Sarah Atkins and Kevin Harvey
Language use is centrally important to the way in which we constitute our experiences of health and illness, as well as ultimately being of clear practical importance to those working in the healthcare professions, who must communicate medical ideas on a regular basis. It is perhaps not surprising then that healthcare communication, in all its various aspects, has become an important research theme in Applied Linguistics. In the following study, we will illustrate how some of the corpus linguistic methodologies you will have encountered so far in this book can be usefully adopted in the field of healthcare communication studies. As a means of practically illustrating the application of these methods, we make a case study of a specific type of healthcare discourse, that of adolescent email language, in particular on the topic of sexual health. This will make use of the one-million-word Adolescent Health Email Corpus (AHEC), a collection of adolescent health emails taken from a UKbased health website, a data-set originally compiled by Harvey (2008). The corpus study here offers us a means of investigating and understanding the language young people use in relation to sexual health issues, which may have important practical implications for healthcare professionals who need to communicate with this age group on a regular basis.
Our experiences of health and illness are not simply based in the biological ‘realities’ of our bodies, but, crucially, in the language we use to talk about them. If we take the view that language and discourse work to constitute our understanding of ourselves and the world around us, then this is vitally important to the way we make sense of the social experience of health:
illness cannot be just illness, for the simple reason that human culture is constituted in language … and that health and illness, being things which fundamentally concern humans, and hence need to be ‘explained’, enter into language and are constituted in language, regardless of whether or not they have some independent reality in nature.
(Fox 1993: 6)
It is certainly true that we are constantly presented with the need to ‘explain’ illness. In an increasingly medicalised society, discourses surrounding the body saturate the texts we receive on a daily basis, such as in news media and advertising. When we, ourselves, experience illness, we find out about it through the language of healthcare professionals, through conversations with our family and friends, through books and internet media and so on. This central importance of language and discourse in our experience of illness has given rise to a field of study that has become known as ‘healthcare communication’ over the last three decades. Broadly, this field has incorporated the many diverse aspects and textual genres that impinge on our experiences of what it means to be ill: for example, interactions in hierarchical, institutional medical settings between healthcare practitioners and patients, professional communication between practitioners, patient narratives of experience as well as genres such as government health education material, media representations of health news and advertisements that project particular ideas about health and our bodies.
Research on communication in institutional healthcare settings in particular has contributed significantly to the sociological study of health practitioners and patients (Sarangi 2004: 2). Although, as many commentators point out, the focus of a substantial amount of this research has exclusively been on doctor–patient interaction (Candlin 2000), there exists an increasing body of enquiry into other forms of medical communication which has considered, for example, the verbal routines of a variety of non-physician personnel including nurses (Crawford et al. 1998), physiotherapists (Parry 2004), and pharmacists (Pilnick 1999) – as well as exploring written medical discourse in various communicative contexts such as medical note-taking (Hobbs 2003) and case histories (Francis and Kramer-Dahl 2004). Though diverse and wide-ranging, what these studies have in common is their close focus on language in use and the consequent pointing up of the crucial role of language in the practice of medicine and health care (Sarangi 2004: 2).
Methodologically, much of this research has taken a sociolinguistic and discourse analytic perspective, including conversation analysis, text/genre analysis and critical discourse analysis. These perspectives have provided rich points of entry into the description and interrogation of medical practice. Moreover, many healthcare language studies have combined perspectives. There has been, for example, a recent tendency for conversation analysis and interactional sociolinguistic methodologies to be supplemented by a strain of critical discourse analysis, with the research impetus being as much to criticise and change practices in institutional healthcare settings as to describe and understand them (e.g. McHoul and Rapley 2001: xii). However, such studies, as Adolphs et al. (2004) observe, are typically qualitative in their approach to analysis, based on relatively small databases and without originating in large collections of data. This has led to a more recent call by a number of researchers in healthcare communication studies to make greater use of more substantial datasets (Skelton and Hobbs 1999a).
