|The International Electronic Journal of Health Education|
[Reprint (PDF) Official Layout of this Article]
IEJHE, Vol. 2(4), 150-158, October 1, 1999, Copyright © 1999
Connotative Meanings of Sexuality-related Terms among Nursing Students in the Dominican Republic
Wayne W. Westhoff, M.S.W.,
M.P.H., Ph.D, CHES1; Robert J. McDermott, Ph.D., FAAHB1; Ramona
Valentín de Sierra, R.N., M.A.2; Judy C. Drolet, Ph.D., CHES3;
Joyce V. Fetro, Ph.D., CHES3; Jennifer Joerg-Cole, M.S.W., M.P.H.1
1University of South Florida College of Public Health, Department of Community and Family Health; 2 Universidad Autonoma de Santo Domingo, Santo Domingo, Dominican Republic; 3 Southern Illinois University, Department of Health Education and Recreation
Corresponding author: Robert J. McDermott, PhD, FAAHB,University of South
Florida, College of Public Health, 13201 Bruce B. Downs Blvd., Tampa, Florida 33612.
Phone: 813.974.6700; fax: 813.974.9912; e-mail: RMCDERMO@HSC.USF.EDU
Received June 23, 1999; Accepted August 23, 1999
The attributes assigned by 733 nursing students in the Dominican Republic to constructs representing sexuality-related events (e.g., abortion), objects/people (e.g., penis, lesbian), and abstract terms (e.g., femininity) were examined. A survey comprised of semantic differential scales, 49 sexuality-related terms, and selected demographic items was administered. Gender differences in the evaluation of constructs were assessed by means of t-tests. Males and females differed significantly on only 1 of 9 abstract terms (p<.006) and 2 of 25 events (p<.002). Overall, 27 of the 49 terms (55.1%) were assigned predominantly negative attributes. The representational meaning and semantic significance of some sexuality-related constructs could influence aspects of education and care, including medical and sexual history taking.
The relationship between a word and its meanings can be complex, and in studies of language, is known as semantics (Megginson, 1996). Communication involving sexuality-related words can encounter significant roadblocks. The mere articulation or description of certain words, objects, actions, and even people can generate two types of meaning for individuals -- denotative (referential) and connotative (representational). A person may find it easy to state the denotative meaning or dictionary definition of a word, but simultaneously have considerably more difficulty in successfully articulating its connotative meaning, due to an association (emotional or otherwise) that the word evokes (Megginson, 1996). In the theoretical framework of the meaning assigned to language discussed by Osgood, Suci, and Tannenbaum (1957), connotative meanings of specific constructs can vary depending on factors such as personal experience, age, gender, culture, language, ethnicity, religiosity, time, and setting.
In the health fields a large pool of sexuality-related terms is used by health care providers, including health educators, nurses, therapists, counselors, physicians, and other health professionals to convey meaning about sexual health, functions, relationships, behaviors, lifestyles, and consequences of sexual practices. The selection of terms by health professionals and the connotative translations of these terms by patients may not always produce optimal communication in the health care setting. Previous research supports the notion that an independent rating or evaluation can be applied to determine the connotative meanings assigned to various forms of birth control (McDermott & Gold, 1986-87) and to sexuality-related terms in general (McDermott, Drolet, & Fetro, 1989).
Under certain circumstances language may lose its communicative value and even contribute to the creation of significant communication barriers. In fact, two individuals may assign entirely different connotative or representational meanings to the same constructs due to differences in their previous experiences and sets of beliefs.
An example is the connotative or inferred meaning of the word drugs. Few people would argue against a denotative or referential meaning as "substances, other than food and water, that have a direct effect on the structure or
The selection of terms by health professionals and the connotative translations of these terms by patients may not always produce optimal communication in the health care setting.
function of an individual" (Mullen, McDermott, Gold, & Belcastro, 1996, p.458). However, the representational meaning to each person may be unique. To some individuals, drugs may be defined in terms of their positive and therapeutic effects on the body systems to combat disease, correct metabolic disorders, or restore well-being. To other persons, drugs may represent social deviance and call to mind the negative consequences of substance abuse and lawlessness. The meaning of drug clearly is not limited to the relative simplicity of the material substance itself.
