Stigma as ‘othering’ among Christian theology students in South Africa

Abstract

HIV is a health and developmental crisis that has profoundly challenged the Christian church in sub-Saharan Africa. Responding to stigma and prejudice against HIV and people living with HIV and AIDS has been a major concern of theologians and Christian leaders. However, Christians themselves and the church as a community are equally prone to stigma and prejudice. The author contends that this stigma is grounded in the dynamic of ‘othering’, which, among Christians, takes on religious or theological overtones. Drawing on qualitative data from theology students in South Africa, the paper assembles a model of AIDS stigma as othering. The central story or axis of the model is the dynamic of othering, comprising three themes, viz. lack of empathic contact, disconnection, and distancing. There are three main dynamics that appear to contribute to or feed into othering, viz. emotions related to sexuality and HIV, theology of health and judgement, and contextualised knowledge of HIV. Finally, the model presents two primary results of othering, viz. disengagement from HIV through passivity and hopelessness, and prejudice against those living with HIV. The paper endeavours to reveal the possible biblical roots of AIDS stigma. Through this, the deep violence embedded in such stigma is exposed and contrasted with a theology of inclusiveness and engagement.

Résumé

Le Virus d' Immunodéficience Humain (VIH) est un problème de santé et de développement qui a profondément remis en question l’église chrétienne en Afrique sub-saharienne. Une préoccupation majeure des théologiens et des leaders religieux était d'apporter une réponse à la stigmatisation et aux préjugés à l’égard du VIH/SIDA et des personnes vivant avec le VIH. Cependant, les chrétiens eux-mêmes et l’église, en tant que communauté, sont également enclins à la stigmatisation et aux préjugés. L'auteur soutient que cette stigmatisation est ancrée dans la dynamique de differentiation or « othering », qui, parmi les chrétiens, prend des références religieuses ou théologiques. S'appuyant sur des données qualitatives provenant des étudiants en théologie en Afrique du Sud, le papier assemble un modèle de stigmatisation liée au SIDA comme differentiation or « othering ». Le principal axe du modèle est la dynamique de differentiation or « othering », comprenant trois thèmes, à savoir: l'absence de contact empathique, la déconnexion et de distanciation ou éloignement. Il y a trois principales dynamiques qui semblent contribuer à nourrir de differentiation or « othering », à savoir : les émotions liées à la sexualité et au VIH, la théologie de la santé et du jugement, et la connaissance contextualisée du VIH. Enfin, le modèle présente deux résultats primaires de differentiation or « othering », à savoir: désengagement vis-à-vis du VIH/SIDA par la passivité, le désespoir et les préjugés envers les personnes vivant avec le VIH. Le papier s'efforce de révéler les racines bibliques de possible stigmatisation liée au SIDA. Grâce à cela, la violence profonde incorporée dans cette stigmatisation est exposée et contrastée avec une théologie de l'inclusivité et de l'engagement.

Keywords:

• HIV
• stigma
• othering
• Christian
• clergy
• faith-based

Mots clés:

• VIH
• stigmatisation
• othering
• chrétien
• clergé
• foi-basé

Introduction

The Christian church, which views itself as an instrument of reconciliation, has frequently been an instrument of exclusion and stigma (Gill 2007). As a South African educator of theology students in Christian responses to HIV and AIDS, I have been confronted by the apparently extensive stigmatising and prejudicial attitudes of students towards people who are living with HIV and AIDS (PLWHA). It has become apparent to me that Christian theology students – most of whom are leaders in their churches and some of whom are already ordained clergy – keep HIV and PLWHA at a distance.

Moreover, it has become apparent that this distancing or othering seems to be supported by a fairly consistent and even coherent framework or model of HIV and PLWHA that is rooted, to at least some extent, in the Bible and Christian theology. While no student has actively advanced an actual theology that endorses stigma, there appears to be an unarticulated and probably unconscious mental model, drawing on both the Bible and theology, that supports and fuels AIDS stigma. This is not merely a negative personal attitude or stance towards HIV and PLWHA; many people hold such attitudes for a wide variety of psychological and social reasons. Rather, this appears to be a partially formulated and biblically endorsed model. I believe it is a similar mental model that is used to ‘other’ and exclude women and gay people, indeed all people who do not conform to the dominant Christian social profile – male, heterosexual, healthy, and morally conservative.

While there is much good theological literature that opposes stigma and exclusion and that advances a theology of inclusion, there is little literature that seeks to unearth and understand the dynamic of stigma among Christians as a way of othering and excluding PLWHA. Unless we truly understand the deep dynamics and nuances of such a mental model, it is difficult for us – as health workers, educators, and theologians – to deconstruct the model and replace it with a theology and world-view that is genuinely Christian.

My aim in this paper is thus to uncover a model of AIDS stigma as othering, drawing on the academic assignments of theology students who were addressing questions about how they have grown through a course on Christian responses to HIV and AIDS. The objectives of the paper are to (1) develop a model of AIDS stigma as othering, (2) locate some of the biblical roots of AIDS stigma among Christians, and (3) expose the stark violence that lies at the root of AIDS stigma, thereby bringing well-established Christian theologies of inclusiveness into greater clarity.

I will introduce the topic of stigma, explaining the notion of ‘othering’ and describing existing research on AIDS stigma among Christians. After explaining the methodology used in the study, I present a grounded theory model of AIDS stigma as othering. This model illuminates the dynamics and nuances of stigma and othering among many Christians. I then briefly explore possible biblical and theological foundations of stigma and othering, as exposed by the model and as rooted in a limited interpretation of the Bible. Finally, I make two suggestions for the disassembly of this model.

