ArticleLiterature Review

Structural stigma: Research evidence and implications for psychological science

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Abstract

Psychological research has provided essential insights into how stigma operates to disadvantage those who are targeted by it. At the same time, stigma research has been criticized for being too focused on the perceptions of stigmatized individuals and on microlevel interactions, rather than attending to structural forms of stigma. This article describes the relatively new field of research on structural stigma, which is defined as societal-level conditions, cultural norms, and institutional policies that constrain the opportunities, resources, and well-being of the stigmatized. I review emerging evidence that structural stigma related to mental illness and sexual orientation (a) exerts direct and synergistic effects on stigma processes that have long been the focus of psychological inquiry (e.g., concealment, rejection sensitivity), (b) serves as a contextual moderator of the efficacy of psychological interventions, and (c) contributes to numerous adverse health outcomes for members of stigmatized groups—ranging from dysregulated physiological stress responses to premature mortality—indicating that structural stigma represents an underrecognized mechanism producing health inequalities. Each of these pieces of evidence suggests that structural stigma is relevant to psychology and therefore deserves the attention of psychological scientists interested in understanding and ultimately reducing the negative effects of stigma.

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... Finally, individual stigma refers to alterations in the stigmatized individuals' cognitive, emotional, or behavioral processes in response to the stigma, which comprises maladaptive coping strategies, such as concealment of identity [3,4]. So far, previous studies have indicated that structural stigma impairs the psychological well-being of SGM individuals directly [7,8] and indirectly by synergistically interacting with stigma at other levels [9][10][11][12]. ...
... Furthermore, the extent to which these mediating mechanisms operate might depend on structural stigma. Because the presence of SGM communities in a given locale differs as a function of its structural climate and restricting the legal establishment and operation of SGM organizations is itself a form of structural stigma [9,12], individuals in less stigmatizing contexts have more opportunities to participate in the community [27]. It was previously reported that sexual minority men in neighborhoods with more representations of gay men were more likely to be involved in their community [28], suggesting that community participation might be more beneficial in low-stigma countries. ...
... Nonetheless, some evidence suggests that community participation is most beneficial in more stigmatizing contexts [29,30]. Due to higher rates of interpersonal and individual stigma experienced by SGM individuals in high-stigma contexts [12], these individuals' need to participate in and potential to benefit from the community might be greater. In other words, community participation might improve mental health through increased identity disclosure, which may be augmented in high-stigma countries, since individuals in such countries conceal their identity from more people [9,10]. ...
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Article
Purpose Although discriminatory laws, policies, and public attitudes (i.e., structural stigma) are linked to adverse mental health outcomes among sexual and gender minority (SGM) populations, little attention has been paid to protective factors, such as community participation, about which inconsistencies exist whether it ameliorates or exacerbates mental health burdens. Thus, we examined the mediator roles of identity disclosure and victimization and the moderator role of structural stigma in the association of community participation with depression. Methods Data from the EU-LGBTI-II survey assessing community participation, identity disclosure, victimization, and depression among sexual minority men ( n = 62,939), women ( n = 38,976), and gender minority adults ( n = 15,845) in 28 European countries were used. Structural stigma was measured as discriminatory legislation, policies, and societal attitudes using publicly available data. Results Findings showed that community participation predicted lower and higher levels of depression through identity disclosure and victimization, respectively. For sexual minority men and women, structural stigma moderated the indirect effect through identity disclosure, with a larger effect in higher structural stigma countries. Only for sexual minority men, the indirect effect through victimization was also moderated, with a larger effect in high-stigma countries. For gender minorities, no moderation effect was found. Conclusions Community participation is differentially linked to depression through identity disclosure and victimization, and as a function of structural stigma. It can be a double-edged sword, especially for sexual minority men in high-stigma countries, who are expected to pay the price while enjoying its benefits, highlighting the targets and considerations for interventions.
... This conceptualization of structural transphobia builds on theory and scholarship on structural stigma, defined as "societal-level conditions, cultural norms, and institutional policies that constrain the opportunities, resources, and wellbeing of the stigmatized" [32]. Various forms of structural stigma -whether in the form of discriminatory laws/policies, prejudicial individual attitudes aggregated to the geographic level, or both -have been identified as key determinants of mental and physical health inequities across multiple stigmatized groups [33], including women [34], people of Color [35,36], and sexual minorities (e.g., lesbian, gay, and bisexual people) [37]. This research underscores the importance of developing structural stigma measures that encompass both societal attitudes (e.g., cultural sexism) and laws/policies [38]. ...
... Doing so afforded us considerable sample size and variability in state-level transphobia. Consistent with prior research on structural stigma among transgender and other stigmatized populations [3,26,27,29,30,33,36], we hypothesized that transgender adults living in US states with higher (vs. lower) levels of structural transphobia would report greater psychological distress and be more likely to endorse past-month and lifetime suicidal thoughts, plans, and attempts. ...
... To date, these inequities have been largely attributed to individual-level stigma processes, such as exposure to transphobia via interpersonal interactions and/or internalizations of these experiences [21,23,25]. Despite substantial evidence that structural stigma in the form of discriminatory laws/polices and prejudicial societal attitudes also shapes mental health outcomes among multiple stigmatized groups [33,34,36,38,52] -as well as increasing calls to incorporate contextual factors into suicide research [53][54][55][56] -scholars have rarely conceptualized or rigorously measured structural transphobia by accounting for both transphobic laws/policies and attitudes across US states. Nor have they comprehensively assessed structural transphobia's associations with multiple dimensions of suicidality (e.g., thoughts, plans, attempts) and/or psychological distress among a large national sample of transgender adults. ...
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Purpose: Transgender adults face increasingly discriminatory laws/policies and prejudicial attitudes in many regions of the United States (US), yet research has neither quantified state-level transphobia using indicators of both nor considered their collective association with transgender adults’ psychological wellbeing, hindering the identification of this potential social determinant of transgender mental health inequity. Methods: We therefore used factor analysis to develop a comprehensive structural transphobia measure encompassing 29 indicators of transphobic laws/policies and attitudes at the state level, which we linked to individual-level mental health data from a large national sample of 27,279 transgender adults (ages 18–100) residing in 45 US states and the District of Columbia (DC). Results: Controlling for individual- (i.e., demographics), interpersonal- (i.e., perceived discrimination), and state- (i.e., income inequality, religiosity) level covariates, transgender adults from US states with higher (vs. lower) levels of structural transphobia reported more severe past-month psychological distress and were more likely to endorse past-year and lifetime suicidal thoughts, plans, and attempts. Conclusion: Findings provide novel evidence that transphobic laws/policies and attitudes, at the state level, collectively shape a range of important mental health outcomes among transgender adults in the US. Multilevel intervention strategies, from affirming mental health treatments to provider-training interventions to supportive legislation, are needed to address structural transphobia’s multifaceted nature and negative mental health consequences.
... 1,2 The majority of HIV stigma research to date has focused on the individual level, and has demonstrated that individual people living with HIV (PLWH) who experience greater stigma have worse mental health, are less likely to be linked to care, are less adherent to antiretroviral therapy, and are less likely to achieve viral suppression. 3,4 Yet, theorists working in structural stigma 5 and intersectionality 6,7 have called on HIV researchers to shift their focus beyond the individual level and attend to social and structural conditions to better understand experiences and outcomes of HIV stigma. Greater understanding of the social-structural conditions that shape HIV stigma is critical for tailoring intervention strategies to reduce and promote resilience to HIV stigma. ...
... Hatzenbuehler's definition of structural stigma spans societal-level conditions, cultural norms, and policies that constrain the opportunities, resources, and wellbeing of stigmatized people. 5 Structural stigma research has drawn attention to place-based variability in experiences and outcomes of stigma. Evidence generally suggests that stigmatized people living in places with greater structural stigma, indicated by aggregated attitudinal data and/or policy analysis, report greater individual-level experiences of stigma and have worse health outcomes than stigmatized people living in places with less structural stigma. ...
... Evidence generally suggests that stigmatized people living in places with greater structural stigma, indicated by aggregated attitudinal data and/or policy analysis, report greater individual-level experiences of stigma and have worse health outcomes than stigmatized people living in places with less structural stigma. 5 Quantitative research on structural stigma often incorporates countries and states as the unit of analysis, and therefore much work on structural stigma to date has been conducted at macro levels (e.g., national, international). Yet there may be important variations in structural stigma at more local geographic levels, including within states. ...
Article
Objectives: To understand how place and social position shape experiences of HIV stigma among people living with HIV (PLWH) in Delaware. HIV stigma impedes the health and wellbeing of PLWH. Yet, HIV stigma is often studied through psychosocial perspectives without considering social-structural conditions. Recent theorists have hypothesized that place and social position, two key social-structural conditions, fundamentally shape PLWH's experiences of stigma. Due to residential segregation of racial/ethnic and lesbian, gay, bisexual, transgender, and queer (LGBTQ) populations, place and social position are often inextricably intertwined within the U.S. Methods: Qualitative interviews were conducted with 42 PLWH and 14 care providers in 2017. Interviews were conducted with English- and Spanish-speaking PLWH in all three counties in Delaware, including: Wilmington in New Castle County, Smyrna in Kent County, and Georgetown in Sussex County. Results: Results suggest that PLWH's experiences of HIV stigma are shaped by place and social position. Although HIV stigma is still prevalent across Delaware, participants reported that HIV stigma is more pronounced in Kent and Sussex counties and in rural areas. Latinx and Haitian PLWH are at greater risk of experiencing HIV stigma than other racial/ethnic groups, with participants identifying misinformation within Latinx and Haitian communities as a key driver of HIV stigma. HIV stigma is further compounded by medical mistrust in the Haitian community. In contrast, participants noted that LGBTQ PLWH in Sussex County are somewhat buffered from HIV stigma by the LGBTQ community, which is reported to be more knowledgeable about HIV and accepting of PLWH. Conclusions: Multi-level interventions that address social-structural conditions in addition to individual-level factors are recommended to best address HIV stigma in Delaware. Interventions should target drivers of stigma, such as lack of knowledge, and consider how place and social position uniquely shape PLWH's experiences of stigma.
... [2] Whereas my circumstances have been contributed by the surrogacy economy of the P.R.C. and PLA that violates the Geneva Conventions, the American Psychological Association's reliance on the proxies to ensure the implementations on Geneva Conventions led to the incident by the Denial-of-Service (DoS) attacks targeted on me. [3] [4] As with "no information is created" in the natural science, "no information is destroyed" holds true for the social science and the humanities. For the remedies on the PLA's cyber-based psychological attacks, I am disclosing the epistemological dualism I adopted for the gender discourse on P.R.C.'s dualism in international law during my undergraduate studies with the mental model on independent variable of the structural dictatorship, and by the exclusion of expression, the original monist a priori syntax in the semantics can be located in the doublecopy theory and the redundancy the assertion of the dictator's wills in my marriage process in the I/O networks, in my activities in America in 2019 with a general relativity mindset with I IJSER ISSN 2229-5518 IJSER © 2022 http://www.ijser.org the American SIM card. ...
... [12] [13] With the PLA and China Academy of Science's approach in ICANN and I/O that originally designed for the outer space sciences in the information pipelines, the monopolization in the TCP/IP protocols in the import / export control regime is diagnosed to be the source of structural aggressions on the proxy due to the human trafficking on me with surrogacy economy. [4] The psychological structural stigma's source by the technical analysis originated from the surrogated economy from the ICANN and explains the gross privacy breaches of the American LGBTQIA + community to the commercial domains. [14] [3] The cyber monopolization of the P.R.C. is identified to be the "might is right" mentality in materialization from the Maoist dictatorship which underlies the behaviors of most of the regime population from grassroot to the dictatorial ruler(s). ...
... [33] However, sheer power might see this differently, and the defense on aggression is a gendered one in undemocratic civil structures. [34] [4] In the latter regimes, the historic injustices are exactly reproduction that underlies the core policy interests of dictatorial rules balancing between the production & distribution of recourses. [29] The symmetry breaking of the gendered status quo is the least predictable or calculable result by the power political regimes with cyber powers and domain politics. ...
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Article
Upon Brexit & Trade War, the research took a supply-side analysis in macroeconomic paradigm for the purpose and cause of the actions. In the geopolitical competitions on crude oil resources between the allied powers & the Russian hegemony, the latter of which has effective control over P. R. China's multilateral behaviors, the external research induced that trade war, either by complete information in intelligence or an unintended result, was a supply chain attack in prohibiting the antisatellite weapon supplies in the Northern regions of mainland China in relation to Russia. Although no substantive change to international relations, the Trade War's prohibitive effect on the high frequency trading in the monetary domain of CNY was observed, which had been the source of economic bubbles in the import-export control regime with centralized banking. The paper argues that by realism in economy & military strategy, trade war was ineffective in deterring the covert operations of the People's Liberation Army by their territorial strategies and raises questions in humanitarianism in conflict situations. Moreover, with gross privacy breaches by mass surveillance in domain politics, totalitarianism with coercions, and counterfeit of drone strikes, traditional methods of threat elimination are rendered less pragmatic apart from the adversaries' cyber security breaches. With the scientific approach, I offer an ecological paradigm with historic analysis of the Chinese military's conducts in terms economics. The territorial methods of the PLA are contextualized into the ecological paradigm in regionalism & public administration. Electronic combats of the Chinese regime with the Great Firewall and Denial-of-Service attacks not only contribute to the diminishing natural freedoms of the population, but also transgress the fundamental right to health along with non-traditional nuclear threats to P.R.C. itself.
... [30] However, cross-domain semantic analysis is still a risk for psychological & psychosocial threats in military sociology & human-relation-based coercions, which underlies the reason for human trafficking & trafficking in person that accompanied me even to and in the United States of America. [25] [29] [26] As I have hedged my homosexual marriage Gestalt psychodynamics to the structural dictatorship of P.R.C. since my undergraduate studies with the discourse of "ménage à trois", sexism had been the discourse & disguise for me in the social-theatre approach under the surveillance networks. [31] [2] [11] As the human trafficking harms the adversaries inflicted on me, ...
