Issues Magazine

Cultural and Historical Factors in Aboriginal Women’s Sexual Health

By Janelle Trees

Understanding the culture and history of Aboriginal women in Australia throws light on their unique relationship with and attitudes to the medical profession.

Apart from the intimate and confronting nature of gynaecological examinations, including the Pap test, many historical, cultural and societal factors impact on Aboriginal women that are very likely to contribute to a hostile or non-trusting attitude towards medical personnel regarding sexual health.

It is clear that indigenous people carry an excessive burden of infectious disease generally and sexually transmitted infections (STIs) specifically. Unlike other diseases, which are considered to be consistently under-reported for indigenous people (because of issues related to indigenous identification and access to health care), STIs may be relatively over-reported among indigenous people. In contrast, notification of STIs may be relatively low for non-indigenous people in Australia (i.e. more people have the diseases than we know). Non-indigenous Australians may be better at keeping their bugs a secret, perhaps with the complicity of doctors who, whether being over-worked, lax or discrete, fail to notify.

Bowen and Fethers this year described STIs as hyper-endemic in remote indigenous communities. In Western Australia in 2002, 91% of notifications for syphilis were identified as indigenous, with the disease affecting all ages. Although the achievement of an effective vaccine against human papilloma virus (HPV) offers great hope for the struggle against cervical cancer on a world scale, predictions of the demise of the Pap smear may be premature, and access to culturally safe Pap test providers remains an issue for Aboriginal women. Incidence and mortality from cervical cancer among indigenous women have been estimated at 10 times the rates for mainstream Australian women.

Some STIs are thought to be co-factors in the development of cervical cancer. Chlamydia – an often asymptomatic, sexually transmitted bacterial infection that can cause sterility in women if left untreated – may be a major co-factor, with Naucler finding a strong association between chlamydia and HPV. The incidence of chlamydia in Aboriginal and Torres Strait Islander people is known to be much higher than for other Australians. Treatment remains a major public health problem, particularly in remote indigenous communities.

The high rate of STIs in Aboriginal women reflects the use of rape as a means of conquering a people. Infection with disease, including venereal diseases, was a means of ethnocide wherever Europeans invaded new parts of the world. Sometimes disease may have even been used consciously as a weapon of extermination. There are persistent tales of smallpox-infected blankets being given to indigenous people in the Americas and here in Australia. Colin Tatz, an authoritative scholar, remains unconvinced that Europeans in Australia used disease as a weapon. Although he is probably correct, the fact that Aboriginal people believe that this occurred colours their interaction with doctors.

The high rate of notification of sexually transmitted diseases may also reflect the history of surveillance of Aboriginal people. Viewing black (or foreign) people as a reservoir of disease is, of course, a central tenet of racism.

Interference by the church and the state in the sexual relationships of Aboriginal people has a long and very nasty history. Regulation of this most private sphere of a person’s life was considered part of the business of the state in Australia for many years, mostly as a domestic reflection of the White Australia policy.

In his 1929 report the Queensland Chief Protector of Aborigines, John Bleakley, advocated marriages solely between persons “on similar planes of civilisation” and stricter controls of sexual relations between Aboriginal women and white men in particular. In the Northern Territory, Chief Protector Neville enacted legislation on marriage between races with the specific aim of “breeding out” Aboriginal people.

Mixed race children were often removed to institutions in which interaction with the opposite sex was tightly controlled and their sexuality suppressed in the fine Christian tradition. At the same time the children were often subjected to sexual (as well as physical) abuse in the homes, missions and camps where they were imprisoned.

This legacy of rape, indiscriminate abuse and subsequent disease has had a huge impact on the relationship that Aboriginal women have with their own bodies and health, and with the medical profession. It must be a real factor, however difficult to quantify, in the avoidance by Aboriginal women of Pap tests and treatment for sexually transmitted and other diseases of the genital organs.

The history of interaction between Aboriginal women and medical service provision has often been inextricably tied up with the history of the Christian missions as much as with direct intervention by the state. Even when they were not themselves actively engaged in campaigns of physical genocide (“smoothing the pillow of a dying race”), the missionaries carried with them a fierce determination to smash the cultural traditions of their targets.

