Stigma: Conceptualization, Cross-Cultural Comparisons, and the Stigma of Sexual Minorities

Stigma: Conceptualization, Cross-Cultural Comparisons, and the Stigma of Sexual Minorities

Stigma Defined
Stigmatization has been referred to by Crocker, Major, and Steele (1998) as an essential challenge to an individual’s basic humanity. They explain that “a person who is stigmatized is a person whose social identity, or membership in some social category, calls into question his or her full humanity; the person is devalued, spoiled, or flawed in the eyes of others” (p. 504). Stigma, a term whose English usage dates back to the 1300’s, is derived from the same Greek roots as the verb “to stick”, and originally referred to a type of tattoo, or mark, that was cut or burned into the skin of criminals, slaves, or traitors in order to visibly identify them as blemished or morally polluted persons (Herek, 2004). These individuals were to be avoided or shunned, particularly in the public sphere (Healthline Network Inc., 2007). Stigma has been linked to poor mental health, physical illness, academic underachievement, infant mortality, low social status, poverty, and reduced access to housing, education, and jobs (Allison,1998; Braddock & McPartland, 1987; Clark et al., 1999).

When conceptualizing stigma in the modern sense, the psychological and sociological literature highlights several components essential to the understanding of this term (Goffman, 1963; Jones et al, 1984; Link & Phelan, 2001). First, stigma refers to an enduring condition or attribute, usually a physical or symbolic mark borne by an individual. Secondly, the attribute or mark is not inherently meaningful, but, meanings are attached to it through social interaction. Furthermore, the meanings that a society or larger group attaches to the mark are considered to be negative. In the process of stigmatization, the association of marks with “discrediting dispositions”, or negative valuations, results in the development of stereotypes that are widely shared and well known among members of a particular culture (Jones et al., 1984). These stereotypes become the basis for the sanctioned exclusion, or the shunning of members of a particular group ( Major& Eccleston, 2004). According to Goffman, stigma is an extensively discrediting attribute that reduces the individual “from a whole and usual person to a tainted and discounted one” (p. 3). Stigmatizing attributes may be conceived of as, visible (e.g. cleft palate) or invisible (e.g. sexual orientation), controllable (e.g. cross-dressing) or uncontrollable (e.g. epilepsy), and are often linked to appearance (e.g. physical deformity), behavior (e.g. pedophile), or group membership (e.g. African American).

Goffman (1963) suggested two levels of distinct social atmospheres that exist with respect to individuals with concealable stigmas (i.e. those that are not immediately evident), the discredited and the discreditable. In the discreditable atmosphere, the individual’s stigmatized status is not immediately evident and may be successfully concealed (which Goffman referred to as “passing”); however, the possibility exists that the individual’s stigma may be revealed, either intentionally by that individual, or by some uncontrollable occurrence. In the discreditable situation, the analysis of stigma becomes concentrated on the behaviors that the individual employs in stigma management (i.e. the revealing and concealing of information). However, in the discredited situation, the individual’s concealable stigma has been revealed and therefore, impacts both the individual’s behavior, and the behavior of others in response to him or her. Therefore, a third feature of stigma is that it tends to overwhelm the entire identity of the individual that possesses the attribute or mark. According to Herek (2004), stigma is differentiated from social disapproval that results from an “annoying habit or personality flaw…rather it trumps all other traits and qualities”. Herek further states that, once individuals within a society “come to know about a person’s stigmatized status, [they] respond to the individual mainly in terms of it” (p. 14).

Finally, as a fourth feature of stigma; the roles of the stigmatized and non-stigmatized individuals tend to be differentiated by power, that is, stigmatized individuals and groups tend to have less access to resources and power than non-stigmatized individuals. In the socio-political culture, stigma may be conceptualized as constituting a power relationship wherein, the stigmatized attribute or mark is utilized to marginalize and discount an individual, or group of individuals; resulting in rejection, exclusion, disapproval, and discrimination (Link & Phelan, 2001).

It is important to note and draw distinctions between the concept of stigma and the related, but not synonymous, constructs of deviance, marginalization, and discrimination. Deviance has been represented as an undesirable departure from the normative standards of a society( ), whereas marginalization refers to the relegation or confinement of an individual or group to a lower social standing, or outer edges of social standing (Frable, 1993). Discrimination refers to the practice of Similar to individuals who are considered to be deviant or marginalized, stigmatized individuals also represent a departure from societal norms. However, individuals may be considered deviant or marginalized not only as a result of negatively valued characteristics, but also as a result of positively valued attributes (e.g. extreme wealth) as well (Crocker et al., 1998). Stigmatization, on the other hand, is always related to some negatively valued characteristic that serves to devalue and discredit the individual (Jones et al., 1984).

