HEALTH COMMUNICATION

2018, VOL. 33, NO. 6, 771–781

https://doi.org/10.1080/10410236.2017.1312203

Reducing Susceptibility to Courtesy Stigma

Catherine L. Bachleda and Leila El Menzhi
School of Business Administration, Al Akhawayn University

ABSTRACT
In light of the chronic shortage of health professionals willing to care for HIV/AIDS patients, and rising
epidemics in many Muslim countries, this qualitative study examined susceptibility and resistance to
courtesy stigma as experienced by nurses, doctors, and social workers in Morocco. Forty-nine in-depth
interviews provided rich insights into the process of courtesy stigma and how it is managed, within the
context of interactions with Islam, interactions within the workplace (patients, other health profes-
sionals), and interactions outside the workplace (the general public, friends, and family). Theoretically,
the findings extend understanding of courtesy stigma and the dirty work literature. The findings also
offer practical suggestions for the development of culturally appropriate strategies to reduce suscept-
ibility to courtesy stigmatization. This study represents the first to explore courtesy stigma as a process
experienced by health professionals providing HIV/AIDS care in an Islamic country.

Introduction culturally sensitive approaches to the management and reduc-

Health services across the world are struggling with a
chronic shortage of health professionals. Globally, there are
an estimated 7.2 million shortfall of doctors, nurses, and
midwives, with 25% of the deficit in the African region
(Campbell et al., 2013). This crisis is particularly acute in
specialties such as HIV/AIDS care (World Health
Organization, 2006), the result of the reluctance of many
health professionals to care for patients with this disease
(e.g., Hassan & Wahsheh, 2011). Indeed, the biggest limiting
factor for treatment and containment of HIV worldwide is
the insufficient numbers of trained health workers (World
Health Organization, 2006).
Studies suggest that the unwillingness of many health pro-
fessionals to care for HIV/AIDS patients stems, in part, from
the stigma associated with caring for these patients (e.g.,
Haber, Roby, & High-George, 2011). Yet, it is difficult to
find any studies that have explored how HIV/AIDS health
professionals experience HIV stigma, and in turn, how they
resist stigmatization, particularly within the context of an
Islamic country. This lack of research is surprising, for two
reasons. First, the predominately Muslim, Middle East and
North Africa (MENA) region, has one of the fastest growing
HIV/AIDS infection rates in the world (e.g., Abu-Moghli,
Nabolsi, Khalaf, & Suliman, 2010), bringing with it an increas-
ing demand for health professionals willing to care for HIV/
AIDS patients. Second, although HIV/AIDS-related stigma is
apparent in most communities, it appears to be more promi-
nent in Muslim societies due to social and cultural conserva-
tism (Hasnain, 2005). This has led to calls for greater
understanding of the Muslim experience of HIV stigma
(e.g., Abu-Moghli et al., 2010) and the development of
tion of such stigma (e.g., Bos, Pryor, Reeder, & Stutterheim,
2013). Therefore, the present study sought to explore how the
stigma associated with HIV care is experienced and managed
by a range of Muslim health professionals.
Background
HIV/AIDS care as dirty work
Stigma can be defined as an attribute that taints or discredits
an individual in the eyes of another (Goffman, 1963). Much of
the literature has focused on those who directly experience
stigma. However, stigma may also “by courtesy” affect those
associated with stigmatized individuals, including health care
professionals (Goffman, 1963, p. 30). In this context, courtesy
stigma reflects the devaluing of a person based upon the
“disgrace” associated with their occupation or social role
(Goffman, 1963, p. 3). In line with this notion, Hughes
(1951) discussed the concept of dirty work, which he defined
as work with a physical, moral or social taint. He argued that
although society sees dirty work as necessary, society also
perceives such work as distasteful, and tainting to the worker.
Some scholars (e.g., Ashforth & Kreiner, 1999) have since
expanded Hughes’ (1951) ideas.
Placed in the context of HIV/AIDS work, the physical taint
of dirty work may arise from the perception that those who
work in HIV care are at high risk of contamination from
contact with materially offensive and dangerous substances
such as infected blood and other body fluids. Regarding social
taint, HIV/AIDS has been closely associated with stigmatized
others such as sex workers, homosexuals and drug users (e.g.,
Parker & Aggleton, 2003). By being in regular contact with

CONTACT Catherine L. Bachleda c.bachleda@aui.ma; catherine.bachleda@gmail.com School of Business Administration, Al Akhawayn University, Hassan
Avenue, Ifrane, 53000, Morocco.
© 2017 Taylor & Francis Group, LLC
772 C. L. BACHLEDA AND L. EL MENZHI
individuals that are subjected to significant social disapproval,
those who provide HIV/AIDS health care may also become
tainted. Indeed, several studies have found that stigma can be
transferred to individuals who do not possess the discrediting
attribute (e.g., Sigelman, Howell, Cornell, Cutright, & Dewey,
1991). Finally, the moral taint of dirty work may arise for
HIV/AIDS health professionals if the work they undertake is
perceived to contravene moral or religious codes of conduct.
Islam, for example, forbids extramarital sex (e.g., Hasnain,
2005). Moreover, in many Muslim countries, the majority of
the general public believe that immoral sexual behavior is the
only cause of HIV/AIDS (Hasnain, 2005; UNAIDS, 2011).
Thus, as an occupational group, HIV/AIDS health profes-
sionals are heavily associated with all three types of taint.
Indeed, it could be argued, particularly in a Muslim country
that these workers undertake the dirty work of the health
profession. How this taint is experienced by such health work-
ers, however, seems to have been largely ignored by the
literature. Therefore, the present study aims to fill this litera-
ture gap, by answering the research question:
RQ: How is the stigma associated with HIV/AIDS care experi-
enced and managed by Muslim health professionals?
