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The concept of stigma has undergone important shifts in definition and characterisation since its initial articulation by Erving Goffman in the 1960s. Here, we contend that the study of stigma has focused too heavily on psychological approaches and has neglected to sufficiently incorporate understandings of stigma and stigmatised individuals as embedded in local moral contexts. What exactly is encompassed by the conceptual umbrella of stigma is far more than a compelling theoretical question, since definitions of stigma directly inform efforts to empirically research and combat stigma.
The modern idea of stigma owes a great deal to Goffman, who viewed stigma as a process based on the social construction of identity. Persons who become associated with a stigmatised condition thus pass from a “normal” to a “discredited” or “discreditable” social status.1 In his original discussion of stigma, Goffman included both psychological and social elements, but his ideas have primarily been used in the analysis of the psychological impact of stigma on individuals. This has created an understanding of the psychology of the stigmatised, focusing on the processes by which stigma is internalised and shapes individual behaviour. Yet, this has been to the exclusion of considerations of how social life and relationships are changed by stigma.2
Recently, the field of sociology has contributed to this discussion by creating a broader understanding of stigma that identifies social processes that occur within the sociocultural environment and whose effects can be observed within the individual. Specifically, the model of stigma proposed by Link and Phelan3 4 includes a component of structural discrimination, or the institutionalised disadvantages placed on stigmatised groups. This opens the door for us to begin to elucidate the ways that power—social, economic, and political—shapes the distribution of stigma within a social milieu.
More recently, anthropological contributions to the study of stigma have focused on stigma as embedded in moral experience and on the stigmatised as a person with a moral status.5 6 The moral standing of an individual or group is determined by their local social world, and maintaining moral status is dependent on meeting social obligations and norms. Individuals with (or associated with) stigmatised conditions are de facto unable to meet these requirements. Thus, stigma decays the ability to hold on to what matters most to ordinary people in a local world, such as wealth, relationships and life chances. Yet, we must remember that the stigmatised and those who stigmatise are interconnected through local social networks. Although stigma may share features across contexts, it uniquely affects lives in local contexts.
Understanding the unique social and cultural processes that create stigma in the lived worlds of the stigmatised should be the first focus of our efforts to combat stigma. Measuring what matters most is facilitated by ethnographic methods, through which the local value systems can be explored in far greater depth than what is possible through standard survey instruments. By combining observation with in-depth interviews, we can see the difference between individual’s stated moral ideals and their actions. This knowledge in turn facilitates understanding what stigma does to people and how it can be addressed. The combination of quantitative and qualitative research efforts can contribute to what has elsewhere been suggested as a “science of stigma”,7 where the questions of epidemiology (morbidity, mortality, quality of life, costs) can inform ethnographic research on the causes, course and potential solutions for stigma. Such a multidisciplinary approach to stigma is necessary to create a dialogue among key players in academic and medical research and public policy to create anti-stigma interventions that have real and measurable outcomes.
The present focus on legislation to prevent formal, institutionalised consequences of stigma is admirable, but it does not create large social change. Anthropology can contribute to this discussion by examining the altering of moral worlds that lead to large cultural changes. We only have to look to the examples of depression and smoking in the US context to see that the relative stigma of specific conditions and actions can and does change across time. For example, there is a significant trend toward destigmatisation of depression that indicates a major cultural shift,8 meaning that a widespread change has occurred in the way that society morally regards and responds to a particular issue. Conversely, smoking has become increasingly stigmatised, and smoking rates in the USA have substantially dropped.9 Despite much scholastic attention and public education efforts to achieve these trends, we do not really understand the processes by which these shifts in norms and moral experience have occurred.
We currently know surprisingly little about the moral processes that undergird stigma. Until we admit this, we will limit our ability to understand and create effective strategies for overcoming stigma. Most stigma research has failed to address this central issue. In addition to the psychological and macrosocial components of stigma, we must understand how the moral standing of individuals and groups in local context affects the transmission and outcome of stigma. By focusing on how local values enacted in people’s lives affect stigma, we will be able to create more effective and measurable anti-stigma interventions. This will be a positive step forward for social scientists as much as for all other professionals concerned with the health, well-being and moral status of individuals and populations.
Competing interests: None declared.
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