This paper provides an understanding of what stigma is and the implications that it may have for policy and practice. The analysis relates particularly to employment. This includes exploring the link between stigma and social exclusion.
Additionally, the paper examines the relationship between stigma, discrimination and human rights violation. It describes how the three are intimately connected, reinforcing and legitimizing each other.
An understanding of stigma and its implications will help guide individual and collective responses to overcoming wider issues of marginalization or social exclusion, discrimination, racism and other social injustices. The papers also provide some of the interventions to addressing issues of stigma in employment.
Stigma and discrimination has long been a major public concern. People can be stigmatized based on their race, beliefs, obesity, and health status such as mental illness and AIDS (Maclean et.al 2009). Stigma has a dramatic, though under recognized effect on the life opportunities of stigmatized individuals including employment opportunities, access to education, health and housing (Maclean et al. 2009). People with HIV/AIDS and those with mental health problems have been reported to experience more stigma than those with other health problems (Gale etal., 2004). As a result, we will primarily concentrate on these stigmatized individuals.
In exploring this topic, the paper provides an understanding of what stigma is and the implications that it may have for policy and practice. The analysis relate particularly to employment. This includes exploring the link between stigma and social exclusion. Additionally, the paper examines the relationship between stigma, discrimination and human rights violation and describes how the three are intimately connected, reinforcing and legitimizing each other.
Understanding what stigma and discrimination are is important in order to address the prevalence stigma has in society. An understanding of stigma and its implications will help guide individual and collective responses to overcoming wider issues of marginalization or social exclusion, discrimination, racism and other social injustices (Brohan & Thornicroft 2010).
What is stigma?
Stigma has been defined differently by various authors. For example, Stafford & Scott (1986) define stigma as a characteristic of a person that is contrary to the norm of the society. Graham Thornicroft, a research leader at the Kings College Institute of Psychiatry in London, conceptualized stigma as comprising of three main problems: problems of knowledge (ignorance), problems of attitudes (prejudice) and problems of behaviour (discrimination) (Thornicroft et al., 2011, p.260)
Erving Goffman, a renowned sociologist, defined stigma as a phenomenon whereby an individual with a deeply discrediting attribute is excluded or rejected by the society as a result of the attribute (Goffman 1963). Expanding on Goffman’s work, Link & Phelan (2001) model stigma as comprising of four key components:
a) Labeling – whereby an individual’s personal characteristics become noticed as conveying an important difference (Link & Phelan 2001);
b) Stereotyping – wherein the differences are linked to undesirable characteristics (Link & Phelan 2001);
c) Separating – which involves drawing a distinction between the mainstream/normal group and the labeled individuals.
d) Discrimination and loss of status – where the label group is devalued, rejected and even excluded from the mainstream group (Link & Phelan 2001).
Clearly, stigma has been given a varied set of definitions depending on the author. What is clear, however, is that for an individual to become stigmatized; he/she must possess certain characteristics or attributes regarded unacceptable in a particular social context.
Discrimination with stigma
It is hard to define stigma since it is found in beliefs and people’s attitudes. Discrimination, on the other hand, is easier to identify as it relates to an actual behaviour. In line with Goffman’s analysis and that of Link and Phelan (2001); we conceptualize discrimination as an end result of stigmatization and not as separate from stigma.
As defined by the UNAIDS (2000), discrimination refers to any form of arbitrary distinction, restriction or exclusion of a person by virtue of certain attributes or characteristics perceived to be socially unacceptable. That is, a display of hostile behaviour towards an individual on account of the perceived difference between the individual and the rest of the society. It follows that discrimination is an action taken based on a pre-existing stigma.
It can manifest in three major forms: direct discrimination, structural discrimination and insidious forms of discrimination (Phelan & Link 2006). Direct discrimination occurs when, for example, an employer overtly rejects a job application from someone perceived to possess a trait that is stigmatized (Phelan & Link 2006). Structural discrimination, on the other hand, is more subtle. For instance, white employers may engage in structural discrimination by relying on job recommendations that are biased in terms of race. While there is no direct denial of job based on colour, discrimination has clearly taken place. Similarly, placing treatment facilities for stigmatized diseases such as schizophrenia in isolated settings constitute structural discrimination (Link & Phelan 2006).