Strategies to deflect HIV/AIDS courtesy stigma
Although it is difficult to find any studies that have explored
how courtesy stigma is experienced and managed by a range
of HIV/AIDS health professionals in a Muslim country, the
literature does suggest that courtesy stigma, in general, is a
process that can be resisted. Two models are particularly
relevant to the present study. In the first model, Ashforth
and Kreiner (1999), after exploring the various ways in
which members of “dirty” occupations such as funeral direc-
tor, butcher, prison guard, and exotic dancer were able to deal
with their job-related stigma, proposed that individuals
involved in dirty work use coping strategies such as reframing
(changing the meaning of their work to something positive),
recalibrating (placing greater weight on some aspects of their
work), and refocusing (emphasizing the non-stigmatized fea-
tures of their work).
In the second model, Schneider and Conrad (1981), after
examining how different individuals cope with the disease of
epilepsy, identified two main typologies or groups of indivi-
duals. The first “unadjusted” group of individuals did not
develop strategies to minimize the impact of epilepsy on
their lives. These individuals felt that the disease, with its
associated discrimination and stigma, had a significant nega-
tive impact on their lives, with some reporting a sense of
being “incarcerated” by aspects of the disease. Conversely,
the second “adjusted” group were able to minimize the nega-
tive impact of epilepsy on their lives by using various judicial
disclosure, concealment, and quasi-liberated strategies to
deflect discrimination and stigma. If placed within the context
of HIV/AIDS courtesy stigma, judicial disclosure might be
reflected by an HIV/AIDS health professional only revealing
that they worked with HIV/AIDS patients when necessary.
Concealment might be reflected by an HIV/AIDS health
professional admitting to working as a doctor or nurse but
implying, or stating, it was within a non-HIV/AIDS depart-
ment, and a quasi-liberated approach might be reflected by a
heath professional publically announcing the stigma and
attempting to educate others about the disease.
Arguably, these two models reflect different approaches to
dealing with courtesy stigma, with the Ashforth and Kreiner
(1999) strategies of reframing, recalibrating, and refocusing,
reflecting cognitive tactics individuals use to manage the taint
of dirty work, and the Schneider and Conrad (1981) strategies
of judicial disclosure, concealment, and publically announcing
the stigma, reflecting behavioral tactics.
Islam and HIV/AIDS
With approximately 1.6 billion Muslim followers or 23% of
the global population, Islam represents the world’s second
largest religion, surpassed only by Christianity (Lipka, 2016).
Universally, Muslims believe in one God, the Qur’an or God’s
Holy book, the Prophet Muhammad through whom God’s
word was brought to the human race, a day of judgment by
God, life after death, and God’s control over human destiny
(e.g., Rassool, 2000).
As a religion, Islam defines culture, and this, in turn,
provides guidance for every facet of a Muslim’s life
(Hasnain, 2005). On sexual relationships, Islam considers
men as guardians of women and marriage as the bedrock of
society. Extra-marital sex is prohibited, as is homosexuality
and the taking of illicit drugs, including alcohol. Moreover, in
most Muslim countries, education, or even open discussion
about sexual behavior, reproductive health, or HIV/AIDS are
considered taboo (Hasnain, 2005). Indeed, many Muslims
regard discussions about safe sex and provision of condoms,
particularly for unmarried young adults as morally wrong
(e.g., Balogun, 2010). As a result, condom use is severely
limited, prohibited, or associated with immoral behavior in
many Islamic countries (Setayesh, Roudi-Fahimi, El Feki, &
Ashford, 2014).
Due to these strict religious and social norms, it is
assumed, by most of the Muslim population, that unmarried
Muslim men and women do not engage in sexual relation-
ships, and that married couples do not engage in extra-marital
sex. Studies, however, suggest that this is not always the case.
While there is a paucity of literature on premarital sex in
Muslim countries, the limited research available suggests
that most young Muslims men in their 20s and 30s, and
some young women, have had sex prior to marriage, although
due to religious conservatism, such sexual activity is often
opportunistic and guilt-ridden (Roudi-Fahimi & El Feki,
2011). Furthermore, some married Muslim men regularly
engage in high-risk behavior such as having sex with female
sex workers, having sex with other men, or injecting drugs.
Such behaviors add to the spread of HIV/AIDs, particularly
when most sex workers in Muslim countries have limited
social support, are not routinely screened for HIV or other
sexually transmitted diseases (Hasnain, 2005), and rarely use
condoms (Mumtaz et al., 2013). In Morocco, for example,
almost 90% of HIV infections in men are acquired through
having sex with female sex workers (the main mode), having

sex with other men, or injecting drugs. Conversely, over 70%
of women become infected with the disease via their husbands
(Mumtaz et al., 2013). The latter is in part due to lack of
knowledge, and in part because men tend to have greater
power in relationships than women, so it would difficult for
a woman to demand condom use, or for that matter faithful-
ness, even if she suspected that her husband might be infected
with HIV (Hasnain, 2005).
In contrast to many western countries where the nature of
HIV/AIDS disease and its transmission is well known by the
majority of the population, in many Muslim countries, mis-
conceptions about the disease are commonplace, with most
Muslims believing that the disease is only transmitted through
immoral sexual practices (Hasnain, 2005; UNAIDS, 2011).
Such beliefs contribute to the prominence of HIV/AIDS
stigma and discrimination in Muslim societies (Hasnain,
2005). Furthermore, most Muslim countries are collectivist
societies with strong group identities (Hofstede, Hofstede, &
Minkov, 2010). Thus, for many Muslims, should one member
of the family carry out an immoral act, the entire family and
close friends are also tainted by this individual’s activity,
simply because they belong to the same group of people,
even though they may be unaware of the act. Hence, fear of
social disgrace and bringing shame to their families and
community often manifests as a reluctance for those at risk
of contracting HIV/AIDS to seek testing, and for those diag-
nosed with the disease, to seek medical treatment (Setayesh
et al., 2014). Indeed, in some countries, Iran, for example,
before the fairly recent implementation of more effective
HIV/AIDS programs, death from suicide, as a result of the
stigma associated with the disease, was greater than death
from the disease itself (Alaei & Alaei, 2004).