Berg (1995) reminds historiographers that the connotative meanings of words can change over time. For instance, a hundred years ago the word nurse gave rise to images of "hand maidens" and "clinical subservient helpers to physicians" (Berg, 1995, p.163). While these images may not have been shed universally even today, the connotation of nurse, at least in the U.S., is much less rigid, much more enlightened, and considerably more professionalized. Similarly, since the 1950s, words like "Negro" and "crippled" have acquired negative connotations, and according to Megginson (1996), have been replaced in the English language by either more "neutral" terms (e.g., "black" and "handicapped") or by words with a "positive" polarity (e.g., African-American" and "differently-abled").
Another example of connotative interpretation is the lack of a universally accepted sexual language and the dual meaning of words that make it difficult to discuss an area that already is laden with emotion and feeling. Connotative meanings assigned to sexuality-related constructs may present significant impediments to optimal sexual health and functioning. Such impediments may prevent individuals from being open to sexuality education, from obtaining sexual counseling and therapy, or from achieving favorable outcomes from such interventions. They also may limit a person's ability to provide a reliable medical and sexual history, to feel comfortable during a physical exam, or to describe symptoms related to sexual organs or sexual functioning. It cannot necessarily be assumed that the health professional has any greater comfort with sexual language than the patient she or he is trying to serve, since the practitioner is also a product of a complex belief and value system as well as cumulative experience.
In a somewhat different context, the problem of intended meaning and actual interpretation is augmented when language is used as a "power tool" between the sexes. To illustrate this point, Roffman (1991) refers us to the baseball vernacular used as sexual metaphors in some geographic regions of North America. Most people who are baseball literate understand the denotative meanings of the baseball terms: first base, striking out, and home run. However, the connotative meanings may be quite different. Whereas a male can speak of getting to "first base" or "striking out" with his date, one similarly expects scoring a "home run" to be nothing short of genital intercourse.
To represent this point in still another way, one need only look at the scientific definition of sexually transmissible infections. These disorders and their corresponding acronym (STIs) are part of everyday language. However, what thoughts, feelings, and visceral reactions come to mind when some of these words are spoken? The STIs get labeled by health professionals as a collection of disorders, but perhaps with only casual regard for the connotative meanings they create for the patient getting screened, diagnosed, educated, or counseled. Roffman (1991) notes that such words are anti-sexual in tone and lead one to believe that the diseases are linguistically blamed on sex. Quite unlike the STIs, problems such as the common cold, influenza, or tuberculosis do not get labeled as BTIs (breath transmitted infections).
Baudhim (1973) assessed the offensiveness of selected words and found that words with sexual connotations were judged to be the most offensive. Robinson, Balkwell, and Ward (1980) reported that males and females associated different meanings for the word intercourse. Moreover, among women who had experienced sexual intercourse, the word love was associated with intercourse, but among sexually inexperienced women, the word marriage was more likely to be associated. Kutner and Brogan (1974) showed that men had a larger slang vocabulary than women to describe sexual intercourse, a finding also demonstrated by Walsh and Leonard (1974). In general, in mainstream U.S. culture, males may have a larger vocabulary to represent and describe other aspects of sexual activity than their female counterparts (Sanders & Robinson, 1979). Other investigators refute these notions (Kramer, Thorne, & Henely, 1978; Rubenstein, Watson, Drolette, & Rubenstein, 1976).
Purpose of the Study
In the past, research often has focused either on the analyses of words synonymous with male and female genitalia and the act of sexual intercourse, or else the creation, use, or impact of other slang expressions (Sanders & Robinson, 1979; Simkins & Rinck, 1982). Although investigations of connotative meanings of sexual vocabulary have been reported previously on university students in the U.S. (McDermott & Gold, 1986-87; McDermott, Drolet, & Fetro, 1989) studies of a similar nature in non-English speaking countries are more difficult to find in the literature. The purpose of this study was to examine the attributes assigned to selected constructs representing sexuality-related events, objects/people, and abstract terms by nursing students at a university in the Dominican Republic. Nurses are included in the array of health care practitioners whose work necessitates their having sensitivity to, and understanding of, complex sexuality-related matters. This fact may be even more relevant in Latin American countries such as the Dominican Republic where nurses are confronted with unique sexuality-related issues that impact the educational and therapeutic aspects of patient care, including strong, culturally-ascribed gender roles, limited sexual dialogue, and a religious tradition predominated by Roman Catholicism. All of these factors may influence sexuality-related beliefs and potentially affect exchanges and interactions between nurses and patients. Unlike in the U.S. and a few other countries, where health educators are specially prepared, credentialed, and recognized as a health occupational group, it is nurses who conduct much of the formal, as well as the informal health education that takes place in the Dominican Republic. A study of nursing students at a university in the Dominican Republic is further warranted to examine their assigned meanings to the language of sexuality so that relevant educational experiences that reflect the role of language might be incorporated into their pre-professional experience and training.
