This is a revised version of an item written for Bill Cockerham’s Encyclopaedia of Medical Sociology a while back. Stigma, I noted somewhat uncontroversially, denotes the presence of an attribute that discredits its possessor. Since it is evident such attributes have varied by time and place, it is apparent that stigma and stigmatization necessarily involve a narrative of social relations: an attribute that shames bearers at one spatio-temporal juncture can pass them by at another. Goffman (1963), who pioneered the study of stigma as a social relation, contributed a range of conceptual insights that have survived half a century. His distinction between people who are ‘discredited’ and ‘discreditable’ has been especially influential within medical sociology. The discredited possess a conspicuous or intrusive attribute that they cannot conceal, their principal challenge being to negotiate or manage the (stereotypical) impressions that others have of and bring to their dealings with them. By contrast, the discreditable have an attribute or condition that is potentially shaming but which is inconspicuous or non-intrusive: for them the challenge is to manage the information that others have about them (who to tell, when and with what consequences?). The challenges and threats confronting people who are blind or stutter differ from those facing people with diabetes.
The development of the ‘labelling perspective’ in the USA prompted sociologists like Freidson (1970) to apply its insights to health. Scheff (1966) concluded that the process of labelling was the prepotent ‘cause’ of mental illness. His legacy survives in US medical sociology in a ‘modified’ labelling theory of mental illness. Less controversially, the salience of culturally authoritative acts of labelling on the part of doctors for attributions of shame and their sequelae became part of normal science. Ironically in view of the early labelling theorists’ focus on ‘labellers’, this was to translate into an intensive medical sociological interest in ‘labellees’. Rather than study the political economy and vested interests behind medicine’s construction and application of diagnostic labels, researchers switched their attention to the ‘personal tragedies’ such labels occasioned. The very act of passing on a diagnosis of HIV assigns the recipient a new social status, possibly even a master-status, from which he or she cannot easily recover. The labellee thus becomes a victim with a personal tragedy to resolve. The communication of an erroneous diagnosis can be no less damaging to its recipient: someone diagnosed by a state-licensed physician as ‘epileptic’ is, to all intents and purposes, epileptic.
Medical labelling does not always lead to self-labelling: people with diabetes or HIV/AIDS do not necessarily define and see themselves differently (or negatively) subsequent to diagnosis. But on the other hand diagnoses can precipitate a change of orientation such that people, as it were, ‘discriminate against themselves’. This tendency is present in the studies of epilepsy of Schneider and Conrad (1983) in the USA and Scambler and Hopkins (1986) in the UK. The latter refer to ‘felt’ as opposed to ‘enacted stigma’. While enacted stigma refers to episodes of discrimination against people with epilepsy on the grounds of socially unacceptable difference, felt stigma refers to the fear of encountering such discrimination, together with an internalized sense of shame. According to the ‘hidden distress model of epilepsy’ put forward by Scambler and Hopkins, felt stigma is typically more disruptive of the biographies of adults with epilepsy than enacted stigma. Specifically, acute felt stigma leads to a coping strategy premised on non-disclosure and ‘passing as normal’; people with epilepsy typically being discreditable rather than discredited, this has the effect of reducing opportunities for enacted stigma; felt stigma itself leads people to deny themselves full engagement in society, affecting relationships, lifestyle and work options; the result is that felt stigma is the principal source of unresolved tensions and problems and obstacles to accomplishment.
It was practitioners of disability studies who offered an alternative to medical sociology’s focus on passive labellees with coping problems. Thomas (2007) contrasts sociology’s ‘deviance paradigm’ with an ‘oppression paradigm’ arising out of the social model of disability. The oppression paradigm switches the emphasis back to the labellers and their historical, political and cultural roots. In this way the investigative focus becomes the oppression of the socially ‘abnormal’ by the socially ‘normal’, and of the ‘dis-able-bodied’ by the ‘able-bodied’. The focus of much research in disability studies is thus ‘disablism’.