Stigma has also been related to prejudice, as an individual that is stigmatized is frequently the target of negative, faulty, and overgeneralized affective responses directed toward the individual, or a group as a whole (Allport, 1954). Similarly, stereotypes represent cognitive representations of expectancies projected upon groups or individuals. Prejudice and stereotypes are similar to stigmatization in the respect that they, like stigma, are also steeped in deeply rooted cultural beliefs regarding the value of various groups; however, the term stigma is considered to encompass a much more complex process involving individual and group responses to deviance that extend to individual character and identity (Jones, 1986). Summarily, while related to marginality, deviance, prejudice, and stereotypes; stigma subsumes and extends upon these concepts. Essentially, stigma can be conceptualized as encompassing and incorporating the concepts of deviance (i.e. undesirable departure from the norm), prejudice (i.e. personal, culturally defined negative beliefs with respect to deviation from the norm),and stereotypes (i.e. content laden cognitions attached to groups or individuals regarding expectancies of behavior patterns, competencies, incompetencies, personality characteristics, etc., and marginalization (i.e. the ostracizing and denial of resources directed at an individual or group based upon prejudice). Stigma, can therefore be viewed as developing from an affective response (prejudice), cognitive representations (stereotypes), marginalization (behaviors) Most importantly, stigma is relationship and context specific; it is not viewed as residing within the individual, but within the collective milieu.

It is important to recognize the dynamic context in which stigmatization occurs. Jones et al. (1984) stressed that the process of stigmatization is a relational one, and noted that “a behavior or attribute that is labeled as deviant or discrediting by one individual may simply be viewed as a benign and a charming eccentricity by another” (p. 5). Furthermore, Crocker, Major, and Steele (1998) contend that “stigmatized individuals possess (or are believed to possess) some attribute, or characteristic, that conveys a social identity that is devalued in some particular social context” (emphasis added; p. 505). In addition to the role of the social environment in influencing stigmatization of certain characteristics, the physical environment can also potentially facilitate stigma. For example, the lack of handicap accessible entrances into buildings (constructed environment) and uneven terrain (natural environment) contributes to the stigmatization experienced by individuals with physical limitations (Hebl & Kleck, …). As such, both the physical and social environments converge to fundamentally determine whether a particular characteristic will become stigmatized, or simply fail to be attended to by the other members of a society at all.

Erving Goffman (1963) distinguished several varieties of universal and historically stigmatizing conditions consisting of; overt or external physical deformities (e.g., albinism), blemishes of individual character (e.g., addiction), and tribal identity (e.g., nationality, religion, race). Building upon Goffman’s premises, Jones et al. (1984), developed the six dimensions of stigma that influence whether a personal quality or condition is considered to be stigmatizing within a particular cultural context. The six dimensions are as follows; concealability, the extent to which others can discern the stigma; course of the mark, relating to whether the mark becomes more salient, prominent, or debilitating over time; disruptiveness, the degree to which the stigma interferes with the flow of interpersonal interactions; aesthetics, which relates to others reactions to the unattractive stigma; origin, involves others perceptions of the stigmatizing attribute as congenital, deliberate, or the result of an accident, essentially, one’s responsibility for the mark; and peril, which involves others impressions as to the threat or danger that the stigmatizing attribute presents to themselves. Believing these dimensions of stigma to be rationally rather than empirically based, Deaux, Reid, Mizrahi, & Ethier (1995), utilized experimental procedures and complex statistical analyses in an attempt to identify the underlying distinctions between social identity and the dimensions of stigma. The researchers concluded that the dimensions of peril, concealability, and origin tend to be the most central in relation to stigma, supporting the rationally developed ideas of Goffman(1963) and Jones et al.(1984). Crocker and colleagues (1998), however, contend that visibility and controllability tend to be the most significant dimensions of stigma. These researchers posit that, due to the fact that visible stigmas are immediately apparent to others, the stigma hence determines a primary schema through which everything about the individual becomes filtered. As such, the visibility of one’s stigma determines how attentive the stigmatized person becomes to the fact that others are reacting to them based upon their stigmatizing mark and the prejudice associated with it. Controllability of one’s stigma is directly related to other’s perceptions of the individual’s ultimate responsibility for possessing the stigmatizing mark. Perceived controllability is a significant factor in the prejudice faced by stigmatized individuals, as research has indicated that individual’s with stigmas that are perceived to be controllable (e.g., overweight, homosexual) face more rejection and are less liked than those whose stigmas are perceived to be uncontrollable. As such, perceived controllability of stigma has a tremendous impact on the way in which stigmatized individuals interpret others’ reactions to them and have significant implications for their self-esteem (Crocker & Major, 1994).

