About the author:

Lina Brou is a research instructor and quantitative researcher in the Department of Family Medicine. She holds an MPH in epidemiology from Emory University and is currently an epidemiology Ph.D. student in the Colorado School of Public Health. Her research interests include health policy, social determinants of health, integrated behavioral health and health equity.

Stigma causes suffering. People who are already struggling with the burdens of illness and injury are worse off because of it- making them sicker and shortening their life span. It contributes to health inequities but is often left out of conversations on social determinants of health mostly because of its elusive nature and abstract definition.¹ Bruce Link & Jo Phelan developed a working definition of stigma widely used today that contains four components: “the cooccurrence of 1) labeling, 2) stereotyping, 3) separation, 4) status loss and the discrimination in the context to which power is exercised.”^2,3 As Goffman notably wrote, stigma reduces an individual “from a whole and usual person to a tainted, discounted one.”⁴

There are three types of stigma that have been studied throughout the biopsychosocial literature- intrapersonal, interpersonal and structural stigma. Intrapersonal stigma is also known as self-stigma in which negative attitudes from the public about a person’s specified characteristic is internalized and negative consequences such as low self-esteem and poor self-efficacy occur.⁵ Interpersonal stigma is the most studied and most experienced by individuals manifesting in instances such as hate crimes but also in more subtle forms. For example, a person who injects drugs may have a stigmatized experience during a healthcare encounter by a member of the care team. Structural stigma is driven by societal-level conditions such as cultural norms and institutional policies and laws that shape inequalities in power, resources, and social capital.⁶

There are numerous studies that emphasize the detrimental impacts of different types of stigma on health including healthcare access and health outcomes. Stigma has been shown to adversely affect the health of marginalized groups based on social characteristics such as race/ethnicity, socioeconomic status, sexual orientation and gender and based on an individual’s health status such as HIV status^7,8  and mental illness.^9,10 The effect of stigma based on these social or health characteristics can lead to worsening of self-stigma and psychological distress. Furthermore, social isolation and stress lead to the stigmatized not seeking or remaining in evidence-based practices, impeding their ability to maintain a job, live independently and achieve personal goals. These consequences of stigma bidirectionally impact other social determinants of health such as education, socioeconomic status, and social support. For example, persons with HIV have been shown to have higher rates of depression and anxiety compared to the general population and persons with physical disabilities have increased risk of depressive symptoms and major depressive disorders.¹¹ Conversely, those with mental illness find stigma as a barrier to recovery.

Mitigating these impacts on health can be complex. While behavioral therapy, peer support, community programming, and mass media campaigns can work to reduce the impact of intrapersonal and interpersonal stigma, structural stigma interventions usually manifest as legal, policy, and advocacy strategies and professional education. For example, to reduce stigma in the healthcare setting, institutional interventions can include “culturally-specific mental healthcare programs, clinical assessments that omit problematic or pathologizing questions about gender or sexuality and anti-stigma training for healthcare professionals.”¹¹ At a larger scale, legislation that decriminalizes homosexuality and that protects the rights of people based on their sexual preference or identity can mitigate structural stigma as well.

Stigma is pervasive as a powerful social determinant of health. While studies have found that stigma interventions at an individual, public and structural level can be effective, more research is needed to determine which best chip away at stigma’s effects. Furthermore, the relationships between other social determinants of health should be further explored as well as multimodal and multilevel interventions. Improving the inequitably distributed burden of stigma among marginalized groups is therefore essential in promoting and advancing health equity.

 

1.         Link B, Hatzenbuehler ML. Stigma as an Unrecognized Determinant of Population Health: Research and Policy Implications. J Health Polit Policy Law. 2016;41(4):653-673.

2.         Hatzenbuehler ML, Phelan JC, Link BG. Stigma as a fundamental cause of population health inequalities. Am J Public Health. 2013;103(5):813-821.

3.         Link BG, Phelan JC. Conceptualizing Stigma. Annual Review of Sociology. 2001;27(1):363-385.

4.         Goffman E. Stigma; notes on the management of spoiled identity. Englewood Cliffs, N.J.: Prentice-Hall; 1963.

5.         Corrigan PW, Rao D. On the self-stigma of mental illness: stages, disclosure, and strategies for change. Can J Psychiatry. 2012;57(8):464-469.

6.         Goldberg DS. On Stigma & Health. The Journal of Law, Medicine & Ethics. 2017;45(4):475-483.

7.         Hatzenbuehler ML, O'Cleirigh C, Mayer KH, Mimiaga MJ, Safren SA. Prospective associations between HIV-related stigma, transmission risk behaviors, and adverse mental health outcomes in men who have sex with men. Ann Behav Med. 2011;42(2):227-234.

8.         Herek GM, Capitanio JP, Widaman KF. HIV-related stigma and knowledge in the United States: prevalence and trends, 1991-1999. Am J Public Health. 2002;92(3):371-377.

9.         Corrigan PW, Shapiro JR. Measuring the impact of programs that challenge the public stigma of mental illness. Clin Psychol Rev. 2010;30(8):907-922.

10.       Link BG, Struening EL, Rahav M, Phelan JC, Nuttbrock L. On stigma and its consequences: evidence from a longitudinal study of men with dual diagnoses of mental illness and substance abuse. J Health Soc Behav. 1997;38(2):177-190.

11.       Jackson-Best F, Edwards N. Stigma and intersectionality: a systematic review of systematic reviews across HIV/AIDS, mental illness, and physical disability. BMC Public Health. 2018;18(1):919.