Stigma as ‘othering’

Insiders and outsiders have been a feature of human society since prehistory. Indeed, sociologists argue that the division of the world into insiders and outsiders is essential for the development of society, by creating a clear and delineated cultural identity (Cromer 2001). The distinction between insider and outsider, however, inevitably leads to value judgements. We insiders are viewed as good and virtuous, while those outsiders are bad and evil (Deacon, Prosalendis & Stephney 2005; Mageto 2005). There is a dividing wall of hostility between the insider and outsider. Those on the outside – the others – are ‘less than’. They are less than us, less than Christian, less than human, and less than worthy. To be sure, they are objects of pity, and so we will reach out to them with Christian charity. We may even invite them in. But they are not like us – they are ‘the other’.

Sociologists, philosophers, and feminists have introduced the notion of ‘othering’ to describe the processes by which people who are different from us become increasingly alien, to the point that they are barely human (Cromer 2001). Othering effectively increases the distance between groups of people. Some theorists thus regard othering as a key dynamic underlying stigma (Deacon et al. 2005). Following Goffman, stigma can be defined as ‘a powerful discrediting and tainting social label that radically changes the way individuals  … are viewed as persons’ (Alonzo & Reynolds 1995:304).

Othering is a central component of AIDS-related stigma. ‘The “not me – others are to blame” phenomenon has become particularly prevalent in relation to disease threats in modern society’ (Deacon et al. 2005:7). Benton (2008:316) says, ‘This is us – and they are not us’. Stigma ‘effectively brands “the other” as undesirable’ (Ackermann 2005:388). ‘AIDS is perceived as a disease of “others” – of people living on the margins of society, whose lifestyles go against social norms and are often considered “wrong” or “sinful”’ (Mahendra, Gilborn, Bharat, Mudoi, Gupta, George, et al. 2007:617).

Othering PLWHA has been of particular concern in sub-Saharan Africa because of the high prevalence of HIV in our communities (NDOH 2008). Stereotyping, stigma, prejudice, and discrimination towards PLWHA have been sources of ongoing concern among AIDS workers. In some instances, PLWHA have lost their lives because of their HIV-positive status; Gugu Dhlamini is a well-known example of this, as a South African woman stoned to death by her community after she disclosed her status in 1998 (Jewkes 2006). Others have lost their jobs, been denied promotion, and been rejected by their families (Centre for the Study of AIDS 2003; Skinner & Mfecane 2004).

Othering of PLHWA is particularly salient in South Africa because of our long history of institutionalised racism. ‘Much of the current blame and othering of HIV/AIDS in South Africa can be traced to its complex history in racism, patriarchy and homophobia’ (Petros, Airhihenbuwa, Simbayi, Ramlagan & Brown 2006:75). Apartheid was effective at keeping groups separate, fostering marked divisions between insiders and outsiders. Separateness, combined with massive power differences, created a fertile environment for the flourishing of othering (Petros et al. 2006).

The church is widely viewed as an institution ideally suited to challenge and deconstruct prejudice in the community (Somlai, Heckman, Kelly, Mulry & Multhauf 1997; Van Wyngaard 2006). Perhaps part of the confidence in the church is grounded in the view of the Bible as offering hope and liberation for those at the margins of society (Bosch 1991). Indeed, a search of the academic literature turns up numerous papers that support the important contribution of the church in this regard (Benton 2008). In Kenya, for example, HIV-positive priests have publicly disclosed their status, helping to reduce HIV stigma in their communities (Ambasa-Shisanya 2006). In a South African study (Birdsall 2005:5), out of 1,582 organisations in the National AIDS Database, 162 self-identified as faith-based organisations (FBOs). The vast majority (96%) of these were Christian, and among these 7% were Anglican and 6% Methodist (these two denominations make up the bulk of participants in this paper). FBOs in South Africa provide a wide range of services, particularly prevention (awareness and HIV counselling and testing) and care and support (Birdsall 2005:20).

Much of this literature, however, works from an assumption that stigma is a problem ‘out there’ in the community and that ‘we here’ in the church are immune to this problem and in a position to remedy it ‘out there’ – in transactional analysis terms, ‘We're okay – you're not okay’. The church thus views itself as a sanctuary to which those who experience stigma can flee for refuge from the world out there that is fraught with stigma and discrimination. While the church may, therefore, be a place of hope and healing, it paradoxically furthers the dynamic of othering by accentuating the distance between the ‘virtuous church’ and the ‘godless community’.

There is little literature that addresses the prevalence of prejudice within the church community and particularly within Christian leadership (Mageto 2005). It is reminiscent of Jesus' metaphor (Luke 6:42) of our obsession with the speck in the eyes of those around us and our blindness to the log in our own eye (Phillips 2006). Theological literature has attended well to the question of prejudice and stigma in the world, showing how the Gospel message challenges and brings release from these evils (Ackermann 2005; Bouwer 2007; Conradie 2005; Olivier 2006). However, much of this literature is written from a moral high ground that fails to turn the mirror on to ourselves as Christians. This imbalance between outward-looking and inward-looking theological literature is itself an example of othering within academia.

The small body of literature and research that looks at prejudice and stigma against HIV and PLWHA among Christians is not favourable (Ambasa-Shisanya 2006; Cox, Chung, She & Fung 2004; Crawford, Allison, Robinson, Hughes & Samaryk 1992; Genrich & Brathwaite 2005; Green & Rademan 1997; Maughan-Brown 2006; Skinner & Mfecane 2004). Some Christian leaders are found to endorse prejudicial beliefs about HIV, believing it to be God's judgement on promiscuity or God's solution to population growth. PLWHA themselves have related their experiences of stigmatisation from the church (Centre for the Study of AIDS 2003:14) – for example, one man in this study reported, ‘You sit down [in church] and they all get up and go sit somewhere else’.

