The relationship between sex and cervical cancer has sometimes been used to position women who develop cervical cancer as promiscuous and, therefore, sexually bad. This article explores sexual discourses informing cervical cancer prevention policy. We contend that a good girl/bad girl discourse influenced the particular direction of policy development. This historically pervasive discourse positions women who have sex outside certain ‘acceptable’ heterosexual relationships as, at best, promiscuous, and, at worst, as ‘whores’. When this discourse is prominent, publicising the association between sexuality and cervical cancer may deter women from being screened. New Zealand’s cervical cancer prevention policy has therefore downplayed the relationship between sexual behaviour and cervical cancer. We question whether or not it is in women’s best interests for policy to submit to, rather than directly challenge, such sexist discourses. Unarticulated norms around heterosexual intercourse and heterosexuality were also found to inform cervical cancer prevention policy. © 1999 Elsevier Science Ltd. All rights reserved.
An association between heterosexual sexual activity and cervical cancer was recognised early last century, and much attention was given to differences in cervical cancer incidence between nuns (very low) and prostitutes (high) (Lacey, 1992). More recently, epidemiological research has identified numerous sexual risk factors for cervical cancer (e.g., higher numbers of sexual partners; an earlier age of first intercourse), and an association between sex and cervical cancer is now virtually unquestioned. The medical community widely accepts a model of cervical cancer as mimicking, or being, a sexually transmitted disease (STD) (Franco, 1991; Rosenberg & Gollub, 1992). Recently, both experimental and epidemiological research have indicated that certain types of a sexually transmitted virus, human papilloma virus (HPV), are the primary causal agent in most cervical cancers (Cox, 1995).
(For recent reviews of all risk factors for cervical cancer see Bornstein, Rahat, & Abramovici, 1995; Cox, 1995; Schiffman & Brinton, 1995.) However, the relationship between HPV and cervical cancer is not straightforward. HPV is common in the general population (Braverman & Strasburger, 1994), and only a small proportion of women with high-risk type HPV infections will develop clinically evident lesions, and only a very small proportion of women with these lesions will go on to develop cervical cancer (Kenney & Reuss, 1994). Therefore, HPV is considered a necessary but not sufficient cause of cervical cancer (in almost all cases) (Cox, 1995; zur Hausen, 1989). While various cofactors are believed to contribute to the development of cervical cancer, specific knowledge of these, and their mechanisms, is less certain.
1 Although sexual risk factors for cervical cancer are well-established, this information appears to be somewhat problematic in the development of policy for cervical cancer prevention. It has been suggested that publicity about the association between cervical cancer and sexuality (which inferentially links it with STDs, promiscuity, and stigma) may deter women from having smears (Department of Health/Te Tari Ora, 1990; Eardley et al., 1985; Public Health Commission/Rangapu Hauora Tumatanui, 1994), and may cause women to feel blamed if they develop cervical cancer. In New Zealand, this concern has led to information about sexual risk factors being deliberately excluded from cervical cancer prevention strategies (Department of Health/Te Tari Ora, 1990; National Cervical Screening Programme, 1990).
In this article, we address the question of how discourses and assumptions about women’s sexuality influence prevention policy (possibilities) for cervical cancer, and explore the effects these have. This article identifies certain sexual discourses, and discusses the ways they have implicitly shaped cervical cancer prevention policy directions. Through doing this, we seek to challenge the inevitability and hegemony of certain sexual discourses, and open up cervical cancer prevention policy to new interpretative possibilities. This article developed from a study of cervical cancer prevention policy in New Zealand, and draws on data from New Zealand cervical cancer prevention policy documents, international cervical cancer prevention literature, and interviews with key informants from around New Zealand (Braun, 1997).
