Researchers have long recognized that social stigma can be a significant burden on people's health. Various studies have concluded that people who are stigmatized because of their race or ethnicity, sexual orientation, disability, mental health status, or other factors may be more likely to fall ill and less likely to recover than non-stigmatized individuals.
But Columbia University Professor Mark Hatzenbuehler, PhD, a Robert Wood Johnson Foundation (RWJF) Health & Society Scholar, notes that the study of stigma and its effects has been conducted in silos, with researchers focused on stigma as it relates to a particular community rather than across communities. "We have good data on individual forms of stigma and how it relates to health," he says. "But researchers don't tend to look at multiple stigmatized groups simultaneously, so the health consequences of stigma at a population level can be somewhat obscured."
Hatzenbuehler and colleagues Jo Phelan, PhD, and Bruce Link, PhD, make just that case in a new paper in the American Journal of Public Health, arguing that it's time to take a broader view by examining stigma across a series of communities to find better ways to combat its health effects. They write that the accumulated research "makes a compelling case that stigma represents an added burden that affects people above and beyond any impairments or deficits they may have," and that it can affect their housing, employment status, extent and quality of education, social relationships, access to and quality of health care, and more. Link is the co-director of Columbia’s RWJF Health & Society Scholars program, and Phelan is an affiliated faculty member.
As a result, the researchers explain, stigma can deny people the resources they need to stay or get healthy, or deplete the resources they already have. In their article, they describe the ways stigma can harm people’s health by affecting:
- Resources, including access to money, knowledge, power, prestige, and beneficial social connections;
- Social isolation, driven by an individual’s fear of rejection or, in the case of those with concealed stigmas, fear of being exposed;
- Psychological and behavioral responses, “the internalization of negative societal perceptions of one’s stigmatized status or group” and behavioral/coping responses to stigma; and
- Stress, resulting from the individual’s diminished social position, or from experiencing discrimination or unfair treatment.
Hatzenbuehler and his colleagues argue for a different approach, noting that the “literature would be considerably strengthened by greater theoretical and empirical attention to stigma.” Such an approach might reveal findings across stigmatized communities that overlap, or it could identify gaps in the research that need to be filled.
What’s Old Is New
The authors point to a number of existing databases, some newly available and some older, that could be of particular value in such analysis. The National Longitudinal Study of Adolescent Health (known as Add Health), for example, began gathering data from more than 20,000 youths in 1996, and tracked those same respondents for 12 years as their health and life circumstances evolved. The size of the database, its inclusion of relatively recent data, and its longitudinal nature make it possible for researchers to identify and compare health trends among stigmatized groups over time.
The authors also observe that even databases without recent data might yield new insights, if analyzed through a stigma lens. They point to a 2000 study of social support systems for patients with heart disease, which found that interventions aimed at reducing depression were effective with White male patients but not with women or Black men. They observe that because “factors such as social isolation are set in motion by stigma, altering these factors at the individual level—as was attempted in the ... study—may not gain much traction therapeutically in the absence of stigma-reducing changes at the social-structural level.” In other words, the absence of supportive social structures for women and Black men could be at the root of the differences in their health outcomes.
Such examinations of structural forms of stigma are rare, the authors note. Indeed, Hatzenbuehler’s own recent work on the subject was among a mere handful of efforts to focus on the issue. In a 2011 study, he found that the risk of suicide attempts among lesbian, gay, and bisexual youth was 20 percent greater for those living in counties with high structural stigma—fewer schools with gay-straight alliances, and the absence of relevant anti-bullying policies, for example.
Jump-Starting the Research
Hatzenbuehler and his colleagues argue that public and private funders have an important role to play in triggering a broader examination of stigma’s health effects. “The engine producing inequality is … frequently unrecognized or misunderstood and requires multiple fields of inquiry to expose it, including interdisciplinary research from such diverse fields as anthropology, psychology, sociology, epidemiology, and biology,” they write. “This requires a concerted effort on the part of funding agencies, including the National Institutes of Health, to provide the necessary resources to ensure that such research is conducted.”
It’s not clear to Hatzenbuehler precisely where these new inquiries into the workings of stigma will lead. But he and his colleagues are convinced that the exploration will be valuable. “When you gather data together,” he says, “you see trends you’d miss if you focused on just one group …. So if we attend to stigma in a larger context, it might help us understand patterns of population health inequalities and design better interventions to reduce these inequalities.”