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Abstract

This entry reviews the deﬁnition, public health consequences, and moral status of stigmatization. Stigmatization involves identifying and marking an undesirable characteristic in a way that narrows a person’s social identity to that characteristic. The consequences of stigmatization include marginalization and, in some cases, dehumanization. Stigmatization often contributes to poor global health outcomes, particularly for the diagnosis and treatment of infectious diseases and mental illness. In other cases, however, such as smoking cessation, stigmatization may result in improved health outcomes. Both consequentialist and non-consequentialist frameworks address the ethics of using stigmatization as a public health tool although these theories reach different conclusions.

Introduction

The term stigma is derived from the Greek stem stig(mark or tattoo) plus ma (which denotes an action). Taken literally, a stigma is a mark. The sorts of persons and activities that have been historically stigmatized, however, make it clear that stigmatization is not a neutral act. For example, Greek amphorae from the ﬁfth century BC represent injustice as a ﬁgure covered in marks associated with criminal acts. Branding, rather than tattooing, was a common method of marking criminals in the Byzantine Empire under Constantine I and well into eighteenth century France, where the courts could order prisoners branded with the ﬂeur-de-lis.

Historically, stigmatization extended beyond criminal acts to other physically and morally undesirable traits, including contagions. Medieval lepers insufﬁciently marked by the pox of the disease had to wear a bell to warn others to keep their distance. Nineteenth-century prostitutes with cutaneous manifestations of syphilis were forced into inﬁrmaries designed speciﬁcally to segregate syphilitics from the general hospital population. So-called moral contagions – such as pregnancy out of wedlock, as represented in Hawthorne’s The Scarlet Letter, or mental illness, as depicted in Francisco Goya’s paintings of asylums – were also common targets of stigmatization. Unwed mothers and the mentally ill were often institutionalized to separate them from the broader community, at least until their condition had resolved.

While not as signiﬁcant a social force, antistigmatization campaigns have strong historical roots in the Christian and Enlightenment traditions. Drawing on New Testament concerns for prostitutes, tax collectors, Samaritans and other non-Jewish ethnic groups, and lepers, early Christian movements embraced radical equality with stigmatized populations. From a secular standpoint, William Shakespeare’s portrait of Shylock (“Hath not a Jew eyes?”), Victor Hugo’s sympathetic description of Quasimodo in The Hunchback of Notre Dame, and William Defoe’s focus on illegitimacy and determinism in Moll Flanders can all be interpreted as historical literary efforts to destigmatize certain populations.

Stigmatization And Global Health

Despite anti-stigmatization efforts, however, stigma continues to play an active and largely destructive role in global public health. Though subject to cultural variation, stigmatizing beliefs are attached to a wide range of health conditions, including schizophrenia, depression, sexually transmitted diseases, epilepsy, physical disability, leprosy, and drug, alcohol, and tobacco addiction. Epidemiologists and social scientists have found that stigmatization contributes to preventable morbidity and mortality by driving harmful behaviors underground, delaying care seeking, and decreasing life chances. Self-stigma, or the internalization of stigmatizing societal beliefs, has also been linked to lower self-esteem and non-adherence to recommended treatment, both of which exert a negative impact on the course of an illness (Corrigan et al. 2009). Increased stress associated with stigmatization also directly affects health through neurohormonal activation, leaving stigmatized populations at increased risk for cardiovascular and endocrine diseases (Marmot 2006).

Stigmatization also exacerbates health disparities both because it tends to affect groups already at risk for worse health and because marginalized groups are more likely to have stigmatizable conditions.

For example, among individuals with acquired immunodeﬁciency syndrome (AIDS), the experience of stigmatization in the form of negativity, discrimination, and social avoidance is associated with increased rates of depression, decreased clinic attendance, and greater reluctance to disclose human immunodeﬁciency virus (HIV) status to potential partners. Among HIV-positive patients, a high degree of perceived stigma is associated with poor adherence to antiretroviral therapy. Perceived stigma is highest among those HIV-positive patients – especially the poor and uneducated – who are already at risk for health disparities. Similarly, the stigmatization of tuberculosis (TB) is associated with diagnostic and treatment delay, particularly in populations already at risk for health disparities including immigrants, women, and the poor. TB-associated stigmatization has signiﬁcant economic consequences, including job loss and exclusion from market spaces, and decreased social opportunities, particularly marriage prospects for single women. In the developing world, TB is also perceived as a marker for HIV status, resulting in the transfer of HIV-associated stigma to individuals with TB.