The Functions of Stigma
Self-enhancement
Through the process of down-ward comparison theory, stigmatizing others can be seen as a mechanism for enhancing the self-esteem and subjective well-being of the stigmatizer. According to Wills (1981), downward comparison can take two forms: passive or active. In passive comparison one may simply seek out others whom they perceive to be less advantaged than they within a particular context; whereas, active downward comparison involves deliberately derogating, or harming another. Accordingly, stigmatization may take the form of either, or both, of these processes. This micro-level explanation for the function of stigma, while applicable within certain contexts, fails to fully encompass the essential nature of stigma, in the respect that it fails to recognize the complex social and cultural processes associated with stigmatization.

Disease Avoidance
The process of stigmatization is a pervasive force evidenced in virtually every society throughout the world. According to Crocker et al., “the universality of social stigma suggests that it may have some functional value for the individual who stigmatizes, for the group from which he or she comes, for the society, or all of these” (p.508). Proponents of bio-cultural and evolutionary theories regarding stigma indicate that the universal tendency to stigmatize others focuses primarily on the adaptive process of “avoidance” that served to protect primitive societies from others perceived to be a threat to their survival. One such threat that tended to arouse anxiety and fear in primitive societies, identified by Kurzban & Leary (2001), is the transmission of parasitic diseases and illness. According to this theory, the high cost of interacting with diseased individuals made it functional for individuals, and societies, to readily identify diseased individuals and avoid contact with them (Park, Faulkner, & Schaller, 2003). As a significant number of contagious diseases are accompanied by “markers, lesions, discoloration of body parts…and behavioral anomalies” (Kurzban & Leary, 2001, p. 198), the shunning of individuals possessing such marks, and the development of intense psychological reactions to such maladies would have increased evolutionary fitness. Indeed, contemporary research indicates that individuals have very strong reactions to visible indications of disease, findings that coincide strongly with the research presented earlier herein indicating visibility as one of the most significant dimensions affecting stigmatization (Jones et al, 1984). Park et al. (2003) have highlighted research findings that indicate that individuals with physical disabilities are often the target of “disease-avoidance” stigmas. Park and colleagues indicate that “non-disabled” individuals tend to display a host of non-verbal behaviors such as, stiffness, less self-manipulatory behavior (e.g., playing with one’s hair or touching one’s face), avoid eye contact, and smile less frequently when engaged in interaction with a person with a disability; all of which indicate the presence of anxiety and discomfort. In one such study, a majority of participants who sat next to a disabled individual in a movie theater described themselves as “tense”, “jittery”, and “on edge” while viewing the film (Snyder et al., 1979; as cited in Park et al., 2003). Similarly, studies indicate that interactions with individuals with facial disfigurations have been shown to result in “threat like” cardiovascular reactivity in participants (Blascovich et al., 2001; as cited in Park et al., 2003). Although Park and colleagues have specifically focused upon the threat of contagion as an impetus to stigmatization, they do not, however, fall victim to the purely “essentialist” view of stigma, instead indicating that evolved psychological mechanisms are largely domain-specific and may manifest in various ways across cultures; that is, culture beliefs dictate who becomes stigmatized and the nature of the stereotypes associated with that stigma.