A number of health communication studies have begun to turn to corpus methodologies, although these are few in comparison with other applied linguistic themes, such as lexicographic and lexical studies, grammatical and register variation and genre analysis. Thomas and Wilson (1996), in a comparatively early corpus interrogation of health language, make use of a 1.25-million-word corpus of practitioner–patient exchanges, setting out to demonstrate that computer content analysis can overcome the ‘shortcomings of straight quantitative analysis’ and has ‘the potential to provide results which are in some respects comparable to manual discourse analysis’ (1996: 92). Although thoroughly detailing patterns of linguistic use, the question arises whether corpus tools actually contribute anything new to the understanding of healthcare communication here, an understanding that might be otherwise achieved by manual discourse analytic procedures. Indeed, Thomas and Wilson pose this question themselves. Though the use of corpus tools enabled the researchers to quickly and accurately identify significant aspects of the health practitioners’ language use, the study gives little emphasis to actual samples of extended stretches of language in use, and how linguistic components actually function in the dialogic context of the practitioner–patient exchanges they were investigating.
More recently, Skelton and colleagues (e.g. Skelton and Hobbs 1999a; Skelton et al. 1999, 2002) demonstrate the methodological advantages of integrating quantitative with qualitative approaches. As a starting point, they use frequency counts of words and phrases, complementing such quantitative findings with qualitative assessments of how such phrases operate in context through the use of concordance outputs. The authors contend that it is only through qualitative methods, such as concordance lines with subsequent recourse to extended stretches of text, that general patterns in health language can be explicated. Quantitative methods can identify general patterns, ‘but these patterns exist in a complex context that can only partly be described quantitatively’ (Skelton 1999b: 111). Skelton and colleagues’ research utilises these corpus tools to examine assorted themes in health communication, including metaphor, pronominal usage and linguistic imprecision, demonstrating a range of uses for the corpus approach. Rather than providing a broad linguistic characterisation of the particular communicative practices in question, the authors confine their analyses to investigating specific linguistic phenomena. For this reason, their studies are not concerned with harnessing comparative data, contrasting, for example, their various datasets with general reference corpora.
Such a comparative approach is adopted by Adolphs et al. (2004) in their corpus analysis of NHS Direct exchanges between professionals and patient callers. Adolphs et al. compare a corpus of health professionals’ language with a corpus of general spoken English, identifying a set of keywords that appear with greater frequency in the NHS Direct consultations. As with Skelton and colleagues’ research, Adolphs et al. (2004) avoid the limitations of decontextualised quantitative analyses. Having isolated a number of linguistic features quantitatively, the researchers examine these key items in their original discourse environment using concordance lines and conversation analysis techniques in order to provide close descriptions of interactional processes. These methodological stages afford the authors a means of understanding the uniqueness of these professional– patient exchanges, enabling them to characterise the nature of NHS Direct consultations where they identify an overarching tendency for professionals to use politeness strategies and the language of convergence in their interactions with callers. As these corpus approaches to health language demonstrate, then, corpus tools are not ends in themselves and cannot provide explanations for the linguistic features observed (McEnery 2005). It is important to supplement quantitative approaches with qualitative support.
The health email data for the corpus-based case study which we focus on are taken from an online health forum, Teenage Health Freak (www.teenagehealthfreak.org), a UKbased website which provides health information for young people. Operated by two doctors specialising in adolescent health, the Teenage Health Freak website has been running since its launch in 2000. It is designed to be user-friendly, interactive, confidential and evidence-based, employing non-technical, accessible language and colourful graphics, with young people themselves actively being involved in the design and construction of the website.
A central feature of Teenage Health Freak is the ‘Ask Dr Ann’ facility. This interactive feature of the website allows young people to email their questions in confidence to the online GP persona, ‘Dr Ann’. It should be noted that these online requests for advice do not constitute emails in the traditional sense; they are not sent via the contributors’ individual, personal email accounts, but communicated anonymously via a universal posting platform on the website. Given the large influx of emails that the site receives, it is not possible for the website doctors to respond to all postings. Our corpus analysis therefore focuses on the adolescent communiqués rather than the professionals’ comparatively infrequent returns. Permission was given to collect and analyse emails sent to the Teenage Health Freak website between January 2004 and December 2005. Comprising 62,794 messages (a total of one million words), the corpus contributes a substantial snapshot of the health concerns communicated on a daily basis by the website’s teenage contributors.
