Week 4 Lecture Slides on Stigma, Sane, and Insane

STIGMA, SANE, and INSANE Week 4 Prepared by Johannes Machinya  Stigma, Sane, Insane Contents Managing stigma – Understanding Stigma as a social Impact of...

STIGMA, SANE, and INSANE Week 4 Prepared by Johannes Machinya  Stigma, Sane, Insane Contents Managing stigma – Understanding Stigma as a social Impact of individual and stigma process stigma structural approaches Types of stigma and Stigma in different Definition their social contexts: manifestations HIV/AIDS, and mental illness  It often refers to an attribute that is deeply discrediting, i.e., identifies an individual as possessing undesirable characteristics, and is defined and enacted through social interaction (Goffman, 1963) Types of stigma according to Goffman Goffman identified three distinct types of stigma: 1. stigmas of the body; 2. stigmas of character; 3. Stigmas associated with social collectivities. All are socially, culturally, and historically variable What is considered stigmatising is not universal or static; it changes based on social norms, cultural values, and historical contexts. Stigmas of the body (Physical stigma) These are stigmas related to visible physical attributes or conditions that deviate from what is considered "normal" in a given society, e.g., disabilities, scars, or other physical deformities. Such stigmas often lead to the person being viewed as less capable or undesirable based solely on their appearance. Stigmas of character (Moral stigma) These refer to perceived flaws in an individual's character, personality, or behaviour. They include attributes such as being perceived as immoral or promiscuous, dishonest, dangerous or unpredictable. People with character stigmas are often viewed as morally corrupt, weak, or dangerous, which leads to their social rejection or devaluation. Stigmas associated with social collectives This type of stigma pertains to being part of a socially devalued or marginalised group based on race, ethnicity, religion, nationality, or other social categories. The stigma is not because of the individual's actions but because they are perceived as inherently inferior or problematic due to their group membership. Stigma: A social process “Stigma is typically a social process, experienced or anticipated, characterized by exclusion, rejection, blame or devaluation that results from experience or reasonable anticipation of an adverse social judgment about a person or group” (Weiss and Ramakrishna, 2004: 536)  Stigma as a social process Negative labelling: assigning of a derogatory label to an individual or group based on perceived characteristics/attributes It marks the individual or group as different, deviant, or inferior compared to the dominant social norms or values Typically involves a combination of stereotyping, prejudice, and discrimination Stigma as a social process (Negative labelling) 1. Stereotypes A set of generalised beliefs/thoughts/ideas that society shares about members of a group Stereotyping reduces the complexity of individuals to a few negative attributes, ignoring their unique characteristics and abilities Stigma as a social process (Negative labelling) 2. Prejudice Negative attitudes/feelings/emotions directed at a person or group of people based on their membership into a stereotyped group This may include feelings of fear, disgust, or contempt, e.g., a person may feel uncomfortable around someone living with HIV due to prejudice Stigma as a social process (Negative labelling) 3. Discrimination Behaviour or actions driven by prejudice that acts to differentiate or negatively impacts a certain group Discriminatory behaviorus may include avoidance, verbal abuse, or unfair treatment in social, professional, or institutional settings Stigma as a social process Social discrediting This happens when a stigmatised individual or group is regarded as less worthy, less competent, or morally questionable by others It impacts their social standing, identity, and access to resources or opportunities: Loss of social value Overshadowed social identity, e.g., someone with mental health illness may be perceived only in terms of their condition and not other attributes like skills, knowledge There is always a moral judgement associated with social discrediting, where the stigmatised person is seen as morally inferior Results in exclusion, marginalisation, or discrimination of stigmatised individual Impact of the stigma process Negative labelling can become self-fulfilling: individuals may internalise these views and begin to see themselves as unworthy or less capable This results in “felt” stigma (Scambler 2004) ❖It entails and often results an internalised sense of shame, blame and guilt, and “a frequently disruptive and sometimes disabling fear of being discriminated” (Cameron 2005) Self-stigma can also decrease self-esteem and one’s sense of self-worth, causing individuals to withdraw from social interactions or avoid seeking help Impact of the stigma process Enacted stigma: the actual experiences of discrimination or unfair treatment individuals face due to their association with a particular stigmatised attribute, condition, characteristic, or identity NB: Not only does stigma affect an individual’s sense of self, it is also considered a significant social determinant of health that contributes to morbidity, mortality and health disparities A recap: Stigma as a social process 1. Social construction of stigma: How stigma is created, maintained, and manifested in society. 