Social scientists and theologians should give a great deal more attention to prejudice and stigma within the church. This could facilitate a recognition and breakdown of othering, through creating awareness of our own role in promoting othering. The distance that is created between ‘them’ and ‘us’ would decrease, and we would begin to recognise that everyone is ‘us’. As the apostle Paul might say (Ephesians 2:14), the dividing wall between them and us would be broken down, and we would discover our shared humanity. This paper is a small contribution to this goal.

Methodology

I adopted an exploratory, qualitative approach to this study, informed in particular by grounded theory (Charmaz 2006; Ezzy 2002). This design is supported by the relative absence of published literature on the subject. There is, therefore, a need to conduct an initial exploration of the field. Qualitative, text-based methodologies are well suited to the exploratory design. The design is also supported by my interest in the nuanced dynamics of stigma, which would not easily be addressed through a quantitative approach.

This study was conducted at the Theological Education by Extension College (TEEC) in Johannesburg, South Africa. TEEC is a college that has its roots in the struggle for liberation, and is part of a network of colleges throughout the world, particularly in developing countries (Steyn 1997). Many of our students are mature, and most live in disadvantaged communities. Students are drawn from a diverse range of denominations, including Lutherans, Presbyterians, and Roman Catholics, though most students are Methodist (61%) or Anglican (23%) (TEEC 2010:5). TEEC follows a form of distance learning called ‘extension’, which involves self-directed study within the context of students' local church community and possibly with the help of local tutors (Burton 2000).

For several years, I have coordinated the course ‘Facilitating Christian responses to HIV and AIDS’, which is one of the first courses that students undertake towards a Diploma or Bachelor's Degree in theology. Students submit two assignments for this course on HIV. The assignments attend to their knowledge of HIV and AIDS as a medical, social, and human-rights challenge; their theology of HIV and AIDS in terms of judgement, healing, pastoral care, and inclusivity; and their ability to engage with HIV and AIDS in the community through a community assessment and HIV workshop.

The last assignment task asks students, ‘Describe what effect this course has had on you personally (250 words)’. This task facilitates reflexive learning (Fook 2002) – to turn the mirror on themselves and explore the ways in which they have changed through this learning experience. The task is a standard requirement for this course and is not graded – students receive written feedback, but not a mark. The responses of all 102 students who answered this task in the 2008 class (i.e. the entire population) formed the data for this study (thus no sampling of the population was conducted).

Measuring prejudice and stigma, however, is a methodological challenge (Nyblade 2006), particularly regarding the influence of impression management on the validity of one's data. I have elsewhere defined impression management as ‘the processes of adapting to situational demands to create a favourable impression in order to obtain a desired outcome’ (Van Breda & Potgieter 2007:100). In the context of HIV-related stigma, impression management is the tendency of people to deny that they stigmatise HIV and PLWHA in order to make a good impression on others. We can expect this tendency to be most common among those who have the most to lose as a result of stigmatising attitudes, such as Christian leaders.

The data used in this study are similarly vulnerable to impression management. Students undertook this task with the expectation that it was ‘for marks’. The fact that we do not allocate a mark to this task probably does nothing to reduce this expectation. Students would be under considerable pressure to present their attitudes and learning in a highly positive light. Consequently, we must be suspicious of students' comments that all their negative attitudes towards PLWHA have been resolved.

However, many students made reference in this task to the attitudes that they had before doing this course. And many of these references were particularly frank. Given the pressure towards impression management, one might expect that students would be reluctant to present any negative attitudes or behaviours, for fear that we would fail them. These references typically have a clear ‘ring of truth’ to them. This does not mean that the data are above question, but it does suggest that students' comments about the negative attitudes they held before they did the course are less vulnerable to impression management than comments about current positive attitudes and values. It is, in other words, easier to acknowledge the prejudices that I used to have than the prejudices that I currently have.

After obtaining permission from TEEC, I photocopied all of the answers to this task, yielding 102 sets of data. I stripped the data of identifying information, keeping only the student number to secure the audit trail. Through several initial readings of all the texts, I began to recognise a central theme of othering – a sense that before this course students had little contact with ‘those people’ who have HIV and AIDS.

Using open coding (Ezzy 2002), I worked through all of the texts again and extracted key phrases, words, and ideas, which I listed in a separate document. This produced a list of 150 fragments. I worked through this list several times, looking for similarities between the fragments, grouping them eventually into 19 themes. One of the themes – disconnect – began to appear as a core code around which the other codes clustered. At this point, the beginnings of a theory of stigma among theology students began to emerge, which centred on the dynamic of othering. I attempted preliminary definitions of the themes and reflected on the relationships between them.

I then returned to the 102 original texts and formally coded all of the data. This entailed a close reading of the texts. I copied phrases, sentences, or paragraphs that were associated with the themes into a new document (keeping track of student numbers for audit purposes). I sorted these fragments according to theme, and read through them several times to ensure the coherence of sets of texts associated with each theme.

Using axial coding (Ezzy 2002), I continued to explore how the various themes that I had identified related to each other, playing with different combinations and sequences, looking for associations, and especially attending to the central concept or axis that would hold the whole together. I returned to and adjusted my emerging theory, in light of my repeated readings of the texts. I also reread the literature, to facilitate a dialogue between my data and the published literature. In the process I discarded or combined a number of smaller or peripheral categories, ending with 16 categories.