One of our principal considerations concerning the compilation of the corpus was whether such an amount of data was sufficiently representative: does such a quantity faithfully represent the health communication patterns and concerns of young people who contribute to the website? Although we ideally wanted to collect more data, taken by Sinclair’s (1991: 18) pronouncement that a corpus should be as large as possible, we argue that, for the purpose of beginning to identify and describe patterns and commonalities in young people’s beliefs about health and illness, one million words is a sufficient amount of data, or at the very least constitutes a substantial starting point. Given its size and focus on a particular communicative setting (the domain of adolescent health adviceseeking), the corpus constitutes a specialised corpus. For a specialised corpus, one million words is by no means a small amount (according to Flowerdew 2004: 19, a corpus is generally considered small if it contains no more than 250,000 words). The methodological advantage of using a specialised corpus is that its smaller size lends itself to a more detailed, qualitative-based examination than is possible with larger, more general corpora, such as the 100-million-word British National Corpus or the Bank of English. The close examination of concordance lines with recourse to the linguistic co-text, for example, provides a rich source of data to complement more quantitative-based studies (Flowerdew 2004). In short, then, our corpus constitutes a suitable linguistic resource for the purposes of beginning to identify and describe patterns and commonalities in young people’s beliefs about health and illness.
In order to initially ascertain the pertinent themes and items to be researched in the AHEC, frequency lists were generated, as well as a keyword comparison being made with the British National Corpus (BNC) using WordSmith Tools (Scott 2004). Keywords are an important indicator of both expression and content (Seale et al. 2007) and have been used by an increasing number of researchers as a means of identifying key themes characterising health language corpora (Adolphs et al. 2004; Harvey et al. 2007; Seale et al. 2007) (see Scott, this volume, on how keyword significance is calculated). Table 43.1 provides a representative overview of the central health themes that can be seen to emerge in the AHEC through keyword groupings.
Notably, the lexical patterns clustering around the topic of sexual health predominate in the keyword lists, a topic which will be explored in the ensuing study.
As well as being a theme flagged up by our keyword analysis of the corpus, the issue of adolescent sexual health has been highlighted as being an urgent contemporary concern (e.g. British Medical Association 2003, 2005; Bradley-Stevenson and Mumford 2007) with the necessity of ‘doing something about teenage sexuality and sexual knowledge’ pressing on the minds of policymakers (Brown et al. 2006: 169). The prevalence of sexually transmitted infections (STIs) among teenagers is high and continues to increase (British Medical Association 2003), including a recent rise in the number of newly acquired cases of HIV/AIDS (Society for Adolescent Medicine 2006). As the Health Protection Agency (2006) report, in the UK people between the ages of sixteen and twenty-four account for approximately 11 per cent of new diagnoses of HIV each year, while the number of young people receiving treatment for the infection has tripled since 1996. Research indicates that, although often aware of the risks involved in taking part in sexual activity, adolescents are liable to have limited and erroneous understandings about reproductive health (Smith et al. 2003; Mason 2005). Yet, tellingly, these negative constructions of teenage sexual health are generated by an ‘outsider perspective’, prompted by what researchers deem to be the issues rather than young people themselves.
According to Jackson (2005), a different perspective to that provided by much of the literature emerges when young people are asked to formulate their own ‘insider perspectives’ concerning sexual health, thus indicating whether their sexuality-related concerns ‘concur with those in the public and academic world’ (Jackson 2005: 85).