Stigmatization similarly impedes efforts to identify and treat mental illness. For example, immigrant minority women who perceive that their community stigmatizes depression are less likely to seek treatment for depressive symptoms. Among Chinese men and women with schizophrenia, self-stigma is the single strongest predictor of treatment compliance, accounting for 60 % of the variability in clinic attendance. Similarly, stigma is a strong predictor for treatment-seeking behavior for individuals with depression and schizophrenia across multiple socioeconomic groups.

Among obese individuals, higher rates of stigma are associated with increased body dissatisfaction, decreased self-esteem, and increased exercise avoidance, and obesity negatively impacts physician attitudes toward their patients. Other conditions in which stigmatization has been found to play a role in health and healthcare seeking behaviors include: intravenous drug use, smoking-related cancers such as head and neck and lung cancer, ﬁbromyalgia, urinary incontinence, and various dermatologic conditions including psoriasis and eczema.

As this brief review suggests, much of the research on stigma’s health effects has examined single outcomes at one level of analysis – for example, associations between stigma and self-esteem among individual respondents with a particular illness (Hatzenbuehler et al. 2013). Researchers have carried out parallel track investigations for speciﬁc disease categories, including mental illness, obesity, HIV/AIDS, disability, and non-pathological but stigmatized characteristics including minority sexual orientation and race/ ethnicity. They have examined a similarly diverse range of outcomes, including social and economic factors (e.g., housing, employment, education, and social relationships), psychological/behavioral consequences, and speciﬁc measures of health. As a result of this fragmentation, much of the current research does not treat stigma as an important unifying construct with implications for the social determinants of population health. As the psychologist Mark Hatzenbuehler (2013) and colleagues argue, however, stigma should itself be considered a fundamental cause of health inequalities.

Stigma may also manifest differently depending on cultural interpretations of illness. For example, stigma regarding mental illness in China spreads quickly from the affected individual to his or her family because of etiological beliefs regarding mental illness that assign a “moral defect” to sufferers and their families (Yang et al. 2007). This contagion model results in a kind of “social death that threatens the very existence, value, and perpetuity of the family group” for individuals with mental illness and their relatives (Yang et al. 2007, p. 1529). In Japan, by contrast, mental illness is often considered to be a weakness of personality from which a person can never recover, and the majority of the general public maintains a greater social distance from affected individuals.

To better assess the role of stigma in health outcomes, further research is needed to understand how stigma is inﬂuenced by broader sociocultural factors such as education, immigration, urbanicity, income, and religion. It is also important to clarify whether stigma regarding different disease processes (e.g., schizophrenia vs. HIV/AIDS vs. physical disability) is directly comparable given wide variations in beliefs regarding the etiology and the social signiﬁcance of each disease.

Defining Stigmatization

Despite the well-acknowledged impact of stigmatization on global health, social scientists, historians, epidemiologists, and bioethicists do not uniformly agree on a deﬁnition of stigmatization. This is partly because stigma scholars have focused on different aspects of stigmatization, including the motivations for social groups to stigmatize, the health and economic effects of stigmatization, why some people or traits are stigmatized and not others, and the justiﬁcations and social norms that promote or allow stigmatization.

The most commonly used model of stigmatization comes from the sociologists Bruce Link and Jo Phalen (2001). Ultimately grounded in social, economic, and power structures, they argue that stigmatization comprises a fourfold process: distinguishing differences between persons, linking those differences to negative stereotypes, creating social distance based on the marked trait, and losing status with consequent discrimination. For example, a person who has been institutionalized for mental illness is marked because having had a mental illness is associated with the negative stereotype dangerous. As a result, he or she becomes isolated and suffers status loss and discrimination and, subsequently, fewer social and economic opportunities.