From this process, it appeared that the dynamic of othering (which included psychologically disconnecting from HIV, avoiding interaction with PLWHA, and distancing from PLWHA) was the ‘central story’ (Ezzy 2002:92) that held together all the bits of data that I had collected.

A key limitation of the study is the question concerning impression management, as previously discussed, given that the data emerged through an assignment rather than research-oriented interviews by someone unrelated to TEEC. Although I have advanced arguments for having reasonable confidence in the results, this study should be regarded as preliminary and requiring further investigation and confirmation. A further limitation concerns the relatively brief texts from which to work – about 250 words per respondent – and the textual nature of the data, which prohibited probes to explore responses further.

A number of mechanisms were included to enhance the trustworthiness (Lincoln & Guba 1985) of the study. Credibility was enhanced through prolonged engagement and persistent observation – I have taught this course and read these assignments for eight years, in addition to running tutorial classes for students. During this time I have gained an in-depth familiarity with the attitudes of TEEC students throughout their studies, and was thus able to read the data collected here with that familiarity. I also teach a course on HIV to social work students at a university, which provided a point of contrast against which to compare the data from the TEEC students. Since conducting this analysis, I have read two further sets of responses to the same assignment, which have generated responses consonant with the results presented here.

A model of AIDS stigma

The model that emerged through the inductive analysis of the data is presented in Figure 1. This model seeks to explicate the dynamic of prejudice against HIV and PLWHA among Christian theology students. Given that many of our students are already leaders, lay ministers, or ordained clergy, I believe that this model can be transferred to Christian clergy. The central story or axis of the model is the dynamic of othering, represented in the middle row by three themes: lack of empathic contact, disconnection, and distancing. There are three main dynamics that appear to contribute to or feed into othering, which are represented at the top of the model, viz. emotions, theology, and knowledge. Finally, the two primary results of othering are represented at the bottom of the model: disengagement and prejudice.

Fig. 1. A Model of AIDS Stigma as Othering.

Othering

I start with the dimension of othering, because this is the central proposition of the model. Othering involves holding the issue of HIV, and consequently the people who are infected and affected with HIV and AIDS, at arm's length. It is a form of denial; but rather than denying the existence of HIV, othering involves putting AIDS ‘out there’, far away from oneself, so that it does not touch one. In this way, HIV becomes something remote and impersonal about which we need not worry.

Psychological and emotional disconnection from the issue of HIV is central to this dynamic of othering. For example, one student wrote, ‘I had turned the volume in my ear down so low that I could barely hear the word HIV/AIDS. Surely I knew about it, but I did not KNOW about it.’ This student reflects a psychological numbing towards the subject of HIV – filtering it out of consciousness. Another student reported, ‘Slogans, advertisements and teachings about HIV/AIDS were such a bore, so much that I'd switch off the radio or television for that matter.' Several students used spatial terms like ‘distant’ and ‘far away’ to describe their attitude towards HIV before doing the course – ‘I thought it was something far away from me’ and ‘I have been at a distance.’ One student reported her annoyance at being forced to do this compulsory course:

I did not want to do this course – I was irritated that it was a TEE core course because I felt it had nothing to do with me or with getting a degree. (I was focusing on theological academics not on spirituality.)

Interpersonal disconnection or lack of empathic contact is a corollary of disconnection. At its most basic level, lack of empathic contact is simply a lack of contact with PLWHA – ‘In fact, it was astounding, I had never even met someone with HIV/AIDS.’ One of the assignments for this course requires students to interview people who are infected with HIV, and to assess their needs and their experiences of human rights. This contact helped to break down not only the lack of contact, but also the lack of empathy – ‘After visiting the AIDS hospice in X, I have a greater understanding of the problems that these people face and how the disease affects their whole being’ and

It opened my heart up to the personal aspect of the disease. So often we think of AIDS in terms of statistics and not of emotions and people. I have much more empathy and compassion for those living with the disease.

Those who did have previous contact with PLWHA report that they had never engaged deeply with the experience of being HIV positive, and that they had always kept PLWHA at an interpersonal and emotional distance. Through this new contact they developed an empathic understanding of being HIV positive – ‘Prior to this course I thought that I had sufficient knowledge of HIV and AIDS, but working with people who have HIV and addressing this issue with people in the church for the first time provided new personal experiences.’

Distancing is the third component of othering, and involves the division of the world into two camps: them and us. ‘They’ (the others) become different from and less than us, and thus not worthy of our attention and energy. The following statement beautifully illustrates this:

The distance between myself and the people living [with] HIV/AIDS before I started this course is coming closer and closer, because now I know that they are my brothers and sisters in Christ. I have learned from doing this course that whoever of us suffer from AIDS, I myself suffer too because we are in one body of Christ.

A number of students had divided people into ‘those HIV-positive people who are sinners’ and ‘we who are the beloved children of God’ – ‘I believed it was a “self-inflicted” disease, and therefore not my problem.’

Several students gave expression to the dynamic of distancing by conceiving of HIV as someone else's problem – ‘I held the prevailing attitude that HIV/AIDS is something out there, not something to bother about – that it's a government problem, not a church problem.’ Several indicated that HIV was something that did not touch them – ‘I always failed to understand the saying “we are all affected” until I was engaged to this course. Realities have been revealed to me of which I now claim proudly that I am really affected by this pandemic.’

Contributors to othering

The data suggest that there are three main dimensions that contribute to othering, viz. emotions, which I have loosely understood as non-rational factors that help to create distance between the student and those living with HIV; theology, which refers to ‘Christian’ beliefs that provide support to (or at least do not challenge) othering; and lack of accurate and contextual knowledge, which serves to keep the topic of HIV distant and depersonalised. These dimensions are presented in the top third of the model in Figure 1.