Insidious discrimination occurs upon realization by the stigmatized individual of the negative labels applied to them which render them as incompetent, less trustworthy and dangerous (Phelan et.al, 2000). The ultimate result of such is strained and uncomfortable social interaction, unemployment, low self-esteem, depressive symptoms, compromised quality of life and more constricted social networks (Phelan et.al, 2000).
Human rights violation
Stigma, discrimination and violation of human rights are intimately connected, reinforcing and legitimizing each other (Wood & Aggleton 2010). Their manifestations are varied occurring at work places, in communities, families, in education and also in health services. The two concepts “stigma” and “discrimination” are inter-related in the sense that stigma leads people to engage in discriminatory actions (Wood & Aggleton 2010). Discrimination, on the other hand, is an enactment of stigma. It thus encourages and reinforces stigma (Wood & Aggleton 2010).
Discrimination is also a human right violation. As enshrined in The Universal Declaration of Human Rights, all are equal before the law and are entitled to equal protection without any discrimination (UNAIDS 2000).
Based on this principle, discrimination on the basis of certain characteristics such as HIV/AIDS status is thus prohibited and is considered a violation of human rights. Stigma and discrimination are thus a violation of fundamental human rights. Discrimination directed at stigmatized individuals such as those living with HIV/AIDS violates basic rights such as the rights to health, privacy, dignity, and freedom from inhuman and degrading treatment (UNAIDS 2000).
Link between stigma and social exclusion
As noted above, the ultimate effect of stigmatization is discrimination and social exclusion. People who are stigmatized, such as those living with HIV/AIDs, obesity and those with mental illness are often discriminated against and ultimately excluded or alienated from the society. Their exclusion is also a violation of fundamental human rights. For example, the Rastafarians were in the past discriminated against, in the UK.
As Chevannes (1998) argues, the Rastafarians were stigmatized in the UK and subsequently excluded from the mainstream society due to urban myths. Ultimately, this exclusion led to their discrimination in employment opportunities and in the workplace, which in turn resulted in their alienation due to suspicion and fear among the mainstream society.
Having defined stigma and discrimination, and having explored on the link between stigma and social exclusion, it is worth exploring its impact and the implication that it may have for policy and practice.
Impact of stigma
Stigma associated with mental illness is a major issue facing many employers and employees alike in employment. According to estimates by the World Health Organization (WHO), one in four people are likely have mental illness at some point in their lifetime (WHO 2001). Stigmatization of such individuals can lead to social exclusion, low self-esteem and reduction in life chances especially in areas of employment.
A number of authors including Brockington et al., (1993) and Crisp et al., (2000) have shown that people with mental health problems are stigmatized largely due to perception of dangerousness, benevolence, fear and authoritarianism. Read & Baker (1996) and Berzins et al., (2003) find evidence that individuals with stigma related to mental health problems have experienced harassment both in the workplace and community.
Moreover, there is strong evidence that stigma results in delayed help-seeking behaviour in these individuals. It prevents such persons with mental health problems from acknowledging symptoms and obtaining the much needed help due to feelings of shame, guilt, inferiority and the wish for concealment (Grove 2012). As noted by Goffman (1963), stigmatized individuals may accept the negative labels placed on them resulting in self-stigma which manifests in many ways including shame, self-hatred and self-isolation.
Similarly, HIV/AIDs related stigma is reported to have severe implications on the stigmatized person. The onset of HIV and AIDS during the early 1980s triggered responses of stigma, fear, denial and discrimination which have, up-to date, been targeted at individuals perceived to be infected (UNESCO 2002). Such individuals become rejected not only by the community but also by their beloved ones. These individuals are also reported as having been denied access to health and education services on several instances. Research also shows that such individuals receive unfair treatment in the workplace.