If sociology was tardy in positioning biographical accounts of ‘shameful’ personal tragedies in wider social and structural contexts, this is a deficit now being addressed (Scambler & Paoli, 2006). Link and Phelan (2001: 363) draw on disability as well as sociological studies to define stigma as ‘the co-occurrence of its components – labelling, stereotyping, separation, status loss, and discrimination’, stressing also that for stigmatization to occur ‘power must be exercised’. Discrimination here does not simply refer to one individual’s treatment of another, but to structural or institutional discrimination (that is, to a ‘disabling environment’). Link and Phelan’s concept also encompasses discrimination some steps removed from labelling and stereotyping, as when a loss of status by stigmatization occasions a spiralling of disadvantage. Stigma, they insist, ‘is entirely dependent on social, economic and political power – it takes power to stigmatize’. With specific reference to HIV/AIDS, Parker and Aggleton (2003: 5-6) similarly insist on the salience of concepts like discrimination and power for understanding stigma: for them stigma functions ‘at the point of intersection between culture, power and difference’.
Scambler (2009) argues for a distinction between stigma (an ‘ontological deficit’ associated with shame) and deviance (a ‘moral deficit’ associated with blame). He argues that norms of shame and blame are alike embedded in social structures. Work-to-welfare programmes directed at the chronically ill and disabled, he suggests, can only be explained sociologically with reference to the post-1970s reinvigoration of relations of class relative to those of the state. The ‘benefits’ of work have to be set against the partial transmutation of clients’ shame into blame (via a state-imposed and policed moral imperative to work) also designed to contain labour costs and social transfers. Any reduction in stigmatization has therefore to be set against the currencies of (class-induced) exploitation and (state-induced) oppression. Stigmatization, according to this argument, is rarely the sole ingredient of disadvantage.
Finally, Green (2009) has recently suggested that we may be approaching ‘the end of stigma’. She argues that people with long-term conditions are increasingly refusing to be defined by their conditions and are finding their own voice. This kind of ‘fighting back’ has been defined by Scambler and Paoli (2006) as ‘project stigma’ with reference to shame and ‘project deviance’ with relation to blame. Green articulates her thesis about the end of stigma in more detail, writing of three ‘challenges to stigma. She maintains, first, that the ‘technological’ challenge is increasingly being met, with the result that many symptoms are better controlled and less noticeable than was the case. Second, the ‘personal’ challenge – namely, to construct a narrative projecting a positive self – is now being more overtly and effectively addressed. And third, the ‘organization’ challenge too has become more common currency: there is growing resistance at a political and societal level to the notion that those who are ill are inferior. Certainly there is more attention now being paid to the role of macro-social and economic structures in producing and reproducing stigma, a step well beyond interactionist preoccupations with persona tragedies.
References
Freidson,E (1970) Profession of Medicine. New York; Free Press.
Goffman,E (1963) Stigma: Notes on the Management of Spoiled Identity. Harmondsworth; Penguin.
Green,G (2009) The End of Stigma? Changes in the Spocial Experience of Long-term Illness. London; Routledge.
Link,B & Phelan,J (2001) Conceptualizing stigma. Annual Review of Sociology 27 363-385.
Parker,R & Aggleton,P (2003) HIV and AIDS-related stigma and discrimination: a conceptual framework and implications for action. Social Science and Medicine 57 13-24.
Scambler,G & Hopkins,A (1986) ‘Being epileptic’: coming to terms with stigma. Sociology of Health and Illness 8 26-43.
Scambler,G & Paoli,F (2006) Health work, female sex workers and HIV/AIDS: global and local dimensions of stigma and deviance as barriers to effective interventions. Social Science and Medicine 66 1848-1862.
Scambler,G (2009) Health-related stigma. Sociology of Health and illness 31 441-455.
Scheff,T (1966) Being Mentally Ill: A Sociological Theory. Chicago; Aldine.
Schneider,J & Conrad,P (1983) Having Epilepsy: The Experience and Control of Illness. Philadelphia; Temple University Press.