This study used the Connotative Meanings of Sexuality-related Terms Survey developed by McDermott, et al. (1989) that employs three sets of scales representing events, objects/people, and abstract terms. McDermott, et al. (1989) reported Cronbach alphas of .93, .95, and .91 respectively for the three scales. Details concerning the identification of terms and the development and validation of these scales can be found in Gold, Regin, McDermott, and Drolet (1985). The three scales included 25 sexuality-related events, 15 sexuality-related objects or people, and 9 sexuality-related abstracts terms. Fifteen pairs of bipolar adjectives were arranged at opposite ends of a seven-point scale as described in Osgood, et al. (1957). Data from Gold, et al. (1985) indicated that these bipolar adjectives were not necessarily identical for the three categories of terms. The relevant adjectival pairs are shown in both English and Spanish in Table 1. In addition, demographic data related to gender, age, ethnicity, and religion were collected. The original English version of the survey was translated into Spanish by two bilingual professors, one from the United States and the other from the Dominican Republic. A panel of bilingual health professionals in the Dominican Republic reviewed the translated version. The survey was back-translated, and then pretested in the Dominican Republic, a process known as cultural decentering that helps assure item validity (Pasick, Sabogal, Bird, D'Onofrio, Jenkins, Lee, Engelstad & Hiatt, 1996).
Surveys were distributed in classroom settings by one of the researchers to students enrolled in nursing courses at a university in Santo Domingo. Nursing students were given written and verbal instruction "to rate each sexuality-related construct according to their initial impressions" and were encouraged "not to spend too long on any one item." The bipolar scales were scored from 1 (positive) to 7 (negative). Values were summed and overall means were calculated for each term as illustrated in previously published works (Gold, et al., 1985; McDermott & Gold, 1986-87; McDermott, et al., 1989).
Comparisons between the attributes assigned to sexuality-related terms by males and females were made through a series of t-tests with an initial alpha level of .05. The Bonferroni step-down correction, as recommended by Pedhazur (1982), was applied to the alpha level to account for multiple comparisons. This correction made the criterion for statistical significance more rigorous and decreased the probability of making a type I error. With these adjustments, the new criterion values for events, physical objects/people, and abstract terms were .002, .003, and .006 respectively. The research plan was reviewed and approved by the Institutional Review Board of the primary sponsoring university.
Table 1 Bipolar Adjectives Used to Assess Connotative Meanings of Sexuality-Related Terms
|The survey of 49 sexuality-related
terms was completed by 733 nursing students. The respondents included 522 females (71.2%)
and 174 males (23.8%) with a mean age of 23.0 years. In all, 65.5 percent of the nursing
students reported themselves to be Hispanic, 21.8 percent Native (Indian), 2.9 percent
Black, and 9.8 percent "other" ethnic backgrounds. The relatively high
percentage of persons self-classifying as Native (Indian) might be due to the government's
use of Indio as one classification of skin color on citizen identification
documents. Among the students surveyed, 68.3 percent indicated that they were Roman
Catholics, 11.1 percent said that they were Protestants, and 20.6 percent reported
themselves to be of other religious denominations.
Assessments of sexuality-related events by this sample of nursing students are reported in Table 2. Of the 25 events evaluated, both males and females assigned their most positive attributes to the same constructs: sexual monogamy, pregnancy, orgasm, erection, cohabitation, and ejaculation. The events given the most negative evaluations by male and female respondents also were relatively consistent. Both groups identified rape, chlamydia, gonorrhea, and sexual abuse as the most negative events. There were statistically significant gender differences (p=.002) found in the evaluation of two terms: date rape and extramarital sex, where females' evaluations were more negative for both items. Although not statistically significant using the more rigorous alpha level derived through the Bonferroni method, the term vasectomy was evaluated as being slightly positive by female nursing students (M=3.25), but slightly negative by their male counterparts (M=4.23) where "4" was considered as the midpoint of the rating scale. Conversely, female respondents evaluated masturbation as a slightly negative event (M=4.39), whereas male respondents assessed it as being a slightly positive event (M=3.75).