Alongside their basic medical supplies they carried their cultural baggage, including patronising assumptions of cultural superiority. Unlike their hapless “clients”, who were reeling in culture shock, they were armed with what was, to them, a consistent ideology of social place. These were the charitable traditions of the English middle class.

An emphasis on caring for the poor (or “heathen”) children as the innocent victims of parental ignorance (or parental “state of sin”) dovetailed with a liberal tradition of charity dating back at least to the Industrial Revolution in Britain, which came into full flower in the 19th century. This tradition of the deserving poor has a particular moral and political framework that ties health care to the struggles for the spiritual salvation of individuals while explicitly excluding any attempt to address problems systematically generated by the dominant culture.

In her History of Australian Medicine course at the University of New South Wales, Dr Susan Hardy outlined the system of admission to early English and then Australian hospitals whereby a prospective patient needed to obtain a ticket or note from an employer (or someone else from a higher class). This kind of system is still evident in some aspects of welfare today. The Salvation Army, for example, acts as an advocate for working people with their debtors, presumably on the assumption that they have some kind of spiritual or moral influence with those for whom they advocate.

Some Aboriginal women raised in the institutions to which so many were taken have the missionaries’ discipline in their daily lives. Some who were not institutionalised have never­theless internalised the hygienic practices and work ethic encouraged by the government policy of assimilation. My mother, who is of Aboriginal and Anglo-Celtic descent, grew up with scrupulous attention to detail in her grooming and dress by a mother who may have feared her children being taken away. This anxiety is very common.

One of the women in Maureen Kirk’s 1999 study “indigenous women speak out to bring about change” spoke of this explicitly in the medical context:

We’ve always been very careful about cleanliness because my mother didn’t want whites saying we were dirty. She’d scrub us up to go shopping and we’d be scrubbed within an inch of our lives to go to the doctor. It had to do with doctors, see, because we had to be cleaner than other kids. Mum was always scared about it. Them thinking we are dirty. Even now you always have a shower and put clean things on when you go to the doctor.

The fear of being excluded on (sometimes spurious) health or hygiene grounds was valid. It was not until the Whitlam reforms of 1973, when the White Australia policy was officially abandoned, that the relevant clause was deleted from the teacher’s handbook. It allowed for the exclusion of Aboriginal children from school if any “whites” complained that they were a potential source of contagion. This had been enshrined since the 1880s, and not infrequently enforced.

Issues of shame and discrimination, which always exist as barriers to diagnosis and treatment of STIs, become magnified in light of indigenous women’s issues. These include life-long subjection to “everyday” racism and inequality; domestic violence and abuse; police violence, harassment and rape; and cultural exclusion.

While travelling recently in rural New South Wales, my sister, her cousin and I were refused service at a café in spite of the evident availability of many tables. While I am fair-skinned and, if dreadlocked, quite European in my appearance, my sister is golden and her cousin, who was with us, is mahogany brown. We are well-educated, well-spoken and well-dressed. Less well-resourced indigenous people endure this kind of discrimination daily.

Many doctors and nurses whom Aboriginal women contact are from the same ethnic or “racial” group (i.e. Australians of northern European descent) as the economically and politically powerful “elite” whose actions continue to control almost every aspect of their lives. It is arguable that some medical teams appear somewhat indistinguishable from other, punitive, state agencies.

There is a lack of clarity, and not just by indigenous people, over the question of the distinction between health care and the coercive apparatus of the state. Some doctors, nurses and health administrators may be happy to act as de facto police, particularly some of those attracted to working with people they see as needing to be policed.

In New South Wales, where the state government actually passed legislation to facilitate the removal of children from their parents (in the 1915 amendment to the Aboriginal Protection Act), fear of doctors is sharp because doctors, in the minds of many Aboriginal people, are closely associated with the state. Ministers, teachers, doctors, mission managers and policemen were all implicated in the kidnapping of children, who were raised in “children’s homes” and then placed in menial jobs, sometimes never to be seen by their parents again. This was done in the name of an ideology of health, hygiene, prosperity and for “the good of the children”. Resistance to health promotion campaigns and to visiting the doctor or the hospital may have some basis, whether conscious or not, in this experience.