Control
According to Fiske (1992), “stereotyping operates in the service of control”. Differing from prejudice (i.e. affect) and discrimination (i.e. behavior), stereotypes refer to individuals convictions, or beliefs (i.e. cognitions) concerning an individual based upon their real, or perceived, group membership. Descriptive stereotypes involve perceptions as how one is expected to behave, what they are “supposed to” like, and the types of activities that they are “fit” to do, as based upon their group membership. These might include the notions that; Asians are adept at mathematics but poor drivers, homosexuals are good interior designers but inept in sports, and African Americans are good dancers but lacking academically, to name but a few. Descriptive stereotypes, or the way in which a person is “supposed” to be, taint personal interactions. Fiske refers to these stereotypes as constraining as they “anchor the interaction, weighing it down and holding it back”. Prescriptive stereotypes, on the other hand, are seen as even more controlling; essentially prescribing the way in which groups should act, think and like, lest there be sanctions. Examples include the ideas that women should be good caregivers, boys should be athletic, and so on. As such, prescriptive stereotypes constrain and control the targeted individual. As such, Fiske likens this type of stereotype to a “fence” that surrounds and controls social interactions. Stereotypes, therefore, reinforce the power that one group exerts over another through limiting the options of the stereotyped; in this way stereotypes maintain power and power maintains stereotypes. Considering that stereotypes constitute a dimension of stigma, any conceptualization of stigma must entail the concepts of power and control, which are inextricably intertwined. One might argue that subordinates also stereotype those in power,

In Group Out Group differentiation
Falk (2001) contends that all societies stigmatize certain conditions and behaviors as a way of providing group solidarity by way of delineating “outsiders” from “insiders”, or “out-groups” from “in-groups”. The stigmatization of others is utilized as a means of achieving greater harmony among members of the in-group. Through the designation of certain behaviors as deviant, collective moral vision is established. As Durkheim(1895) wrote:
Imagine a society of saints, a perfect cloister of exemplary individuals. Crimes or deviance, properly so called, will there be unknown; but faults which appear venial to the layman will there create the same scandal that the ordinary offense does in ordinary consciousness. If, then, this society has the power to judge and punish, it will define these acts as criminal (or deviant) and treat them as such. Therefore, investigating the reasons for the types of behaviors that a society stigmatizes can reveal a great deal about how that society defines itself morally, ethically, and politically. In essence, a clear definition of what society tries to declare as deviant provides a clearer definition of what that society whishes to declare as "true" and "good" (Falk, 2001).

Due to the sheer breadth of “stigmatizing marks” that are contained beneath the umbrella term “stigma”, and due to the rich cultural nature of those marks, it is clear that no single theory could provide a comprehensive analysis, or definition of that which is, “stigma”. Following from the research that is herein mentioned a conceptualization of stigma presented by Link & Phelan ( ), offers a most comprehensive definition. According to the researchers, stigma is a process in which; four specific components converge; (1) Individuals differentiate and label human variations, (2) Prevailing cultural beliefs tie those labeled to adverse attributes, (3) Labeled individuals are placed in distinguished groups that serve to establish a sense of disconnection between “us” and “them”, (4) Labeled individuals experience “status loss and discrimination” that leads to unequal circumstances. In this model stigmatization is also contingent on “access to social, economic, and political power that allows the identification of differences, construction of stereotypes, the separation of labeled persons into distinct groups, and the full execution of disapproval, rejection, exclusion, and discrimination.” Subsequently, in this model the term stigma is applied when labeling, stereotyping, disconnection, status loss, and discrimination all exist within a power situation that facilitates stigma to occur.

Cross-Cultural Examples of Stigma
China: Epilepsy
Epilepsy, a common neurological disorder characterized by recurring seizures, is associated with various social stigmas. Fong & Hung (2002) conducted a study in Hong Kong which documented public attitudes towards individuals with epilepsy. Of the 1,128 subjects interviewed, only 72.5% of them considered pregnancy to be appropriate for epileptics; 11.2% would not let their children play with others with epilepsy; 32.2% would not allow their children to marry persons with epilepsy; additionally, employers (22.5% of them) would terminate an employment contract after an epileptic seizure occurred in an employee with unreported epilepsy (Fong, Hung, 2002). The researchers posit that the stigmatization of epilepsy is deeply rooted in Chinese culture. Ideas that attribute the cause of epilepsy to bad fate, heredity, negative geomantic forces, and the malignant influences of gods, ghosts, or ancestors, are all accusations about the moral status of the Chinese family This can be reflected by almost one-fifth of respondents reporting being reluctant to disclose the diagnosis if their family member had epilepsy. They “felt ashamed for their families” or were “afraid of being discriminated against” (Fong & Hung, 2002). In the Chinese collectivist context, moral blame is applied not to the epileptic alone, but extends to the entire family. Fong & Hung suggest that more effort be afforded to improving the public awareness of, attitudes towards, and understanding of epilepsy in Chinese culture through education in the schools and within the community through epilepsy-related organizations (Fong, Hung, 2002).