Sex is a taboo topic and hence does not comfortably fit into socially acceptable language use (Stewart 2005). Previous research concerning sexual health in adult language has discovered much use of vague terms and euphemistic language. Given the powerful and pervasive influence of sexual taboos, it might be expected that the way in which adolescents communicate sexual concerns would similarly involve circumlocutions, vague language and euphemisms. Yet little is actually known about the precise nature of young people’s use of language here. In the context of professional advice-seeking, Ammerman et al. (1992) found that young people were much more familiar with nontechnical and slang terms rather than common medical lexis in relation to sexual health. Moreover, rather than confine themselves to a limited set of genitourinary-related terms, the adolescents were prone to linguistic variety, employing a range of synonyms. A consequence of this lexical diversity was the increased potential for misunderstanding between professionals and younger patients. Practitioners should therefore not assume, Ammerman et al. (1992) suggest, that adolescents understand standard medical vocabulary in discussions of sexual health.
Contrary to Ammerman’s study, sociolinguistic research by Harvey et al. 2007 revealed that teenagers commonly adopted a medico-technical register in (online) requests for sexual health advice from professionals. The adolescents’ messages, moreover, were characterised by non-euphemistic language, with the young people describing themselves, their anatomy and their sexual identities in meticulous and explicit linguistic detail. As Harvey et al. (2007) observe, their findings contrast with the degree of vagueness and apparent difficulty in calling experiences to mind that practitioners and researchers have found elsewhere with adolescents. Whether the adolescents would have displayed the same non-euphemistic frankness and meticulous linguistic detail in other communicative contexts, away from the anonymity of online communication, remains yet to be precisely established. Nevertheless, Harvey et al.’s (2007) study highlights how valuable language data from the online medium can be for offering access that we might not otherwise have to the communicative strategies adolescents use in talking about sexual health, a medium of communication which will be further investigated here.
The AHEC possesses a range of emails dedicated to the subject of sexually transmitted infections (STIs). Table 43.2 lists the total frequencies of all the sexually transmitted infections and related conditions that appear throughout the corpus as a whole.
The table shows that HIV/AIDS makes up 39 per cent of the total number of references to STIs in the AHEC, with mention of other infections being comparatively infrequent. It is interesting to speculate whether the lexical preference for AIDS and HIV is in any way a reaction to or reflection of the recent rise in the number of newly acquired cases of HIV/AIDS among adolescents. Whatever the case, it is certain that practically all young people are aware of HIV/AIDS (Rosenthal and Moore 1994). Thus, given the primacy of HIV and AIDS in the corpus, and its significance to the teenage
population more generally, the remainder of this chapter will focus on the adolescents’ knowledge and representation of these two concepts.
With the advent of AIDS and HIV, it became apparent to everyone that unprotected sex could lead to terrible consequences and sex now carries ‘connotations of health risk and death’ (Woollett et al. 1998: 370). Although it is not possible to ascertain whether the saliency of the terms HIV and AIDS in the corpus is due to the emotional impact of these two phenomena and their potential lethality, the lexical preference for HIV and AIDS, the latter in particular, is revealing. Emails about HIV and AIDS (314 in total) cover a range of themes, central among which are questions relating to HIV/AIDS terminology and conceptual definitions of the terms (of which there are seventy-eight occurrences: 24 per cent), concerns regarding transmission and causation (seventy-two: 23 per cent), and questions about symptoms and the likelihood of having HIV/AIDS (sixty: 19 per cent). As Table 43.2 reveals, the lexical item AIDS appears nearly twice as regularly (209) as HIV (114). Of the 209 occurrences of AIDS, seventeen co-occur with HIV, which suggests a relationship between the two. The following extended concordances are typical examples (replete with their original spelling, punctuation and capitalisation):
• how does HIV/AIDS get passed on
• what happens when a man or women is hiv and has aids
• how are the drug manufacturers involved in the crisis(HIV/AIDS)
• Can you be born with HIV or AIDs or do have to catch it ?
• I keep reading all peoples advice and knowledge about HIV and AIDS and it keeps saying infected person. How does someone innitally become infected?