... [34] Therefore, my behaviour online as an independent variable to the structural dictatorial human trafficking command chain became a variable to the structural stigma indicators. [26] [35] I was asked to edit an internal pitch video of the Ministry of Public Security of P.R.C. in 2015 with no mandatory confidential contract that I intended to submit to the American government in my trip for marriage in 2019, and the psychological coercions in the exogenous human trafficking surveillance network were embedded in the narratives with the technical information. Detailed information as evidence is in Appendix A of the article, along with the poison pen letter addressed to my birth mother following the USCIS letter on U/T VISA process in Appendix B. [36] As my abnormal psychological pragmatism in the online interactions faced by human trafficking and human rights abuses has suggested, my physiological presence in the mass surveillance regime is the threat to outer space security. ...
... [48] [49] [2] From my experience in the marriage process and being human trafficked, the militarization of religion by the exogenous semantic network with mandatory use of simplified Chinese is due to the interest in cryptographic network and enslaving territorial population by technical designs, which also underlies the global cyber threats & structural stigma by the increasing use of personal & commercial devices with Simplified Chinese dubbed sources from the CPC command chain. [26] The antimatter electrolysis behind the NGC 3034 multispectral data processing was achieved with the theoretical hypothesis, which is non-computable but in relation to the physical analysis on instrumentation & satellite-signal-computation paradigm. Temporary Turing completeness was achieved in the series of experiment with the conjecture of infinite irrationals in a topologically invariant globular space such as the earth in relation to time: "whenever the square root of n is irrational, 1 is irrational". ...
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The research observed, in parallel and comparatively, a surveillance state's use of communication & cyber networks with satellite applications for power political & realpolitik purposes, in contrast to the outer space security & legit scientific purpose driven cybernetics. The research adopted a psychoanalytic & psychosocial method of observation in the organizational behaviors of the surveillance state, and a theoretical physics, astrochemical, & cosmological feedback method in the contrast group of cybernetics. Military sociology and multilateral movements were adopted in the diagnostic studies & research on cybersecurity, and cross-channeling in communications were detected during the research. The paper addresses several key points of technicalities in security & privacy breach, from personal devices to ontological networks and satellite applications-notably telecommunication service providers & carriers with differentiated spectrum. The paper discusses key moral ethical risks posed in the mal-adaptations in commercial devices that can corrupt democracy in subtle ways but in a mass scale. The research adopted an analytical linguistics approach with linguistic history in unjailing from the artificial intelligence empowered pancomputationalism approach of the heterogenous dictatorial semantic network, and the astronomical & cosmological research in information theory implies that noncomputable processes are the only defense strategy for the new technology-driven pancomputationalism developments.
... Heteronormativity is communicated in schools overtly through the presence of homophobic and transphobic language, bullying behavior, gendered dress codes, and rules prohibiting "public displays of affection" (6)(7)(8)(9)(10)(11). Heteronormativity is also communicated covertly through school spaces (e.g., gendered restrooms), policies and practices (e.g., dividing sports into boys' and girls' teams), and widely shared values (e.g., beliefs that sexual orientations and gender identities are irrelevant because all students should be treated the same) (12)(13)(14). School environments thus perpetuate structural stigma, referring to the mechanism through which institutional policy and practice and larger societal norms erase, discriminate, and victimize LGBTQ+ populations (15)(16)(17). By decreasing or foreclosing social safety, which is manifest through social connection, inclusion, and protection (18), and allowing minority stress experiences to occur (19), structural stigma contributes to negative mental, physical, and academic outcomes for LGBTQ+ populations (16,(20)(21)(22)(23). ...
... Stigma scholars point to structural stigma as the fundamental cause of population health inequities (17,70,71). On the individual level, structural stigma contributes to the psychological processes of minority stress through such mechanisms as experiences of discrimination or concerns about concealment and disclosure of identity (15,22,31,72). Institutional spaces like schools, as part of their function for (re)producing heteronormative subjects, generates and sustains structural stigma that then impacts the health and wellbeing of LGBTQ+ young people. ...
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Article
Introduction Schools in the United States are hierarchical institutions that actively (re)produce the power relations of the wider social world, including those associated with heteronormativity. Structural stigma, informed by heteronormativity and perpetuated through schools, contributes to the production of academic and health disparities among youth who are lesbian, gay, bisexual, transgender, queer, or of other gender and sexual identities (LGBTQ+). We draw upon 5 years of qualitative data from a cluster randomized controlled trial conducted in New Mexico that used implementation science frameworks to promote the uptake and sustainment of evidence-informed practices (EIPs) to examine how power operates to hinder or promote the ability of school staff to change school environments, disrupt structural stigma, and increase safety and support for LGBTQ+ youth. Methods Data sources included annual individual and small group qualitative interviews with school professionals (e.g., administrators, school nurses, teachers, and other staff), several of whom took part in Implementation Resource Teams (IRTs) charged with applying the EIPs. Other data sources included bi-weekly periodic reflections with implementation coaches and technical assistance experts. Data were recorded, transcribed, and analyzed using deductive and inductive coding techniques. Results The IRTs experienced variable success in implementing EIPs. Their efforts were influenced by: ( 1 ) constraining school characteristics, including staff turnover and resource scarcity; ( 2 ) community-based opposition to change and concerns about community backlash; ( 3 ) the presence or absence of supportive school leadership; and ( 4 ) variations in school, district, and state policies affecting LGBTQ+ students and attitudes about their importance. Findings illustrate how diverse power structures operated in and across outer and inner contexts to bound, shift, amplify, and otherwise shape how new practices were received and implemented. Conclusion Findings indicate that the efforts of IRTs were often a form of resistant power that operated within and against school hierarchies to leverage epistemic, discursive, and material power toward implementation. To improve health equity, implementation scientists must attend to the multiple real and perceived power structures that shape implementation environments and influence organizational readiness and individual motivation. Implementers must also work to leverage resistant power to counter the institutional structures and social norms that perpetuate inequities, like heteronormativity and structural stigma.
... External stigma originates from outside the individual and can include episodes of discrimination experienced on an individual level (Meyer, 2003), such as decreased quality of nursing care provided to patients with OUD. Hatzenbuehler (2016) describes a form of external stigma as structural stigma in which "societal-level conditions, cultural norms, and institutional policies that constrain the opportunities, resources, and well-being of the stigmatized (p. 2)." ...
... This study identified examples of external (structural, public) and internal stigma experienced by the OUD community. Structural stigma is imbedded in rules, policies, and procedures that arbitrarily restrict the rights and opportunities of individuals (Hatzenbuehler, 2016). Structural stigma was evidenced by such things as MOUD prescribing barriers, the need to go to specialized prescribing clinics, limited access to treatment, and insurance barriers (Atkins et al., 2020;Garrett & Young, 2022). ...
Article
Introduction: Healthcare professionals, particularly nurses, have negative attitudes towards individuals with opioid use disorder (OUD) and these attitudes can contribute to suboptimal care. The aim of this study was to identify stigma, barriers and facilitators experienced by members of the OUD community when interacting with the healthcare system. Design: A qualitative exploratory design used semi-structured focus group interviews to address the study aim. Methods: Following IRB approval, purposive sampling was used to recruit participants with a history of OUD, family caregivers of individuals with OUD, and support group leaders from regional recovery groups to provide a broad perspective of stigmatizing issues and barriers to care. Focus group discussions were conducted, and video recorded using web-based conferencing software. Transcripts from the focus groups and field notes were analyzed and coded into themes. Results: Both structural and social determinants of health were identified by participants as stigmatizing and/or barriers to care. Thematic content analysis resulted in eight themes: stigmatizing language, being labeled, inequitable care, OUD as a chronic illness, insurance barriers, stigma associated with medications for OUD (MOUD), community resources, and nursing knowledge and care. Conclusion: Members of the OUD community are challenged by both internal and external stigma when seeking healthcare. Stigma negatively affects public support for allocation of resources to treat OUD. Interventions aimed at reducing stigma are critical to support effective OUD treatment and prevent barriers to OUD care. Clinical relevance: Understanding the complex relationships between stigma and structural determinants of health will allow nursing science to develop educational interventions that provide the next generation of nurses with the knowledge, skills, and attitudes needed to advance health equity for individuals with OUD.
... Consumers with a diagnosis of BPD and their carers/ families are often confronted with structural stigma when accessing health services for their mental health condition [1][2][3][4]. Structural stigma is defined as "the societal-level conditions, cultural norms, and institutional policies that constrain the opportunities, resources, and wellbeing of the stigmatized" ( [5] p.742). Stigma is a multi-level phenomenon that occurs within various interpersonal, organisational, and structural contexts causing health inequities in accessing services and supports [5], and poor health outcomes [6] for consumers with BPD [3,[7][8][9] and their carers/families [1,2,10,11]. ...
... Structural stigma is defined as "the societal-level conditions, cultural norms, and institutional policies that constrain the opportunities, resources, and wellbeing of the stigmatized" ( [5] p.742). Stigma is a multi-level phenomenon that occurs within various interpersonal, organisational, and structural contexts causing health inequities in accessing services and supports [5], and poor health outcomes [6] for consumers with BPD [3,[7][8][9] and their carers/families [1,2,10,11]. BPD is a serious mental illness associated with longstanding and persistent patterns of instability in psychosocial functioning, including problems regulating emotions, self-image, interpersonal relationships, impulsivity, and suicidality [12]. ...
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Article
Background People with Borderline Personality Disorder (BPD) and their carers/families continue to experience structural stigma when accessing health services. Structural stigma involves societal-level conditions, cultural norms, and organizational policies that inhibit the opportunities, resources, and wellbeing of people living with attributes that are the object of stigma. BPD is a serious mental illness characterized by pervasive psychosocial dysfunction including, problems regulating emotions and suicidality. This scoping review aimed to identify, map, and explore the international literature on structural stigma associated with BPD and its impact on healthcare for consumers with BPD, their carers/families, and health practitioners. Methods A comprehensive search of the literature encompassed MEDLINE, CINAHL, PsycINFO, Scopus, Cochrane Library, and JBI Evidence-Based databases (from inception to February 28th 2022). The search strategy also included grey literature searches and handsearching the references of included studies. Eligibility criteria included citations relevant to structural stigma associated with BPD and health and crisis care services. Quality appraisal of included citations were completed using the Mixed Methods Appraisal Tool 2018 version (MMAT v.18), the Joanna Briggs Institute (JBI) Checklist for Systematic Reviews and Research Syntheses Tool, and the AGREE II: advancing guideline development, reporting, and evaluation in health care tool. Thematic Analysis was used to inform data extraction, analysis, interpretation, and synthesis of the data. Results A total of 57 citations were included in the review comprising empirical peer-reviewed articles (n = 55), and reports (n = 2). Studies included quantitative, qualitative, mixed methods, and systematic review designs. Review findings identified several extant macro- and micro-level structural mechanisms, challenges, and barriers contributing to BPD-related stigma in health systems. These structural factors have a substantial impact on health service access and care for BPD. Key themes that emerged from the data comprised: structural stigma and the BPD diagnosis and BPD-related stigma surrounding health and crisis care services. Conclusion Narrative synthesis of the findings provide evidence about the impact of structural stigma on healthcare for BPD. It is anticipated that results of this review will inform future research, policy, and practice to address BPD-related stigma in health systems, as well as approaches for improving the delivery of responsive health services and care for consumers with BPD and their carers/families. Review Registration: Open Science Framework (https://osf.io/bhpg4).
... But it leaves unanswered how provider-based intervention stigma toward each medication may be also driven by sociodemographic factors, as well as the regulations resulting from such factors, or the role other social forces contribute to this stigma. To Table 1 Stigma typology and definitions (adapted from Hatzenbuehler, 2016 andPescosolido &Martin, 2015). address these issues, the present study explores how social forces driving intervention stigma toward MOUD vary among methadone, buprenorphine, and naltrexone. ...
... These policies are framed by participants as promoting structural stigma that trickles down to affect provider-based intervention stigma. This finding both aligns with existing research on the synergistic effects of structural stigma on other stigma processes (Hatzenbuehler, 2016) and indicates that stigma reduction efforts targeting only the MOUD attitudes of treatment professionals without also addressing upstream structural drivers of provider-based intervention stigma may be insufficient. Changes prompted by COVID-19 have offered an opportunity to test MOUD provision with loosened regulations for supervised methadone dosing and telemedicine for buprenorphine prescribing (Green et al., 2020;Krawczyk et al., 2020), but the effect of these changes on downstream provider-based stigma processes is unclear. ...
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Article
Despite a substantial evidence base for effectiveness, medications for opioid use disorder (MOUD) are often stigmatized. Even healthcare professionals working in substance use treatment may describe these medications as undesirable forms of medical intervention. Many argue they prefer an “abstinence-based” approach to treatment, free of pharmacotherapy. Nonetheless, between the three evidence-based U.S. treatment medications, which include methadone, buprenorphine, and naltrexone, there is evidence of variation in how stigma operates toward each intervention. Using in-depth semi-structured interviews with 59 U.S. treatment professionals based in New Mexico and Texas, this study shows the drivers of “intervention stigma,” or stigma toward the use or provision of a medical treatment or procedure, toward each type of MOUD. Participants describe a stigma hierarchy framing naltrexone as most acceptable, followed by buprenorphine, and finally methadone, which inverts the relative clinical efficacy of each medication. Pharmacological and regulatory differences, prioritization of psychosocial interventions, suspicion regarding profit motives, and the value placed on their personal experiences as former clients in treatment in tandem with professional anecdote over scientific evidence, contribute to different levels of stigma towards each of the three medications. Acknowledgement of the deleterious effects of stigma toward people who use drugs is growing, including attention to how MOUD is also subject to stigma. This study provides detailed descriptions of the multiple drivers of stigma toward different treatment medications that may serve as key leverage points for future destigmatization efforts.
... Structural causes of inequality are stable, interconnected societal forces that systematically advantage some social groups and disadvantage others (Bonilla-Silva, 2015;Carmichael & Hamilton, 1967;Crenshaw, 1989;Haslanger, 2016;Hatzenbuehler, 2016;Jones, 1997;Salter et al., 2018). Research across the social sciences has documented how structural factorswhich include societal institutions and cultural beliefscontribute to inequalities in life outcomes between racial (Hoffman et al., 2016;Lawrence & Mollborn, 2017;Pierson et al., 2020;Reece & O'Connell, 2016;Roberts & Rizzo, 2021), gender (Bian et al., 2018;Cheryan et al., 2017;Herd et al., 2019;S.-J. ...