Semi-structured interviews were undertaken with 18 informants who had been involved with cervical cancer prevention policy development in New Zealand, research pertaining to cervical cancer, or had been otherwise involved in the area. Informants represented a range of perspectives: academic; cervical screening; consumer; consumer/advocacy organisations; gynecology; Maori 2 health; policy analysis and development; public health; sexual health; and women’s health. Two people who were commonly cited as key figures in the cervical cancer area declined our invitation to participate. Interviews covered informants’ professional involvement with cervical cancer and cervical cancer policy development, and their views regarding cervical cancer prevention policy, and the possibility of primary prevention. Four interviews were conducted by telephone.
With informants’ consent, interviews, which lasted between 30 minutes and 2 hours, were audiotaped and transcribed. In the one interview where the informant chose not to be audiotaped, notes were taken and expanded after the interview. Data were analysed using discourse analytic techniques. This form of discourse analysis moves beyond an analysis of the descriptive content of texts to explore the common-sense assumptions and discourses which underlie them (Gilbert & Mulkay, 1984), and to examine the ways subjects and objects are created in them (Burman & Parker, 1993). With such an approach, language and discourse are viewed as producing meaning, knowledge, truths, beliefs; as being a social practice (Burman & Parker, 1993; Fairclough, 1992; Parker, 1990; Potter & Wetherell, 1987).
THE GOOD GIRL/BAD GIRL DISCOURSE
Tiefer (1995) contended that “sexualities and sexual experiences are produced, changed, and modified within an ever-changing sexual discourse” (p. 19). Discourses can also function to position individuals in particular ways (Davies & Harré, 1990). In this sense they can [help] construct women’s subjectivity—her “conscious and unconscious thoughts and emotions . . . her sense of herself and her ways of understanding her relation to the world” (Weedon, 1987, p. 32). Thus, sexual discourses can both affect how sexuality is socially understood, and, in turn, how women understand themselves in relation to those meanings. 3 Feminist scholars have argued that particular representations of STDs have been utilised since the 19th century in constructing (and judging) female sexuality (Kehoe, 1988; Leonardo & Chrisler, 1992). STDs are employed to reinforce a dichotomy between sexually ‘good’ and sexually ‘bad’ women: The good girl is sexually responsible, has one (preferably spousal) sexual partner, and does not get STDs.
The bad girl is sexually irresponsible, has many sexual partners, and gets STDs (and is thereby punished) (Boston Women’s Health Book Collective, 1984; Leonardo & Chrisler, 1992; Tiefer, 1995). So, what we have called the good girl/bad girl discourse draws on historical notions of both STDs and Christian morality around monogamy (e.g., see also Hollway, 1984, 1989). This discourse not only effectively dichotomises women’s sexuality by offering women two positions, good or bad, but also ‘punishes’ women for their sexuality. In our research, some key informants explicitly noted that this good girl/bad girl discourse had informed attitudes to cervical cancer and its prevention.
For example, one informant noted that during the Cartwright Inquiry 4 it became evident that many of the issues concerning the (lack of) prevention and treatment of cervical cancer were related to a: Polarised attitude towards women’s sexuality. Good girls, bad girls. Goddesses and whores . . . That was the underlying psychology behind it . . . . . So if you were nice you would not have got it, and all the work on male partners was just conveniently ignored 5 (A women’s health activist/academic ) This informant explicitly stated that this moralistic discourse has historically been used to position and judge women who develop cervical cancer as bad girls. The good girl/bad girl discourse offers only these two positions, with few alternative interpretative possibilities. The contention that “the wages of sex are a positive smear” (Skrabanek & Jamieson, 1985, p. 654) (written by two doctors, and published in a letter to the New Zealand Medical Journal!) is a vivid example of how such traditional moral discourses on women’s sexuality have been deployed to position women who develop cervical cancer as bad, and how women have been blamed for their condition. The notion of ‘promiscuity’ The concept of promiscuity can be seen as a manifestation of the good girl/bad girl discourse.
