avoid infection and the distancing and containment of bodies with HIV/AIDS. [44]

This image was published on September 2, 2000. Similar to Image 5, it accompanied an article describing epidemiological data in Puerto Rico; in this case, describing a reduction in overall AIDS cases, and positioning HIV/AIDS as the sixth cause of death in the Island. In it a person living with HIV/AIDS can be seen lying in a bed with half of his/her face covered by a sheet. A person in the background dressed in white has no identifying characteristics besides the color of the clothing, which might suggest a health professional in a hospital scenario. Multiple studies have documented stigmatizing attitudes towards people living with HIV/AIDS among health related professionals (CRUZ, ORTÍZ-TORRES, MÉNDEZ, 2001; RODRÍGUEZ QUIÑONES, 1999; SANTANA & DANCY, 2000; TREZZA, 1994; WALLACK, 1989). It is unrecognizable if the person in the bed is alive or dead since the open eyes can be interpreted as both.

Although people with HIV/AIDS are living longer in countries like Puerto Rico due to the availability of HIV drugs, images such as this one still promote an association of HIV, death, and sickness. The covering of the infected body can be interpreted as a form of hiding the visual evidence of death from others, if one believes the person to have died, or as a form of caring for a patient if one understands him to be alive. Still, the portrayal of people living with HIV/AIDS as bedridden is far from the reality of most people living with the condition today in Puerto Rico. The image portrays an association of HIV/AIDS with inevitable decay and total health deterioration. Therefore it stigmatizes as it presents an almost invalid body, if not dead, that cannot fend for itself. [45]

Visual representations of the body with AIDS have been present since the beginning of the epidemic on banners, in TV commercials, movies, and other media. Some have been used to make people aware of the impact of the disease and fight for the rights of people living with HIV/AIDS through a critical analysis of the political dimensions of the epidemic. Such is the case of the use of visual images by groups such as the Coalition to Unleash Power (ACT UP) since the early eighties (CRIMP & ROLSTON, 1990). Other images were used in the same decade, particularly in newspapers in the United States and Puerto Rico (CUNNINHAM, RIVERA-RODRÍGUEZ, STEIDEL-FIGUEROA, & CUNNINGHAM, 1997), to conjure up fear in those who engage in risk activities and to portray the epidemic as pertinent to only certain groups (e.g. sex workers, gay men) (GILMAN, 1988). Although theorists on AIDS-related stigma have stated that having information on the subject diminished the levels of stigmatization of the disease, attention must be given to the diffusion of information related to HIV/AIDS through the media, in this case images in newspapers. Even with the amount of information gathered on means of transmission and the social dimensions that foster them (poverty, education, and oppression), HIV/AIDS continues to be a stigmatizing condition. [46]

The images analyzed in this research evidence the stigmatizing notions attached to the body living with HIV/AIDS. These meanings are evidenced through images that conjure negative perspectives of people living with HIV/AIDS, even when reporting potentially positive news. For example, articles addressing movies on the beneficial role of community based organizations, the approval of bills to ensure the rights of people living with HIV/AIDS, and the reduction of overall cases in Puerto Rico, evidence that there are instances in which positive news can be reported regarding HIV/AIDS. Still, even those articles are accompanied by images that can foster negative interpretations of people living with HIV/AIDS as subjects close to death, that should be avoided, and whose bodies are in a constant process of decay. These images promote the stigmatization of HIV/AIDS, even when the articles they are published with show another face of the epidemic. [47]

In these images the body with HIV/AIDS is portrayed as a dangerous entity. It is dangerous because it is infected with a disease and because of the supposed risk of infection it poses to others. This was evident in images 1 and 2 in which sexuality and drug use were portrayed as means of bodily infection. They also portray a clear association of infection with evil and death. This was evident in the presence of a skull-like drop of drugs in Image 2 and in the presence of the grim reaper in Image 1. The dangerous nature of this body resides in two dimensions: due to its engagement in activities that are associated with transmission either literally (such as in the case of drug injection) or metaphorically (such as the case of kissing and its association to sexuality), and because after being infected it threatens the bodily health of the rest of society that comes into contact with it. These dimensions have been previously documented in AIDS-related stigma research that has described wide held conceptions that people who have HIV/AIDS deserve it due to their association with activities socially viewed as negative and that they represent a threatening focus of infection for the rest of society (CAPITANO & HEREK, 1999; HEREK & CAPITANO, 1998; 1999). [48]