• what is hiv or aids
In these instances (and in the other twelve messages in which the two terms co-occur), the adolescents clearly, and crucially, distinguish the concepts of HIV and AIDS, conceiving them as separate entities while also being connected in some way (given the oblique (/) or conjuncts (‘and’, ‘or’) that co-ordinate them). However, of the remaining 192 occurrences of AIDS in the corpus, 192 (92 per cent) appear in isolation: that is, with no mention of HIV, the virus that can cause AIDS (UNESCO 2006). The following examples are typical of the range of contexts in which AIDS in isolation is used:
• how do i know if iv got aids
• Can you get AIDS by being fingered?
• dear dr anne. i am gay and i have given someone a blowjob i think i have aids please help
• What does AIDS stand for?
• I had sex without using a condom and i am really scared i might be pregnant or might have aids
• I received oral sex about 6 months ago, now i am noticing some pimple on my penis, I don’t know if it is from masturbating or if it is herpes, could you help me. And also can you get genital warts, or AIDs from oral sex.
• i am worried that i have aids
• I had unprotected sex with a girl and ejaculated inside her. she has had many sexual partners and im not sure if she had always practiced safe sex. im worried i may have aids. is the risk that great?
• i have had sex with my boyfriend for the first time and the condom kept snapping so we decided to not use one what are the chances of me bein pregnant or having aids? please answer this im really really wottied
The absence of any reference to HIV and the foregrounding of AIDS indicate a terminological conflation of the two concepts, a misconception that is liable to have profound consequences in terms of how the adolescents conceive of and understand HIV and AIDS. For instance, in a number of the examples, there is the underlying belief that AIDS is a communicable infection, not a syndrome or range of conditions (UNESCO 2006), with its being constructed as, and confused with, a virus or disease, something that can be readily transmitted via sexual activity: ‘can you get … AIDS from oral sex’, ‘can you get AIDS by being fingered?’ and so on.
Collapsing the distinction between HIV and AIDS in this way inevitably results in confusion and reinforces ‘unrealistic and unfounded fears’ (Watney 1989: 184) on the part of the adolescents who may well mistakenly believe themselves to be at risk of AIDS but not HIV. Such extreme worst-case scenarios conceive of AIDS as something that sets in immediately after infection, a unitary phenomenon rather than a collection of different medical conditions – beliefs which obscure, if not efface altogether, the existence of HIV, the virus, which is indeed infectious. Such erroneous conflation of HIV infection with AIDS (by definition, the stage of HIV infection ‘when a person’s immune system can no longer cope’; Terrence Higgins Trust 2007: 1) repeats some of the early and fundamental misconceptions and negative attitudes about AIDS that were widespread during the 1980s and 1990s (Sikand et al. 1996; Helman 2007).
For example, Warwick et al.’s (1988) in-depth study into youth beliefs about AIDS revealed that a significant number of young people, as with many adults, were unable to distinguish between HIV infection and AIDS, a finding which they attributed to the media’s consistent failure to provide the public with accurate information. This fundamental misunderstanding (identifying AIDS as a transmissible disease) was related to the ‘public terror about “catching” AIDS from people in public places or during casual contact’ (Grover 1990: 145). Such beliefs (and the emotive linguistic choices encoding them) prevalent during that period are still apparent in the adolescent health emails communicated over twenty years later. For instance, one of the central ways in which adolescents describe becoming infected with HIV or developing AIDS is through use of the lemma CATCH, the second most common verb (thirteen times) used to signify contraction after GET (fifty-two). The use of CATCH as a verb encoding transmission of HIV/AIDS is telling, implying a more active role for subjects:
• can you catch aids if havnt had sex?
• how do you prevent catching h. i. v
• is the aids virus difficult to catch?
• Can you catch HIV if you wear a earring that might have been worn by somebody else before?
• out of ten what is the average to catch aids when having sex
• how can you catch hiv
• if i have sex with someone with aids without protection can i cath it
• can you catch aids if someone masterbates you
• Can you be born with HIV or AIDs or do have to catch it ?
• the other day i had sex without using a condom i am going to take a test but i am also worried i could have caught an STI or AIDS or sumthing wot shall i do ?!!!!!