The term promiscuity tends to refer to a (socially undesirable) form of ‘careless’ or ‘irresponsible’ sexual behaviour, and is enlisted to judge and label women who engage in sexual behaviours which do not fit within certain (traditional) moral criteria. The term has been employed frequently and seemingly unproblematically with regards to women who develop cervical abnormalities and cancer. That is, women who get cervical cancer have (historically) been considered to be promiscuous. As one informant noted it had been a popular perception that: Women that got cervical cancer were promiscuous. They were whores, sort of prostitutes ( Informant working with cervical screening and policy ) This informant described how the cause and meaning of cervical cancer for women has historically been constructed through the good girl/bad girl discourse and the notion of promiscuity. It has been suggested that the media, in particular, tended to promote the idea of female promiscuity in the development of cervical cancer (Davey, 1986; Eardley et al., 1985) and that this functioned to punish women who deviated from traditional sexual norms (Bickley, 1987; Eardley et al., 1985).
Some informants assumed that when we raised the prospect of primary prevention, we were suggesting telling women that being promiscuous was a risk factor for cervical cancer. For example, There is this conflict, because if the primary prevention says that the more promiscuous younger you are, the more you’re at risk, that can put some of the older and more staid women off screening ( Policy analyst ) It was interesting that informants made a link between promiscuity and cervical cancer with regard to primary prevention, as we only referred to providing sexual risk factor information. This indicates a somewhat automatic association, and suggests that the good girl/bad girl discourse still implicitly informs meanings around cervical cancer. Other informants spontaneously used the term to challenge the validity of the assertion that (only) promiscuous women get cervical cancer. For example, You can also get cervical cancer through very minimal sexual contact. So it’s, you know, although there may well have been studies which show a link , it doesn’t mean that you have to have been sexually promiscuous in order to get the disease ( A women’s health activist ) However, it could be argued that the reference to promiscuity in this quote reinforces popular notions of what it is (i.e., women who have more than “very minimal sexual contact”). When informants referred to promiscuity, they usually used the term to repudiate previous uses, to dispute the relationship between promiscuity and cervical cancer.
However, no informants directly challenged the concept itself, and the assumptions it relies on and imparts. There has been no attempt to deconstruct the term, or to question its (albeit ‘self conscious’) utilisation. It is worth considering whether the use of such a problematic term, without challenging its validity as a construct, is beneficial (e.g., it may mean that women who develop cervical cancer are no longer labelled promiscuous), detrimental (e.g., through not explicitly challenging it, promiscuity may be unintentionally reinforced as a valid construct), or both. If the notion of promiscuity is only silenced (rather than contested), women (and men) may assume promiscuity when they hear about sexual risk factors for cervical cancer. Despite the ascendancy of a permissive discourse around sexuality since the 1960s (Hollway, 1984, 1989), the good girl/bad girl discourse appears to remain influential.
Therefore, the emotive aspects, and the historical function, of the label/construct ‘promiscuous’ probably remain. The focus on promiscuity also ignores male risk factors and emphasises female risk factors. This term is gender specific—women can be promiscuous, but heterosexual men are rarely described in this way. By focusing on promiscuity, the role of the (male) partner in transmitting HPV (Bosch et al., 1996; Brinton, 1992; Kjær et al., 1991; Schiffman & Brinton, 1995; Thomas et al., 1996) is ignored, male responsibility is obscured, and the blame and solution for cervical cancer are located firmly with the woman.
MATERIAL EFFECTS OF SEXUAL DISCOURSES
Discourses can have effects by offering people ways of understanding and perceiving themselves, and by creating socially accessible meanings and norms. The potential negative effects of the good girl/bad girl discourse exist at two levels: Effects on women who develop cervical cancer, and effects on women who are targeted for screening. Within a discursive context in which cervical cancer is linked to promiscuity, a woman with cervical cancer must have been a bad girl. For women with a potentially life-threatening disease, this added insult to her moral character is unacceptable. For women to resist this positioning, they would have to challenge pervasive and powerful discourses around sexuality, and would need, at the very least, access to oppositional (feminist) discourses. The good girl/bad girl discourse may also affect cervical cancer prevention. If cervical cancer is believed to be related to promiscuity, women who do not regard themselves as promiscuous might believe they are not at risk, and so not perceive cervical cancer as a potential problem.