... To promote structural thinking about well-known inequalities, the standard between-group comparison approach needs to meet additional assumptions. Specifically, reasoners must perceive that the two groups are matched on all relevant intrinsic characteristics (e.g., abilities, motivation), such that the only difference between them is their societal constraints (for related theorizing, see Hatzenbuehler, 2016;Lantz et al., 2021;Lu et al., 2020). This assumption is easily met for novel inequalities that reasoners have no prior beliefs about (e.g., gender differences in playing Green-Ball) but not for inequalities that are widely stereotyped as being intrinsically based (e.g., gender differences in playing with dolls and trucks). ...
Article
To make accurate causal inferences about social-group inequalities, people must consider structural causes. Structural causes are a distinct type of extrinsic cause—they are stable, interconnected societal forces that systematically advantage some social groups and disadvantage others. We propose a new cognitive framework to specify how people attribute inequality to structural causes. This framework is rooted in counterfactual theories of causal judgment and suggests that people will recognize structural factors as causal when they are perceived as “difference-making” for inequality above and beyond any intrinsic causes. Building on this foundation, our framework makes the following contributions. First, we propose specific types of evidence that support difference-making inferences about structural factors: within-group change (i.e., observing that disadvantaged groups’ outcomes improve under better societal conditions) and well-matched between-group comparisons (i.e., observing that advantaged group members, who have similar baseline traits to the disadvantaged group, experience more favorable societal conditions and life outcomes). Second, we consider contextual, cognitive, and motivational barriers that may complicate the availability and acceptance of this evidence. We conclude by exploring how the framework might be applied in future research examining people’s causal inferences about inequality.
... These findings are similar to those shared the women with HIV in this study who expressed fear of being identified as a woman with HIV when seeking care at the local health center which included specific areas for the provision of HIV care and antiretroviral therapy refills. These forms of structural stigmas within the health system are barriers to care and treatment requiring amelioration to reduce health inequities (Hatzenbuehler, 2016) In this current study, the use of dehumanizing language was a powerful form of labeling and discrediting of women and persons with HIV. In Rwanda, dehumanizing language was also a central component of the 1994 genocide against the Tutsis (Ndahiro, 2019). ...
... From a systems perspective, there are opportunities to redesign HIV prevention, care, and treatment services to ameliorate the structural stigmas within the health system described by some participants of this study (Hatzenbuehler, 2016). Finally, the beneficial effects of support groups were identified as key in helping Rwandan women with HIV to accept self. ...
Article
Background Stigma is an underlying cause of health inequities, and a major barrier to HIV prevention, care, and treatment. Experiences of HIV stigma have been shown to reduce engagement in care across the HIV care continuum, from testing and diagnosis to long-term retention in care and anti-retroviral therapy adherence. In Rwanda, approximately 130,000 women are living with HIV, representing a prevalence rate (3.7%) which is substantially higher than Rwandan men (2.2%). Both the national Rwanda and City of Kigali HIV and AIDS strategic plans identify stigma as a key concern for reducing the burden of HIV. Objectives The first objective of this study was to understand the sources of HIV-related stigma among women living with HIV in Rwanda. The second objective was to understand the cultural, linguistic, and contextual context of HIV-related stigma and the intersection of HIV-related stigma to the HIV care continuum (engagement in care, medication/treatment adherence) among women with HIV in Rwanda. Design This study used a cross-sectional, qualitative design. Setting and Participants. Three-three women from urban and rural settings in Rwanda were recruited from public HIV treatment and care centers to participate in this study. Method Focus groups discussions, guided by a structured interview guide, were used to collect qualitative data. Framework analysis was used to analyze the data, which was collected during July 2018. Results The participants in this study highlighted that Rwandan women with HIV experience all forms of stigma – enacted, anticipated, perceived, and internalized – associated with HIV as well as structural stigma. Further, three major themes – dehumanizing language, importance of motherhood in the context of HIV, and overcoming HIV stigma – emerged from the data. Conclusion The results of this study are among the few to give voice and perspective to the stigma experiences of Rwandan women with HIV. The women with HIV participating in this study shed light on the pervasive and culturally constructed effects of stigma that continue to exist. Further, the findings from this study highlighted the significant intersection of the role dehumanizing language experienced by Rwandan women with HIV. Additionally, the intersectional identities of being a woman with HIV and a mother and their relationship to societal and cultural norms and expectations must be considered concurrently. Finally, the beneficial effects of support groups was identified as key in helping Rwandan women with HIV to accept self.
... Racial discrimination may also precipitate depressive symptoms by motivating internalized self-negativity, diminished self-worth, and disempowerment given one's dehumanized and marginalized racial status in a white supremacist society (Brondolo et al., 2016). The literature thus suggests that for Asian Americans, COVID-19 racism represents an emergent social determinant of behavioral health, a contemporaneous form of structural stigma (Hatzenbuehler, 2016), and an ecological risk factor for negative health outcomes (Chen et al., 2020; and population-level racial health inequities (Saw et al., 2021(Saw et al., , 2022Wu et al., 2021). ...
... This is alarming given possible neurodevelopmental disruptions to executive function and self-regulation otherwise coalesced during emerging adulthood, and the potential propagation of chronic alcohol use disorder and dependence and their long-term sequelae (Daw et al., 2017;Nixon, 2013). Our results delineated an important psychological mechanism by which COVID-19 racism-arguably an evolving form of both race-based traumatic stress (Carter, 2007) and structural stigma (Hatzenbuehler, 2016) impacting Asian Americans-engenders affective disturbance and maladaptive coping responses in turn. Concerningly, the uninterrupted expansion of COVID-19 racism may portend a societal shift toward a "new normal" of anti-Asian hate and imply nontrivial psychiatric consequences for this population. ...
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The COVID-19 pandemic has incited widespread anti-Asian racism, which is linked to numerous behavioral health consequences including depressive symptoms. As racism-induced depressive symptoms are linked to coping-related alcohol use and because alcohol-related problems represent a significant public health concern in this population, we investigated whether COVID-19 racism predicted alcohol use severity through depressive symptoms and drinking to cope motives among Asian American emerging adults (N = 139; M age = 23.04; 50% women, 50% men). We conducted a serial mediation wherein COVID-19 racism predicted alcohol use severity sequentially through depressive symptoms and drinking to cope motives. COVID-19 racism directly and significantly predicted alcohol use severity. The indirect effect via depressive symptoms and drinking to cope motives was also significant, suggesting that COVID-19 racism is likely a risk factor for alcohol-related problems. Results inform intervention science and highlight the need for policy and behavioral health services to curb COVID-19 racism.
... Temporal social experiences in surveillance and especially cyber surveillance states are largely disrupted by the disrespect on direct sensual experience & reporting thereof exemplified by case law systems. The permeation of top-down propaganda deeply rooted in historic materialism in communist regimes, there is no other presumption than the presumption of realism (Biddle, 2020& Hatzenbuehler, 2016 [8,24] . The application of historic materialism in the biological sciences, treating human beings as in a historic materialist framework, can be the root cause for the communist developments in the psychosocial warfares. ...
... Temporal social experiences in surveillance and especially cyber surveillance states are largely disrupted by the disrespect on direct sensual experience & reporting thereof exemplified by case law systems. The permeation of top-down propaganda deeply rooted in historic materialism in communist regimes, there is no other presumption than the presumption of realism (Biddle, 2020& Hatzenbuehler, 2016 [8,24] . The application of historic materialism in the biological sciences, treating human beings as in a historic materialist framework, can be the root cause for the communist developments in the psychosocial warfares. ...
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Modern and contemporary politics of P. R. China contain many elements similar to neo-Nazism if not anti-communist.The derivation from Communist doctrines was a less-known debate inside the CPC party leadership soon after the declaration on the founding of People’s Republic of China -notably between Mao, Zedong and the state leadership which resulted in the criminalization of the first president Liu, Shaoqi. The researcher, as a self-identified cisgender homosexual male and Christian, observed the cultural revisionist developments of the P. R. C. regime from early childhood to date. The article enumerates some elements of the Chinese culture’s characteristics in taming and eliminating psychological and social identity formation that constitutes the regime stability in its dictatorial diplomatic rhetorics. It adopts the Christian theology and queer theology in a Gestalt recombination for the non-identity problem albeit with predominant militarization of religion approaches by the “United Front Working Group” for populist enslavement. The article hypothesizes a receptive psychosocial identity from such population in general, and the similar for Buddhist cultural origins. With the influences of designed propaganda media in media psychology, the political responses in mass psychological phenomena from the suppressed regime is considered to be a reflection on their inner senses of helplessness from the active and reactive failures of identity formation. The amplification of such phenomena is contributed by the nationalism propagandas and a gaslighting technique applied toInternational relations, which results in subjectiveStockholm syndrome in some portions of the population.Relative intersubjectivity and absolute personal identity will be discussed in the conclusions, and its implications to dictatorial politics.
... Stigma around mental illness operates at individual, interpersonal, and societal levels [6]. An appropriate design to test this hypothesis may look at changes in self-reported problems and attitudes towards mental health at the micro-(e.g., household), meso-(e.g., network, community), and macrolevel (e.g. ...
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Purpose The prevalence of mental health problems has rapidly increased over time. The extent to which this captures changes in self-reporting due to decreasing stigma is unclear. We explore this by comparing time trends in mental health and stigma-related indicators across English regions. Methods We produced annual estimates of self-reported mental disorders (SRMDs) across waves of the Health Survey for England (2009–18, n = 78,226) and three stigma-related indicators (knowledge, attitudes, and intended behaviour) across waves of the Attitudes Towards Mental Illness survey (2009–19, n = 17,287). Differences in trends were tested across nine Government Office Regions using linear models, adjusting for age, sex, ethnicity, marital status, and social class. Results In 2009, SRMDs did not vary by region (p = 0.916), whereas stigma-related indicators did (p < 0.001), with London having the highest level of stigma and the North East having lowest level of stigma. Between 2009 and 2018, the prevalence of SRMDs increased from 4.3 to 9.1%. SRMDs increased and stigma-related indicators improved at different rates across regions over time (SRMDs p = 0.024; stigma-related indicators p < 0.001). London reported the lowest increase in SRMDs (+ 0.3 percentage point per year) yet among the largest improvements in attitudes and intended behaviour across regions. Conclusions Improvements in attitudes towards mental illness did not mirror changes in self-reported mental health problems across English regions over the past decade. The findings do not support the argument that changes in public stigma, at least when defined at this regional scale, have been driving the increase in self-reported mental health indicators in recent years.
... At each of these tiers, higher levels of stigma may be related to lower PrEP use among GBMSM through multiple mechanisms affecting providers and patients [9,10]. Structural stigma-a determinant of health inequities among marginalized populations [8,11,12]-may make providers less comfortable inquiring about same-sex sexual behavior, preventing providers from identifying GBMSM patients who might benefit from PrEP [13][14][15]. In addition to shaping dialogue between providers and patients, structural stigma may further influence provider judgment about condomless sex between two males or numbers of sex partners [16,17], attitudes which are associated with unwillingness to provide PrEP [16,18]. ...
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State-level structural stigma and its consequences in healthcare settings shape access to pre-exposure prophylaxis (PrEP) for HIV prevention among gay, bisexual, and other men who have sex with men (GBMSM). Our objective was to assess the relationships between same-sex marriage laws, a measure of structural stigma at the state level, provider-patient communication about sex, and GBMSM awareness and use of PrEP. Using data from the Fenway Institute’s MSM Internet Survey collected in 2013 (N = 3296), we conducted modified Poisson regression analyses to evaluate associations between same-sex marriage legality, measures of provider-patient communication, and PrEP awareness and use. Living in a state where same-sex marriage was legal was associated with PrEP awareness (aPR 1.27; 95% CI 1.14, 1.41), as were feeling comfortable discussing with primary care providers that they have had sex with a man (aPR 1.63; 95% CI 1.46, 1.82), discussing with their primary care provider having had condomless sex with a man (aPR 1.65; 95% CI 1.49, 1.82), and discussing with their primary care provider ways to prevent sexual transmission of HIV (aPR 1.39; 95% CI 1.26, 1.54). Each of these three measures of provider-patient communication were additionally associated with PrEP awareness and use. In sum, structural stigma was associated with reduced PrEP awareness and use. Policies that reduce stigma against GBMSM may help to promote PrEP and prevent HIV transmission.
... Scholars have argued that the law produces and endorses stigma toward those who seek and provide abortion care (Abrams, 2014;Weitz & Kimport, 2015), contributing to the development of restrictive policies that instruct individuals how to view those who seek abortion care. In his overview of structural stigma, Hatzenbuehler (2016) encouraged research that utilizes "methods that are new to the stigma literature… to explore interrelationships among structural, interpersonal, and individual forms of stigma" (p. 748). ...
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Prior to and since the 2022 Dobbs decision, U.S. state laws have endorsed individuals surveilling and punishing those associated with abortion care. This practice presents an urgent need to understand the characteristics of abortion stigma, particularly the perspectives of individuals with stigmatizing beliefs. To examine the concept and characteristics of abortion stigma, we interviewed 55 individuals about whether they thought there should be consequences for getting an abortion and, if so, what the consequences should be. Adults from three states (Michigan, Kansas, and Arizona) were purposively sampled to include a range of abortion identities and levels of religious engagement. We used reflexive thematic analysis to code and interpret the data. Participants imagined consequences including financial penalties, incarceration, and forced sterilization. Three themes highlighted how abortion was described as violating the law, women's gender roles, and religious doctrine; accordingly, abortion was imagined as deserving of negative consequences, although abortion was legal in all states during data collection. We argue that these imagined consequences relied on carceral logics and interconnected sexist, racist, and classist stereotypes that reflect and reproduce abortion stigma. This study deepens the understanding of abortion stigma from the perspective of the stigmatizer, underscoring the danger of legislation grounded in stigmatizing beliefs.