Interestingly, sexual misconduct brings greater disgrace
than illicit drug use, with even a hint of extra-marital relations
or homosexuality likely to result in the person in question
being shunned by their family and their community (Hasnain,
2005). Thus, by the time individuals seek treatment for HIV/
AIDS, they are often in the advanced stages of the disease
(Setayesh et al., 2014). It should be noted, however, that while
Islam clearly opposes the risk behaviors that contribute to
acquiring HIV/AIDS, Islam does not prohibit health profes-
sionals from caring for HIV/AIDS patients. Indeed, Muslims
are expected as part of their beliefs, to care for the weak and
suffering (Rassool, 2000).
Research methodology
Method
This qualitative study comprised in-depth interviews with
Moroccan health professionals (doctors, nurses, social work-
ers) directly involved in HIV/AIDS medical care. Morocco
was chosen as the site of this study for three reasons. First,
Morocco is a Muslim state located in North Africa, with a
99% Sunni Muslim population (Kabasakal & Bodur, 2002),
and while the available data suggest a low HIV/AIDS preva-
lence in the general population, in line with other MENA
countries, there is a trend of rising epidemics among female
sex workers, men having sex with men, and injecting drug
HEALTH COMMUNICATION 773
users (Mumtaz, Riedner, & Abu-Raddad, 2014). Second,
although Morocco has undergone rapid societal change in
recent years (Desrues, 2012), in common with many other
Muslim societies, much of the population still views HIV/
AIDS as a disease contracted by immoral behavior. This
perception results in pronounced stigmatization of those liv-
ing with the disease (Hasnain, 2005; UNAIDS, 2011), and in
turn, those caring for HIV/AIDS patients. Finally, the existing
literature on the social aspects of HIV/AIDS in the MENA
region is severely limited (e.g., Badahdah, 2010), resulting in
calls for more research to be undertaken (e.g., DeJong &
Battistin, 2015; Hasnain, 2005).
In Morocco, nine regional centers deliver HIV/AIDS med-
ical care and treatment. The centers are well equipped and
situated in public hospitals either within the Department of
Infectious Diseases or the Department of Internal Medicine.
However, as is the case in many other Muslim countries, by
the time patients are referred to one of the centers, most are
in the advanced stages of the disease and have often been
abandoned by family members in an effort to protect the
family name from disgrace (Setayesh et al., 2014).
At the time of the study, a total of 70 health professionals
were employed in the nine centers, all of whom were indivi-
dually telephoned and, following a brief explanation of the
research, invited to take part in the study. Twenty-one indi-
viduals (seven doctors and 14 nurses) were either on annual
leave, sick leave, maternity leave, or opposing shifts when the
interviews were undertaken, resulting in a total of forty-nine
participants. Thus, 70% of the total population of HIV/AIDS
health professionals in Morocco participated in the study.
There was no apparent profession or demographic difference
between those who did participate and those who did not.
Each interview was conducted in person and lasted
between 40 and 60 minutes. For participant convenience,
interviews were held in French. While Arabic is the official
national language in Morocco, and English is popular, French
is most widely used in business, government and the profes-
sions (Sadiqi, 2006). Participants were assured anonymity in
regard to the information gathered and its later use. The
interviews were conducted by the second author as she is
Moroccan, speaks fluent French and English, and had profes-
sional contacts within the Moroccan Directorate of
Epidemiology and Disease Control, under which the nine
centers are administered. Interviews were recorded with the
permission of the interviewees and, to reduce researcher bias
and ensure data quality, the audiotapes were transcribed ver-
batim by an independent third party and subsequently
checked by another to ensure the transcripts were an accurate
reflection of what was said by interviewees. Transcripts were
then translated into English using the back-translation
method recommended by Brislin (1980).
During the semi-structured interviews, participants were
asked about: their involvement in HIV/AIDS care (role,
length of experience in healthcare and HIV/AIDS work, and
HIV/AIDS training received, if any); perceived positive and
negative aspects of working with HIV/AIDS patients; percep-
tions and experiences related to how their family, friends,
other professionals, and the public viewed their work; and
where relevant, strategies used to deflect perceived
774 C. L. BACHLEDA AND L. EL MENZHI
Table 1. Demographic characteristics of participants.
Characteristic n = 49 Characteristic
Gender Role
Male 19 Doctor
Female 30 Nurses
Age Social Worker
18 to 24 years 1 Marital Status
25 to 34 years 20 Married
35 to 44 years 10 Single
45 to 54 years 11 Divorced
55 to 64 years 6
65 and above 1 the few minor disagreements were resolved through
disapproval associated with their work. This latter question
was a simple open question, Ashforth and Kreiner’s (1999)
and Schneider and Conrad’s (1981) coping constructs were
not mentioned. Further, the questions were used to informally
guide the interview conversation versus strictly itemize the
discussion.
Participant characteristics
Table 1 summarizes the main demographic characteristics of
the participants. Stated monthly incomes were also indicative
of participant position and seniority, and in keeping with
positional requirements, all doctors had doctoral degrees,
and all nurses and social workers had either attained bachelor
degrees or undertaken high school education. Further, 39
(79.6%) participants had received formal training on HIV/
AIDS.