For example, The anecdotal evidence was very compelling that (pause) women who were not sexually promiscuous were not expecting [cervical cancer] to be a problem ( A women’s health activist ) This indicates that the good girl/bad girl discourse (and the notion of promiscuity) allows women to position themselves as ‘other,’ as good, and thus exclude themselves from being ‘at risk’ of cervical cancer. Even if women perceived themselves as potentially at risk, the good girl/bad girl discourse may still undermine screening efforts. In this discursive context, screening can become associated with stigma. A number of informants suggested that this context made it less likely that women would be screened. For example, The women involved in the programme found that one of the barriers to getting women to come along for a smear was that it might imply that they’d been promiscuous ( Maori health worker ) One of the resistances that people had in those times to actually being screened was that there had been quite a lot of publicity linking cervical cancer with promiscuity.
And we had picked up, and providers had picked, people thought that in asking for screening they were admitting to promiscuity, and in that being offered, there was some sort of labelling going on ( Policy analyst ) One of the barriers to women having a smear test is that myth that women that got cervical cancer were promiscuous. They were whores or prostitutes. Women feel bad about that, so that actually prevents women going to have smear tests ( Informant working with cervical screening and policy ) In this context, for a woman to choose to be screened, she may have to re-evaluate herself in light of the good girl/bad girl discourse and position herself as ‘bad.’ These quotes suggest a process of self-selection by women. Given a choice between a position of promiscuous (and vulnerable) or not-promiscuous (and safe), it is easy to understand how potentially at-risk women could erroneously assume they are safe if they do not consider themselves to be promiscuous, and therefore choose not to be screened.
SEXUAL DISCOURSES AND CERVICAL CANCER PREVENTION POLICY
Historically, the good girl/bad girl discourse appears to have been the dominant discourse through which women’s sexuality has been understood in relation to cervical cancer. While informants challenged its validity, they also discussed and theorised the potential (negative) effects of primary prevention largely in terms of this discourse. That is, it was suggested that women may take information about an association between cervical cancer and sexual behaviour (necessary for primary prevention) as a reason for not being screened and may be/feel blamed and stigmatised (Braun & Gavey, 1998). In New Zealand, the policy solution to the dilemma around risk factors and the effects of the good girl/bad girl discourse has been to suppress information about the connection with sexuality (Deparment of Health/Te Tari Ora, 1990). This largely reflects the influence of a protectionist discourse (where the deleterious effects that information may have are used to inform practice, and the aim is to protect women from potential harm [via screening]) (see Braun & Gavey, in press). Current New Zealand prevention policy, which appears to neither agree with, nor explicitly challenge, the good girl/bad girl discourse, necessitates a move away from the area of sexuality.
Indeed, as one informant noted, New Zealand’s National Cervical Screening Programme policy is an attempt to undermine the (potential) negative effects associated with the good girl/bad girl discourse through making sexuality invisible: It was basically a way of trying to get around the good girl bad girl dichotomy ( A women’s health activist/academic ) Cervical cancer appears to have been constructed in policy as a ‘clean’ disease, one not associated with sexuality or STDs. Cervical cancer is therefore not a reflection on the woman’s morality. This construction has been achieved through silencing the connection between STDs and cervical cancer. However, this approach renders impossible simultaneous primary prevention strategies that could explicitly target sexual practices. Moreover, current strategies may limit the possibility of primary prevention in the future, as the good girl/ bad girl discourse which makes primary prevention problematic now is likely to remain as an implicit reference if it is not contested. However, the good girl/bad girl discourse is not the only discourse around (hetero)sexuality informing prevention policy.