The dimension of emotions is made up of three themes: fears, myths, and sex. Some students reported feelings of fear, intimidation, and anxiety about HIV and PLWHA – ‘Truly speaking I was somehow afraid’, and ‘Although I understand how HIV can and cannot be transmitted, at first I found it intimidating to get too close to, let alone hold the hand of a person with HIV.’ Some students reported believing myths about HIV and AIDS that served to keep HIV at a distance:

There was a theory in my town that this disease does not exist. It is a plan of whites to limit the blacks in making babies, because they were afraid of losing when we are voting politically. I was convinced of that.

And a handful of students reported cultural anxiety about talking openly about sexuality and sex that resulted in their avoidance of the subject of HIV – ‘I was also not prepared to participate in any talks about sexuality. I would feel ashamed.’ The importance of this dimension is that these emotions intensify other dynamics that contribute to othering, making the topic of HIV threatening and thus aversive.

The second dimension, theology , is similarly made up of three themes: God's judgement, scripture, and theology. This is a central dimension, of equal importance to the dimension of othering in terms of the number of statements that fell in this dimension. In this dimension, students mobilised a range of ‘Christian’ beliefs about HIV that support their own othering attitudes. It is not possible with these data to determine whether the theology comes before the othering or whether the othering results in a theology of distance. It is probable that these two dimensions are mutually reinforcing.

The first theme in theology is a belief that HIV is God's judgement on those who are infected. This theme is central to the model, and is one that is commonly reported in the published literature. Many students reported quite candidly that they used to believe that HIV was punishment from God for people's immorality – ‘I thought that it is a punishment from God for those who misbehave, who are bad’ and

Before I started this course my mind was full of nonsense because I thought that AIDS is God's punishment to the world for her disobedience to God, especially those who engaged in sexual activities outside their marriages or who practise sex before marriage. Now I realise I was wrong.

A number of students extended this from a rather passive belief that PLWHA are being punished to an endorsement of this view – ‘My thinking used to be negative towards PLWHA and the disease itself. I used to think that theologically they were sinners, unclean, shameful and God is punishing them because they deserved to be punished’ and

I must confess that I am one of those who thought that God is punishing the sexually immoral with AIDS. … I did not see the grace of God necessary for them because they are sinners. I was happy that God is punishing them.

The second theme under theology is the use of scripture to back up and defend these beliefs. A number of students used scripture to defend their judgemental views of HIV – ‘From the background of Genesis 3 [the story of the fall of Adam and Eve in the Garden of Eden] I had that thinking of AIDS as God's judgement due to sin’, and ‘I discriminated against PLHWAs and used to condemn them using the scripture’, and ‘Believe me, I could prove my view [that AIDS was punishment for those who lived an immoral life] with texts from the Bible.’

One of the assignment tasks in this course requires students to grapple with the view that HIV is God's judgement on the sexual promiscuity of this generation. A number of students reported that they used to look very superficially at scripture – ‘This task really challenged me to search deeply and meditate on God's truth’, and ‘Theologically this course has also been a challenge for me as I have had to really look at scripture and decide for myself in regards to the many differing arguments that are out there’, and ‘This has strengthened my desire to be able to hear God when He speaks to me and to be able to separate what comes from God and what is evil under the cloak of the Word of God.’

The third and final facet of theology is a theme that I have called theology. This is a more specific use of the term than for the broader dimension. Here it refers primarily to the recognition by students that they had an underdeveloped theological understanding of HIV. One student articulates this as follows:

Before responding to the call from God to serve His church, I was so passionate about AIDS ministry, but then I had no theological understanding of HIV. But this course has shaped and constructed my theological understanding and has developed a desire to be part of every work of fighting AIDS.

Another student said,

My theological thinking around the issue of HIV was not good. I didn't have a stand because I did not have enough knowledge to back my theology. This course made me to have a stand and broadened my theology about the issue of AIDS.

A third student wrote, ‘This course changed my unnamed and sometimes unconscious theological assumptions about illness, gender, sex, sexuality, the Bible, the Church, and so on, opening myself up for vigorous debate.’

The third and final contributor to othering is a lack of knowledge about HIV. We know from HIV-prevention studies that knowledge does not directly influence behaviour; however it does influence attitudes, which in turn impact behaviour. The data on knowledge elicited in this study suggest that lack of knowledge about HIV (or incorrect or narrow knowledge) contributes to keeping HIV at a distance – HIV becomes a vague thing of little import to the student. This dimension has two components: knowledge itself and the contextualisation of HIV in the broader society.

Many students made reference to having a lack of knowledge about HIV. Many simply reported that they had little knowledge – ‘I have realised that I had little knowledge about HIV/AIDS’ and ‘I was very ignorant in relation to the issue of HIV/AIDS.’ A number of students, however, gave more nuanced responses. For example, some students recognised that they used to think they had good knowledge, but now realise how superficial it was – ‘Before this course I thought I knew a lot about HIV but as the course progressed I realized that my knowledge was inadequate.’ Some recognised that their knowledge was inaccurate or based on untested assumptions – ‘I took things for granted like taking knowledge as the proper information without verifying it’ and ‘Through this course … I have increased my knowledge of HIV hugely (in spite of having attended previous courses). Now I have discovered (sometimes shocking) facts which I found out for myself, rather than them being fed to me.’