United States: Welfare
Rogers-Dillon (1995) focused upon the experiences of welfare stigma in female welfare recipient’s daily lives in urban Philadelphia, Pennsylvania. Although Rogers-Dillon’s study is limited in generalizability by its small sample size (n=10), it nonetheless offers insight into the nature and experience of stigma with respect to the concepts presented herein. Through a series of interviews with the women of the study, Rogers-Dillon presents several significant findings. All of the women reported going on welfare as an economic necessity, and most expressed no reservations in doing so. One individual, Diane, expressed, “It is instinctive, you don’t have to think about there is a crumb and I’m hungry, go get it. It’s survival”(p. 445). Although the stigma of welfare did not deter the women from accepting assistance, they reported being significantly aware of the stereotypes attributed to individual’s on welfare. As another participant, Kim, stated ( they [welfare recipients] are lazy…unmotivated…not smart and didn’t get a good education…they are bleeding the government and they are bleeding us” (p. 446)

Food stamps immediately reveal the user’s status as a welfare recipient. In relation to Goffman’s (1963) suppositions, up until the point of actually utilizing their food stamps to make a purchase, the individual is in a discreditable state. In this state the individual is primarily concerned with stigma management. Gina, an African-American woman in the study, reported the anxiety she experienced attempting to conceal her food stamps when purchasing items in “white neighborhoods”, whereas, Lisa, a Caucasian woman, repots driving outside of her suburban neighborhood when using her food stamps to avoid being seen by people she knows (Rogers & Dillon, 1995). The individual is immediately discredited upon the usage of their food stamps, and their stigma is consequently revealed. In reaction to having one cashier yell to another seven aisles away that she “needed change…for food stamps” as Diane was attempting to discretely make her purchases with food stamps, Diane stated “I couldn’t crawl close enough to the ground, I felt so bad” (p. 449). Diane expresses her experience in a very relational way, she does not experience stigma until her status is revealed; “it is her being on food stamps in relation to other people that creates Diane’s feelings of stigmatization in the grocery store”(p. 440; emphasis in original). Rogers & Dillon found that the women in this study utilized several techniques to manage stigma, such as; avoidance: using cash instead of food stamps in certain situations, or sending children to the store, and recasting: viewing their use of assistance in a more positive light, especially when recognizing that similar others also used food stamps. Highlighting the American tendency to oppose the notion of “welfare recipient” with that of “tax paying citizen” relegates the individual to that of a non-citizen, an outsider, and “an object of the community’s actions rather than a member of that community” (p. 441). Rodger’s & Dillon conceptualize the stigmatization of welfare recipients as rooted in the design and history of the American welfare system, in combination with the cultural opposition of the social identities of “citizen” and “welfare recipient”; highlighting the relational and situational aspects of stigma as previously mentioned herein.

United Kingdom: Smokers
The increasing stigmatization of smokers in Britain has been linked to symbolic, experiential and institutional bases, particularly with respect to higher rates of smoking in lower socio-economic (SES) groups. According to a study conducted by Farrimond & Joffe (2006), thematic analysis of free association tasks completed by forty smokers and non-smokers from high and low SES groups identified several areas of stigmatization of smokers by non-smokers. Smokers were stigmatized via association with a negative aesthetic (e.g. smell and negative appearance), the perception of smokers as “polluters” of the environment and other people’s lungs, and the association of smokers with “out groups”. The researchers assert that higher SES smokers challenge the legitimacy of such stigmatization; whereas lower SES smokers tended to internalize these negative projections. Consequently, lower SES smokers are more likely to view themselves as presenting a negative appearance (e.g. dirty, smelly, yellow teeth) ,being polluters, and “outcasts”. According to the authors, there exists a significant relationship between SES and rates of smoking, indicating that a significant larger number of individual’s from low SES groups smoke when compared to high SES groups.