Nursing students' assessments of sexuality-related objects/people are reported in Table 3. Of the 15 objects/people rated, both males and females assigned their most positive evaluation to nipples and clitoris, with females reporting penis and males reporting vagina as the third most "positive" word choices respectively. Males and females also were similar in their relatively negative evaluations of the following constructs: transsexual person, multiple sex partners, homosexual person, heterosexual person, and bisexual person. Among the 15 rated objects/people, there were no statistically significant differences in evaluation of constructs with gender as the criterion for comparison (p=.003).
Evaluations of sexuality-related abstract terms by these nursing students are reported in Table 4. Of the 9 abstract terms, the most positive assessments by male respondents were given to virginity, and birth control. Among female respondents, the most positive attributes were assigned to virginity and femininity. Abstract constructs evaluated most negatively by both male and female nursing students were prochoice, gay, and impotence. However, a statistically significant gender difference (p=.006) was found for only the term femininity. The term was rated less positively by male nursing students (M=3.41) than by their female peers (M=1.92).
Sexuality-related events (with Spanish translation)
Sexuality-related physical objects/people (with Spanish translation)
Sexuality-related abstract terms (with Spanish translation)
|Table 2. Mean Gender Differences in Evaluation of Sexuality-Related Events|
|Event||Male Index||Female Index||t||p||Sign|
*p<.002 (Bonferroni corrected) ns
|Table 3 Mean Gender Differences in Evaluation of Sexuality-Related Physical Objects/People|
|Male Index||Female Index||t||p||Sign.|
|Multiple sex partners||4.39||1.74||4.88||1.41||1.233||0.219||ns|
*p<.003 (Bonferroni corrected) ns= nonsignificant
|Table 4 Mean Gender Differences in Evaluation of Sexuality-Related Abstract Terms|
|Male Index||Female Index||t||p|
*p<.006 (Bonferroni corrected) ns=nonsignificant
In the present study, only 3 out of the 49 constructs surveyed were found to have attributes assigned significantly differently with respect to gender. In addition, when comparing the most positive and most negative evaluations given to constructs, there was far more agreement than disagreement across gender. Since a comparable study of U.S. nursing or other health professions students does not exist, the best comparison of these results is made to U.S. students in general university studies. In contrast to some U.S. studies (Kutner & Brogan, 1974; McDermott, et al, 1989; Terry, 1983; Walsh & Leonard, 1974), differences along gender lines among these respondents in the Dominican Republic clearly were less pronounced. For instance, McDermott, et al. (1989) used a similar survey with a sample of general education students at one large midwestern U.S. university and found gender differences for 9 of 25 sexuality-related events, 5 of 14 sexuality-related objects/people, and 2 of 11 sexuality-related abstract terms. The similarities found in the present study might be attributable to the homogeneity of persons selecting nursing as an occupational endeavor with respect to relevant dimensions of sexuality-related attitudes. Alternatively, the similarity of responses between male and female nursing students might be explained by a stronger cultural and religious homogeneity of values, beliefs, and experiences than what is found in a general sample of university students in a U.S. university. Perhaps the explanation is a combination of these factors.Examination of the data in Table
Strong negative evaluations associated with transsexual person, bisexual person, homosexual person, multiple sex partners, and gay would suggest a strong posture against variation in sexual behavior in this sample of student nurses.