• how do i catch HIV?
Biber et al. (1999) describe ‘catch’ as an ‘activity verb’, a verb denoting actions and events ‘that could be associated with choice’ (1999: 361). As the above emails illustrate, ‘catch’ implies specific notions of agency on the part of subjects in the sense that it is within their power to prevent infection, with responsibility framed in terms of both general or universal agency (encoded via the second person: ‘Can you catch … ?’) or individual control via the first-person singular pronoun: ‘Can I catch … ?’. As Johnson and Murray (1985: 152) put it, ‘catching’ an ailment (as in catching a cold) semantically implies a degree of co-operation: ‘We catch things … in ways which are our own fault; we blame ourselves – we should have worn galoshes, and should not have sat in a draught.’ This notion of personal agency, of being responsible for becoming infected, communicated through the verbal concept of ‘catching’, is made further apparent in the adolescents’ questions above by their explicitly referring to prevention and avoidance strategies (‘how do you prevent catching h. i. v?’, ‘is the aids virus difficult to catch?’), as well as their seeking clarification as to whether specific activities are liable to result in contracting HIV/AIDS – activities which, by implication, should therefore be avoided: ‘can you catch aids if someone masterbates you?’, ‘if I have sex with someone with aids without protection can i cath it?’. Here, then, both HIV and AIDS, if the requisite care is taken, are constructed as preventable through individual agency. Infection with HIV is not an inevitable outcome as, alarmingly, some young people have perceived it to be (Warwick et al. 1988).
However, many commentators and public health bodies stress that neither HIV nor AIDS can be ‘caught’ (Watney 1989: 184). Indeed, contemporary health promotion literature produced by standard-setting organisations such as UNESCO continually warns against the use of this verb to signify the way that people might become HIV positive, since it only helps to reproduce myths about HIV and AIDS (UNESCO 2006; IFJ 2006). In the health emails above, for example, the various realisations of the lemma CATCH unavoidably and infelicitously conjure notions of the common cold and influenza, as evidence from the British National Corpus (BNC) attests. Consulting the 100-million-word British National Corpus, a corpus representative of both spoken and written English language as a whole, reveals that, as a transitive verb, ‘catch’ co-occurs with the direct objects ‘cold’ (113), ‘chill’ (twenty-one), ‘bug’ (twenty) and ‘colds’ (seven). As these collocates indicate, one typical use of the verb ‘catch’ in general English is to describe the acquiring of relatively minor infections, in the sense of their being widespread and generally innocuous (though ‘bug’, of course, potentially relates to more serious infections such as MRSA, the so-called ‘super bug’; Knifton 2005). With regard to more serious viruses and illnesses, other less euphemistic constructions are used in the BNC to describe the process of becoming infected and the onset of morbidity: for example, HIV is typically ‘contracted’, ‘got’, ‘acquired’, while AIDS is ‘got’, ‘developed’, ‘contracted’.
Given this association, a corollary of using ‘catch’ to describe infection with HIV/ AIDS is to encode the assumption that the virus can be acquired via casual contact, possessing a transmission efficacy similar to both colds and influenza. As such, talk of ‘catching’ HIV/AIDS figuratively transforms the virus from something which is, in reality, difficult to transmit and is only communicable via specific routes (Terrence Higgins Trust 2007: 2) to something highly contagious, liable to spread rapidly and extensively. And this underlying metaphor of HIV/AIDS as ‘invisible contagion’ (Helman 2007: 395) and attacking from without (Weiss 1997) extends to the adolescents’ emails about acquiring HIV/AIDS outside of those that explicitly refer to ‘catching’ the virus. There are, for instance, ten further questions concerning HIV/AIDS transmission that draw on metaphors of contagion:
• my girfreind as already kissed a boy and she wants to kiss me would I get aids?
• i want to know if AIDS can gotten through kissing?
• Can you get aids from dogs?
• does anyone who has aids have to be quarantied
• can you get hiv from somebody who doesn’t have it?