Data analysis
Data analysis commenced as soon as the first interview
transcripts were available and continued throughout the
study. Both researchers coded the transcripts independently,
drawing on the three phase coding process described by
Corbin and Strauss (1990). Throughout the coding process,
the researchers used the constant comparison technique
(Corbin & Strauss, 1990), by which text newly coded was
constantly compared to text coded earlier to ensure consis-
tency. In the first phase of coding (open coding), the
researchers after reading and re-reading the transcripts,
assigned words or phrases to capture the essence of each
sentence of the data (Glaser & Strauss, 1967). In the second
phase of coding (axial coding), the researchers sought to
reassemble the data to form themes (Charmaz, 2006). This
process involved methodically grouping together under a
single category, codes that made conceptual sense regarding
new or novel themes, and themes that appeared to align
with existing research. Themes identified during early tran-
scripts were followed up in later interviews. No new themes
were identified during the last ten interviews, suggesting
that theoretical saturation had been reached (Glaser &
Strauss, 1967). In the third phase of coding (selective cod-
ing), a phase which converged with the second coding
phase, the researchers connected identified themes with
relevant literature. Analytic memos (Charmaz, 2006) were
used throughout this process.
For the first six transcripts, the researchers met after cod-
n = 49 ing each transcript to compare coding results, and after that,
every third or fourth transcript. Coding variations were
22
22
resolved through discussion and consensus (Bradley, Curry,
5 & Devers, 2007). As a check on interpretation (Shenton,
2004), an independent fellow researcher was provided with
27
17 the raw interview transcripts and asked to code and identify
5 themes using the above process. The consensus was high, and
discussion.
It should be noted that an iterative approach (Tracy, 2013)
was used, whereby the researchers continually moved between
an emic examination of the data for themes and an etic review
of existing theories to try and explain the data. The research-
ers did not enter the analysis with the concepts of reframing,
recalibrating, refocusing, or judicial disclosure, concealment,
and publically announcing the stigma in mind, nor did the
researchers originally plan to use dirty work as a theoretical
framework to explain HIV courtesy stigma. On the contrary,
these foci were identified as transcript data were classified into
categories, and analytic memos were written to clarify the
meaning of the categories. As data analysis progressed, it
became evident that the identified categories reflected the
coping strategies developed by Schneider and Conrad
(1981), and Ashforth and Kreiner (1999), and that dirty
work provided a theoretical lens that could help explain the
stigma associated with providing health care to HIV patients
in a Muslim society.
Findings
Three major themes were identified from the data, suggesting
that health professionals’ susceptibility to HIV-related stigma
was dependent upon the degree to which they could resist
stigmatization within interactions related to their Islamic
faith, interactions within the workplace (patients, other health
professionals), and interactions outside the workplace (the
general public, family and friends). Each theme, consistent
across all centers, is discussed below.
Interactions related to Islam
Results suggest that interactions related to religion (Islam)
were seen to be the main basis for HIV/AIDS stigmatization
in patients and by courtesy. Religion, however, was also seen
to be an effective means of resistance to courtesy
stigmatization.
With respect to stigmatization in patients, the link between
Islam and HIV/AIDS was evident in comments such as that
made by a young female doctor, from Center B, who reflected,
“As Muslims, religion rules our lives, so people automatically
judge others using religion, and this is why HIV patients are
so stigmatized,” or, that made by a male nurse from Center G,
who stated, “Many people say that if one has HIV then one
does not respect the religion.” A senior male doctor from
Center D was more specific, suggesting that stigmatization
arose, not simply because of the religion per se, but because
of a perceived transgression of religiously sanctioned acts,
stating that Moroccan society tended to “associate HIV

automatically with sex outside marriage and because this act is
forbidden in Islam, it is religion that is used to stigmatize the
disease.” Similarly, a female nurse in Center I reflected:
Most Moroccans associate the disease with sexual misconduct and
vice. Hence, based on religious teachings many people consider
HIV patients as people who have sinned and transgressed religion.
Indeed, one female doctor, from Center C, in emphasizing
this link between religiously sanctioned actions and HIV
stigmatization gave the following illustration, “In other coun-
tries if a girl of 13 has HIV they would look to the cause,
maybe a blood transfusion, but in Morocco, because of the
religion, she would automatically be labeled a prostitute.” This
association between religiously prohibited practices and HIV/
AIDS also caused unease for the caregivers themselves at
times, with one male nurse from Center E confiding, “I am
being very frank here, there is always this influence of religion
when dealing with HIV patients, indeed I struggle with it
myself sometimes, especially when dealing with homosexual
patients.”
For some, the stigmatization of HIV/AIDS was exacerbated
by religious leaders. For example, a female nurse in Center A
asserted “I believe that religious leaders and Imams play a role
in this stigmatization, none of them ever talk about HIV in
their religious shows or explain how anyone can get the virus
without the use of drugs or sex,” and a male doctor from
Centre C declared “I think that religious leaders create bar-
riers to many initiatives that aim to fight the spread of AIDS
and educate people, condom distribution campaigns for
young people, for example.”
Religion was also seen to be at the heart of HIV/AIDS
courtesy stigmatization. For example, one male nurse from
Center H, who had worked with HIV/AIDS patients for over
20 years, in attempting to explain why he thought some
disapproved of his work, stated “Religion is important for all
Moroccans, and because HIV is linked with things banned or
“Haram” in Islam, it is the real cause of stigma, both for our
patients and for us.” Some, more specifically, made comments
suggesting a moral taint underpinned courtesy stigmatization.
For instance, a female social worker in Center A, remarked,
“Moroccan society tends to judge people living with HIV
using religion and in turn, I think they see our job as some-
what sinful because it is directly linked to HIV,” and a male
doctor, from Center D, with 15 years’ experience, including
5 years in the specialty of HIV/AIDS observed:
AIDS is automatically linked to sexual deviance and a violation of
religious norms. Hence, some fear us because they think if we
interact daily with HIV patients, we eventually become (morally)
contaminated ourselves.