Some students made explicit links between their lack of knowledge and their negative attitudes:

For quite a long time I thought I knew almost everything about HIV/AIDS, only to discover that all I knew was less than a quarter of what I now know. I confess that in the beginning of the year I even undermined this course, thinking that there is no need for me to get to know more about HIV/AIDS. Not being aware that many people have been infected because of these negative thoughts

and ‘I had a negative attitude because I was not aware actually what is HIV/AIDS and what causes it to spread so quickly. I had a negative attitude because I was ignorant in learning more about AIDS.’

A specific facet of knowledge is knowledge of the context of HIV. A number of students said that they lacked awareness of how prevalent HIV is:

When I started off, I was unaware of how wide-spread and vast the infection rates are. I am now very aware of it and the fact that probably touched me most was when X at the AIDS Hospice said that one in three in the townships are infected. It made me realise that I have three children and none of them are infected, so some other mother has more than one infected child.

Several students thought that HIV was a simple result of sexual immorality, and have come to recognise the complex, multifaceted nature of the spread of HIV – ‘The role which social causes (poverty, migrant labour, etc) play in the spreading of the virus was something I never fully realized before’, and ‘I have come to realise that HIV is not just a question of morality gone wrong, but is also a consequence of the social ills of our time for which we all bear some responsibility’, and ‘Studying this course has affected my faith and theological perspective in that HIV requires us to look not only at sexual morality, but at how we are living generally. HIV is a social issue.’

The importance of knowledge of context is that if HIV is spread simply and solely through sexual immorality, HIV becomes privatised, and it is easier to stand in judgement of the individual sinner. Recognising the social factors that influence people's sexual choices – such as the role of patriarchy, the legacy of colonialism and apartheid, and the socioeconomic vulnerability of women – facilitates the development of compassion for those who are socially vulnerable to HIV infection. This compassion helps to break down othering by developing empathy and identification.

Results of othering

The third part of the model concerns the results of othering, and is represented in the bottom third of Figure 1. These results should not be seen as exclusively one-directional. Some of the results of othering may in fact contribute to othering or may just be facets of othering. Nevertheless, from the data, these dimensions do appear to be consequences or results of the dynamic of keeping HIV at a distance. Two main dimensions comprise the results of othering, viz. disengagement and prejudice.

The dimension of disengagement refers to the lack of involvement in addressing the challenges of HIV and AIDS. There is some similarity between this dimension and the theme of lack of empathic contact discussed previously. That theme, however, was focused on the simple lack of (or lack of in-depth) contact with PLWHA, while disengagement is focused on the lack of personal response to the challenge of HIV in the community. Disengagement comprises three themes, viz. passivity, hopelessness, and lack of role clarity.

Passivity refers to the recognition of not being sufficiently engaged with the challenge of HIV. This is eloquently expressed by one student:

Personally I had to introspect myself what difference have I contributed towards those who are infected and affected. I have not done much. I have spoken about HIV but done nothing towards making a difference. I got scared when I had to answer the question, ‘What has the church done to stop stigmatisation?’ I am the church and I have not done much.

Other students also expressed remorse for their lack of involvement – ‘I feel quite ashamed of my lack of active, physical response to PLWHA prior to the course – I've learned that prayer alone is not enough’ and ‘I can't help but feel guilty that I did not do enough at school. I also kept quiet about the silence of the church around the AIDS issue.’ One student linked her passivity and theology:

The experience of this course has taught me that a theology of HIV/AIDS can therefore never be merely a book or pulpit theology, but that it must be more encompassing, more activist and more missionary. My theological thinking and faith has thus been made firmer and my attitude towards HIV/AIDS has been challenged, and such challenges leave no place for either stridency or complacency.

The feeling of hopelessness is a result of seeing HIV as something that cannot be engaged with or effectively responded to by students. For example, a number of students report that they viewed HIV as an irremediable death sentence – ‘I used to see the HIV diagnosis as a death sentence and thought no one can do anything about it, but after I learned this material I see it as another chronic disease pending cure.’ Similarly, some students felt overwhelmed by the enormity of the challenge, which also contributed to disengagement – ‘At the beginning I was powerless in the face of the AIDS epidemic as I believed there is nothing I can do to help the people who are infected and affected by the disease.’

The lack of role clarity is the third theme under disengagement. This theme concerns a lack of recognition of what God's vision is for our own engagement with HIV. For many students this involved a recognition that they were not living out their Christian duty – ‘I did not see myself as having a role to play in eradicating stigma, let alone teaching people about the truth of HIV’ and ‘I had forgotten that my call is that of serving God's people … all those living and dying with HIV/AIDS.’ For some this emerged as recognition that they were not living as Jesus would:

After learning about all the things Jesus did to those despised by the society, I got challenged on some of the things I normally do to other people and I have asked myself if I am doing what I am supposed to as a follower of Jesus.

The second result of othering is prejudice , with one main theme – judgement – and a secondary theme of how the church's judgement creates barriers to the message of God's love expressed through Jesus Christ. Prejudice is personal – it is a feeling or attitude directed not just towards the issue of HIV but also towards those individual people who are living with HIV and AIDS.

Judgement is regarded as a negative and moralistic attitude towards those who are living with HIV and AIDS, and was a frequently occurring theme in the students' responses. Many students simply acknowledged that they had negative attitudes towards PLWHA – ‘I highly stigmatised the HIV/AIDS people with sinful behaviour and therefore I discriminated against them’ and ‘I realised how judgemental I have been.’ A number of students acknowledged a lack of awareness of their prejudices – ‘Opening my eyes to prejudices I was not aware that I harboured.’