These images also portray the need to isolate the body with HIV/AIDS as a method to avoid transmission; a traditional epidemiological and public health practice with HIV/AIDS (KALICHMAN, 1998). This was evident in images 5 and 6 in which infected bodies were completely or partially covered with a bubble or a bed sheet. Segregation is seen as a way of dealing with the presence of a body that is not wanted or deemed inappropriate. In the work scenario the body is portrayed as one that can still carry out socially productive tasks such as those involved in office work; therefore, people can tolerate it and allow it to exert its presence as long as it is contained in its bubble. On the other hand, the sick and socially non-productive body is almost completely covered in a bed sheet as if to avoid even the most basic of visual contacts; as if this avoidance would make it completely disappear. AIDS-related stigma has been fostered by interpretations of people living with HIV/AIDS as individuals that cannot contribute productively to society (GARCÍA VARGAS, 2001; LEARY & SCHREINDORFER, 1998). These examples evidence the interpretation of the body with AIDS as an entity that people have to coexist with, but do so under strict measures of containment and desire for its complete invisibility. [49]

Finally, and probably most significant of all for their bodily analysis, these images portray the body with HIV/AIDS as a fragmented entity. This is evidenced in images 3 and 4 in which the bodies are literally torn apart or fading piece by piece. The body with AIDS is portrayed as an entity that is out of control of the embodied individual. In light of this portrayal the person living with HIV/AIDS is inevitably attached to a decaying body that will slowly either fade into nothingness or simply break apart. This body is in a process of disintegrating, in contrast to the healthy body that is interpreted as an integral physical entity. It echoes TURNER'S (1996) position on bodily ownership that is lost in moments of sickness. Since no final cure has been found for the condition, even with available drugs, the final destination of the body with AIDS is death. Their out of control bodies can serve as vehicles of stigmatization. [50]

With more than 28,000 AIDS cases and an undetermined amount of HIV cases, Puerto Rico unfortunately contributes to making the Caribbean the second most affected region in the world (OCASET, 2003; WHO/PAHO/UNAIDS, 2000). The stigmatization of the disease, and those living with it, fosters their social exclusion and makes their access to treatment and health services more difficult. We must embrace efforts that explore the manner, at times evident and at times implicitly, in which the stigmatizing notions regarding those living with HIV/AIDS are socially developed and perpetuated. The role of the body in this process must be part of this agenda. [51]

As we have seen through the analysis of visual images gathered from the aforementioned source, the portrayal of bodies with HIV/AIDS as sick and fragmented entities which are in a constant deterioration process contribute to the development of stigmatizing attitudes towards them. Due in great part to the availability of drugs in Puerto Rico people are living longer and healthier lives and contribute in many ways to social development. Nevertheless, at the same time the images presented here evidence still existing notions that the body with HIV/AIDS is inevitably bedridden, fragmented, infectious, and therefore not useful to society. [52]

Continuous developing literature on the subject of the socially constructed body can serve as theoretical reference points to guide us in the development of strategic analyses that can contribute to a better understanding of the underlying meanings attached to the body living with HIV/AIDS. The role of the body in consumer culture, the discipline mechanisms enforced upon it, and the notions of the body as a personal possession can contribute to make the infected body stigmatized. These theoretical contributions open the door to a world of possibilities and challenges; let us embrace them. [53]

The authors would like to thank Dr. Ineke CUNNIGHAM for her collaboration as a judge in the analysis of the images presented in the study and for allowing the use of images of her ongoing research on HIV/AIDS and the media in Puerto Rico. Dr. CUNNIGHAM can be contacted at: University of Puerto Rico, Center for AIDS Education and Research, P.O. Box 23345, San Juan, P.R. 00931-3345.

1) If you would like to see the remaining images from the analysis not included in this article contact the first author at nvaras@rrpac.upr.clu.edu. <back>

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Nelson VARAS-DÍAZ, Ph.D., is a social-community psychologists and a researcher at the University of Puerto Rico's University Center for Psychological Services and Research. His research addresses the stigmatization of HIV/AIDS through social policy, the media, and the medical establishment.

José TORO-ALFONSO, Ph.D., is a clinical psychologists and an Associate Professor at the University of Puerto Rico. His research addresses the social construction of masculinity among men who have sex with men, and HIV prevention.

University of Puerto Rico
Center for Psychological Services and Research
P.O. Box 23175
Río Piedras, P.R. 00931-3175

Varas-Díaz, Nelson & Toro-Alfonso, José (2003). Incarnating Stigma: Visual Images of the Body with HIV/AIDS [53 paragraphs]. Forum Qualitative Sozialforschung / Forum: Qualitative Social Research, 4(3), Art. 7, http://nbn-resolving.de/urn:nbn:de:0114-fqs030375.

Forum Qualitative Sozialforschung / Forum: Qualitative Social Research (FQS)

ISSN 1438-5627

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