Others gave specific job-related examples that seemed to be
indicative of courtesy stigma, such as that provided by a male
nurse from Center D who remarked, “Once during a screen-
ing campaign, we had a group of the Muslim Brotherhood
who said we should leave because we were encouraging pros-
titution and sexual misconduct.”
In spite of the above, for many participants to the present
study, religion also formed the basis for a quasi-liberated
approach to deflecting stigmatization or use of a reframing
HEALTH COMMUNICATION 775
strategy. Illustrating the former, a female doctor in Center H
first talked about compassion and justice being central to
Islam and how good Muslims should not reject those suffer-
ing from HIV/AIDS simply because of their disease, and then,
reflecting the educative component of a quasi-liberated parry
to stigma, stated “I remind my colleagues that we are here to
treat the sick, not to judge, only God can judge.” Similarly, a
male doctor in Center F stated: “I remind others that God is
merciful and we should also be.” Illustrating the latter, a
female nurse from Center C, used religion to positively
reframe the meaning of her work, disclosing:
Knowing my religion helps to reduce the sense of disapproval I
sometimes feel because we need to help patients whatever their
illness is. Those who respond negatively to me because of my
work or my patients do not really understand Islam.
Interestingly, there was some evidence of participants
managing the opposing perspectives of Islam being both a
cause and a cure for courtesy stigma, by selecting one side of
the contradiction and ignoring the other. For example, one
mature female doctor from Center G, in describing how
others saw her work, stated:
I am proud of the work I do, I am not here to judge, and nor
should others, I am here to help the sick, we are all Muslims, and
these people are really suffering physically and psychologically,
most have been rejected by their families and are completely
alone, so I feel that I am providing the extra support and care
that they deserve.
In this statement, the health professional, although hinting
that others judge her work and the patients she treats, focuses
on the humanitarian side of her job. Thus, she selects the
aspects of her job associated with an important pillar of being
a good Muslim, namely caring for those that are less
fortunate.
There was also some evidence of participants managing the
tensions arising from Islam being both a cause and a cure for
courtesy stigma by treating these opposing perspectives as
interrelated. For instance, one female doctor from Center I
appeared to recognize that these perspectives of Islam were
not necessarily mutually-exclusive when she remarked:
Religion is often used to judge those with AIDS and us. However,
I have also used it to assist others like my family to understand
why I do this job, everyone has his/her life destiny, and God must
have wanted me to do this work.
Interactions within the workplace: Patients and other
health professionals
Reflecting strong dirty work overtones, aversion to HIV/AIDS
work was a commonly perceived reaction from other health
professionals. For example, one of the senior male doctors
from Center D felt that the reason other health professionals
refused to care for HIV patients was either “because they fear
contamination, they do not want the huge workload asso-
ciated with their care, or because they have a negative view
of people with HIV.” Moreover, many participants felt that
other health professionals tended to dissociate themselves
from HIV/AIDS work and workers, providing the basis for
an “us versus them” perspective of the world. As an example
776 C. L. BACHLEDA AND L. EL MENZHI
of the former, one female social worker from Center A men-
tioned that when she met with doctors and nurses from other
departments, she was always introduced as “the social worker
from the HIV Center.” As an example of the latter, one male
doctor from Center B stated: “They simply do not want one of
our (HIV) patients around one of ‘their’ patients.”
However, in spite of the perceived stigma associated with
the work of HIV/AIDS, for the majority of participants, the
work environment through interactions with other health
workers and patients provided a degree of protection from
stigmatization by facilitating the use of Ashforth and Kreiner’s
(1999) reframing, refocusing, or recalibration coping strate-
gies. Reframing was evident in comments that positively refo-
cused the meaning of HIV work, such as “We are helping in
the fight against the expansion of AIDS in Morocco,” made by
a male nurse from Center F, and the comment “By doing this,
I have a sense of fulfilling the real mission of being a doctor,”
made by a senior male doctor, located in Center B. Shifting
attention from the tainted features of the work to the non-
tainted features of the work, was reflected in refocusing com-
ments such as “HIV/AIDS is a multidisciplinary disease, it
allows me to put into practice almost everything I have
learned, it is a real intellectual challenge, and I love it,”
made by a female doctor in Center H. Finally, in an example
of recalibration, a male nurse from Center E, when explaining
how he dealt with a perceived aversion, by other colleagues, to
HIV/AIDS patients stated “I tell my colleagues, that (unlike
other departments) at least in our department we know
whether a person has HIV or not and, consequently, we can
take appropriate precautions.” This comment clearly places
greater weight on the inside knowledge associated with his
work than on other, perhaps more tainted, characteristics.
Interactions outside the workplace: The general public,
family, and friends
Almost all participants described how Moroccan society is still
very judgmental toward people with HIV/AIDS and men-
tioned how this disapproval also reflected on them. For exam-
ple, a doctor, who had worked with HIV/AIDS patients for
over 7 years, observed: “Because we show compassion toward
these patients many assume we condone the practices that led
to the disease.” Given this environment, it is not surprising
that all three of Schneider and Conrad’s (1981) coping stra-
tegies were evident, in varying degrees, when participants
dealt with strangers, members of the public, or less immediate
family and friends. Judicial disclosure was commonly used
with many participants admitting that they used a selection
process, based upon the perceived tolerance and open-mind-
edness of the person they were talking to when deciding
whether to divulge details about their work. For example, a
female nurse stated:
In general, I omit telling people that I work in the HIV depart-
ment in order to avoid their disapproval and their observations
and questions about the patients, their lives, how they look. . . one
time, I was asked why we don’t burn them! So I will tell people
when I know that the person is knowledgeable and tolerant
otherwise I say that I work in another department, Cardiology
for instance.