Both the protectionist discourse and prevention policy for cervical cancer are also influenced by a permissive discourse, which challenges the principle of monogamy and bestows on all people the right to express their sexuality in any way they choose, as long as no one is hurt (Hollway, 1984, 1989). This contests the morality of, and indeed ‘risks’ associated with, the good girl/ bad girl discourse. A policy that ostensibly ignores sex may also function to avoid problematising the permissive discourse. Knowledge of cervical cancer risk factors, and the ‘dangers’ around sexuality, challenges the validity of a sexual discourse which allows (compels?) women (and men) to have sexual freedom, without necessarily raising notions of responsibility. A policy that does not provide sexual risk factor information does not highlight potential risks of heterosexual sex, and therefore may uncritically perpetuate an unmodified version of permissive heterosexuality as acceptable. The number of informants who advocated primary prevention or maintained that women should be given sexual risk factor information (see Braun & Gavey, in press, 1998) appear to suggest that policy should be developed that is not entirely limited by concerns about the possible effects of these sorts of sexual discourses. Such informants advocated that primary prevention was important. For example, I think [information about sexual risk factors for cervical cancer] should just be part of the general education of the young . . .
I don’t think that it should be suppressed as information, but I think it should be handled sensitively, with the two issues about the fact that not all cervical cancers are likely to be caused by a sexually transmitted agent, and secondly that people who get this disease don’t necessarily themselves have to have had lots of partners. ( An academic ) These informants argued that risk factor information should be made available to women so that they have the opportunity to make informed choices about their sexuality. Other authors have also suggested that a way to overcome misconceptions and myths around sex and cervical cancer (for Maori women) is to provide accurate risk information (Manihera & Turnbull, 1990). This position echoes a discourse that we have elsewhere termed “the right to know” where it is advocated that individuals have a right to have information that may be relevant to them or their health, irrespective of the presumed potential effects of that information (see Braun & Gavey, in press). In cervical cancer prevention there is some conflict between strategies that may be optimal for most women who are currently sexually active, and those that may be optimal for girls and women who are not (yet) sexually active.
Primary prevention activities that highlight a sexual association may be beneficial for the latter group, in that they may allow these women the possibility of making informed choices about their sexual practices. However, they are arguably of less benefit to women who are currently sexually active, and may have already come into contact with HPV. Furthermore, for these women, such strategies may have ‘costs,’ in that they may deter them from screening. At another level, information about sexual risk factors may challenge and change stereotypes and prevailing problematic constructions of women’s sexuality/STDs. If health workers do not disseminate and discuss sexual risk factors for cervical cancer, but focus exclusively on screening, they do not challenge (or even refer to) the good girl/bad girl discourse.
We question whether such actions may subtly reinforce the notion that bad (promiscuous) women get STDs. One informant suggested that the way to overcome the positions created by the good girl/bad girl discourse is to explicitly resist and reject the positions that it offers. We’ll only overcome the resistances and the labels, by rejecting those labels, by saying lets not be pushed around by these categories, lets not allow ourselves to be put into those categories . . . lets get out of them, lets challenge their reality, they don’t have any basis. ( A women’s health activist/academic ) For women, the (potential) lack of relevance of the positions the good girl/bad girl discourse offers might provide a prospect for resistance: If women are unwilling to accept a position of either ‘good’ or ‘bad,’ they might explore ways to subvert this discourse through access to oppositional discourses.
These may be made more accessible by the dissemination of sexual risk factor information which highlights the (currently almost invisible) role of male sexual behaviour in cervical cancer risk. The first half of this article explored the influence of the good girl/bad girl discourse and permissive discourse on cervical cancer prevention policy. We will now examine the implicit reference to certain sexual norms in talk and literature around cervical cancer, and discuss how these further constrain possibilities for prevention.
Rather than viewing sexuality as natural and shaped by biology, many feminist and other theorists have tended to view it as constructed in various visible and invisible ways in specific socio-historical environments (Foucault, 1978; S. Jackson, 1996; Tiefer, 1995). This conceptualisation does not deny that certain constructions around sexuality are hegemonic and seemingly natural. Margaret Jackson (1984) identified the equation of heterosexual sexual activity with coitus, and the presumption of heterosexuality as the norm as the most fundamental, and highly problematic, assumptions of sexology. Both assumptions have implications for cervical cancer prevention policy. Normative heterosexual practice: The ‘coital imperative’ The promotion of non-penetrative sexual practices and a de-emphasising of the centrality of sexual intercourse could form part of cervical cancer primary prevention.