• Hi im 14 (duh) and i have never had sex or used injection drugs (or drugs at all) but from a toothbrush is it possible for me to get HIV?
• Dr Ann, I am food for nats and mosquitoes, they absolutly love me, but if they have bitten someone that has AIDS, then I am bitten, Can i be at risk of getting AIDS? Thanks Ann
• can i get aids off my cat?
• i know you said that you cant get hiv from kissing. but we were told in sex education that if you are french kissing and swallow the persons spit you can get hiv. is this true? please tell me bacause i hav been put off kissing now.
As with the emails evoking notions of ‘catching’ HIV/AIDS, these adolescents’ concerns similarly communicate fear of contagion and pollution. Here, however, ambiguity over transmission is related not just to sexual activity but to a wide and common range of circumstances, with, for instance, even toothbrushes and household pets being potential contaminants and sources of the virus. This perceived infiltration by HIV/AIDS of routine aspects of everyday and domestic life resonates with folk beliefs common in the first years of the AIDS epidemic when the virus was believed to be ‘transmitted by virtually any contact with an infected person’ (Helman 2007: 395). Such a conception draws on the notion of the ‘miasma’ theory of disease (Lupton 2006), the folk model of infection which conceives of infected persons as being surrounded as if by a miasma or contagious cloud of poisonous bad air liable to cause disease (Helman 2007: 395). Miasmatic beliefs such as those evident in the foregoing emails, where HIV/AIDS is metaphorised as something highly contagious and invisible, are closely related to what is believed to be the imperceptibility of persons with HIV infection, highlighting the difficulty for some young people of being able to identify who might or be infected (Warwick et al. 1988: 117). Although, against the total number of emails relating to HIV and AIDS, there are comparatively few questions from the adolescents about potential ‘carriers’ of the disease, the small number that are present in the corpus, and reproduced in full below, expose overlapping attitudes towards and attributions about people perceived to be infected with HIV:
• how do you know if a person has hiv? can you tell just by looking at them and if they are 16 then will any symptoms be apparent
• is AIDS spread by homosexuals
• i have a boyfriend who told me he’s been injecting drugs. i heard that drug users can get hiv/aids from using needles. is this true? what should i tell my friend? should i tell anyone else?
• have gay men got more chance of getting HIV
To have HIV/AIDS here is to possess characteristics or symptoms that are outwardly evident (and therefore discernible simply ‘by looking’) and to be deemed to belong to certain social categories (to be gay, to be an injecting drug user). One way of making sense of these constructions is to see them as separating those individuals who are assumed to be safe and free of infection (presumably so determined through their clean, asymptomatic appearances) and those whose behaviour constitutes them as a high-risk group. Yet crucially, as Watney (1989: 185) argues, there is no essential relation between HIV and any particular social group or category of people. Risk of HIV infection arises from what people do, what activities they actually participate in, not from what group they belong to or how they are labelled. Consequently, the social distance which these adolescents appear to place between themselves and groups they associate with HIV/ AIDS potentially engenders complacency on their part: infection with HIV is seen as something that happens to others, specifically to the perceived ‘high-risk’ and minority groups first associated with AIDS.
Not all of the adolescents’ emails, in the shape of distorting metaphorical transformations and alarmist folk beliefs, display such hysterical responses to HIV and AIDS. The most commonly occurring emails about HIV and AIDS in the adolescent health corpus are fundamental questions concerning definitions and terminology, specifically: ‘What is HIV/AIDS?’ and ‘What does HIV/AIDS stand for?’ One way of interpreting these open and elementary types of enquiry is, of course, to regard them as emblematic of knowledge deficits about sexual health. Yet equally, such questions might be considered vital responses to a contemporary and potentially life-threatening condition that, despite being in its third decade, is still commonly misunderstood (Helman 2007). AIDS did not arrive with its own vocabulary and so has been the source of linguistic difficulties from the start (Koestenbaum 1990). As Crystal (1997: 120) observes, the unabbreviated form of AIDS is ‘so specialized that it is unknown to most people’. Yet even among health experts the acronym poses problems, having been variously understood as both ‘Acquired Immune Deficiency Syndrome’ and ‘Acquired Immunodeficiency Syndrome’, distinctions which although seemingly insignificant nevertheless demonstrate the semantic instability that surrounds the term. Thus if, as Callen (1990: 181) argues, to be AIDS literate involves mastering a specialist language of shorthand, then the questions ‘What is AIDS?’ and ‘What does AIDS stand for?’ are very well placed indeed.