... Lastly, policy and practice in China should focus on preventing childhood abuse and being left behind and improving the living conditions and mental health status of LGB young adults though policy preference and family support, especially for those living in arduous family environments. For example, state social and policy environments aimed at reducing structural stigma are needed for improving mental health outcomes among LGB populations (Hatzenbuehler, 2016(Hatzenbuehler, , 2017. ...
Article
Background Lesbian, gay, and bisexual (LGB) young adults are at increased risk of mental distress in China. To better carry out psychological intervention, it is essential to understand unique patterns of mental distress and their association with childhood abuse/neglect, including experiencing being left behind by migrating parents. Objective In a sample of Chinese LGB young adults, we examined: (1) associations between childhood abuse and left-behind status and mental distress; (2) latent profiles of mental distress; and (3) associations between childhood abuse and left-behind status and latent profiles of mental distress. Participants and setting A sample of 630 Chinese LGB young adults aged 18–30 years was recruited to complete an online survey. Methods Participants provided demographic information and completed validated measures of childhood abuse experience and mental distress. Latent profile analysis (LPA) was used to identify patterns of mental distress, and logistic regression analysis was used to examine the relationships among these variables. Results Results showed that all forms of childhood abuse and left-behind status were associated with all dimensions of adulthood mental distress. The LPA suggested a 3-group solution as optimal (no mental distress, mild mental distress, and moderate/severe mental distress). Participants who experienced any forms of childhood abuse were more likely to be members of both the mild mental distress and moderate/severe mental distress groups (all p's < 0.001). Also, participants who had left-behind status were more likely to be in the moderate/severe mental distress group (AOR = 1.61, p < .05). Conclusions Our findings highlight the need for interventions aimed at addressing childhood abuse/neglect among Chinese LGB young adults, as these experiences increase the risk for mental health issues in adulthood.
... Although minority stress is often measured at the individual level through scales of outness, internalized homophobia and perceived discrimination [5,6], researchers have also acknowledged that experiences of minority stress may differ based on the gender and sexuality norms encountered in different spaces. These norms also have a socio-legal dimension, and thus experiences of minority stress are also dependent on structural stigma, or the level of protection and/or criminalization that individuals experience from various levels of government [3,7]. Due to the substantial amount of time spent at work, work has the potential to amplify or mitigate minority stress through both adverse experiences that LGBTQ people have in the workplace as well as work's ability to provide a safe and supportive working environment [6,8]. ...
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PurposeLesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals experience high rates of adverse mental health outcomes due to the stressors they experience in families, communities, and society more broadly. Work and workplaces have the potential to influence these outcomes given their ability to amplify minority stress, and their ability to influence social and economic wellbeing in this already marginalized population. This study aims to identify how sociodemographic characteristics and characteristics of work, including degree of precarity, industry and perceived workplace support for LGBTQ people, influence self-reported mental health among LGBTQ people in two Canadian cities.Methods Self-identified LGBTQ workers ≥16 years of age (n = 531) in Sudbury and Windsor, Ontario, Canada were given an online survey between July 6 and December 2, 2018. Multivariate ordinal logistic regression was used to calculate odds ratios (OR) to evaluate differences in gender identity, age, income, industry, social precarity, work environment, and substance use among workers who self-reported very poor, poor, or neutral mental health, compared with a referent group that self-reported good or very good mental health on a five-point Likert scale about general mental health.ResultsLGBTQ workers with poor or neutral mental health had greater odds of: being cisgender women or trans compared with being cisgender men; being aged
... Inadequate or inaccurate knowledge about transmission routes (for instance, that transmission can occur via contact with saliva or skin) and fear of infection in the general population exacerbates stigma towards people living with, or groups associated with, BBVs and STIs (Smith-Palmer et al., 2020). As marginalised communities often avoid situations in which they fear being the target of discriminatory behaviour (Herek, 2002;Pachankis, 2007), the stigma experienced by people affected by BBVs and STIs may result in unequal access to treatment services (Benintendi et al., 2021;Hatzenbuehler, 2016;Paquette et al., 2018;Smith-Palmer et al., 2020;Sweeney & Vanable, 2016). Recent improvements and innovative training strategies that prioritise the involvement of marginalised clients, such as providing education in conjunction with social contact, focusing on recovery and hearing testimonies from persons with lived experience, have contributed to a reported reduction in some levels of stigmatising attitudes amongst healthcare workers (Geibel et al., 2017;Gronholm et al., 2017;Knaak & Patten, 2016;Nyblade et al., 2019;Sukhera & Chahine, 2016). ...
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Stigma in health services undermines diagnosis, treatment and successful health outcomes for all communities, but especially for those affected by blood‐borne viruses and sexually transmitted infections (STIs). This study sought to examine experiences in accessing and receiving health services, including what characteristics promoted better health, safety and well‐being for people with blood‐borne viruses or STIss. It conducted 46 in‐depth interviews with people who inject drugs, gay men and other men who have sex with men, sex workers, people in custodial settings, culturally and linguistically diverse people, Indigenous Australians and young people in one Australian urban community setting. Findings reveal that stigma persists in the provision of healthcare services, and that previous experiences of discrimination or fear of mistreatment may result in a reluctance to continue to access services. On‐going staff training and education are important to ensure healthcare environments are welcoming and inclusive. Specialised services and services that employed peers were seen as favourable. Attending different services for different health needs created particular access challenges and undermined participant ability to engage in more holistic healthcare. The fragmented structure of health services was thus seen as a barrier to accessing health services, and stronger collaboration between health services is recommended.
... Beyond the individual cognitive processes typically explored in public health HIV-stigma research, stigma occurs at multiple levels (e.g., interpersonal, community). Increasingly, research has explored structural stigma, which refers to societal norms, laws, policies, and institutions (Campbell 2021b;Hatzenbuehler 2016;Hughto, Reisner, and Pachankis 2015;Miller et al. 2018). Importantly, the processes operating at these multiple levels are interacting and cooperating in the production of HIV; "Stigma emanates from many societal and individual systems whose interconnections cannot be divorced from one another. ...
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HIV stigma negatively affects the social experiences of people living with HIV (PLWH) and remains a challenge to HIV prevention, treatment, and care. Research has overwhelmingly focused on individual cognitive measures of HIV stigma (e.g., internalized, anticipated, and experienced). However, little research explores the interactions and societal structures through which HIV stigma is produced. Data from qualitative interviews with 30 black gay and bisexual men living with HIV in the U.S. Deep South revealed an interconnected and interdependent set of processes that produce and reproduce HIV stigma. These included social interactions (silence, euphemism, and gossip), witnessed acts of marginalization, word-of-mouth transmission of HIV misinformation, and laws and policies carried out within the education and criminal justice systems. Efforts to reduce stigma that focus on individual beliefs and attitudes are critical to improving the well-being of PLWH. However, reducing HIV stigma requires intervening on the social interactions and structures through which HIV stigma is produced and reproduced.
... Patients with BPS and HFS were more susceptible to the negative attitudes of people around them concerning their condition. Collectively, these issues indicate that stigma occurs at multiple levels, ranging from intrapersonal to interpersonal, and to various structural levels (43). Most patients with craniofacial movement disorders do not feel different from unaffected people and will not deliberately conceal the disease from their friends. ...
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Background Facial appearance and expressions influence social interaction. Hemifacial spasm (HFS), blepharospasm (BPS), and blepharospasm-oromandibular dystonia (BOD) are common forms of craniofacial movement disorders. Few studies have focused on the mental burden and quality of life (QoL) in patients with craniofacial movement disorders. Therefore, this study investigated mental health and QoL in these patients. Methods This cross-sectional study included 90 patients with craniofacial movement disorders (HFS, BPS, and BOD; 30 patients per group) and 30 healthy individuals without craniofacial movement disorders (control group) recruited from October 2019 to November 2020. All participants underwent QoL and mental health evaluations for depression, anxiety, and stigma using the 36-item Short Form Health Survey (SF-36), Hamilton Anxiety Rating Scale (HAMA), Hamilton Rating Scale for Depression-24 (HAMD-24) and a questionnaire related to stigma. Results Depression was diagnosed in 37 (41.11%) patients, whereas 30 patients (33.33%) had anxiety. HAMA scores were significantly higher in the BPS and BOD groups than in the control group. Nineteen patients (21.11%) experienced stigma and SF-36 scores were lower in various dimensions in the movement disorders groups compared to healthy controls. The role-physical and social function scores were significantly lower in the movement disorders groups than in the control group all p < 0.05. The vitality scores of the BPS group and mental health scores of the BPS and BOD groups were significantly lower than those of the control group. Correlation analysis showed that the eight dimensions of SF-36 correlated with education level, disease duration, HAMD score, and HAMA score (all p < 0.05). Regression analysis demonstrated that the HAMD score correlated with general health, vitality, social function, role-emotional, and mental health (all p < 0.05). The HAMA score correlated with body pain after adjusting for education level and disease duration. Conclusion This study highlights the significant frequency of mental symptoms, including depression, anxiety, and stigma, which lower QoL in patients with craniofacial movement disorders.
... Although we did not observe significant associations between exposure to heterosexism and age, decreased coping resources and increased levels of depression in younger participants indicate the urgent need to take protective measures focused on youngest members of the GSD community. Importantly, such interventions should focus not only on individual but also socio-ecological and structural dimensions of stigma which contribute to health inequalities in the first place and decrease the effectiveness of psychological interventions aimed at reducing the impact of stigma on health (Hatzenbuehler, 2016). Tailored initiatives, such as inclusive education or mental health support for GSD youth, introduced at the right moment, help to alleviate the negative outcomes resulting from exposure to social prejudice and exclusion during this critical developmental period (Snapp et al., 2015;Phillippi et al., 2021). ...
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Lesbian, gay, bisexual, transgender, and queer populations are disproportionately affected by chronic stress associated with stigma which contributes to health adversities including depression. Negative impact of stigma on health can be alleviated by factors such as resilience. Little is known however on how exposure to stigma, protective factors and mental health change with age among gender and sexually diverse persons. Our study aimed at investigating this issue. Our sample consisted of (i) 245 sexually diverse cisgender women, (ii) 175 sexually diverse cisgender men, and (iii) 98 transgender and gender diverse persons. We collected data through a web-based survey. Linear regression models were performed to investigate the interactions of age and each group of participants for resilience, stigma exposure, and mental health indicators (depression and self-esteem). We hypothesized that resilience and mental health indicators will be positively associated with age in all distinguished groups despite the continued exposure to minority stress. The analysis yielded no significant relationships between stigma exposure and age among study participants. However, we observed significant interaction effects of distinguished groups of participants and age in case of self-esteem, depression, and resilience. Self-esteem and resilience were related positively, and depression was negatively associated with age in all study groups. Additionally, we observed that sexually diverse cisgender men demonstrated significantly increased resilience, reduced depression and higher self-esteem compared to other groups. Although the exposure to stigma did not decrease with age, resilience and self-esteem increased, suggesting that LGBTQ persons manage to thrive despite adversities.
... Structural stigma related to mental illness has been identified in the domains of legislation (e.g., restriction of rights, inadequate protection from discrimination), healthcare, the criminal justice system, and the media. Although the limited existing research is primarily descriptive, there is also preliminary evidence that levels of structural stigma in a society correspond to levels of self-stigma and perceived discrimination at the individual level and are associated with negative health outcomes [20,24]. It is likely that structural stigma related to gambling disorder similarly exists in various domains and has negative consequences for the wellbeing of affected individuals. ...
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Purpose of Review Gambling disorder is among the most stigmatized mental health problems. More research is needed to understand the mechanisms that underlie this stigma and the effects of stigma-reduction interventions. This paper reviews extant literature on the stigma of gambling disorder and highlights evidence from this research and the broader mental illness stigma literature to help advance research on the prevention and reduction of gambling-related stigma. Recent Finding The public stigma of gambling disorder includes stereotypes of affected individuals as “greedy” and “irresponsible,” beliefs that affected individuals are to blame for their problems, and desire to avoid social contact with affected individuals. Stigmatizing attitudes held by the public are often internalized by individuals with gambling disorder, which leads to problem concealment, reduced treatment-seeking, and decreased self-esteem. Women with gambling disorder, as well as those with more severe gambling problems and who perceive greater stigma by the public, are most vulnerable to self-stigma. There is evidence that certain beliefs may underlie the stigmatization of gambling disorder, including beliefs about its causes. Contact- and education-based interventions show efficacy for the reduction of mental illness-related stigma more broadly; additional research is needed to determine the efficacy of various stigma reduction strategies for gambling disorder specifically. Summary Gambling disorder is highly stigmatized relative to other mental health problems, in part because it is viewed as more likely to be caused by controllable factors. Interventions that emphasize the biopsychosocial etiology of gambling disorder may help to prevent and reduce the blame and stigmatization of affected individuals. Structural stigma within domains such as legislation, healthcare, and the gambling industry, interventions to reduce self-stigma, stigma among mental health professionals, and the influence of culture on stigma and its reduction are critical issues for future research.
... Structural stigma refers to the geographically bound societal conditions, such as laws, policies, and community attitudes, that undermine the welfare and life chances of a stigmatized population (Hatzenbuehler, 2016). Structural Content courtesy of Springer Nature, terms of use apply. ...
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Across the lifespan, most sexual minority individuals experience the closet—a typically prolonged period in which no significant others know their sexual identity. This paper positions the closet as distinct from stigma concealment given its typical duration in years and absolute removal from sources of support for an often-central identity typically during a developmentally sensitive period. The Developmental Model of the Closet proposed here delineates the vicarious learning that takes place before sexual orientation awareness to shape one’s eventual experience of the closet; the stressors that take place after one has become aware of their sexual orientation but has not yet disclosed it, which often takes place during adolescence; and potential lifespan-persistent mental health effects of the closet, as moderated by the structural, interpersonal, cultural, and temporal context of disclosure. The paper outlines the ways in which the model both draws upon and is distinct from earlier models of sexual minority identity formation and proposes several testable hypotheses and future research directions, including tests of multilevel interventions.