The root causes of stigma related to HIV/AIDS are fear and moral judgement (UNESCO 2002). HIV/AIDS pandemic is associated with fear of causal transmission of virus, fear of living with the virus, fear of loss of productivity, and imminent death (UNESCO 2002). Moral judgment is also considered as the root cause of the stigma. People infected with the disease are often seen as self-blaming, since the transmission of the pandemic is linked to stigmatized behaviour.
HIV/AIDS-related stigma remains a barrier to effectively managing this epidemic. The fear of shame and discrimination prevents such infected individuals from seeking the much needed help and support, thereby making prevention and management extremely difficult. The feelings of shame, guilt and the fear of discrimination impedes an individual’s willingness and ability to adopt preventive behaviours. This results in delayed help-seeking behaviours.
Stigma still appears to be a major issue facing many employers and employees. There is increasing evidence of people being turned down for a job simply because they are infected with stigmatized illnesses. Others have also reported as having stopped looking for employment because they expect to be discriminated against.
For example, a study led by Graham Thornicroft found over a third (34%) of the participants as having been shunned by people due to their mental illnesses (Thornicroft et.al, 2007). The study also found nearly a quarter (25%) of the participants as having stopped applying for work because they anticipated discrimination, and another 37% who were afraid of initiating close personal relationship due to fears of being discriminated against (Thornicroft et al., 2007).
However, it was found that for those who anticipated discrimination, their experiences did not necessarily confirm this. Nearly half (47%) of those who had stopped looking for work and 45% of those that were afraid of initiating personal relationships because they anticipated discrimination did not in the actual sense experience this (Thornicroft et al., 2007). The study also found that 71% of the participants wished to conceal their illness, raising concerns about delayed help seeking behaviours due to fears of discrimination once their condition is disclosed (Thornicroft et al., 2007).
Similarly, a recent survey on 500 leading employers in the UK conducted by SHAW Trust, showed that one in three employers thought that persons with mental illness were less reliable than the rest of the workforce (Thomas 2012). The survey also found that negative attitudes held by employees towards the mentally ill were a major barrier to employing individuals with mental illness. This indicates that stigma is still a major concern in the employment.
Implications on policy and practice:
There is a current policy spotlight on providing stigmatized individuals with greater employment support. This is largely due to emerging evidence of discrimination of stigmatized individuals in employment. It should be noted that some societies may increase the level of stigmatization through their laws, rules and policies. Legislations such as limitations on international travel and migration and those that include compulsory screening and testing tend to increase stigmatization and create a false sense of security concerns among individuals who may not necessarily be dangerous (EU report 2010).
There is, however, a range of standards and policy initiatives which have been formulated to help address problems of stigmatization. The National Service Framework for Mental Health, for example, has incorporated standard services which must be adhered to including guidance on social inclusion, tackling stigma, and ensuring health promotion among those with mental illness (DFID 2007).
There is also the Disability Discrimination Act (DDA) 1995 which prohibits discrimination of disabled individuals in terms of employment, union membership and access to housing, health and education services (DFID 2007). The definition of disability is extended by the DDA 2005 to include people diagnosed with HIV. This implies that people with traits or attributes considered stigmatized are protected against discrimination in recruitment, training, promotion and from unfair dismissal. Such individuals are also protected against harassment and discrimination by colleagues in the workplace.
However, despite these policy initiatives, it is apparent that stigma and discrimination is still an issue. For example, in the UK and the US, elaw and licensing practices are making it increasingly difficult for stigmatized individuals to be employed (Gonzalez 2012). Under the American with Disabilities Act, disabled persons can be denied a license especially where such a person poses a threat to others that cannot be reasonably eliminated (Gonzalez 2012).
Also, a study by the HIV Law project on professional licensing practices in the US reported over 20 states with requirements that prohibit granting or renewal of license for persons with communicable or infectious diseases including HIV (Gonzalez 2012). Adding to this discriminatory licensing criterion, the study found that science based data was largely ignored, thereby promoting stigma and denying stigmatized individuals employment opportunities.