Several students linked their own judgemental attitudes to their Christian beliefs – ‘I sometimes use my faith for a wrong attitude to those people. I have learned that I must stop being judgemental to people who are infected by HIV and AIDS’ and

I always violated my faith with people with HIV/AIDS before. But while I studied this course I became changed in attitude. Now my faith and my spirituality have become sympathetic with the people living with HIV/AIDS, giving them a message of hope.

One student expressed his judgemental attitude and his new insights vividly:

A far and even greater issue was my own personal prejudices about people living with HIV/AIDS. Before engaging in this course I had my own assumptions about people living with HIV. My sermons would dwell on the subject of moral behaviour and telling the youths how they should behave as their behaviour shames God and the Church. The course opened my eyes to the plight of people living with HIV/AIDS. What it also taught me is that a person is not a great uMfundisi [minister] by how well he can criticize, but by how well he/she is able to show compassion for those infected and affected.

A handful of students reflected on the way these judgemental and prejudicial attitudes create barriers for the good news of Jesus Christ:

I wept as she [a woman infected with HIV through a rape] told me how her church had rejected her. She told me of a sermon where AIDS was projected as God's answer to weed out unbelieving sinners from Africa. My heart broke as I realised how I've been part of the problem by having these terrible attitudes

and ‘I need to repent and examine my own complicity in a society that has created fertile ground for the spread of this sexually transmitted epidemic.’

The biblical and theological roots of AIDS stigma among Christians

There are many theologies or theological facets to AIDS, most of which are focused on the provision of hope and redemption. Ackermann (2005) has been particularly effective in illuminating the dynamics of, and theological responses to, AIDS stigma. There is, however, little theological literature that addresses stigma as othering, which is the central story that has emerged from this study. It is clear from the data that Christian theology students have a wide range of prejudices towards HIV and PLWHA. Moreover, the model that has emerged here suggests that these are, to at least to some degree, grounded in and informed by Christian belief. This raises the question of the degree to which AIDS stigma has roots in the Bible.

The Bible is replete with insider/outsider language and the dynamics of othering, from the earliest chapters of Genesis (Sadler 2006). Although the second testament presents God's mission as the reconciliation of the cosmos under Christ (Ephesians 1:9–10), the biblical narrative of God's people is largely in conflict with this mission. The fall of Adam and Eve in Genesis 3 results in a separation of humanity out of fellowship with God – the first instance of othering. After Cain kills his brother, he too is expelled from the fellowship of his family (Genesis 4). He becomes marked as other (Genesis 4:15); he receives in his body a sign – a literal stigma – to show that he must be treated differently. In the flood narrative (Genesis 6–9), Noah and his family are separated from the rest of humanity, a violently catastrophic example of the division of the world by God into insider and outsider. The Tower of Babel narrative (Genesis 11) is essentially an explanation of why we are all different: these differences are attributed to the hand of God, and thus beyond question.

These prehistory narratives reach a climax in the Abrahamic narrative. God singles out Abraham's family as a chosen people, to be uniquely blessed by God (Genesis 12:1–3). Although God's mission is revealed in Genesis 12:3 as being to the whole world, the overriding message is that Israel alone has a special relationship with God: Israel is the insider and consequently everyone else is the outsider. The dynamic of othering is now entrenched. Even the missionary message can be interpreted as a form of othering. Israel is the channel through which all nations will be blessed, reinforcing Israel's special insider status, and showing the rest of the world to be disconnected and separated from God.

There are numerous narratives throughout the first testament in which Israel obliterates (or attempts to obliterate) the other (Cromer 2001). These wars are frequently endorsed by God on the grounds that the others are not part of God's chosen people (Anderson 1988). As such, the nations become less than human and thus more easily dispensed with (Spronk 2007). Paterson (2003:36) notes that this form of sectarianism ‘plays a key role in allowing people to commit atrocities with a good conscience. If we can persuade ourselves that “the other” is less than human, then we don't have to worry about treating them like animals.’

Although most theologians reject the association of the Christian church with Israel (Witherington 2004), the foundation for othering has been laid throughout the pages of the Bible. In the second testament, after Jesus' death, the tension was between Greek and Jew, slave and free, male and female (Galatians 3:26–29; Ephesians 2:11–22). The tension itself points to the dynamic of othering as being active in the early church. Yet even here the solution involves an insider (those who are ‘in Christ’) and an outsider (those who are outside Christ). And those who are outside are in desperate need of salvation, lest they perish. Insiders, therefore, have the power to dispense the message of redemption to outsiders who are powerless.

The themes that have emerged through the current study, leading to the model of AIDS stigma, suggest that in addition to the social dynamics involved in stigma, such as fear of contagion, lack of knowledge, and anxieties around sexuality, there is the crucial dynamic of othering. For Christians this is typically grounded in a biblically defended construction of PLWHA as being outsiders. PLWHA are defined as sinners, as immoral, and as potentially threatening. Consequently, they form part of those who are outside the circle of God's chosen people.

This perception is reinforced by the use of the Bible to justify the belief that God stands in judgement on PLWHA. These people are cursed by God because of their immorality (Skinner & Mfecane 2004). As such, they have called judgement upon themselves (Chepkwony 2004). Good Christians, then, should stand by the judgement of our God – after all, who are we to question God's sovereignty? This dynamic – a call to the authority of a deity – is different from the forms of stigma reported in the public health, psychological, and sociological literature. In those studies, stigma is primarily located in the fears of the individual (Brown, Macintyre & Trujillo 2003) or in the structures and mores of society (Deacon et al. 2005). Here, stigma is located in the person of God.

By aligning our stigma with God's alleged stigma, we adopt a tremendously powerful position (Schmid 2005). And power is an essential component of stigma (Deacon et al. 2005; Gilmore & Somerville 1994); those who are powerless cannot stigmatise those who are powerful. Thus stigma is the privilege of the insider – stigma both requires power and produces power. Othering in the name of God is consequently a supreme form of oppression.