In an aim to narrow the smoking gap between the economic classes in Britain, the government has targeted lower SES groups with tobacco control interventions which play on the negative aesthetic of smokers and the “peril” which they represent. Britain’s Department of Health’s Tobacco Control campaign ,“Ugly Smoker”, utilizes such slogans as, “You Smoke, You Stink” and “Smoking makes your teeth minging (a colloquial British term for an ugly, disgusting woman, used by young people)” and the “Second-hand smoke is a killer” campaign has banned smoking in most public spaces and uses warning labels on cigarette packs such as “smoking seriously harms you and others around you” (Farrimond & Joffe, 2006; p. 490). Although these campaigns aim to lower rates of smoking in lower SES groups, it appears that these techniques may, in actuality, only be effective in dissuade higher SES groups from changing their behavior. Farrimond & Joffe’s study indicates that , unlike higher SES smokers, lower SES groups tend to internalize stigmatization rather than challenge it, and the current campaigns targeted at lower SES groups ultimately only further stigmatize and marginalize lower SES smokers, the results of which are retrograde with other health promoting initiatives such as HIV/AIDS prevention (Bayer & Stuber, 2006; as cited in Farrimond & Joffe, 2006). The utilization of such techniques aimed at playing upon and exacerbating lower SES groups’ already stigmatized status, aside from being ethically questionable, are more likely to perpetuate smoking inequalities between higher and lower SES groups rather than diminish them. This is evident in the fact that rates of smoking in lower SES groups remains as high as ever, despite increasing stigmatization and social censure (Farrimond & Joffe, 2006)

South Africa: HIV/AIDS
HIV/AIDS related stigma is ubiquitous, occurring in a significant number of societies globally; the result of which has significant implications for prevention, treatment, and care. Examples of the stigmatization of HIV/AIDS are boundless and virtually universal. According to Dodds (2004), the widespread stigmatization of sex in South Africa, in combination with former President Thabo Mbeki’s well publicized refusal to acknowledge the extent of the AIDS crisis in the region, have resulted in the increased stigmatization, marginalization, and deaths of South African AIDS sufferers. According to a November 2008, New York Times report, due to Thabo Mbeki's rejection of scientific consensus on AIDS and his embrace of AIDS denialism, an estimated 365,000 people had perished in South Africa. Drawing from interviews, fieldworker diaries, and focus groups, Dodds (2004) highlights the way in which the economic and political context of South African culture serves to sustain the stigma of AIDS and the impact that this imparts on communal stereotypes and HIV intervention efforts in one South African community of 20,000 individuals (which Dodds does not name to protect the confidentiality of the participants of the study). Of individuals ages 15-49 in this community, 16% are infected with HIV and 36% of women attending ante-natal clinics are also infected. Heterosexual sex is the most common mode of transmission, and levels of HIV among adolescents are increasing exponentially (Campbell, 2003; as cited in Dodds, 2004).

Dodds (2004) posits that South Africa’s post apartheid political atmosphere and desire to create a newer and brighter future through positive citizenship, combined with the teaching of Christian missionaries and their traditional Victorian attitudes on sexual expression, has fueled the stigmatization of sex and created silences in public discourse regarding sexuality and HIV/AIDS. The origin of the disease as stereotypically associated with promiscuous sex, drug abuse, and poverty has symbolically marked individuals infected with HIV as representations of all that threatens to undermine post-apartheid nation building. Dodds found the stigmatization of individuals with HIV to be rife within the South African community, relating anecdote after anecdote supporting his claims. According to Dodds, several families with a relative with HIV reported hiding them away, preventing them from receiving care, and disowning the bodies of the infected deceased as a means of avoiding the stigma attached to their disease. As a result of stigma, individuals often fail to disclose their positive status to others or seek treatment, further fueling the transmission of the disease.

Further highlighting the impact of the political atmosphere on the development of stigma, Dodds (2004) references the way in which many informants spoke of members of the apartheid regime injecting Black political prisoners with HIV prior to releasing them back into the public to infect others; while others spoke of HIV as resulting from “White envy” and proposed that Whites infected Blacks through lubricated condoms as a means of “reducing the Black vote” (p. 240).

Additionally, Dodds (2004) relates the stigmatization of individuals with HIV in the South African culture studied as exacerbated by extreme poverty, low education, high unemployment, and the overall political marginalization and disempowerment. In this cultural context, the lack of resources was identified as precipitating a lack of hope among people with AIDS. As one support worker expressed in Dodds’ study, “We visit people with AIDS in their homes to offer emotional support…but you find people expecting more from us because they are sick and have nothing to eat. How can you motivate people to live positively if they are hungry?”.

Impact of Stigma on Individual
Clinical care directed to individuals living with HIV, researchers believed, should include considerations for patient sensitivity to social stigma (Reece, Tanner, Karpiak, Coffey, 2007).