The results from the corpus analysis have practical relevance for health practitioners and educators concerned with the health of young people. The corpus approach affords an effective means of identifying the ‘incremental effect’ (Baker 2006: 13) of discursive patterns and commonalities in young people’s understanding of sexual health. If educational initiatives are to be successful, then language, as Cameron and Kulick (2003: 154) argue, must not simply be regarded as ‘a medium for sex and health education but something that must be discussed explicitly as part of the process’, a contestation for which the corpus analysis presented in this chapter provides further support. In particular, it was evident that the adolescents possessed a range of misconceptions about HIV and AIDS, among which perhaps the most alarming was the tendency for some to conflate the two, reinforcing the idea that HIV and AIDS are identical. Such a conflation is liable to obscure awareness of the ways the virus is transmitted, potentially impeding assessments of risk in relation to sexual behaviour. Thus the findings add impetus to the call for evidence-based sex education programmes that provide ‘full and factual information’ (Independent Advisory Group on Sexual Health and HIV 2007: 12). The corpus analysis further highlighted some of the folk conceptualisations of sexual health adolescents operated with, beliefs that may need to be addressed by educators. Responding to lay beliefs like these is crucial since people are liable to filter official health education messages through popular beliefs about health (Helman 2007), reinterpreting them to suit their own needs (Aggleton and Homans 1987: 25).
Our corpus analysis has highlighted the value of the web-based forum as a means of eliciting the views of a generation who have often been reluctant to consult practitioners and others for sexual health advice (Suzuki and Calzo 2004). Studies of young people’s sexuality have been dominated by questionnaire methodologies, often with problemfocused agendas dictated by the researchers. Respondents, pressured into supplying information, may decline to provide answers or substitute random replies for earnest responses (Moore et al. 1996: 186). Additionally, respondents may display euphemistic constraint, under-representing their sexual behaviours and attitudes (ibid.). This is, of course, not to suggest that the adolescent health emails interrogated here are entirely free of fabrication or understatement, but the fact that they are non-elicited means the concerns communicated are principally motivated by what young people deem to be personally relevant – a factor which perhaps helps to account for the often frank and meticulous detail of their self-disclosures.
The corpus-based method we have used here is a novel approach for researching sexual health communication, offering a fresh analytical perspective and thus responding to calls for new modes of research into sexual behaviour. Owing to the fact that the right to privacy is, understandably, jealously guarded in this sensitive area (Moore et al. 1996: 186), it is not surprising that, despite the increasing amount of survey and epidemiological work on the subject, there is a lack of data concerning how people communicate sexual issues in naturally occurring situations. The adolescent health email corpus therefore constitutes a unique vantage point from which to survey contemporary adolescent sexual health.
Baker, P. (2006) Using Corpora in Discourse Analysis. London: Continuum. (This text provides invaluable practical help for researchers wishing to build their own corpus and/or conduct their own corpus analysis.)
Brown, B., Crawford, P. and Carter, R. (2006) Evidence-based Health Communication. Maidenhead: Open University Press. (This wide-ranging text provides a comprehensive overview of contemporary issues in health communication.)
Gwyn, R. (2002) Communicating Health and Illness. London: Sage. (This is an accessible discourse-based survey to health communication.)
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Ammerman, S., Perelli, E., Adler, N. and Irwin, C. (1992) ‘Do Adolescents Understand What Physicians Say about Sexuality and Health?’ Clinical Pediatrics 76: 590–5.
Baker, P. (2006) Using Corpora in Discourse Analysis. London: Continuum.
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