Simplifying Link and Phalen’s approach, there are two essential components of stigmatization: ﬁrst, a trait, activity, or characteristic is identiﬁed and marked as undesirable; and second, the stigmatized person suffers a characteristic set of consequences, which include narrowing his or her social identity to the marked trait. Regarding the identiﬁcation of a particular trait, this occurs when the stigmatizer judges, in accordance with community norms of desirability, that he or she would not want to have the trait himself or herself, that it should be removed from the community, and that the stigmatized person should also want to be free of it. As Link and Phalen suggest, this judgment often involves negative stereotypes but can also involve community standards of beauty or virtue or judgments about threats to community health or welfare.

The marking of a stigmatized trait can take the form of a physical disﬁguration such as branding but more commonly involves behavioral or attitudinal changes toward the stigmatized person. Common attitudes in this context include contempt and disgust and common behaviors include avoidance or evasion, shunning, and even institutionalization or incarceration. The physical, behavioral, and attitudinal changes that mark the identiﬁed trait as undesirable result in a narrowing of social identity, a characteristic consequence of stigmatization. The sociologist Erving Goffman (1963) describes this as a “spoiled identity,” and writes that stigmatization transforms an individual “from a whole and usual person to a tainted, discounted one.” Expanding on this theme, the philosopher Martha Nussbaum argues that stigmatization reduces a person’s social identity to only the marked trait, representing a “loss of uniqueness: the offender becomes a member of a degraded class” (Nussbaum 2006a). If the marked trait is the primary focus of an individual’s social interactions, this prevents him or her from being seen as a human being with a complex social identity and interests.

As the psychologist Patrick Corrigan notes, a spoiled or narrowed social identity is also perpetuated and reinforced through self-regarding attitudes. Looking beyond Link and Phalen’s model, which focuses on stigma largely as another regarding process, the stigmatize does not merely respond to a trait that is socially undesirable but demands that the stigmatized person share his or her judgment that the trait is undesirable. For example, when a person with obesity is stigmatized, the expected consequence is not just social isolation but that obese person also feels ashamed for being obese. In this way, stigmatization is closely associated with shame and self-loathing such that the stigmatized person is encouraged to hide the marked aspect of him or herself because it is disgusting. Stigmatization can result in discrimination, but not all cases of discrimination are also cases of stigmatization. It is the self-perpetuating, internally directed process that helps fully characterize stigmatization and contributes, along with externally enforced isolation, to poor health outcomes. As the legal scholar Scott Burris (2008) notes, a stigmatized person becomes “his own jailor, his own chorus of denunciation.”

To help clarify this deﬁnition of stigmatization, it is useful to contrast stigma with a related concept, quarantine. Quarantine procedures, which date at least to the fourteenth century practice of isolating ships and passengers to prevent the importation of bubonic plague, also target undesirable traits to create physical segregation. Quarantine, however, primarily removes the trait from the social sphere through external enforcement, most commonly physical barriers and external social norms and laws. In contrast, while stigmatization can be achieved through external enforcement via physical barriers such as institutionalization, it is also maintained and enforced through internal mechanisms. Stigmatization works such that the stigmatized person also ﬁnds the trait undesirable. Shame about the marked trait encourages the stigmatized person to keep himself or herself apart from the broader community as opposed to quarantine, which is entirely externally enforced.

Ethical Dimensions Of Stigmatization

Although the broad consensus among philosophers and social scientists is that stigmatization is almost always morally suspect, they have invoked several different ethical frameworks to reach this conclusion, most commonly versions of consequentialism or deontology. Consequentialist approaches can be broadly divided into two groups: act consequentialism, which focuses on the evaluation of a speciﬁc action, and rule consequentialism, which focuses on the evaluation of general rules or policies. In both cases, the key question involves whether a particular action or rule/policy has a net positive or net negative impact on well-being. Those that have a net negative result are morally impermissible.