2, where a rating of "4" represents the midpoint of the semantic differential scale, reveals the terms that evoke the strongest negative reactions by both male and female nursing students are rape, gonorrhea, and incest. The most negative term for males is rape, a somewhat surprising response considering that there was a statistically significant gender difference for the term date rape, where males responded less negatively than females. Females assigned the most negative attributes to date rape among all the constructs surveyed. The connotative difference in meaning between the constructs rape and date rape may be a subtle one, but one that could potentially evoke quite different degrees of negativity among health professionals who are presented with a patient victimized by one of these events. At the very least, these results suggest that subtle differences in representational meaning assigned to rape and date rape may require special sensitivity on the part of the health professional both in times of emergency care or during more routine history taking. Moreover, it suggests that the gender of the practitioner may influence the nature of the exchange with the patient in some subliminal manner. Galanti (1991) points out that among some Hispanics (e.g. Mexicans), even in a health care setting, the discussion of female "private parts" by a male practitioner may be considered inappropriate. Though anecdotal evidence might support her statement, its generalizability across Latin America is unknown, so any applicability to the Dominican Republic is mostly speculative. Clearly, professional education of nurses is unlikely to alter years of cultural inculcation, but it may be able to alert students to their own predisposing attitudes and beliefs around particular events, as well as those of their future patients.
In this study, sexual monogamy produced a strong positive response by males and females. Moreover, extramarital sex, while assigned negative attributes by both sexes, was evaluated significantly more negatively by female nursing students than by males. In sexual history taking, the interviewer needs to be aware of personal biases as well as the possible reluctance of patients to give full disclosure of their sexual behavior, even when it is pertinent to diagnosis and treatment. These data suggest that biases may have a gender basis in selected instances.
Strong negative evaluations associated with transsexual person, bisexual person, homosexual person, multiple sex partners, and gay would suggest a strong posture against variation in sexual behavior in this sample of student nurses. Since these student nurses undoubtedly will see patients who exhibit an array of sexual behaviors, practices, and orientations, it is important for them to confront their feelings and address possible phobic reactions prior to initiating their professional career. However, it is important to point out that the construct heterosexual person also yielded a highly negative mean score among male and female nursing students alike. Moreover, it should be noted that most of the sexuality-related terms surveyed in this study (27 of 49, 55.1%) were given a negative evaluation by the nursing students. Thus, it may be that the level of discomfort with sexuality-related topics is a more general one for this particular sample. According to Galanti (1991, p.33): "Patients may be too embarrassed to discuss certain problems, particularly those of a sexual nature. A health care provider needs excellent communication skills to be able to handle sensitive issues." The patient's reluctance is no doubt magnified when the health professional's participation in such discourse is also tentative.
This study has some notable limitations. The sampling scheme tapped only one university in the Dominican Republic and only the nursing students in attendance on the day of the survey. Therefore, it cannot be assumed to represent all universities or all nursing students in this particular country. Second, the entire universe of possible sexuality-related terms was not presented. Other constructs might elicit different degrees of positive or negative responses from nursing students in the Dominican Republic. Moreover, the set of scales used in this study was developed and validated for English speakers. Despite the back-translation approach used, the actual validity of these scales for these Spanish-speaking respondents cannot be known with certainty. Berg (1995, p.163) emphatically warns researchers not to pass judgment on the "rightness" or "wrongness" of connotations or meanings within cultures. Matsumoto (1994) reminds researchers that even if the words used in translation are the same, there is no guarantee that the constructs have identical meanings and idiomatic interpretation across languages (English and Spanish in this case) or cultures. Galanti (1991) refers to this concept as "cultural relativism," and it could have profoundly influenced the interpretation of the constructs assessed here. The language issue is one of the practical limitations of performing cross-cultural research, but does not categorically negate the value of cross-cultural comparisons (Matsumoto, 1994).
Promoting the understanding of cultural factors in the patient-provider exchange during professional preparation is essential if the twenty-first century health care environment is to be navigated successfully (Leininger, 1996). A clear understanding of the semantics of language is also a necessary component of culturally competent health education since communicative competence is a desired condition for any provider-patient transaction. Sexuality-related words and the constructs they represent to people can be powerful forces (McDermott, 1994). Depending on how a word is perceived connotatively by the sender and the receiver during a transaction in the health care setting, the word may be a channel to learning and understanding, a channel to self-acceptance, a channel to gaining new insights, or a channel to communication block. Communicative competence in provider-patient settings is increased when professionals are alerted to, and reminded of, the idiosyncratic nature of language. Leininger (1985) describes a need for what she calls ethnonursing research to reveal a more in-depth understanding of important connotative and communication issues. In patient education about sexual matters, or in other forms of health education, a more thorough examination of sexual language might be similarly constructive, especially as various aspects of health education attempt to become globalized. Similarity of responses, such as the ones identified in this study, or a more diverse set of responses, as found in other studies cited in this paper, confirm that failure to consider the connotative meanings assigned to words creates the unfortunate possibility that a potentially vital variable in education and therapeutic settings will be ignored.