2. Interactionist perspective: Stigma as arising out of social interactions. Understanding stigma in different contexts 1. HIV-related stigma ❖HIV-related stigma has unique social significance due to its complex interplay with societal attitudes, cultural beliefs, and structural inequalities. ▪ Negative attitudes are reinforced by existing social inequalities related to race, gender, and class – layered stigma, intersectional stigma (Gilbert 2016) Researchers have noted that the stigma associated with HIV is a barrier to prevention and treatment efforts Stigmatised individuals suffer discrimination, which leads to loss of employment and housing, estrangement from family and society, increased risk of physical violence and even murder  Nkosi Johnson who was refused admission as a pupil to a primary school because of his positive status  Gugu Dlamini who was murdered by members of her community a month after disclosing her HIV status on a provincial radio station Understanding stigma in different contexts – cnt’d HIV-related stigma – a reality On average, 1 in 8 PLWH report being denied health services and 1 in 9 are denied employment because of their HIV-positive status An average of 6% reported experiencing physical assault because of their HIV status (UNAIDS 2014) HIV/AIDS and Goffman’s categories of stigma Bodily stigmas Character stigmas, and Stigmas associated with social groups. NB: Gilbert – all these might apply at the same time to PLWH Dimensions of HIV-related stigma HIV-related stigma is categorised into several dimensions: Felt stigma: Refers to the internalised fear of discrimination. Enacted stigma: Refers to actual cases of discrimination experienced by individuals. In SA, there is documented evidence of enacted stigma in the form of denial of health care, job dismissals and rejection by family members, as systematically reported by Panos Dossier ( Dimensions of HIV-related stigma Herek andCapitanio(1998) added “symbolic stigmaa” and “instrumental stigma” Symbolic stigma: Associated with moral judgments and negative stereotypes about people living with HIV/AIDS (PLWHA); it is value-laden Instrumental stigma: Linked to fear of infection and the perceived risk associated with HIV – self-preservation There is also secondary/courtesy stigma: older female caregivers in rural SA had experienced substantial secondary/courtesy stigma because they were looking after family members with HIV Impact of Stigma on the Spread of HIV Deterrence from testing and treatment: It can preven individuals from getting tested due to fear of being labelled or discriminated against. Many people remain unaware of their status, increasing the risk of unknowingly transmitting the virus to others. Reduced disclosure: PLWH may opt not to disclose their status to partners, family members, or healthcare providers for fear of social ostracism and rejection. Non-disclosure undermines prevention strategies and contributes to the continued spread of the virus. ❖Barriers to treatment adherence: Stigma can discourage accessing or adhering to treatment. Some challenges in addressing HIV-related stigma Misinformation and myths: Despite public health campaigns, misconceptions about HIV transmission persist. Moral judgments and stereotypes: HIV is often associated with moral transgressions and seen as a result of "immoral" behaviour. This prevents a nuanced understanding of the disease and stigmatises those affected, making it difficult to change societal attitudes. Structural inequalities: Structural inequalities such as poverty, gender discrimination, and lack of access to healthcare intersect with HIV-related stigma, creating a complex web of discrimination that is difficult to dismantle Policy and political environment: At some point, political leadership exacerbated stigma by spreading misinformation or denying the epidemic’s severity, e.g., during the initial ART rollout. Such actions undermine public health efforts and hinder stigma reduction strategies. Internalised stigma: Many PLWH internalise negative societal attitudes, leading to self-stigma. Self-stigmatisation results in feelings of shame, guilt, and worthlessness, making it even more challenging for individuals to seek help or participate in advocacy efforts. Mental health and stigma in the medical context Stigma of mental illness in the medical profession is enhanced by perceptions of personal failure, lack of willpower, and the cultural expectations that physicians should be resilient and infallible Physicians often trained to prioritise patient care, which can cultivate a culture of neglecting personal health Colleagues who may judge or ostracise physicians experiencing mental health challenges, seeing them as impaired or incapable perpetuate stigma There is a "conspiracy of silence," where physicians avoid acknowledging their own or colleagues' mental health issues Impact of stigma on physicians and healthcare systems Barriers to seeking help: Fear of stigma and professional repercussions prevents physicians from seeking help, leading to untreated mental health issues Negative health and professional outcomes: Mental health stigma can lead to substance abuse, decreased quality of patient care, and even suicidal ideation  Strategies to address mental health stigma Education and awareness: need for training programs that emphasise recognising signs of distress, promoting wellness, and de-stigmatising mental health issues Assessment and identification: Implementing anonymous self-evaluation screening and occupational health assessments can help identify early symptoms of mental health concerns Supportive interventions: Providing confidential support and establishing physician health programs separate from disciplinary bodies can encourage physicians to seek help without fear of repercussions Organisational and cultural changes: A shift in the culture of medicine is needed to promote self-care, early intervention, and remove punitive measures associated with seeking help for mental health issues.  Both HIV/AIDS and mental health stigma require sustained efforts to dismantle harmful stereotypes, educate communities, and implement policies that promote inclusivity and compassion.