Several participants used concealment, for example, one
male doctor from Center E stated: “I never say that I work
with HIV patients, I just say that I am a doctor.” A small
number of participants, reflecting a quasi-liberated approach
to stigma deflection, were open about their work when meet-
ing strangers, using the opportunity to try and erode stereo-
types, directly challenge social disapproval, or simply educate
members of the public. For instance, one male nurse from
Center B stated “Whenever an opportunity to educate people
about AIDS presents itself, I use it, it must be done,” and a
female social worker from Center H revealed:
I let everybody know that I work with HIV patients. I don’t pay
attention to what society might think of me. I have been criticized
for distributing condoms to people. I was told that I am not
supposed to do that since I am a veiled woman. But not all people
can abstain, and I think that condoms play a crucial role in the
prevention of AIDS. So I have no problem talking about the issue
and educating people.
Interestingly, however, when dealing with immediate
family and close friends, almost all participants used a
quasi-liberated approach in the form of ongoing education
about HIV/AIDS and reassurance about their use of precau-
tions, to counter the “fear,” “anxiety,” “shock,” and stigmati-
zation related to their work. For example, a female doctor,
from Center H, after talking about teaching her family the
realities of HIV/AIDS transmission, particularly about the
many married women who were infected via their husbands,
stated “Frankly, at first my father was quite stressed and
anxious. Now, however, I think he understands why I have
chosen to work here and supports what I do,” and a male
nurse from Center A disclosed “When I started working here
it was really hard for my wife, she was constantly scared and
asking why I should choose this area, it took a lot of reassur-
ance about the risks.”
Discussion
This study sought to explore stigma as experienced by the
range of health professionals providing HIV/AIDS care in
Morocco, a Muslim state. Three major themes were identified
from the data suggesting health professionals’ susceptibility to
HIV-related stigma depended on the degree to which they
were able to manage stigmatization through interactions
related to their Islamic faith; interactions within the work-
place (patients and other health professionals); and interac-
tions outside the workplace (the general public, family, and
friends).
Regarding interactions with Islam and in one of the most
interesting findings of the study, participants perceived reli-
gious beliefs to be at the heart of much of the stigma asso-
ciated with their work, mainly because the disease was seen by
most of the Moroccan society to be caused by religiously
prohibited acts. In turn, those caring for HIV patients suffered
from an associated moral taint, because they were seen to
condone the religiously prohibited, sinful behavior resulting
in HIV/AIDS infection.
The findings also indicated that the experience of stigma
was prevalent among all those providing HIV/AIDS health
care (doctor, nurse, and social worker), suggesting that

courtesy stigma impacts Muslim health professionals irrespec-
tive of their occupational prestige. This in itself is noteworthy,
given prior research suggests that doctors are usually afforded
greater occupational prestige than nurses or social workers
(Thomas, 2003), and as a result are somewhat protected from
stigma by the higher status linked to their profession (e.g.,
Kreiner, Ashforth, & Sluss, 2006). In effect, a doctor has a
“status shield” (Hochschild, 1983, p. 174). Indeed, Dick
(2005), argues that higher status individuals tend to delegate
many of the dirty tasks associated with their role to those
lower in the occupational hierarchy, thus avoiding much of
the dirt associated with an occupation.
However, contrary to this presumption, the present study
found that all those who care for HIV/AIDS patients were
equally susceptible to courtesy stigma, regardless of their
occupational status. Speculatively, there could be a number
of reasons for this loss of status shield. First, perhaps the
various types of taint (social, moral and physical) have differ-
ent levels of importance in courtesy stigma. In terms of
physical taint, arising, for example, from contact with materi-
ally offensive substances such as infected body fluids, a doctor,
as argued by Dick (2005), may be able to deflect this source of
taint through delegation to someone lower in the occupational
hierarchy such as a nurse, and a social worker might avoid
this taint altogether by having no physical contact with a
patient when performing their role. However, in relation to
the social taint of working with stigmatized others (such as
sex workers), and the moral taint associated with, for example,
perceptions of condoning contravention of religious and
moral codes of conduct, these forms of taint may be more
difficult to deflect by those higher in the occupational hier-
archy such as doctors, and as a result, they may have more
importance in courtesy stigma. Indeed, Tracy and Scott (2006)
in a comparative analysis of the dirty work undertaken by
firefighters and correctional officers found because correction
officers needed to deal with moral taint, this lead to greater
stigmatization of their role.
Second, the loss of status shield may be a reflection of the
cultural context of the present study. For Moroccans, indeed
all Muslims, Islam is considered a way of life and with this
world view comes a complete moral structure. A Muslim is
not only expected to be morally righteous but is also expected
to contribute to the moral righteousness of their society
(Laluddin, 2014). Perhaps because Muslim HIV/AIDS health
professionals care for HIV/AIDS patients by choice, do not
denounce these patients, or do not take reasonable steps to
distance themselves from the taint associated with the disease,
they are seen to be transgressing their obligation to promote
moral righteousness, and this, in turn, may mitigate any status
shield afforded by their occupation. Indeed, in this context, it
could be argued that HIV/AIDS is not considered as a disease
by Muslim society, rather it is seen as the embodiment of a
moral taint or even a lack of morality.
However, equally interesting about interactions with Islam,
was the finding that many participants used the central
tenants of Islam related to compassion and justice to deflect
courtesy stigma. Love, compassion, and mercy are important
pillars of being a good Muslim, as are visiting and caring for
those that are sick (Ibrahim & Songwathana, 2008). Those
HEALTH COMMUNICATION 777
health workers that were able to link these Islamic teachings
to their work seemed to be successful in offsetting the cour-
tesy stigma associated with caring for HIV/AIDS patients.
This contradiction between religious beliefs being perceived
as the cause of courtesy stigma, on the one hand, and being
perceived as the cure, on the other hand, is intriguing and
raises questions about how the health workers, themselves
Muslims, managed these opposing perspectives of their reli-
gion. In other words, how did the health professionals caring
for HIV/AIDS patients, deal with the tension that stems from
others religious-based judgments that they condone the
immoral acts associated with HIV/AIDS, and by implication
are less pious Muslims, and alternatively, the religious-based
view that they are a good, perhaps even more devout Muslim,
because they show compassion for the sick and less fortunate?