A similar trend was evident in the UK especially when reforms were made to the job and benefit system with the aim of encouraging stigmatized individuals to re-enter the workforce (Gonzalez 2012). According to Laura Dunkeyson, a policy officer at the National AIDS trust, job applicants were often asked about their health status prior to the extension of an offer, which resulted in the exclusion of a number of persons from the workforce (Gonzalez 2012). Moreover, it was reported that, on application of a job by non-disabled and disabled individuals, the non-disabled persons were twice as likely to be invited for the interview as the disabled. Clearly, stigma still exists.
However, popular views about mental illness and HIV/AIDS appear to be improving in term of less social rejection. According to a newly released research by Aviva (2012), over 28% of employees in the UK believe that the stigma associated with mental health problems has dropped. This is attributed to the increased awareness and public understanding of mental health issues. This shows that interventions that aim at improve public knowledge can effectively reduce the level of stigmatization. With improvement in public knowledge, people are more likely to recognize features of illnesses and become more supportive for those with such illnesses.
Interventions to reduce stigma
Efforts to reduce stigma have often been inhibited by the lack of public awareness and knowledge on issues contributing to the stigmatization of persons. Efforts to address stigma have also been inhibited by the lack of incentives/benefits for taking action (DFID 2007). Adding to this, stigma has been perceived as culturally specific and complicated to address (DFID 2007).
The following are some important steps that might be taken to address the issue of stigmatization in employment:
Stigmatized individuals could be provided with employment initiatives such as individual placement and support interventions (IPS) which is more effective than the traditional rehabilitation schemes (Pinfold 2003).
Promote awareness of anti-discrimination legislation in the public (Grove 2012).
Promote social inclusion through strengthening efforts to overcoming administrative, legal and societal barriers that prevent stigmatized individuals from enjoying equal and full participation (EU report 2010).
Education also plays a major role in addressing stigma and discrimination in the society. It plays a key role of lessening the stigma and can affect change where the law has failed such as changing societal attitudes (Knifton 2010).
Supporting meaningful participation of stigmatized individuals in national planning and policy making as well as in other processes (DFID 2012).
The government also has a key role to play alongside law reform and national human rights commissions. They may condemn stigma and discrimination both in employment and in the community
Ensure promotion and protection of human rights in institutional settings
Challenge/address discrimination at workplaces
Ensure policy dialogue and policy reform where necessary
Increase interaction with stigmatized individuals to help build their confidence and increase their self-esteem
Ensure strengthening and building capacity of individuals with stigmatized illnesses through skill building, training and counseling, network building, and income generation (DFID 2012).
Ensure interactive and participatory education. This is highly effective as it fosters greater understanding of stigma and allows people to reflect on their attitudes and actions, thereby catalyzing individual change around stigma (DFID 2012).
Advocate for policies that promote and facilitate effective rights based approach to addressing stigma related issues.
There is also the need to stop mandatory testing except for limited purposes such as blood donations, court orders and epidemiological research.
In addition, there is need for the government to emphasize on the rights of privacy of test results, given the recent changes in law in UK which allows insurance companies the right to know test results.
Stigmatization remains a major issue facing both the employers and employees. People can be stigmatized based on their race, beliefs, obesity, AIDs and even based on their mental health. Stigma has a dramatic, though under recognized effect on the life opportunities of stigmatized individuals including employment opportunities, access to education, health and housing.
Efforts to reducing stigma have often been inhibited by the lack of public awareness and knowledge, lack of incentives/benefits for taking action, and the widely held view that stigma is complex to address. However, a few of initiatives appear to be reducing the level of stigmatization. According to a newly released research, popular views about mental illness and HIV/AIDS appear to be improving in term of less social rejection. This has been attributed to the increased awareness and public understanding of mental health issues
While there is a voluminous literature exploring the public’s perception of stigma, there is need for further research to explore these people’s experiences, the impact on their lives, and ways to addressing these issues. This could help shape interventions and policies for improved legislation.
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