The results of othering, according to the model of AIDS stigma that has emerged in this study, seem to be aligned with this biblical/theological stance. First, there is a disengagement, or withdrawal of interest, from those who are suffering with HIV and AIDS. In a sense, they have been handed over to God; they have brought condemnation on themselves, leaving us with no further obligation. Second, there is an active prejudice, which may or may not translate into discriminatory behaviour. This prejudice is presumably in line with God's judgement, and thus above reproach.

Conclusions

In summary, many Christian theology students report having held a range of stigmatising attitudes towards PLWHA. This stigma is grounded in a mental model that endorses othering and insider/outsider distinctions. This stigma is powerful because it draws on a genuine (though selective and decontextualised) thread that runs throughout the Bible, and appears to be endorsed by God. Christian stigmatisers therefore believe that they draw on the authority of God to defend their attitudes towards PLWHA (perhaps similarly with women, gays, and other marginalised groups). The central feature of this stigma is the dynamic of othering: HIV and PLWHA are placed at a remote distance, separated from us, from the church, and from God. Despite the hope of the Gospel, they are beyond hope and redemption.

Although this study has not attempted to discern what can contribute to reducing stigma among Christian leaders, there are two main recommendations that can be made. These are based both on my experience of teaching HIV to theology students and on the model that has emerged through this study. The first concerns a theology of inclusiveness and the second the action of engagement.

First, a theology of inclusiveness needs to be explored and studied by Christians. In the beginning God created and blessed one humanity (Genesis 1:27). The man and woman were in perfect communion with each other, with God, and with the world. There was no insider or outsider, no distance, and no othering.

Jesus Christ's incarnation (becoming human) serves as a model of God's becoming one of us, and in so doing removing all distance between God and humanity. God, who had always been ‘other’ – transcendent – has now become one of us (Philippians 2:6–8). It is for this reason that Paul says that Christ has abolished or destroyed ‘the dividing wall of hostility’ (Ephesians 2:14). In Christ, there is but one group, living in perfect unity and in harmony with God and the world. God's ultimate vision is for a community reconciled under Christ in which all divisions cease to be (Ephesians 1:9–10). Here there will be only a group; there will be nobody outside the group, and thus even the ‘insider’ will cease to be.

Such a theology of inclusion, rooted in creation, centred on the incarnation, and reaching towards the end of times, celebrates the Kingdom of God and emphasises God's mission to redeem the cosmos. In the context of this kind of theology, any divisions currently experienced (such as those between HIV-positive and HIV-negative people) must be understood as sin, and not part of God's intention and vision for humanity. This theology, which is aligned with much of the published theological literature on AIDS stigma, provides a conceptual framework to challenge all forms of othering.

The implication of such a theology is recognition that when one part of creation suffers, the whole of creation suffers (Benton 2008).

If one member of the body suffers, the whole body suffers (1 Corinthians 12:26). It is within this one body that the compassion of God should be articulated, embodied and experienced. … Denise Ackermann is quite right when she contends that the church, as body of Christ, has AIDS. ( Cilliers 2007 :402)

More than this, the whole world, as the beloved creature of God, has AIDS.

Second, Christians need to engage with those who are other, so as to overcome the unfortunate realities of division and distance. Theology, particularly theology in Africa, cannot be done from an armchair or from the safety of a library or computer. Theology is lived in the real world, in praxis. There is empirical evidence that contact with those who are different from us may reduce prejudice (Cover 1995). South Africa began experiencing the fruit of this after the demise of apartheid in 1994.

Genuine, empathic contact with PLHWA may be a necessary dimension of overcoming AIDS stigma in the church (Benton 2008). This contact should perhaps not take the form of missionary or charity work exclusively, as this continues to reinforce the power differential between the charity worker and the needy person. Rather, such contact could be in the form of action research, in which one person engages with another person, one who happens to be living with HIV, in order to learn about the life world of another person (Zandee & Cooperrider 2008). Such an encounter – journeying through another's landscape of suffering and hope (Chittister 2005) – has the potential to evoke an empathic response, a deep and genuine understanding of the other. The miracle of empathy is that when I intuit what it is like to be you, we become in some way the same, and the distinction between me and you (self and other) is weakened.

Engagement with the other in this way may begin to reveal to the individual how s/he and the church as a whole have sinned. We will begin to acknowledge how our theology of sex, sin, guilt, and punishment (Ndungane 2005), our silence (Ackermann 2005), and our judgemental preaching (West 2003) have served to dehumanise those who have been created in the image of God and for whom we believe Christ died.

These two recommendations are what TEE has built into the learning opportunities of our theology students. Students critically engage with and grapple with the Bible and theology, examining the ways the Bible both supports and undermines stigma, so as to challenge a theology of othering and replace it with a theology of inclusiveness. Students are required to engage with PLWHA in an action research project in such a way that they become the student of a PLWHA who is a teacher. Anecdotally, these learning opportunities seem, in many cases, to transform the AIDS stigma of theology students. These could, perhaps, form a foundation from which to eradicate AIDS stigma from the Church in Southern Africa.

Additional information

Notes on contributors

Adrian D. Van Breda

Adrian D. Van Breda is an associate professor of social work at the University of Johannesburg. He holds a D Lit et Phil focused on measurement theory, a Masters degree in clinical social work, and a Bachelors degree in theology. He has been teaching HIV to both theology and social work students for several years. Prior to this, he was the HIV M&E coordinator for the South African National Defence Force.