One lens through which to view this tension is provided by
dialectical theory (e.g., Baxter, 1990; Werner & Baxter, 1994).
Although advanced within the context of personal relation-
ship development, the theory does offer a useful framework
for understanding responses to opposing perspectives. Central
to dialectical theory is the notion that the tensions arising
from contradictions are not necessarily resolved, rather, indi-
viduals respond to such tensions by using four basic coping
techniques, namely selection (choosing one perspective or
pole of the contradiction and ignoring the other), separation
(accepting the existence of the two opposing perspectives, but
denying the interdependence of the two), neutralization
(accepting the existence of the two opposing perspectives,
but diluting the strength of each through a compromise
approach), or transforming (changing the meaning of the
contradiction such that its contrasting perspective are no
longer seen to be in opposition). Indeed, as indicated earlier,
there was some evidence of participants in the present study
managing the opposing perspectives of Islam being both a
cause and a cure for courtesy stigma, by selecting one side of
the contradiction and ignoring the other, or by transforming
such dialectic tensions into complimentary views.
Concerning interactions within the workplace, aversion
toward HIV/AIDS work, and distancing were commonly per-
ceived reactions from other heath-workers. The aversion to
working with HIV/AIDS patients appeared to be based on
fear of transmission, disapproval of the assumed lifestyle of
such patients, and the heavy workload associated with caring
for these patients. Similar results have been noted in other
studies (e.g., Foreman, Lyra, & Breinbauer, 2003). The per-
ceived distancing by others led to a sense of “us” versus
“them” for some of the participants in this study. This finding
is consistent with Link and Phelan’s (2001) conceptualization
of stigma in which separation by others is a fundamental
component of stigmatization. Further, the results seem to
support Goffman’s (1963) proposition that individuals pro-
viding care to those with socially unacceptable diseases do not
meet the social role or status expectations associated with
professional health workers. Moreover, the present study
extends this premise to include Muslim HIV/AIDS health
professionals, regardless of their role.
In response to aversion and distancing from other health
professionals, participants used one or more of Ashforth and
Kreiner’s (1999) coping strategies, including reframing their
778 C. L. BACHLEDA AND L. EL MENZHI
dirty work as “honorable,” “highly skilled,” or “much-needed”
work. Similar responses have been noted by researchers in
other stigmatized work such as caring for mentally ill patients
(e.g., Bassiri, Lyons, & Hood, 2011), gynecological patients
(e.g., Bolton, 2005), patients undergoing abortion (e.g., Norris
et al., 2011), and digging graves (e.g., Saunders, 1995).
However, the present study extends the prior research to
include caring for Muslim HIV/AIDS patients. Finally, parti-
cipants were able to use patient interactions to refocus their
attention on the benefits associated with their work, including
the intellectual stimulation of dealing with a multi-disciplin-
ary disease.
In respect of interactions outside the workplace, most
participants experienced courtesy stigma in encounters
with the general public and less immediate family and
friends, a finding that is consistent with other studies.
Dwyer, Synder, and Omato (2013), for example, found that
interactions with the public gave HIV volunteers in
Midwestern America, the greatest risk of experiencing cour-
tesy stigma. In the present study, participants used all three
of Schneider and Conrad’s (1981) coping strategies, particu-
larly judicial disclosure, to avoid work associated disap-
proval. Health professionals’ reluctance to disclose the
nature of their work has been noted by researchers in
other stigmatized work including gynaecology (e.g., Bolton,
2005), and abortion work (e.g., Norris et al., 2011). The
present study extends such research to include caring for
HIV/AIDS patients in a Muslim country. Findings also high-
lighted that with immediate family and close friends, almost
all participants fully disclosed the nature of their work and
in a reflection of the quasi-liberated approach to deflecting
stigmatization, used education to manage unfounded fears
or beliefs about contagion. The use of this strategy appeared
over time, to result in a supportive home environment for
most participants. This disclosure separation between those
well known to participants and virtual strangers is interest-
ing. It seems to correspond with Goffman’s (1959) notion of
front and back regions. Back regions are places where an
individual can relax about the nature of their work as they
are surrounded by those who support what they do or have
similar values or beliefs. Conversely, front regions are places
where an individual needs to be on guard and gives the
appearance that their work “embodies certain standards” so
as to avoid disapproval (Goffman, 1959, p. 93). Indeed, such
guardedness is often encouraged by loved ones (e.g., Smith
& Hipper, 2010).
Theoretical implications and future research
From a theoretical perspective, the present study findings
extend understanding of courtesy stigma and the dirty work
literature in a number of ways. First, most existing research
has focused on the stigma associated with patients suffering
from HIV/AIDS rather than the health providers caring for
these patients. Moreover, the limited research that is available
has not examined courtesy stigma as experienced by a range
of health professionals providing HIV/AIDS care, or the stra-
tegies used by these individuals to deflect courtesy stigma.
This research begins to address this imbalance.
Second, it is hard to find any studies that have explored
HIV courtesy stigma in the context of Muslim health profes-
sionals. For societies where Islam is a way of life, this paper
extends the current literature to the use of Islamic principles
in the deflection of stigma and takes a step towards addressing
the call for stigma management strategies that are culturally
relevant for Muslims (e.g., Abu-Moghli et al., 2010).
Interestingly, the findings suggest that although religion
appears to at the heart of much of the stigma associated
with HIV/AIDS care in a Muslim country, Islamic principles
can also be used to decrease a health providers’ susceptibility
to courtesy stigma. As such, further studies into the role of
Islam in resisting stigma might prove to be a useful avenue for
further research.