... Even in recent years, researchers have pointed to the lack of focus on discrimination in research [67,80]. For instance, studies describing undertreatment or reduced life expectancy of people with mental illness rarely discuss structural discrimination as an explanation, but more often provide adherence to treatment, side-effects of medication, sedentary lifestyle, diet, etc. as explanatory factors [9,91]. A higher focus on stigma and discrimination as underlying reasons for, for instance, health disparities might support the development of interventions to reduce these disparities and shift the focus from interventions targeting the patients' lifestyle to the behavior of the stigmatizers (e.g. the health personnel). ...
Article
Introduction: Stigma affects people with mental illness globally, however, it is proposed that stigma is less prevalent in wealthier countries and that people hold more positive attitudes in Northern and Western Europe. Even so, accounts from surveys in Denmark and Sweden reveal that stigma is very much prevalent. Aim: This scoping review aims to shed light on the body of literature regarding mental-health-related stigma in the Nordic Countries and identify knowledge gaps. Methods: We searched four electronic databases in December 2017 and again in June 2020. All types of empirical studies (qualitative, quantitative, and mix-methods) examining the stigma of people with mental illness were included. Results: In total, 61 studies were included. Overall, findings from the Nordic countries resemble global findings. Studies are primarily descriptive, and mostly survey studies of attitudes toward people with mental illness in the general population. Few studies focus on discrimination, and those who do, measure intended behavior in hypothetical situations rather than actual acts of discrimination in real-life situations. Studies were mostly conducted on a community or organizational level; no studies were identified on a system level. Experienced stigma and discrimination by patients, but also relatives, were a focus in one-third of the studies. Very few studies of interventions to reduce stigma and discrimination were identified. Conclusion: More studies into stigma on a system or institutional level are needed. Ways to measure acts of discrimination should be invented. Furthermore, interventions to reduce stigma and discrimination should be developed, targeting all levels of society.
... Enduring stigma toward people with OUD is an underlying cause of the United States' inadequate response to this crisis (Tsai et al., 2019). Stigma -internalized, interpersonal, and structural -is defined as stereotyping and discrimination against people with marginalized social identities (Goffman, 1986;Hatzenbuehler, 2016;Link & Phelan, 2001). The impact of that stigma leads to feelings of unworthiness in those with OUD, impedes access to treatment (Allen et al., 2019;Wakeman & Rich, 2018), and is associated with nonfatal overdose (Latkin et al., 2019). ...
Article
This study aimed to understand contributing factors of stigma toward people with opioid use disorder (OUD). We conducted a randomized factorial survey with Masters in Social Work (MSW) students (n = 70). Students received four vignettes describing a person with OUD, yielding a total of 275 vignettes for analysis. We tested whether stigma differed according to the characteristics of people with OUD. We found significantly more stigmatizing attitudes toward people with OUD who 1) inject heroin versus use oxycodone and 2) do not always take buprenorphine as prescribed versus always takes buprenorphine as prescribed. These findings indicate the need for MSW training that destigmatizes heroin use and inconsistent medication usage.
... Structural or systemic stigma is the third and probably a minor studied entity. It refers to institutional policies and practices surrounding a person that creates inequality by restricting opportunities for people suffering from mental illness (21,22). Stigma also involves perceiving patients with BD with a negative outlook and attributing stereotypes, thus further leading to interference in community participation. ...
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Introduction Dissociative symptoms have been recently related to bipolar disorder (BD) symptomatology. Moreover, the disease burden carries on a share of perceived self-stigma that amplifies the BD impairment. Internalized stigma and dissociative symptoms often seem overlapping, leading toward common outcomes, with reduced treatment seeking and poor adherence. We hypothesize a potential relationship between dissociation and self-stigma in patients suffering from BD. Materials and methods In this cross-sectional study we enrolled a total of 120 adult clinically stable BD outpatients. All participants completed the Internalized Stigma of Mental Illness (ISMI), Dissociative Experiences Scale-II (DES-II), and Manchester Short Assessment of Quality of Life (MANSA). Results Average age and age at BD (BD-I n = 66, 55%; BD-II n = 54, 45%) onset were 46.14 (±4.23), and 27.45 (±10.35) years, with mean disease duration of 18.56 (±13.08) years. Most participants were female ( n = 71; 59.2%) and 40 (33%) of them experienced lifetime abuse, with an average of 1.05 (±0.78) suicide attempts. DES scores (mean 31.8, ±21.6) correlated with ISMI total-score, with significant association with spikes in Alienation (13.1, SD±3.1) ( p < 0.001) and Stereotype (13.8, SD±3.9) ( p < 0.001). Linear regression analysis has shown a significant association between DES total score and alienation ( p < 0.001), stereotype ( p < 0.001) and MANSA total-score ( p < 0.001). Discussion For the first time, our data suggests that self-stigma is associated to dissociative symptoms, reducing overall quality of life in BD. The early identification of at-risk patients with previous lifetime abuse and high perceived stigma could lead the way for an ever more precise tailoring of treatment management.
... Third, the interviews were cross sectional, limiting exploration of future insights and skills to handle stigma and disclosure. Furthermore, the interviews were not designed to explore the critical issue of structural stigma that so many persons with HIV encounter (Hatzenbuehler, 2016). This is an area where future research is needed. ...
Article
Stigma is a fundamental cause of health inequities. Guided by the Adaptive Leadership Framework for Chronic Illness (ALFCI), this descriptive qualitative study explored the challenges of stigma and disclosure experienced by women with HIV (WWH) in the Southern United States. A convenience sample of 22 WWH aged 36 to 62 years were interviewed for this study. Analysis of participant interviews revealed that WWH face a multitude of stigma-related technical and adaptive challenges, which are consistent with the ALFCI. Once identified, technical challenges, such as recognizing the need for support, lack of trust, and fear of rejection, can be overcome by technical work, including providing assistance with HIV disclosure and building a trusted network. By identifying specific adaptive and technical challenges faced by WWH and engaging in technical and adaptive work, the WWH and the provider can reduce the fear of disclosure and the effect of stigma.
Article
We evaluated the hypothesis that neural responses to racial out-group members vary systematically based on the level of racial prejudice in the surrounding community. To do so, we conducted a spatial meta-analysis, which included a comprehensive set of studies (k=22; N=481). Specifically, we tested whether community-level racial prejudice moderated neural activation to Black (vs. White) faces in primarily White participants. Racial attitudes, obtained from Project Implicit, were aggregated to the county (k=17; N=10,743) in which each study was conducted. Multi-level kernel density analysis demonstrated that significant differences in neural activation to Black (vs. White) faces in right amygdala, dorsal anterior cingulate cortex, and dorsolateral prefrontal cortex were detected more often in communities with higher (vs. lower) levels of explicit (but not implicit) racial prejudice. These findings advance social-cognitive neuroscience by identifying aspects of macro-social contexts that may alter neural responses to out-group members.
Article
Rationale As the older adult population increases, understanding the health effects of bias against older adults is increasingly important. Whether structural forms of age bias predict worse health has received limited attention. Objective We hypothesized that communities with greater age bias would have higher mortality among residents aged 65 and older. We expected the association to be unique to age bias, rather than general bias (i.e., sexual minority and racial bias), and that the age bias-mortality association would be strongest in predominantly White and younger communities. Methods Explicit and implicit attitudes toward older adults (N = 1,001,735), sexual minorities (N = 791,966), and Black Americans (N = 2,255,808) were drawn from Project Implicit. Post-stratification relative to U.S. Census demographics was executed to improve the representativeness of county-level explicit and implicit bias estimates. County older adult mortality, estimated cross-sectionally with and longitudinally relative to bias scores, served as outcomes. Models controlled for relevant county-level covariates (e.g., median age) and included all U.S. counties (N = 3142). Results Contrary to hypotheses but consistent with prior work, explicit age bias was cross-sectionally and longitudinally associated with lower mortality, over and above covariates and generalized community bias. The explicit age bias-lower mortality association only emerged in younger counties but did not depend on county ethnic composition. Implicit age bias was unassociated with outcomes. Post-hoc analyses supported that ageist communities may be associated with better health across the lifespan. Explicit age bias predicted lower mortality in young and middle adulthood; better mental health in middle adulthood, but not exercise or self-rated health, mediated the explicit age bias-older adult mortality association. Conclusions Results highlight the uniqueness of older age relative to other stigmatized identities. Further examination of the association of community-level age bias with better health may improve longevity for all communities.
Chapter
Members of the lesbian, gay, bisexual, transgender, and queer (LGBTQ) community experience stigma from both within (e.g., self-stigma) and without (e.g., discrimination by others), and LGBTQ youth may be particularly vulnerable to its effects. LGBTQ youth of color may be at additional risk for mental distress compared to white LGBTQ adults due to their need to adapt to the stressors of stigma while simultaneously developing their identity. These interlocking stressors can have a devastating impact on the development and mental health of these youth. This chapter reviews the literature related to stigma against and within the community of LGBTQ youth of color. We will use an intersectional, ecological-developmental model to examine the interactions between the individual and social structures and review research that delineates processes that maintain stigma in intersectional spaces. A community-resilience framework will be used to review research investigating coping strategies of LGBTQ youth of color. In doing so, we review effective practices that professionals can use to mitigate and prevent stigma formation in this vulnerable community.
Article
Efforts to address mental illness stigma within the healthcare sector have not produced sufficient or sustained changes to delivery, quality, or models of care. One such reason is that many anti-stigma efforts tend to be targeted at interpersonal aspects of stigma, seeking to reduce prejudicial attitudes and improve discriminatory behaviors. Shifting attention to structural aspects of stigma may have unique potential to advance stigma reduction into the future. In this study, the authors conducted a realist case study of interventions to address structural stigma in healthcare organizations. Utilizing a realist multiple explanatory case study approach, authors reviewed data from 62 cases. After developing their initial program theory, 6 exemplar cases were analyzed for possible context-mechanism-outcome configurations. Results suggest that effective interventions required organizational readiness to disrupt existing power asymmetries, shared governance infrastructures, and an alignment of values despite historical mistrust between disparate partners. Mechanisms for change involved proactive management of resistance, disruptive innovation, co-designing processes, and embedding structural change into existing policy. Outcomes included sustainability, reduced coercion, and improved trust. Findings suggest that interventions to address structural stigma can produce sustained policy and practice change if organizations embrace power sharing and trust building while embedding change within policies and governance structures.
Article
Objective: Transgender adolescents experience adversity accessing mental healthcare, which is exacerbated by transgender-specific mental health provider shortages in the United States. Factors associated with variability in transgender-specific mental health provider availability across states – especially at the macro-social level – have yet to be identified, hindering efforts to address these shortages. To remedy this gap, we queried whether transgender-specific adolescent mental health provider availability varied by states’ transgender-specific policy climate. Method: We quantified states’ policy climate by factor-analyzing tallies of the presence/absence of 33 transgender-specific state laws/policies in six domains: parental/relationship recognition, nondiscrimination, education, healthcare, criminal justice, and identity documentation. We then tested whether states’ transgender-specific policy climate was associated with rates of transgender-specific adolescent mental health providers – identified via Psychology Today – per transgender adolescent in all 50 states and the District of Columbia. Results: Transgender-specific adolescent mental health provider availability was substantially lower in states with more restrictive laws/policies for transgender people (rate ratio = 0.65, 95% CI [0.52, 0.81], p = .00017), controlling for state-level conservatism, religiosity, and urbanicity. States’ transgender-specific policy climate was unrelated to rates of adolescent Attention-Deficit/Hyperactivity Disorder-specialty providers, Oppositional Defiant Disorder-specialty providers, and youth mental health provider shortages broadly, providing evidence for result specificity. Conclusions: Transgender adolescents appear to have access to considerably fewer transgender-specific mental health providers in states with more restrictive laws/policies for transgender people, which may compound their already high mental health burden in these contexts. Intervention and policy efforts are needed to address these shortages, particularly in states with increasingly prohibitive laws/policies targeting transgender adolescents.
Article
Collectively, current intersectional SGD research provides an essential corrective to psychology’s tradition of individualistic, single-axis, predominantly White, cisgender and heterosexist research. Because intersectionality is foundationally a social justice project however, the current research also spotlights a dire need for more attention to structural intersectionality and critical praxis in intersectional SGD research.
Article
Stigma is a socially constructed phenomenon that occurs on multiple levels and has broad implications for both individuals with mental illness and society as a whole. Theoretical orientations provide a framework for organizing and advancing research on the stigma of mental illness. This chapter describes theoretical perspectives on types of mental illness stigma, including public stigma, self-stigma, associative stigma, and structural stigma. In terms of public stigma (stereotypes, prejudice, and discrimination directed at people with mental illness), we discuss five theories: (1) modified labeling theory, (2) social-cognitive model, (3) stereotype content model, (4) implicit stigma, and (5) attribution theory. In terms of self-stigma (the internalization of public stigma), we describe the progressive model of self-stigma, stigma resistance, and two theoretical approaches to understand disclosure of mental illness: the disclosure process model and the disclosure decision-making model. While theoretical models to guide research on associative and structural stigma are limited, we review these concepts and suggest areas for future scholarship. Finally, we describe and critique several multi-level models of stigma including the Mental Illness Stigma Framework and the Health and Stigma Discrimination Framework.
Article
The association between stigma and adverse interpersonal outcomes is well established. However, the mechanisms underlying this association have yet to be comprehensively conceptualized and tested, in part because research has neglected to evaluate stigma across multiple levels. To address this gap, we examined whether stigma—measured at individual, interpersonal, and structural levels—prospectively affects loneliness and social support by thwarting fundamental belonging needs, using a longitudinal sample of 315 gay men. Results indicated that thwarted belonging needs prospectively mediated the association between interpersonal discrimination, internalized homonegativity, and concealment motivation and changes in loneliness and lack of social support. When indirect pathways were tested simultaneously, discrimination was uniquely associated with reductions in social support via thwarted belonging needs. In addition, the prospective association between objectively‐measured structural stigma (at the state and county levels) and loneliness and lack of social support was serially mediated by perceptions of structural stigma and thwarted belonging needs. To guide future work, we propose a model outlining pathways by which stigma, across multiple levels, may lead to adverse interpersonal outcomes by increasing relationally‐oriented biological, motivational, cognitive, affective, and behavioral mechanisms that affect belonging needs.