6 It has been asserted that clinical disciplines such as medicine and psychology emphasise the normality and centrality of heterosexual intercourse, as opposed to non-penetrative sexual activities, which leads to, and reinforces, the assumption that sexual activity inevitably involves sexual intercourse (Tiefer, 1995). This assumption was echoed by a number of informants who argued against the viability of primary prevention strategies that would require people to change normative sexual behaviour. They emphasised what people really do in the real world to support such positions. One informant used such ‘real world’ rhetoric to demonstrate the probable lack of effects of primary prevention initiatives that promote the possibility of non-penetrative sexual behaviours. For example, I still think if you start telling people that penetrative sexual activity is risky, and others are not–there’s no great international evidence that you’re going to make a great change.
People are still going to have penetrative sex ( A sexual health doctor ) Such assumptions will limit the perceived viability of cervical cancer prevention which focuses on changing sexual behaviour—such as actively promoting non-penetrative sexual activities as safer alternatives to intercourse. This raises an important question for disease prevention. When the spread of a disease can be potentially reduced by the introduction of social and behavioural changes which radically challenge current norms, should recommended prevention strategies be limited by perceptions of what is realistic, or should challenging those perceptions be part of what prevention can offer? That radical approaches can work despite seeming unlikely was referred to by one informant who discussed how health professionals had never imagined that people would alter their sexual behaviour in terms of long-term risk, but that many people had done this with regards to HIV/AIDS.
While the current context must necessarily inform prevention policy to some extent, if we do not challenge its inevitability, we may limit, and even undermine, the possibilities for social and behavioural change relevant to cervical cancer prevention. Heterosexuality as the norm Feminist discussions of heterosexuality as an institution and of heterosexual privilege (van Every, 1995) have demonstrated the pervasiveness and dominance of the heterosexual norm. It has been argued that “medicine constitutes a particularly powerful instrument of support for the coercive institution of heterosexuality” (Sherwin, 1992, p. 213). It is perhaps not surprising to therefore consider that within most of the cervical cancer literature there is a large and unvocalised assumption of heterosexuality. While the majority of women have had (or will have) heterosexual sex, the lack of consideration of lesbian women is noteworthy. Furthermore, the lack of focus on lesbian women’s risk can be seen as an interesting exception to the ‘bad’-women-get-cervical-cancer equation. A Maori health worker noted this lack of concern for lesbian women’s needs or risks: Informant: I remember [a male doctor] saying, because I asked about the policy doesn’t say anything about lesbians, and he said “oh well there’s plenty of research to show that most lesbians have had sex with men anyway so it covers them.” . . .
I asked a couple of the doctors . . . about how is it transmitted . . . because if HPV can be transmitted by other sexual behaviour, other than penis vaginal sex, then, yes, lesbians do need to know that it’s possible, that they need protect themselves against the spread of HPV . . . Virginia: So doctors didn’t really consider it to be an issue Informant: No no no “most women have had sex with men anyway” There is little literature on lesbian women’s risk for cervical cancer, and there appears to be a lack of discussion about risks of HPV transmission between lesbian partners, or transmission from sexual behaviours other than coitus.
The focus on sexual intercourse as risky explicitly excludes women who have only had sex with a female partner from being at risk. However, evidence suggests that HPV can be transmitted by sexual activities which do not include penetrative sex (Edwards & Thin, 1990), and even lesbian women who have not had sex with men might not be automatically safe if their partners have previously had sex with men. While it has been suggested that lesbian women may be at lower risk of cervical cancer due to lower risks for STDs (Tamkins, 1996), empirical research is rare. One study of STDs in 27 lesbian women attending a geni tourinary medicine clinic found 9 of the 27 had current or past HPV infections and 10 of 25 had abnormal smears (Edwards & Thin, 1990). Edwards and Thin also found HPV infection in one of the three lesbian women who had never had heterosexual intercourse. On the basis of their study, Edwards and Thin cautioned against assuming lesbian women are necessarily safe.