While different versions of consequentialism deﬁne well-being differently – some focusing only on pleasure and others deﬁning it as a constellation of desirable conditions related to human ﬂourishing – they all focus on the net outcome of an act or policy as the appropriate focus of moral judgment. For an act consequentialist, we have to assess the impact of each individual act of stigmatization on the well-being of those involved (including the stigmatizer) to decide whether a given instance of stigmatization is justiﬁed. Because, however, most conversations about stigmatization are concerned with the global impact of the activity, epidemiologists and social scientists more commonly invoke rule consequentialism in considering whether we ought to allow stigmatization of a given trait or adopt policies that reduce the activity. Most rule consequentialists in the public health literature conclude that we are obligated to have policies that reduce or eliminate stigmatization because of its impact on health and the treatment and control of infectious and noninfectious stigmatized conditions.

In contrast to consequentialism, deontic approaches to the moral status of stigmatization focus on whether there is anything independently wrong with stigmatization, regardless of whether or not it has good or bad consequences for wellbeing. Like consequentialists, however, deontologists differ in their assessment of what might make an action or policy non-instrumentally wrong or wrong on its own account. Some focus on whether stigmatization violates basic human rights or human dignity and others consider whether it is unjust or unfair for society to allow stigmatization because of the distribution or disproportional impact of the activity on one particular group. For example, Nussbaum argues the impact stigmatization has on social identity – narrowing the person to merely the stigmatized trait – is dehumanizing such that “we deny both the humanity we share with the person and the person’s individuality” (Nussbaum 2006a). As such, it is always morally impermissible regardless of the net impact on well-being. Others have argued that stigmatizing actions or policies that allow or promote stigmatization are unjustiﬁed because they violate the basic human right to be treated with respect.

A third and less common approach to the moral status of stigmatization comes from virtue ethics, which focuses on the character traits a good person should develop in order to live well. These traits, in turn, inform the intentions, actions, emotions, values, attitudes, and sensibilities with which the good person approaches his or her interactions with others. On this account, because the impulses that lie behind stigmatization – fear, prejudice, discrimination, disgust, etc. – presumably do not fall as a mean between two virtues and are contrary to the reactions a good person would possess, we ought not to stigmatize. Philosophers and social scientists do not commonly invoke virtue ethics in discussing the moral status of stigmatization because the theory does not seem to capture what is wrong with stigmatization. A person should not merely avoid stigmatization because it is bad for his or her character or well-being but, more importantly, because of the impact stigmatization has on its target.

Importantly, consequentialists, deontologists, and virtue ethicists all assume that stigma is directly amenable to intervention. For example, Nussbaum writes extensively on the psychological mechanisms that drive stigmatizers and how the law and social policy might work to reorient this process. In contrast, empirical stigma researchers are often less optimistic that the forces that drive stigma can be easily averted. For example, psychiatrists Graham Thornicroft and Aliya Kassam (2008, p. 191) have argued that stigma research may not be actionable due to its focus on hypothetical rather than real situations and lack of “clear implications for how to intervene to reduce social rejection.” While acknowledging that stigmatizing societal beliefs are indeed difﬁcult to inﬂuence directly, there may be a different level at which to intervene, where appropriate. Strategies focusing on reduction of self-stigma have been found to successfully alter beliefs and enhance coping skills. Similarly, novel investigations exploring the complex interplay between poverty, illness, and stigma among HIV-positive women in sub-Saharan Africa have found that individuallevel livelihood interventions may effectively reduce stigma by directly targeting poverty (Tsai et al. 2013). Ethicists should point to these efforts in identifying mechanisms through which unjustiﬁed stigmatization could be reduced.

Although consequentialists and deontologists reach the same conclusion in most cases of stigmatization, there is signiﬁcant tension between the two over whether stigmatization is permissible in cases in which it appears to have overall positive consequences. For example, the sociologist Amitai Etzioni argues that stigmatization and shame have powerful deterrent consequences and that societies may be justiﬁed in harnessing this effect to prevent future criminal acts (Etzioni 2003). The most important public health example in the debate between consequentialist and deontologists regards social policies that stigmatize smokers to promote smoking cessation, although other examples include the stigmatization of unprotected sex as an AIDS prevention mechanism, the identiﬁcation and shaming of sex offenders through registries and specialized license plates as a community protection mechanism, and proposals to stigmatize bullying to improve child and adolescent mental health.