Article
Objective: This study evaluated the presence of drug-free family and friends in the social networks of patients treated in an inpatient setting for co-occurring psychiatric disorders and substance use problems. Methods: Social network interviews were conducted with inpatients at the Johns Hopkins Bayview Acute Psychiatric Unit with co-occurring psychiatric disorders and substance use problems (N = 90). Results: Participants reported about five social network members, of which four were drug-free. Most participants (> 70%) were willing to include a drug-free person in the current inpatient treatment plan to support recovery efforts (M = 1.8 network members) and identified several areas of recovery support. Conclusions: These results demonstrate that people treated in an inpatient psychiatric setting have local drug-free family or friends that they are willing to include in the treatment process. These findings support further study of methods to mobilize network members to enhance social support during and following hospitalization.
Article
The number of patients with Alzheimer’s disease (AD) and non-Alzheimer’s disease (non-AD) has drastically increased over recent decades. The amyloid cascade hypothesis attributes a vital role to amyloid-β protein (Aβ) in the pathogenesis of AD. As the main pathological hallmark of AD, amyloid plaques consist of merely the 42 and 40 amino acid variants of Aβ (Aβ 42 and Aβ 40). The cerebrospinal fluid (CSF) biomarker Aβ 42/40 has been extensively investigated and eventually integrated into important diagnostic tools to support the clinical diagnosis of AD. With the development of highly sensitive assays and technologies, blood-based Aβ 42/40, which was obtained using a minimally invasive and cost-effective method, has been proven to be abnormal in synchrony with CSF biomarker values. This paper presents the recent progress of the CSF Aβ 42/40 ratio and plasma Aβ 42/40 for AD as well as their potential clinical application as diagnostic markers or screening tools for dementia.
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Article
Due to severe global competition and performance-related academic challenges, Chinese students are compelled to learn English and become bilinguals despite their non-English majors. Consequently, these students frequently experience psychological issues, including mental health stigma. Hence, the present study aims to explore the psychological factors associated with the academic performance of Chinese-English bilinguals as an outcome of their emotional competence, flipped learning readiness, and mental health stigma. Drawing on data from 448 Chinese-English bilingual students in universities in mainland China, the results based on structural equation modeling (SEM) indicated that their academic performance, flipped learning readiness, and emotional competence are negatively influenced by their mental health stigma. Moreover, the findings also validate that both flipped learning readiness and emotional competence significantly mediate the indirect effects of mental health stigma on the academic performance of bilinguals. The study's implications offer new and compelling evidence on the primary issue of mental health stigma among Gen Z bilingual students to raise deterrence against this psychological menace through collaboration across policymakers, academics, and mental healthcare providers.
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Article
Background: Parents and children in LGBTQ+ parent families face unique stressors (i.e., minority stress), but also possess unique resources (i.e., positive identity aspects) related to their family identity. Empirical evidence and theory suggest that these minority stressors and positive identity aspects are situated on the individual, couple, and family level and may be associated with key outcomes, including parent and child health, family functioning, and school-related outcomes. A systematic evidence synthesis and a theoretical placement are currently lacking. The aims of the systematic review outlined in this protocol are thus to (1) map minority stressors and positive identity aspects according to multiple levels in the family system, and (2) to synthesize evidence on their associations with key outcomes. Methods: We will conduct a PRISMA-conform mixed-methods systematic review. Studies will be retrieved using a multi-tiered search strategy, including database searches (PsycInfo, PubMed, Scopus, Web of Science), cited literature searches, authors' publication lists, and study requests. The mixed-methods synthesis will follow a parallel-results convergent synthesis design, where quantitative results will be synthesized via meta-analysis and qualitative results via thematic synthesis. Conclusions: Our proposed systematic review may add to the theoretical understanding of LGBTQ+ parent family functioning and advance social inclusion of LGBTQ+ parent families.
Article
Stigma is widely acknowledged as an issue that causes significant harm to sex workers, forcing people to conceal their experiences. It has also been acknowledged that the stigma relating to sex work can impact researchers, who may experience stigma by association. However, researchers can also have personal experience of sex work themselves, which means they are impacted directly by stigma on several levels and must negotiate difficult decisions relating to disclosure and risk. In this paper, I recount the power that stigma has had over me, discussing the emotional challenges that this has created for me as a researcher and in my everyday life. Furthermore, I reflect on the complications of my positionality and argue that while lived experience is incredibly valuable, as researchers it is also important to be aware of the limitations of our own experiences.
Article
Objective State-level variation in how restrictive policies affect health care access for transgender populations has not been widely studied. Therefore, we assessed the association between structural stigma and four measures of individual health care access among transgender people in the United States, and the extent to which structural stigma explains state-level variability. Methods Data were drawn from the 2015–2019 Behavioral Risk Factor Surveillance System and the Human Rights Campaign’s State Equality Index. We calculated weighted proportions and conducted multilevel logistic regression of individual heterogeneity and discriminatory accuracy. Results An increase in the structural stigma score by one standard deviation was associated with lower odds of health care coverage (OR = 0.80; 95% CI: 0.66, 0.96) after adjusting for individual-level confounders. Approximately 11% of the total variance for insurance coverage was attributable to the state level; however, only 18% of state-level variability was explained by structural stigma. Adding Medicaid expansion attenuated the structural stigma-insurance association and explained 22% of state-level variation in health insurance. For the remaining outcomes (usual source of care, routine medical check-up, and cost-related barriers), we found neither meaningful associations nor considerable between-state variability. Conclusions Our findings support the importance of Medicaid expansion and transgender-inclusive antidiscrimination protections to enhance health care insurance coverage. From a measurement perspective, however, additional research is needed to develop and validate measures of transgender-specific structural stigma to guide future policy interventions.
Article
Objective Country-level structural stigma toward sexual minority individuals (i.e., discriminatory laws and policies and prejudicial attitudes) shows robust associations with sexual minority individuals’ mental health and individual-level stigma processes, such as identity concealment. Whether structural stigma is also associated with interpersonal-level stigma processes, such as victimization, is rarely studied. Whether the association between structural stigma and sexual minority individuals’ interpersonal mistreatment varies across gender, gender nonconformity, and socioeconomic status also remains to be determined. Methods In 2012, sexual minority adults ( n = 86,308) living in 28 European countries responded to questions assessing past-12-month victimization experiences (i.e., physical or sexual attack or threat of violence). Country-level structural stigma was objectively indexed as an aggregate of national laws, policies, and population attitudes negatively affecting sexual minority individuals Results Country-level structural stigma was significantly associated with victimization (adjusted odds ratios [AOR]: 1.13, 95% confidence interval [CI]: 1.04–1.22; p = .004). However, this effect varied by gender, gender nonconformity, and socioeconomic status. For both sexual minority men and women, gender nonconformity and lower socioeconomic status were associated with increased risk of victimization. The strongest association between country-level stigma and victimization was found among gender nonconforming men with lower socioeconomic status (AOR: 1.32, 95% CI: 1.14–1.52; p < .001). Conclusions A much larger proportion of sexual minorities living in higher stigma countries reports victimization than those living in lower stigma countries. At the same time, the association between country-level structural stigma and victimization is most heavily concentrated among gender nonconforming men with lower socioeconomic status.
Article
Stigma-related stress and inflated perceptions of substance use norms are positioned in the literature as theoretically distinct explanations for disproportionate substance use among sexual minorities. As research has yet to examine how these variables may interact in an intervention context, this study examined the impact of recent experiences with violence and harassment due to sexual minority status (i.e., interpersonal stigma exposure) on the effectiveness of a culturally adapted personalized normative feedback intervention for lesbian, bisexual, and queer (LBQ) women. A sub-sample of 499 moderate-to-heavy drinking LBQ women were randomized to receive personalized normative feedback (PNF) on alcohol use or control topics within a broader digital competition designed to challenge negative LBQ stereotypes. At baseline, recent interpersonal stigma exposure strengthened the relationship between perceived LBQ alcohol-related norms and participants’ own alcohol-related behaviors (i.e., consumption and consequences). At follow-up, 3 months later, recent interpersonal stigma exposure moderated the effectiveness of alcohol PNF with substantially less drinking and consequences among participants in the treatment condition reporting recent violence or harassment due to sexual minority status, relative to those reporting no such experiences. Underscoring the utility of PNF for LBQ women and potentially other heavy drinking stigmatized populations, findings suggest that a greater tendency to conform to over-estimated ingroup drinking norms may be another way in which minority status-based violence and harassment contributes to alcohol consumption in stigmatized populations.
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Background Implementation mapping is a systematic, collaborative, and contextually-attentive method for developing implementation strategies. As an exemplar, we applied this method to strategy development for Managed Problem Solving Plus (MAPS+), an adapted evidence-based intervention for HIV medication adherence and care retention that will be delivered by community health workers and tested in an upcoming trial. Methods In Step 1: Conduct Needs Assessment, we interviewed 31 stakeholders to identify determinants of MAPS+ implementation in 13 clinics serving people with HIV in Philadelphia County. In Step 2: Develop Logic Model, we used these determinants as inputs for a working logic model guided by the Consolidated Framework for Implementation Research. In Step 3: Operationalize Implementation Strategies, our team held a virtual stakeholder meeting to confirm determinants. We synthesized stakeholder feedback, then identified implementation strategies that conceptually matched to determinants using the Expert Recommendations for Implementing Change taxonomy. Next, we operationalized implementation strategies with specific examples for clinic settings. We linked strategies to behavior change theories to allow for a mechanistic understanding. We then held a second virtual stakeholder meeting to present the implementation menu for feedback and glean generalizable insights for how these strategies could be operationalized in each stakeholder's clinic. In Step 4: Protocolize Strategies, we incorporated stakeholder feedback and finalized the implementation strategy menu. Findings Implementation mapping produced a menu of 39 strategies including revise professional roles, identify and prepare champions, use warm handoffs , and change record systems . The process of implementation mapping generated key challenges for implementation strategy development: lack of implementation strategies targeting the outer setting (i.e., sociopolitical context); tension between a one-size-fits-all and individualized approach for all clinics; conceptual confusion between facilitators and strategies; and challenges in translating the implementation science lexicon for partners. Implications This case exemplar advances both MAPS+ implementation and implementation science methods by furthering our understanding of the use of implementation mapping to develop strategies that enhance uptake of evidence-based interventions. The implementation menu will inform MAPS+ deployment across Philadelphia in an upcoming hybrid trial. We will carry out Step 5: Test Strategies to test the effectiveness and implementation of MAPS+.
Article
In this Virtual Special Issue (VSI), we curate and discuss a set of 28 articles previously published in the American Journal of Community Psychology (AJCP) focused on lesbian, gay, bisexual, transgender, and queer (LGBTQ) communities. The purpose of this VSI is to bring visibility to this body of scholarship in AJCP and to reflect on how the strengths of our field have been used throughout this work in pursuit of supporting LGBTQ wellbeing. In this VSI, we first discuss articles that help to set the historical background for publications in AJCP. We then discuss papers under the broad themes of HIV/AIDS, identities within ecological context, and social activism among LGBTQ communities. We then reflect on opportunities for our field to further leverage our strengths in contributing to LGBTQ scholarship. Overall, this VSI celebrates the contributions to LGBTQ research already present in AJCP, and we hope inspires future contributions to the pages of AJCP and beyond. In this Virtual Special Issue (VSI) we curate and discuss 28 articles already published in AJCP. These articles bring visibility to LGBTQ focused scholarship in AJCP. We reflect on how the strengths of our field have and can contribute to LGBTQ scholarship. We discuss opportunities to expand our field's contributions to LGBTQ scholarship. We hope this VSI inspires application of our field's strengths to LGBTQ scholarship. In this Virtual Special Issue (VSI) we curate and discuss 28 articles already published in AJCP. These articles bring visibility to LGBTQ focused scholarship in AJCP. We reflect on how the strengths of our field have and can contribute to LGBTQ scholarship. We discuss opportunities to expand our field's contributions to LGBTQ scholarship. We hope this VSI inspires application of our field's strengths to LGBTQ scholarship.
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Introduction Stigma and discrimination among healthcare workers can hinder diagnosis and the provision of appropriate care in dementia. This study is aimed at developing, delivering and evaluating the feasibility of a group antistigma intervention to improve knowledge, attitudes and behaviours in relation to people living with dementia among community health workers (CHWs). Methods and analysis This will be a randomised controlled feasibility trial conducted with 150 CHWs from 14 primary care units (PCUs) in São Paulo, Brazil. PCUs will be randomly allocated (1:1) in two parallel groups—experimental group or control group. Participants from PCUs allocated to the experimental group will receive a 3-day group intervention involving audio-visual and printed materials as well as elements of social contact. The control group will keep their usual routine. Knowledge, attitude and intended behaviour stigma-based outcomes will be assessed at baseline and at follow-up (30 days after intervention) to both groups, with additional questions on feasibility for the experimental group at follow-up. Around 10–15 participants will take part in follow-up semistructured interviews to further explore feasibility. Quantitative analyses will follow an ‘intention to treat’ approach. Qualitative data will be analysed using content analysis. Ethics and dissemination This study was approved by the National Commission for Ethics in Research in Brazil (n. 5.510.113). Every participant will sign a consent form. Results will be disseminated through academic journals and events related to dementia. The intervention materials will be made available online.
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Technical Report
This report summarizes what is known about mental illness-related structural stigma. It begins with an overview of the concepts of stigma and structural stigma, including how they are understood by contemporary scholars. The report then outlines the different ways in which structural stigma manifests in modern institutional systems and social contexts, including: healthcare; employment and income; housing; education; criminal justice; privacy; public participation; travel and immigration; media; and reproduction and parenting. It is apparent there are few areas of social policy affecting people with mental illnesses that remain untainted by stigma. The final sections of the report synthesize the existing knowledge pertaining to addressing structural stigma. The most promising methods involve a combination of legal and policy action, advocacy, inclusive efforts, healthcare reform, education, and research.