In literature and policy relating to cervical cancer causes, risks, and prevention, heterosexuality is often the assumed and unarticulated sexual norm. If medical and prevention literature highlights the risk of cervical cancer for women who have had intercourse, but does not discuss lesbian women’s risk, lesbian women may not attend cervical screening because they appear not to be at risk (Edwards & Thin, 1990; Price, Easton, Telljohann, & Wallace, 1996). In New Zealand’s most recent National Cervical Screening Programme policy (Ministry of Health/Manatu Hauora, 1996), lesbian women were highlighted as being included in the target population of the National Cervical Screening Programme. The policy (Ministry of Health/Manatu Hauora, 1996) also mentioned lesbian women as one of the groups experiencing barriers to cervical screening.
More explicit discussion of the needs and risks for lesbian women is clearly needed. However, the exclusion of discussion of lesbian women’s risks from cervical cancer prevention literature can function not only to discriminate against lesbian women, but also to protect ‘normative’ heterosexuality from scrutiny. If the presumed lower risk of lesbian women (or indeed the ranges of ‘risk’ lesbian women might experience) is not discussed, heterosexuality per se is not problematised. Rather, ‘promiscuity’, an aberration from this norm, can be constructed as problematic, leaving non-promiscuous heterosexuality ‘safe’. This not only reinforces the notion of ‘woman as problem’, but also obscures the role of the male in the transmission of HPV. Thus, attention to promiscuity obscures real risk behaviours, and therefore undermines all women’s ability to assess their level of risk.
Another issue of relevance to cervical cancer prevention is the contradiction between, and juxtaposition of, private sexuality and public sexuality. Sexuality is a site of controversy and contradiction: It is acceptable, even expected, for sex to be paraded, used for advertising and entertainment, yet it is considered a private matter (Sherwin, 1992), not for public discussion. Many people may feel uncomfortable discussing sex (Clarke, 1992). A notion of sexual privacy constructs each individual woman’s sexuality as private, in contrast to general sexuality that is public and discussed. This may be an important mechanism for the perpetuation of the good girl/bad girl sexual discourse: If sexuality is a private, not-discussed area, women may be less able to resist the positions and knowledges the good girl/bad girl discourse evokes.
While the notion of sexual privacy might be used rhetorically, sexuality appears to be controlled or constructed publicly (Foucault, 1978; Joffe, 1986). The media publicly shape ideas about normative sexuality (Tiefer, 1995), and can perpetuate or disrupt dominant (sexual) discourses. With regard to cervical cancer, various authors have noted that the media “seized” (Kitchener, 1988, p. 1089) upon a possible sexually transmitted cause of cervical cancer (Davey, 1986; Kitchener, 1988). The ostensible conflict between the public and the private is played out in the area of, and has implications for, cervical cancer prevention. Medicine and science, institutions which (help) construct normative sexuality (Tiefer, 1995), provide a potential meeting point between the private (the individual) and the public (the normative). Given such an understanding, cervical cancer prevention approaches might not simply be viewed as limited to cervical cancer prevention, but as contributing to vast, complex, and potentially changeable discourses on sexuality.
Prevention approaches to, and research on, cervical cancer appear to have reinforced the public/private divide by isolating women’s sexuality within individual women, and disregarding the broader social context in which sexuality is constructed and interpreted. This focus constructs cervical cancer as a problem of individual women, neglects social factors which make women more vulnerable, and locates the solution within the individual (Armstrong, 1988; Bickley, 1987). Hollway (1995) noted that the use of an individual explanation for problems tends to exclude the use of a social explanation (and vice-versa). Through focus sing on individual women, and the ways the individual is affected by sexuality information, the social context which determines the meanings of that information is ignored, and the functions of those meanings are obscured.