Baudhim, E.S. (1973). Obscene language and evaluative response: An empirical study. Psychological Reports, 32, 399-402.
Berg, B.L. (1995). Qualitative Research Methods for the Social Sciences, 2nd edition. Boston: Allyn & Bacon.
Galanti, G.A. (1991). Caring for Patients from Different Cultures. Philadelphia: University of Pennsylvania Press.
Gold, R.S., Regin, K., McDermott, R.J., & Drolet, J.C. (December 1985). Instruments to measure the connotations of health-related terms. Tests in Microfiche, Set K, (TC 014046), Princeton, NJ: Educational Testing Service.
Kramer, C., Thorne, B., & Henley, N. (1978). Perspectives on language and communication. Signs, 3, 638-651.
Kutner, N.G., & Brogan, D. (1974). An investigation of sex-related slang vocabulary and sex-role orientation among male and female university students. Journal of Marriage and the Family, 36, 474-484.
Leininger, M. (1985). Qualitative Research Methods in Nursing. Orlando, FL: Grune & Stratton.
Leininger, M. (1996). Major directions for transcultural nursing: A journey into the 21st century. Journal of Transcultural Nursing, 7(2), 28-31.
Matsumoto, D. (1994). Cultural Influences on Research Methods and Statistics. Pacific Grove, CA: Brooks/Cole.
McDermott, R.J. (1994). The power of words: Talking about sexuality. In Drolet, J.C., & Clark, K. (eds.), The Sexuality Education Challenge. Santa Cruz, CA: ETR Associates, pp. 255-268.
McDermott, R.J., & Gold, R.S. (1986-87). Racial differences in the perception of contraception option attributes. Health Education, 17(6), 9-14.
McDermott, R.J., Drolet, J.C., & Fetro, J.V. (1989). Connotative meanings of sexuality-related terms: Implications for educators and other practitioners. Journal of Sex Education and Therapy, 15(2), 103-113.
Megginson, D. (1996). Connotations and denotations. Available from http://www.uottawa.ca/academic/arts/writcent/hypergrammar/conndeno.html. Internet accessed May 31, 1999.
Mullen, K.D., McDermott, R.J., Gold, R.S., & Belcastro, P.A. (1996). Connections for Health, 4th edition, Madison, WI: Brown & Benchmark.
Osgood, C.E., Suci, G.J., & Tannenbaum, P.H. (1957). The Measurement of Meaning. Urbana, IL: University of Chicago Press.
Pedhazur, E.J. (1982). Multiple Regression in Behavioral Research. New York: Holt, Rinehart, and Winston.
Pasick, R.J., Sabogal, F. Bird, J.A., D'Onofrio, C.N., Jenkins, C.N.H., Lee, M., Engelstad, L., & Hiatt, R.A. (1996). Problems and progress in translation of health survey questions: The Pathways Experience. Health Education Quarterly, 23(supplement), S28-S40.
Robinson, I.E., Balkwell, J.W., & Ward, D.M. (1980). Meaning and behavior: An emperical study in sociolinguistics. Social Psychology Quarterly, 43, 253-258.
Roffman, D.H. (June/July 1991). The power of language: Baseball as a sexual metaphor in American culture. SIECUS Report, 19(5).
Rubenstein, J.S., Watson, F.G., Drolette, M.E., & Rubenstein, H.S. (1976). Young adolescents' sexual interests. Adolescence, 11, 487-496.
Sanders, J.S., & Robinson, W.L. (1979). Talking and not talking about sex: Male and female vocabularies. Journal of Communication, 29(2), 22-30.
Simkins, L., & Rinck, C. (1982). Male and female sexual vocabulary in different interpersonal contexts. Journal of Sex Research, 18(2), 160-172.
Terry, R. (1983). A connotative analysis of synonyms for sexual intercourse. Male dicta, 7, 237-253.
Walsh, R.H., & Leonard, W.M. (1974). Usage of terms for sexual intercourse by men and women. Archives of Sexual Behavior, 3, 373-376.
[Reprint (PDF) Official Layout of this article]
Copyright © 1999 by IEJHE.
Copyright © 1999 by IEJHE.