In the case of smoking cessation, efforts over the last 30 years to socially isolate smokers and to use internal attitudes such as shame and guilt about smoking have clearly had an impact on overall smoking rates. For example, smokers in communities where smoking is rated as less acceptable are more likely to desire to quit, and these communities have overall lower smoking rates and cigarette consumption. Changing attitudes about the social appeal of smoking has been a cornerstone of tobacco control policies. Consequently, part of the public health community’s concern over the acceptance of electronic cigarettes in places in which tobacco smokers are excluded is that it will undo the positive effects of successful stigmatization of smoking behaviors.

Some public health rule consequentialists, pointing to the net overall impact on well-being of policies that encourage smoking stigmatization, argue that such policies are morally justiﬁed. Even though smoking stigma may add to poor health outcomes among individuals who continue to smoke, the beneﬁt of reducing overall smoking rates justiﬁes this consequence. In contrast, deontologists could argue that, insofar as these policies dehumanize smokers – for example, with advertisements that portray smokers as chimpanzees or equate smoking with pedophilia as in a series of public health posters in France – they are impermissible, regardless of the public health consequences (Burris 2008). They have also argued that, because smoking is more common and more entrenched in lower socioeconomic classes, stigmatizing polices are likely to unfairly impact already disadvantaged populations (Bell et al. 2010). Thus, even if the net result is a beneﬁt to overall well-being, because the burdens are distributed unfairly, these policies are unjust and therefore impermissible.

One way to adjudicate this debate is to differentiate between policies that are frankly stigmatizing and those that aim to denormalize an activity. For example, the World Health Organization notes that denormalization aims to make tobacco use an undesirable practice by informing the public about smoking’s negative consequences on health, society, the economy, and the environment (World Health Organization 2008). Here, the proposed mechanism through which smoking is made undesirable involves education and self-realization on the part of smokers rather than external prejudice involving negative stereotypes of smokers. Described this way, the denormalization of smoking does not clearly (or always) involve dehumanization or violations of basic human dignity. Or as Burris (2008, p. 475) puts it: “Fear of smoking, like the fear of syphilis… may contribute to stigma, but it is not itself stigma, and there is no reason not to promote it if we think it will reduce smoking rates.”

The criminologist John Braithwaite similarly draws a distinction between shaming that is “reintegrative” – i.e., part of a process in which the relationship between the offender and the community is restored and the offender’s identity repaired – from shaming that becomes stigmatization (Braithwaite 1989). Like Burris, he suggests that the use of disapproval and shame is ethically acceptable so long as it does not result in a level of rejection characteristic of stigmatization, in which there is no possibility of restoring a damaged social interdependence. Although such debates ultimately turn on how we distinguish between denormalization and stigmatization, it is important to emphasize that the broad consensus among philosophers and social scientists is that most cases of stigmatization are morally impermissible.

This section concludes with a short list of more complex questions about the ethics of stigmatization, discussions of which can be found in some of the works referenced in this entry. First, what steps are societies permitted to take to reduce or eliminate stigmatization? Is stigmatization itself permitted to stop stigmatizers? Second, does it matter ethically why humans stigmatize one another? Would it be more or less justiﬁable if stigmatization were an evolutionary instinct to protect from biologic contagions, a social instinct to protect communities from destabilizing inﬂuences, or a psychological defense mechanism that serves to reassert the stigmatizer’s own strength when confronted with perceived deviancy? Third, what is the moral signiﬁcance of the impact of stigmatization on the stigmatizers? Do separate obligations exist to reduce stigmatization because it is bad for the character of the stigmatizers?

Conclusion

Stigmatization is an activity that involves identifying and marking an undesirable trait, characteristic, or activity. It is enforced through external social norms and policies and internally directed attitudes about having the marked trait including shame and disgust. Stigmatization has a substantial negative impact on public health outcomes, particularly for infectious disease and mental health, and often disproportionately affects already-vulnerable populations. Although stigmatization is widely held to be unethical, careful differentiation between stigmatization and denormalization may suggest that policies with a positive health impact such as smoking denormalization are justiﬁed.

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