An oft-quoted sociologist’s dictum is that we learn parenting from our own parents. The radical discontinuities in the lives of Aboriginal women mean that some of them have “learned” highly dysfunctional parenting skills. Some women have compensated for the deficiencies in their own childhood by developing exceptionally good skills in looking after other people, without ever really learning to take care of themselves properly.

One of the women in the educational video Pap Test Business said: “I just know I’m so much better at looking after other people than I am at looking after myself”. Her point is usually greeted by nods and sighs of understanding by indigenous women watching the video. Valuing one’s own health highly and taking time for yourself are learned skills. Most Aboriginal women – indeed many Australian women – need to develop those skills, which have their basis in healthy self-esteem.

This struggle for esteem is particularly difficult for indigenous women, many of whom have been dispossessed from their land. They don’t fit into the mainstream but, for many, the living indigenous culture is a struggle to find. Important political elements and economic realities of contemporary Australia seem determined to prevent the integration of the current generation of young Aboriginal and Islander women into society with the level of dignity and equity that might enable most of them to overcome the legacy of the past.

Jo Harrison wrote in her 1991 report from women of the western desert, the Anangu of the Pitjantjatjara lands, that women were emphatic that the most destructive form of child abuse was to remove a child from its country and take away its cultural heritage. The Anangu have a lot of experience, both in the past and the present, of child removal. It has caused a lot of suffering. The current government intervention in the Northern Territory has triggered many fears.

Each of these factors shaping Aboriginal history and life has an impact not only on the willingness, but also on the ability of women to participate in disease and cancer screening and to follow through with treatment.

The health provider, and especially the Pap test provider, plays an important role. Liking and respect for the test provider was important to the women interviewed by Toussaint in her 1998 study. The South-West Sydney Area Health Service report noted that the provision of an experienced and trusted female practitioner was a key component of its program to recruit indigenous women to cervical screening. Thurecht, in her work published in 2000 on this topic, links fears of doctors explicitly to the experiences of the stolen generations:

Many Aboriginal women related their reluctance to visit the doctor specifically to childhood memories of hiding under the bed while mother spoke to the visiting welfare woman, or refusing to have injuries treated by a doctor for fear there would be accusations of abuse.

Medical professionals have the power not only to help you get better, but also to make you much sicker with the wrong treatment. They can legitimise your need to take time off work, validate your pain so that you can qualify for a sickness or disability benefit or to send you to hospital to be mutilated – for your own good.

This is hardly an exaggeration. The extremely high rate of diabetes, and its poor management, in indigenous people means that they are subject to an excessive number of amputations. A Koori woman well-known to the writer was sterilised without her informed consent at a Sydney hospital after the birth of one of her children by a doctor who didn’t think she should have any more.

Indigenous people really can’t win when it comes to expressing pain to doctors. If they are stoic, their pain is dismissed. If they are “overly” emotional their pain is also dismissed.

My brother was sent home from hospital with an untreated broken bone in his hand after an industrial accident. Another brother was sent home with fractured vertebrae, having been told that he was lazy. Although it is always difficult to distinguish racist mistreatment from the vagaries of a health system in perpetual crisis, such a climate does not encourage one to engage with a speculum.

As McCarthy said, the very concept of “compliance”, with its overtones of compulsion, is itself a product of an ethical worldview derived from the ideology of “charity”. This is true even when the services are directly “gifted” by the state and not by religious institutions. These ideologies are themselves generated by the underlying economic system, which, by reducing everything (including medical care) to exchange commodities, produces the very inequalities without which even the notion of charity becomes nonsense.

Awareness of the historical context of work with Aboriginal women struggling to heal ourselves will enrich the work and enable intelligent choices for the greater good. In the most personal and intimate parts of our lives, we need compassionate help free of unconscious moralism.

Educated health workers (including doctors) who are aware of the historical context in which we all work have a better chance of being the right person, in the right place, at the right time.

© Janelle Trees 2008. Reproduced with permission. Reference details are available from the author upon request. Email