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In this article the author reviews research evidence on the prevalence of mental disorders in lesbians, gay men, and bisexuals (LGBs) and shows, using meta-analyses, that LGBs have a higher prevalence of mental disorders than heterosexuals. The author offers a conceptual framework for understanding this excess in prevalence of disorder in terms of minority stress— explaining that stigma, prejudice, and discrimination create a hostile and stressful social environment that causes mental health problems. The model describes stress processes, including the experience of prejudice events, expectations of rejection, hiding and concealing, internalized homophobia, and ameliorative coping processes. This conceptual framework is the basis for the review of research evidence, suggestions for future research directions, and exploration of public policy implications.
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Substantial country-level variation exists in prejudiced attitudes towards male homosexuality and in the extent to which countries promote the unequal treatment of MSM through discriminatory laws. The impact and underlying mechanisms of country-level stigma on odds of diagnosed HIV, sexual opportunities, and experience of HIV-prevention services, needs and behaviours have rarely been examined, however. Data come from the European MSM Internet Survey (EMIS), which was administered between June and August 2010 across 38 European countries (N = 174 209). Country-level stigma was assessed using a combination of national laws and policies affecting sexual minorities and a measure of attitudes held by the citizens of each country. We also assessed concealment, HIV status, number of past 12-month male sex partners, and eight HIV-preventive services, knowledge, and behavioural outcomes. MSM living in countries with higher levels of stigma had reduced odds of diagnosed HIV and fewer partners but higher odds of sexual risk behaviour, unmet prevention needs, not using testing services, and not discussing their sexuality in testing services. Sexual orientation concealment mediated associations between country-level stigma and these outcomes. Country-level stigma may have historically limited HIV transmission opportunities among MSM, but by restricting MSM's public visibility, it also reduces MSM's ability to access HIV-preventive services, knowledge and precautionary behaviours. These findings suggest that MSM in European countries with high levels of stigma are vulnerable to HIV infection. Although they have less opportunity to identify and contact other MSM, this might change with emerging technologies.
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Racial disparities in health are well-documented and represent a significant public health concern in the US. Racism-related factors contribute to poorer health and higher mortality rates among Blacks compared to other racial groups. However, methods to measure racism and monitor its associations with health at the population-level have remained elusive. In this study, we investigated the utility of a previously developed Internet search-based proxy of area racism as a predictor of Black mortality rates. Area racism was the proportion of Google searches containing the "N-word" in 196 designated market areas (DMAs). Negative binomial regression models were specified taking into account individual age, sex, year of death, and Census region and adjusted to the 2000 US standard population to examine the association between area racism and Black mortality rates, which were derived from death certificates and mid-year population counts collated by the National Center for Health Statistics (2004-2009). DMAs characterized by a one standard deviation greater level of area racism were associated with an 8.2% increase in the all-cause Black mortality rate, equivalent to over 30,000 deaths annually. The magnitude of this effect was attenuated to 5.7% after adjustment for DMA-level demographic and Black socioeconomic covariates. A model controlling for the White mortality rate was used to further adjust for unmeasured confounders that influence mortality overall in a geographic area, and to examine Black-White disparities in the mortality rate. Area racism remained significantly associated with the all-cause Black mortality rate (mortality rate ratio = 1.036; 95% confidence interval = 1.015, 1.057; p = 0.001). Models further examining cause-specific Black mortality rates revealed significant associations with heart disease, cancer, and stroke. These findings are congruent with studies documenting the deleterious impact of racism on health among Blacks. Our study contributes to evidence that racism shapes patterns in mortality and generates racial disparities in health.
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Objectives: We sought to understand how local immigration enforcement policies affect the utilization of health services among immigrant Hispanics/Latinos in North Carolina. Methods: In 2012, we analyzed vital records data to determine whether local implementation of section 287(g) of the Immigration and Nationality Act and the Secure Communities program, which authorizes local law enforcement agencies to enforce federal immigration laws, affected the prenatal care utilization of Hispanics/Latinas. We also conducted 6 focus groups and 17 interviews with Hispanic/Latino persons across North Carolina to explore the impact of immigration policies on their utilization of health services. Results: We found no significant differences in utilization of prenatal care before and after implementation of section 287(g), but we did find that, in individual-level analysis, Hispanic/Latina mothers sought prenatal care later and had inadequate care when compared with non-Hispanic/Latina mothers. Participants reported profound mistrust of health services, avoiding health services, and sacrificing their health and the health of their family members. Conclusions: Fear of immigration enforcement policies is generalized across counties. Interventions are needed to increase immigrant Hispanics/Latinos' understanding of their rights and eligibility to utilize health services. Policy-level initiatives are also needed (e.g., driver's licenses) to help undocumented persons access and utilize these services.
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Examines why stereotyping, prejudice, and discrimination are enduring phenomena. Social psychological research, reviewed here in 4 major sections, explains that stereotyping, prejudice, and discrimination have (1) some apparently automatic aspects and (2) some socially pragmatic aspects, both of which tend to sustain them. But, as research also indicates, change is possible, for (3) stereotyping, prejudice, and discrimination seem individually controllable, and consequently, (4) social structure influences their occurrence. Past and present theoretical approaches to these issues are also discussed. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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We sought to determine whether health care use and expenditures among gay and bisexual men were reduced following the enactment of same-sex marriage laws in Massachusetts in 2003. We used quasi-experimental, prospective data from 1211 sexual minority male patients in a community-based health center in Massachusetts. In the 12 months after the legalization of same-sex marriage, sexual minority men had a statistically significant decrease in medical care visits (mean = 5.00 vs mean = 4.67; P = .05; Cohen's d = 0.17), mental health care visits (mean = 24.72 vs mean = 22.20; P = .03; Cohen's d = 0.35), and mental health care costs (mean = $2442.28 vs mean = $2137.38; P = .01; Cohen's d = 0.41), compared with the 12 months before the law change. These effects were not modified by partnership status, indicating that the health effect of same-sex marriage laws was similar for partnered and nonpartnered men. Policies that confer protections to same-sex couples may be effective in reducing health care use and costs among sexual minority men.
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Article
Little is known about how the views of the public are related to self-stigma among people with mental health problems. Despite increasing activity aimed at reducing mental illness stigma, there is little evidence to guide and inform specific anti-stigma campaign development and messages to be used in mass campaigns. A better understanding of the association between public knowledge, attitudes and behaviours and the internalization of stigma among people with mental health problems is needed. This study links two large, international datasets to explore the association between public stigma in 14 European countries (Eurobarometer survey) and individual reports of self-stigma, perceived discrimination and empowerment among persons with mental illness (n=1835) residing in those countries [the Global Alliance of Mental Illness Advocacy Networks (GAMIAN) study]. Individuals with mental illness living in countries with less stigmatizing attitudes, higher rates of help-seeking and treatment utilization and better perceived access to information had lower rates of self-stigma and perceived discrimination and those living in countries where the public felt more comfortable talking to people with mental illness had less self-stigma and felt more empowered. Targeting the general public through mass anti-stigma interventions may lead to a virtuous cycle by disrupting the negative feedback engendered by public stigma, thereby reducing self-stigma among people with mental health problems. A combined approach involving knowledge, attitudes and behaviour is needed; mass interventions that facilitate disclosure and positive social contact may be the most effective. Improving availability of information about mental health issues and facilitating access to care and help-seeking also show promise with regard to stigma.
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Article
Mutual help programs (MHPs) are informal services developed and operated by people with serious mental illnesses for peers with these illnesses. We expect MHPs to have positive effects on quality of life and inverse associations with self-stigma. We hypothesize group identification and social support to be key ingredients that lead to MHPs benefits and hence to also be significant correlates. Eighty-five people with serious mental illness reported current and past MHP experience and completed self-report measures of quality of life, self-stigma, group identification, and social support. Self-stigma was shown to be a significant and large correlate of quality of life. Satisfaction with current and past MHP participation was also associated with quality of life. Group identification and satisfaction with one's support network were significantly and largely associated with MHP satisfaction. MHPs are a specific example of the broader category of consumer operated services which also include drop-in centers and education-for-advocacy programs. Findings about group identification will inform ongoing development of MHPs and consumer operated services, as well as evaluation of these programs.
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We examined the relation between living in states that instituted bans on same-sex marriage during the 2004 and 2005 elections and the prevalence of psychiatric morbidity among lesbian, gay, and bisexual (LGB) populations. We used data from wave 1 (2001-2002) and wave 2 (2004-2005) of the National Epidemiologic Survey on Alcohol and Related Conditions (N = 34,653), a longitudinal, nationally representative study of noninstitutionalized US adults. Psychiatric disorders defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, increased significantly between waves 1 and 2 among LGB respondents living in states that banned gay marriage for the following outcomes: any mood disorder (36.6% increase), generalized anxiety disorder (248.2% increase), any alcohol use disorder (41.9% increase), and psychiatric comorbidity (36.3% increase). These psychiatric disorders did not increase significantly among LGB respondents living in states without constitutional amendments. Additionally, we found no evidence for increases of the same magnitude among heterosexuals living in states with constitutional amendments. Living in states with discriminatory policies may have pernicious consequences for the mental health of LGB populations. These findings lend scientific support to recent efforts to overturn these policies.
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We investigated the modifying effect of state-level policies on the association between lesbian, gay, or bisexual status and the prevalence of psychiatric disorders. Data were from wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a nationally representative study of noninstitutionalized US adults (N=34,653). States were coded for policies extending protections against hate crimes and employment discrimination based on sexual orientation. Compared with living in states with policies extending protections, living in states without these policies predicted a significantly stronger association between lesbian, gay, or bisexual status and psychiatric disorders in the past 12 months, including generalized anxiety disorder (F=3.87; df=2; P=.02), post-traumatic stress disorder (F=3.42; df=2; P=.04), and dysthymia (F=5.20; df=2; P=.02). Living in states with policies that did not extend protections also predicted a stronger relation between lesbian, gay, or bisexual status and psychiatric comorbidity (F=2.47; df=2; P=.04). State-level protective policies modify the effect of lesbian, gay, or bisexual status on psychiatric disorders. Policies that reduce discrimination against gays and lesbians are urgently needed to protect the health and well-being of this population.
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The current research provides a framework for understanding how concealable stigmatized identities impact people's psychological well-being and health. The authors hypothesize that increased anticipated stigma, greater centrality of the stigmatized identity to the self, increased salience of the identity, and possession of a stigma that is more strongly culturally devalued all predict heightened psychological distress. In Study 1, the hypotheses were supported with a sample of 300 participants who possessed 13 different concealable stigmatized identities. Analyses comparing people with an associative stigma to those with a personal stigma showed that people with an associative stigma report less distress and that this difference is fully mediated by decreased anticipated stigma, centrality, and salience. Study 2 sought to replicate the findings of Study 1 with a sample of 235 participants possessing concealable stigmatized identities and to extend the model to predicting health outcomes. Structural equation modeling showed that anticipated stigma and cultural stigma were directly related to self-reported health outcomes. Discussion centers on understanding the implications of intraindividual processes (anticipated stigma, identity centrality, and identity salience) and an external process (cultural devaluation of stigmatized identities) for mental and physical health among people living with a concealable stigmatized identity.
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The authors proposed a process model whereby experiences of rejection based on membership in a devalued group can lead people to anxiously expect, readily perceive, and intensely react to status-based rejection. To test the model, the authors focused on race-based rejection sensitivity (RS-race) among African Americans. Following the development and validation of the RS-Race Questionnaire (Studies 1 and 2), the authors tested the utility of the model for understanding African American students' experiences at a predominantly White university (Study 3). Students high in RS-race experienced greater discomfort during the college transition, less trust in the university, and relative declines in grades over a 2- to 3-year period. Positive race-related experiences, however, increased feelings of belonging at the institution among students high in RS-race.
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In this article the author reviews research evidence on the prevalence of mental disorders in lesbians, gay men, and bisexuals (LGBs) and shows, using meta-analyses, that LGBs have a higher prevalence of mental disorders than heterosexuals. The author offers a conceptual framework for understanding this excess in prevalence of disorder in terms of minority stress--explaining that stigma, prejudice, and discrimination create a hostile and stressful social environment that causes mental health problems. The model describes stress processes, including the experience of prejudice events, expectations of rejection, hiding and concealing, internalized homophobia, and ameliorative coping processes. This conceptual framework is the basis for the review of research evidence, suggestions for future research directions, and exploration of public policy implications.
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The phenomenon of substance abuse during pregnancy has fostered much controversy, specifically regarding treatment vs. punishment. Should the pregnant mother who engages in substance abuse be viewed as a criminal or as someone suffering from an illness requiring appropriate treatment? As it happens, there is a noticeably wide range of responses to this matter in the various states of the United States, ranging from a strictly criminal perspective to one that does emphasize the importance of the mother's treatment. This diversity of dramatically different responses illustrates the failure to establish a uniform policy for the management of this phenomenon. Just as there is lack of consensus among those who favor punishment, the same lack of consensus characterizes those states espousing treatment. Several general policy recommendations are offered here addressing the critical issues. It is hoped that by focusing on these fundamental issues and ultimately detailing statistics, policymakers throughout the United States will consider the course of action that views both pregnant mother and fetus/child as humanely as possible.
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Most of the models that currently describe processes related to mental illness stigma are based on individual-level psychological paradigms. In this article, using a sociological paradigm, we apply the concepts of structural discrimination to broaden our understanding of stigmatizing processes directed at people with mental illness. Structural, or institutional, discrimination includes the policies of private and governmental institutions that intentionally restrict the opportunities of people with mental illness. It also includes major institutions' policies that are not intended to discriminate but whose consequences nevertheless hinder the options of people with mental illness. After more fully defining intentional and unintentional forms of structural discrimination, we provide current examples of each. Then we discuss the implications of structural models for advancing our understanding of mental illness stigma, including the methodological challenges posed by this paradigm.
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This chapter addresses the psychological effects of social stigma. Stigma directly affects the stigmatized via mechanisms of discrimination, expectancy confirmation, and automatic stereotype activation, and indirectly via threats to personal and social identity. We review and organize recent theory and empirical research within an identity threat model of stigma. This model posits that situational cues, collective representations of one's stigma status, and personal beliefs and motives shape appraisals of the significance of stigma-relevant situations for well-being. Identity threat results when stigma-relevant stressors are appraised as potentially harmful to one's social identity and as exceeding one's coping resources. Identity threat creates involuntary stress responses and motivates attempts at threat reduction through coping strategies. Stress responses and coping efforts affect important outcomes such as self-esteem, academic achievement, and health. Identity threat perspectives help to explain the tremendous variability across people, groups, and situations in responses to stigma.