Third, although Ashforth and Kreiner (1999) provide a
compelling conceptualization of dirty workers and the strate-
gies they use to deflect courtesy stigma, there has been little
empirical investigation of the propositions espoused by these
researchers. The present study goes some way to addressing
this gap. Participants displayed the use of cognitive-based
reframing, refocusing, and recalibration strategies to resist or
lessen the impact of courtesy stigma, particularly when inter-
acting within the workplace. Interestingly, however, when
interacting outside of the workplace, participants seemed to
prefer the more behaviorally based strategies of judicial dis-
closure, concealment or education. Perhaps, therefore,
responses to courtesy stigma are situation-specific, and this
may be another avenue for future research.
Fourth, results imply that the various types of taint (social,
moral and physical) have different levels of importance in
courtesy stigma and within Islamic cultures, such that the
protection usually provided by occupational prestige, the “sta-
tus shield” (Hochschild, 1983, p. 174) is mitigated. Perhaps,
therefore, a more in-depth examination of the interdepen-
dence and differences between physical, social and moral
taint, particularly within different cultural contexts, might
prove a fruitful topic for future research.
Finally, results suggest that a dialectical lens may provide a
useful approach for viewing the tensions arising from the
contradiction that religion is both a source and a means of
mitigating courtesy stigma in a Muslim country. Thus, as
suggested by others (e.g., Basu, Dillon, & Romero-Daza,
2016), future research could further examine the applicability
of the dialectical framework for explaining some of the com-
plexities inherent in HIV/AIDS and interactions related to
religion.
Implications for practice
Although the present study is exploratory in nature, it does
provide some insights for those tasked with recruitment and
retention of health workers willing to give care to HIV/AIDS
patients. First, the finding that participants were able to offset
courtesy stigma by using the tenants of Islam related to
compassion could be used as a foundation to develop cultu-
rally specific strategies for reducing courtesy stigma. Social
messages could be crafted that link compassion to caring for
people with HIV/AIDS. Muslim community leaders and scho-
lars could also be encouraged to advocate for HIV/AIDS

health professionals, within the context of these Islamic teach-
ings. Prior studies have found many religious leaders reluctant
to discuss topics related to HIV, due to concerns about being
seen to condone activities prohibited in Islam, such as sex
outside marriage (Kelley & Eberstadt, 2009). Raising the topic
within the traditional teachings of Islam, namely to treat those
that are less fortunate with non-judgmental compassion, may
be a more successful approach.
Second, the results that interactions within the workplace
provide some protection from courtesy stigma could inform
recruitment messages by emphasizing the worthiness of HIV/
AIDS work and the intellectual and professional learning
benefits associated with providing multi-disciplinary care.
Several studies suggest that such benefits increase the reten-
tion of health workers and reduce attrition rates (e.g.,
Henderson & Tulloch, 2008).
Third, the finding that other health professionals have an
aversion to working with HIV/AIDS patients could inform
the development of training programs aimed at mitigating
unfounded fears about HIV transmission in the care of these
patients and highlighting the Muslim’s duty to care for those
that are sick. Various studies indicate that health worker
education can positively impact attitude toward and willing-
ness to care for those with HIV/AIDS (e.g., Ezedinachi et al.,
2002). Perhaps mandatory HIV/AIDS clinical experience
could also be included in the training curriculum of health
professionals. Studies suggest that clinical experience in tradi-
tionally neglected specialties increases the probability that
students will, on graduation, work in these areas (e.g.,
Littlewood et al., 2005).
Fourth, the finding that most participants used judicial
disclosure or active concealment, to avoid disapproval about
the nature of their work, when dealing with the general pub-
lic, and non-immediate family or friends, suggests that com-
munity awareness and education about HIV/AIDS, its causes
and modes of transmission, is still needed in Morocco, as is
more emphasis on the link between caring for those with HIV
and Islamic teachings. Several studies have shown that indi-
viduals who have a greater insight and knowledge of the
disease are less likely to sanction stigma (e.g., Foreman
et al., 2003). Finally, when dealing with immediate family
and close friends, results suggest that health professionals
newly recruited to the specialty would benefit from guidance
on how to broach the nature of their work and how to use
facts about the risk of transmission to resist courtesy stigma at
home.
Limitations
Naturally, there are some limitations to this research. One
limitation is the influence of various psychosocial character-
istics was not explored. Characteristics such as, religiosity, age,
and marital status, sexual preferences, whether the partici-
pants were themselves infected with HIV or had a close family
member who was infected, may have biased some of the
results. For example, the majority of participants in this
study were female, and this may have impacted their feelings
of courtesy stigma, or those with higher levels of religiosity
may have been better equipped to deflect feelings of courtesy
HEALTH COMMUNICATION 779
stigma by using Islamic teachings. Perhaps future studies
might control for such variables. In another limitation, the
findings indicated that the experience of stigma was prevalent
among all those providing HIV/AIDS health care. However,
the sample size restricted a full investigation of whether the
experience of courtesy stigma differed depending upon the
role (doctor, nurse, or social worker) or status of the health
worker. As such, it would be useful if future research exam-
ined this issue in more depth. Finally, this study was restricted
to one Muslim country. Thus, it is hard to know whether the
findings can be generalized beyond the context of Morocco.
Conclusion
Notwithstanding any limitations, this qualitative study, which
examined susceptibility and resistance to courtesy stigma as
experienced by nurses, doctors, and social workers in
Morocco, an Islamic country, provides rich insights into the
process of courtesy stigma and how it is managed, within the
context of interactions with Islam, interactions within the
workplace (patients, other health professionals), and interac-
tions outside the workplace (the general public, friends, and
family). In the process, the study extends understanding of
courtesy stigma, the dirty work literature, and suggests that a
dialectical lens may provide a useful approach for viewing
religious-related stigma in future research.
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