Stigmatization Its Effect On Humans

Despite the fact that stigmatization has a well-known effect on public health, social scientists, historians, epidemiologists, and bioethicists do not all agree on a definition of stigmatization.

This is partially due to the fact that stigma scholars have concentrated on various aspects of stigmatization, such as the reasons for social groups to stigmatize, the health and economic consequences of stigmatization, why certain individuals or characteristics are stigmatized while others are not, and the justifications and social norms that encourage or facilitate stigmatization.

The sociologist Bruce Link and Jo Phalen created the most widely used stigmatization model (2001).

They claim that stigmatization is a four-step process that includes identifying differences between people, connecting those differences to negative stereotypes, establishing social distance based on the marked characteristic, and losing status with subsequent discrimination.

An individual who has been institutionalized for mental illness, for example, is labeled because mental illness is linked to a stereotypical stigma that is harmful. As a result, he or she becomes marginalized, experiences loss of status and inequality, and thus has less social and economic opportunities.

To summarize Link and Phalen’s approach, stigmatization consists of two parts: first, a trait, behavior, or characteristic is defined and marked as undesirable; and second, the stigmatized individual experiences a specific set of consequences, including restricting his or her social identification to the marked trait.

When it comes to the stigmatization of a specific trait, this happens when the stigmatizer decides, based on cultural standards of desirability, that he or she does not want to have the trait, that it should be excluded from the community, and that the stigmatized individual would then want to be rid of it.

This decision, as Link and Phalen point out, often includes negative perceptions, but it may also include cultural expectations of attractiveness or morality, as well as assessments of risks to community health or welfare.

A physical disfigurement, such as branding, may be used to label a stigmatized characteristic, but behavioral or attitudinal changes against the stigmatized individual are more common. Contempt and disgust are common attitudes in this sense, as are avoidance or evasion, shunning, and even institutionalization or imprisonment.

The physical, behavioral, and attitude changes that stigmatize the established trait result in a narrowing of social identity, which is a common consequence of stigmatization.

This is referred to as a “spoiled identity” by sociologist Erving Goffman (1963), who argues that stigmatization transforms a person “from a whole and ordinary person to a corrupted, discounted one.”

Stigmatization, according to philosopher Martha Nussbaum, reduces a person’s social identity to just the marked characteristic, resulting in a “loss of uniqueness: the perpetrator becomes a member of a degraded community” (Nussbaum 2006a). If a person’s social experiences are mostly focused on the marked characteristic, he or she is less likely to be seen as a human being with a diverse social identity and interests.

A spoiled or narrowed social identity is often perpetuated and compounded by self-regarding behaviors, according to psychologist Patrick Corrigan.

Beyond Connection and Phalen’s model, which focuses on stigma primarily as an other-regarding mechanism, the stigmatizer not only reacts to a socially unacceptable trait, but also demands that the stigmatized individual share his or her opinion of the trait’s undesirableness.

When a person with obesity is stigmatized, for example, the predicted outcome is not only social isolation, but also feelings of guilt about their weight.

In this way, stigmatization is related to guilt and self-loathing, causing the stigmatized individual to conceal the marked part of himself or herself because it is repulsive. Discrimination may occur as a result of stigmatization, but not all instances of discrimination are also instances of stigmatization.

It is the self-perpetuating, internally directed mechanism that helps to completely explain stigmatization and leads to poor health outcomes, alongside externally imposed isolation. A stigmatized individual, according to legal scholar Scott Burris (2008), becomes “his own jailor, his own chorus of denunciation.”

To further explain this idea of stigmatization, consider contrasting stigma with quarantine, a similar term. Quarantine techniques, which date back to the fourteenth-century tradition of isolating ships and passengers to avoid the spread of bubonic plague, often target undesirable characteristics to establish physical separation.

External compliance, most usually physical barriers and external social norms and rules, is used in quarantine to isolate the trait from the social domain.

Stigmatization, on the other hand, can be accomplished externally by physical obstacles such as institutionalization, but it is often sustained and implemented internally by internal mechanisms.

Stigmatization has the effect of making the stigmatized individual dislike the characteristic as well. Rather than quarantine, which is imposed exclusively from the outside, shame about the stigmatized trait causes the stigmatized individual to isolate himself or herself from the larger group.

While philosophers and social scientists have reached a wide consensus that stigmatization is almost always morally suspect, they have done so using a variety of ethical frameworks, the most popular of which are consequentialism or deontology.

Act consequentialism, which focuses on the evaluation of a particular behavior, and law consequentialism, which focuses on the evaluation of general laws or policies, are the two types of consequentialist approaches.

The main issue in both cases is whether a specific action, law, or policy has a net positive or negative effect on well-being. Those with a net negative outcome are morally unacceptable.

While various versions of consequentialism interpret well-being differently – some concentrating solely on happiness, while others describing it as a constellation of beneficial circumstances contributing to human flourishing – they both place the proper emphasis of moral judgment on the net result of an act or policy.

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 well-being.

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 the 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 individual-level 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 policies 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.”

Similarly, criminologist John Braithwaite distinguishes between “reintegrative” shaming, which is part of a phase in which the offender’s connection with the community is established and his or her reputation is repaired, and stigmatizing shaming (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.

While such debates ultimately revolve around how we differentiate between denormalization and stigmatization, it is important to note that most cases of stigmatization are morally impermissible, according to a broad consensus among philosophers and social scientists.