Stigma, prejudice and discrimination

This article reviews the development of international research on the relationship between discrimination and health. It provides an overview of theoretical and empirical work on stigma and prejudice and their impact on discrimination and health. It argues that the literature on these issues has drawn primarily from social psychology and has focused on the impact of attitudes associated with stigma and prejudice on discriminatory practices and consequently health outcomes. It also identifies a growing trend in recent research towards a reconceptualization of stigma, prejudice and discrimination from the perspective of social inequality and structural violence, highlighting relations of power and exclusion that reinforce vulnerability within a complex social and political process. It concludes by briefly examining the ways in which this reconceptualization of discriminatory practices has generated a growing interest in the linkages between health and human rights and renewed interest in health and social justice; two major trends in the field of global public health. Social Stigma; Prejudice; Social Inequality Introduction Over the past two decades, there has been growing interest in the relationship between discrimination and health. Although an exhaustive global review of literature on this subject is beyond the scope of this brief article, it is important to highlight some of the most important lines of theorization and empirical research that characterize this area and identify some of the key findings that might guide practical and programmatic responses to human suffering and health challenges caused by discrimination. Stigma, prejudice and discrimination Stigma, prejudice, and discrimination have been an important focus of research attention for a number of decades. In 1963, Goffman’s pioneering book, Stigma: Notes on the Management of Spoiled Identity, initiated a debate about the nature of stigma and discrimination that has grown steadily over the last 50 years 1. The present work examined a wide variety of topics, many of which were first examined by Goffman and subsequently studied from a variety of disciplinary perspectives: physical disfigurement and disabilities, mental illness, homelessness, homosexuality and gender nonconformity, juvenile delinquency, and other issues associated with non-normal 164 FÓRUM FORUM Cad. Saúde Pública, Rio de Janeiro, 28(1):164-169, jan, 2012 STIGMA, PREJUDICE AND DISCRIMINATION IN GLOBAL PUBLIC HEALTH 165 Cad. Saúde Pública, Rio de Janeiro, 28(1):164-169, jan, 2012 and non-normative experiences or behavior 2. Study topics vary and disciplinary approaches to stigma include anthropology, psychology, sociology, education, public health and social work. However, the majority of research carried out to date in this area has focused on stigma and its relation to health conditions (especially mental illness and HIV infection) and has drawn principally from social psychology. The emergence of the HIV/AIDS epidemic in the 1980s can be considered a watershed event for stigma research and work on HIV/AIDS-related stigma and discrimination has “boomed” over the course of the past three decades. The history of research on prejudice and discrimination is similar to that of stigma. Although research on prejudice – linked to Allport’s publication, the Nature of Prejudice 3 in 1954 – started slightly earlier, over the latter part of the 20th century the two areas evolved along parallel but distinctly separate tracks. During much of this time, the development of research on prejudice and discrimination was motivated by growing social concern with racism, especially in the USA. Thus, work in this area has largely focused on race and ethnicity and how racial and ethnic discrimination are driven by prejudice, whereas work on stigma was more closely associated with health conditions 4. Although research on both prejudice and stigma has been influenced by various fields of social sciences, psychology and social psychology have played a particularly important role in the development of literature in this area 5. However, whatever the conceptual framework, the focus on the relation of prejudice and discrimination to health outcomes and what has been described particularly in the United States as health disparities, has only emerged over the course of the past 10 to 15 years 4. In recent years, the focus on both stigma and prejudice has led to a growing body of work on the health consequences of discrimination experienced as a result of these processes. The effects of stigma have been explored in relation to the following sections of the community: people living with or perceived to be at risk of HIV infection 6; people suffering from mental illness 7,8; and the homeless 9. A large body of work has emerged, particularly in the United States, that has sought to measure the experience of discrimination 10,11. In countries such as the Unites States and South Africa, that have experienced a long history of intense racial discrimination, research has been carried out with the aim of understanding the differential experience of “acute” as opposed to “chronic” racial and non-racial discrimination, and their impacts in relation to a range of stressors and psychological factors (such as social desirability, self-esteem and personal mastery) 12,13. Both stigma and prejudice-related discrimination has been examined in relation to what Meyer and colleagues describe as “minority stress” 14. While much of this work has examined the psychological and mental health impacts of stigma, prejudice and discrimination, there has also been a significant increase in work on violence related to these processes 15,16,17. This focus has directed critical attention to documenting the occurrence of discrimination and violation of rights, hate crimes, and the health consequences of discrimination. However, much still needs to be done to build on work in this area to be able to confront these negative consequences with more effective social and public health policies, programs, and interventions. Due to the prevalence of a social psychology perspective in studies on this topic, stigma and prejudice have been conceptualized mainly as negative attitudes held by some in relation to the value of specific groups: racial and ethnic minorities, people that suffer from mental illness, people with HIV, and so on. Discrimination has been seen as a kind of behavioral response caused by these negative attitudes – or as a form of enacted stigma or enacted prejudice. A sharp distinction has thus been made between ideas, attitudes, or ideologies, and their behavioral consequences in discriminatory actions. This distinction between thought and action, in turn, has served as a point of departure for intervention. Many interventions have focused on the thoughts that are perceived to drive discriminatory practices, seeking to change negative attitudes by reducing levels of stigma or prejudice, thus reducing discrimina-