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This review highlights the value of empirical investigations examining actual interactions that occur between stigmatizers and targets, and is intended to stimulate and help guide research of this type. We identify trends in the literature demonstrating that research studying ongoing interactions between stigmatizers and targets is relatively less common than in the past. Interactive studies are challenging, complex, and have variables that are sometimes more difficult to control; yet, they offer unique insights and significant contributions to understanding stigma-related phenomena that may not be offered in other (e.g., self-report) paradigms. This article presents a conceptual and empirical overview of stigma research, delineates the unique contributions that have been made by conducting interactive studies, and proposes what can be further learned by conducting more of such research.
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This article discusses examples of structural stigma that results from state governments' enactment of laws that diminish the opportunities of people with mental illness. To examine current trends in structural stigma, the authors identified and coded all relevant bills introduced in 2002 in the 50 states. Bills were categorized in terms of their effect on liberties, protection from discrimination, and privacy. The terms used to describe the targets of bills were examined: persons with "mental illness" or persons who are "incompetent" or "disabled" because of mental illness. About one-quarter of the state bills reviewed for this survey related to protection from discrimination. Within that category, half the bills reduced protections for the targeted individuals, such as restriction of firearms for people with current or past mental illness and reduced parental rights among persons with a history of mental illness. Half the bills seemed to expand protections, such as those that required mental health funding at the same levels provided for other medical conditions and those that disallowed use of mental health status in child custody cases. Legislation frequently confuses "incompetence" with "mental illness." Examples of structural stigma uncovered by surveys such as this one can inform advocates for persons with mental illness as to where an individual state stands in relation to the number of bills that affect persons with mental illness and whether these bills expand or contract the liberties of this stigmatized group.
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Many assume that individuals with a hidden stigma escape the difficulties faced by individuals with a visible stigma. However, recent research has shown that individuals with a concealable stigma also face considerable stressors and psychological challenges. The ambiguity of social situations combined with the threat of potential discovery makes possessing a concealable stigma a difficult predicament for many individuals. The increasing amount of research on concealable stigmas necessitates a cohesive model for integrating relevant findings. This article offers a cognitive-affective-behavioral process model for understanding the psychological implications of concealing a stigma. It ends with discussion of potential points of intervention in the model as well as potential future routes for investigation of the model.
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Social science research on stigma has grown dramatically over the past two decades, particularly in social psychology, where researchers have elucidated the ways in which people construct cognitive categories and link those categories to stereotyped beliefs. In the midst of this growth, the stigma concept has been criticized as being too vaguely defined and individually focused. In response to these criticisms, we define stigma as the co-occurrence of its components-labeling, stereotyping, separation, status loss, and discrimination-and further indicate that for stigmatization to occur, power must be exercised. The stigma concept we construct has implications for understanding several core issues in stigma research, ranging from the definition of the concept to the reasons stigma sometimes represents a very persistent predicament in the lives of persons affected by it. Finally, because there are so many stigmatized circumstances and because stigmatizing processes can affect multiple domains of people's lives, stigmatization probably has a dramatic bearing on the distribution of life chances in such areas as earnings, housing, criminal involvement, health, and life itself. It follows that social scientists who are interested in understanding the distribution of such life chances should also be interested in stigma.
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This paper hypothesizes that official labeling gives personal relevance to an individual's beliefs about how others respond to mental patients. According to this view, people develop conceptions of what others think of mental patients long before they become patients. These conceptions include the belief that others devalue and discriminate against mental patients. When people enter psychiatric treatment and are labeled, these beliefs become personally applicable and lead to self-devaluation and/or the fear of rejection by others. Such reactions may have negative effects on both psychological and social functioning. This hypothesis was tested by comparing samples of community residents and psychiatric patients from the Washington Heights section of New York city. Five groups were formed (1) first-treatment contact patients, (2) repeat-treatment contact patients, (3) formerly treated community residents, (4) untreated community cases, and (5) community residents with no evidence of severe psychopathology. These groups were administered a scale that measured beliefs that mental patients would be devalued and discriminated against by most people. Scores on this scale were associated with demoralization, income loss, and unemployment in labeled groups but not in unlabeled groups. The results suggest that labeling may produce negative outcomes like those specified by the classic concept of secondary deviance.
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Stigma occurs at both individual and structural levels, but existing research tends to examine the effect of individual and structural forms of stigma in isolation, rather than considering potential synergistic effects. To address this gap, our study examined whether stigma at the individual level, namely gay-related rejection sensitivity, interacts with structural stigma to predict substance use among young sexual minority men. Sexual minority (n = 119) participants completed online measures of our constructs (e.g., rejection sensitivity). Participants currently resided across a broad array of geographic areas (i.e., 24 U.S. states), and had attended high school in 28 states, allowing us to capture sufficient variance in current and past forms of structural stigma, defined as (1) a lack of state-level policies providing equal opportunities for heterosexual and sexual minority individuals and (2) negative state-aggregated attitudes toward sexual minorities. To measure daily substance use, we utilized a daily diary approach, whereby all participants were asked to indicate whether they used tobacco or alcohol on nine consecutive days. Results indicated that structural stigma interacted with rejection sensitivity to predict tobacco and alcohol use, and that this relationship depended on the developmental timing of exposure to structural stigma. In contrast, rejection sensitivity did not mediate the relationship between structural stigma and substance use. These results suggest that psychological predispositions, such as rejection sensitivity, interact with features of the social environment, such as structural stigma, to predict important health behaviors among young sexual minority men. These results add to a growing body of research documenting the multiple levels through which stigma interacts to produce negative health outcomes among sexual minority individuals.
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Objectives: We examined whether past-year suicidality among sexual-minority adolescents was more common in neighborhoods with a higher prevalence of hate crimes targeting lesbian, gay, bisexual, and transgender (LGBT) individuals. Methods: Participants' data came from a racially/ethnically diverse population-based sample of 9th- through 12th-grade public school students in Boston, Massachusetts (n = 1292). Of these, 108 (8.36%) reported a minority sexual orientation. We obtained data on LGBT hate crimes involving assaults or assaults with battery between 2005 and 2008 from the Boston Police Department and linked the data to the adolescent's residential address. Results: Sexual-minority youths residing in neighborhoods with higher rates of LGBT assault hate crimes were significantly more likely to report suicidal ideation (P = .013) and suicide attempts (P = .006), than were those residing in neighborhoods with lower LGBT assault hate crime rates. We observed no relationships between overall neighborhood-level violent and property crimes and suicidality among sexual-minority adolescents (P > .05), providing evidence for specificity of the results to LGBT assault hate crimes. Conclusions: Neighborhood context (i.e., LGBT hate crimes) may contribute to sexual-orientation disparities in adolescent suicidality, highlighting potential targets for community-level suicide-prevention programs.
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Canada announced a policy of multiculturalism in 1971. The goal of the policy was to improve the quality of intercultural relations. Two main elements of the policy were proposed as steps towards achieving this goal: support for the maintenance and development of cultural communities (the cultural component); and promotion of intercultural contact along with the reduction of barriers to such participation (the intercultural component). Research on these issues can provide a basis for the development and implementation of multiculturalism policies and programmes. A review of psychological research on multiculturalism over the past 40 years is summarised. Topics include: knowledge about the multiculturalism policy; acceptance of multiculturalism; acceptance of ethnocultural groups; acceptance of immigrants; discrimination and exclusion; and attachment and identity. Research assessing three hypotheses derived from the policy is also briefly reviewed. Current evidence is that there is widespread support for these features of the multicultural way of living in Canada. Of particular importance for the success of multiculturalism is the issue of social cohesion: is the first component (the promotion of cultural diversity) compatible with the second component (the full and equitable participation and inclusion of all ethnocultural groups in civic society)? If they are compatible, together do they lead to the attainment of the fundamental goal of attaining positive intercultural relations? Current psychological evidence suggests that these two components are indeed compatible, and that when present, they are associated with mutual acceptance among ethnocultural groups in Canada. I conclude that research in Canada supports the continuation of the multiculturalism policy and programmes that are intended to improve intercultural relations.
Article
Objectives: We explored associations between the abolition of Jim Crow laws (i.e., state laws legalizing racial discrimination overturned by the 1964 US Civil Rights Act) and birth cohort trends in infant death rates. Methods: We analyzed 1959 to 2006 US Black and White infant death rates within and across sets of states (polities) with and without Jim Crow laws. Results: Between 1965 and 1969, a unique convergence of Black infant death rates occurred across polities; in 1960 to 1964, the Black infant death rate was 1.19 times higher (95% confidence interval [CI] = 1.18, 1.20) in the Jim Crow polity than in the non-Jim Crow polity, whereas in 1970 to 1974 the rate ratio shrank to and remained at approximately 1 (with the 95% CI including 1) until 2000, when it rose to 1.10 (95% CI = 1.08, 1.12). No such convergence occurred for Black-White differences in infant death rates or for White infants. Conclusions: Our results suggest that abolition of Jim Crow laws affected US Black infant death rates and that valid analysis of societal determinants of health requires appropriate comparison groups.
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Youth exposed to extreme adverse life conditions have blunted cortisol responses to stress. This study aims to examine whether growing up in highly stigmatizing environments similarly shapes stigmatized individuals' physiological responses to identity-related stress. We recruited 74 lesbian, gay, and bisexual young adults (mean age = 23.68) from 24 states with varying levels of structural stigma surrounding homosexuality. State-level structural stigma was coded based on several dimensions, including policies that exclude sexual minorities from social institutions (e.g., same-sex marriage). Participants were exposed to a laboratory stressor, the Trier Social Stress Test (TSST), and neuroendocrine measures were collected. Lesbian, gay, and bisexual young adults who were raised in highly stigmatizing environments as adolescents evidenced a blunted cortisol response following the TSST compared to those from low-stigma environments. The stress of growing up in environments that target gays and lesbians for social exclusion may exert biological effects that are similar to traumatic life experiences.
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*"Ch. 3: The Myths of Coalition," from BLACK POWER: THE POLITICS OF LIBERATION IN AMERICA by Stokely Carmichael and Charles Hamilton. Copyright © 1967 by Stokely Carmichael and Charles Hamilton. Used by permission of Random House, Inc. This article is reprinted with original spelling and grammar intact. 1. Bayard Rustin, "Black Power and Coalition Politics," Commentary (September, 1966). 2. Chapter IV will be devoted to a case study of the Mississippi Freedom Democratic Party as a classic example of what can happen when black people rely on their white political "allies." 3. Selig Perlman, "The Basic Philosophy of the American Labor Movement," Annals of the American Academy of Political & Social Science, Vol. 274 (1951), pp. 57-63. 4. Francis Carney, The Rise of the Democratic Clubs in California, Eagleton Institute Cases in Practical Politics. New York: McGraw-Hill, 1959. 5. Tom Watson, "The Negro Question in the South," Arena, Vol. 6 (1892), p. 548. 6. "The City Must Provide. South Atlanta: The Forgotten Community," Atlanta Civic Council, 1963. 7. Myrna Bain, "Organized Labor and the Negro Worker," National Review (June 4, 1963), p. 455. 8. "Labor-Negro Division Widens," Business Week (July 9, 1960), p. 79. 9. Bain, op. cit. 10. "Representatives and direct Taxes shall be apportioned among the several States which may be included within this Union, according to their respective Numbers, which shall be determined by adding to the whole Number of free Persons, including those bound to Service for a Term of Years, and excluding Indians not taxed, three-fifths of all other Persons." * Niccolo Machiavelli, The Prince and the Discourses, New York: Random House (Modern Library), 1950, p. 84. 11. Saul Alinsky speaking at the 1967 Legal Defense Fund Convocation in New York City, May 18, 1967.
Article
Racial residential segregation is a fundamental cause of racial disparities in health. The physical separation of the races by enforced residence in certain areas is an institutional mechanism of racism that was designed to protect whites from social interaction with blacks. Despite the absence of supportive legal statutes, the degree of residential segregation remains extremely high for most African Americans in the United States. The authors review evidence that suggests that segregation is a primary cause of racial differences in socioeconomic status (SES) by determining access to education and employment opportunities. SES in turn remains a fundamental cause of racial differences in health. Segregation also creates conditions inimical to health in the social and physical environment. The authors conclude that effective efforts to eliminate racial disparities in health must seriously confront segregation and its pervasive consequences.
Article
Stigma operates at multiple levels, including intrapersonal appraisals (e.g., self-stigma), interpersonal events (e.g., hate crimes), and structural conditions (e.g., community norms, institutional policies). Although prior research has indicated that intrapersonal and interpersonal forms of stigma negatively affect the health of the stigmatized, few studies have addressed the health consequences of exposure to structural forms of stigma. To address this gap, we investigated whether structural stigma—operationalized as living in communities with high levels of anti-gay prejudice—increases risk of premature mortality for sexual minorities. We constructed a measure capturing the average level of anti-gay prejudice at the community level, using data from the General Social Survey, which was then prospectively linked to all-cause mortality data via the National Death Index. Sexual minorities living in communities with high levels of anti-gay prejudice experienced a higher hazard of mortality than those living in low-prejudice communities (Hazard Ratio [HR] = 3.03, 95% Confidence Interval [CI] = 1.50, 6.13), controlling for individual and community-level covariates. This result translates into a shorter life expectancy of approximately 12 years (95% C.I.: 4-20 years) for sexual minorities living in high-prejudice communities. Analysis of specific causes of death revealed that suicide, homicide/violence, and cardiovascular diseases were substantially elevated among sexual minorities in high-prejudice communities. Strikingly, there was an 18-year difference in average age of completed suicide between sexual minorities in the high-prejudice (age 37.5) and low-prejudice (age 55.7) communities. These results highlight the importance of examining structural forms of stigma and prejudice as social determinants of health and longevity among minority populations.