My Daily Life  |  Stigma and Discrimination

Addressing The Heart of Stigma

By Dr Rayner Tan and Dr Martin Chio

16 July 2021  |   9 min read

Have you ever wanted to get something off your chest, but found it difficult to share it with someone for fear of being judged or shamed for it? Or perhaps you shared something deeply personal with someone, and received a negative response?

If you have, you would have had a taste of what stigma ‘feels’ like. 

Now, sit with this feeling. Imagine it amplified; imagine it hanging over your head like a dark cloud. This is what it may feel like for individuals living with stigmatised identities. What is stigma and where does it come from? What do you think are the long term effects of stigma on health? Most importantly, what can we do about it?

What is stigma?

Erving Goffman, the Canadian-born sociologist widely cited on his definition of stigma, described stigma as a mark on a person that is ‘deeply discrediting’, which renders the stigmatised person ‘from a whole and usual person to a tainted, discounted one’. He argued that society stigmatises on the basis of what it sees as ‘difference’ or ‘deviance’, which in turn manifests as the perception of a ‘spoiled identity’1.

How do we, in turn, learn what is ‘different’ or ‘deviant’? One explanation is that we interact with people, places, and things on a daily basis which teaches us what makes something deviant2. For example, we learn how we ourselves or others are seen as deviant or different through what we see in public spaces like the media, or through interactions with others in our own family, school, religious institutions, and at the workplace. In one study by the Institute of Mental Health, the researchers conducted focus group discussions with Singaporeans, who identified their interactions with people with mental illnesses, other formative experiences, cultural beliefs, and the negative portrayal of mental health by the media as significantly shaping their understanding of mental health stigma in Singapore3.

Health researchers have also found that stigma can exist in multiple forms that impact individuals in different ways.

  • Perceived stigma is stigma that is anticipated or perceived in society, usually experienced by an individual who identifies with stigmatised identities.
  • Internalised stigma refers to a self-stigmatisation process and a negative self-concept that is informed by one’s understanding of stigma relating to an individual’s own identity.
  • Experienced stigma, also commonly known as discrimination, refers to experiencing actions that disadvantage an individual by virtue of one’s own identity.

Perceived or anticipated stigma alone can prevent someone from seeking help, which highlights the negative impact of formative stigmatising experiences on care seeking and treatment engagement.

How does stigma affect health and health-seeking behaviour?

We now know that stigma serves as a barrier to help-seeking behaviours in many aspects of health. The Singapore Mental Health Study 2016 found that only about one in three people with mental disorders ever sought help in their lifetime, and this rate had not increased from the last population-representative study conducted in 20104. While mental health literacy is a key factor, studies have also found that stigma remains a key barrier to access for mental healthcare5

Offering non-stigmatising services at the clinic or service-provider level, while necessary, is not sufficient to bridge the help-seeking gap for individuals with stigmatised identities. For example, a study on sexual orientation-based stigma in Singapore found that perceived or anticipated stigma alone can prevent someone from seeking help, which highlights the negative impact of formative stigmatising experiences on care seeking and treatment engagement6.

Some stigmatised groups, such as sexual minorities, have been found to suffer from poorer mental health outcomes. Is this because there is something inherently biologically or psychologically innate to such groups that leads to higher levels of mood disorders, substance use, or suicide-related behaviours? The evidence tells us otherwise, and research among such affected groups highlights how stigma has a major trickle-down effect on such health outcomes. For instance, the minority stress theory offers significant insight into how minority stressors, such as sexual orientation-based victimisation or experienced homophobia, may trickle down to compound sexual and mental health problems for sexual minorities7.

A recent study in Singapore among 570 young gay, bisexual, transgender and queer men, aged 18 to 25 years old, found that 58.9% (n=308) and 14.2% (n=76) ever contemplated suicide and attempted suicide, respectively. The study found that higher levels of experienced homophobia were linked to higher levels of depression severity, which was in turn associated with a greater likelihood of reporting such suicide-related behaviours8. Past experiences of trauma, including complex traumas that involve internalised stigma, have also been linked to substance use-related disorders among sexual minorities9, 10.

What part can we play in combating stigma?

In this short article, we have briefly highlighted the definition and potential origins of stigma and its implications for health, especially among stigmatised communities such as people living with mental health challenges or mental illnesses, as well as sexual minorities. What can we do to combat stigma, and build a compassionate society?

Perceived and anticipated stigma are key barriers to help-seeking, and an important way to address this is through upstream efforts. We know that such forms of stigma are fostered and maintained through one’s own social learning, and we can do a lot more to ensure that media portrayals of stigmatised populations do not perpetuate or reproduce such forms of stigma. The Beyond The Label Media Guide is a great initiative that will have positive and lasting implications for mental health stigma, if adhered to. We can do our part, for instance, by taking the time to read through this guide, understand the power of media portrayals on mental health stigma, and not repeat the same stigmatising acts in our day-to-day interactions with others.

Furthermore, efforts can be made in schools to foster a deeper, and more compassionate understanding of minority and vulnerable groups in society. We can also address internalised stigma by ensuring that individuals have access to affordable, quality mental health screening and services that provide opportunities for healing from often complex, traumatic experiences surrounding stigma and discrimination.

Finally, all of us can do our part to help put a stop to stigma. We all have our own stereotypes (certain beliefs about groups of individuals who share an identity) and prejudicial attitudes (negative stereotypes) that are products of our own upbringing or formative experiences. We do not have to feel guilty, or be ashamed of having stereotypes as we are often thrust into environments, not by choice, that have informed our own world views. However, while we are not entirely responsible for these stereotypes, we can be responsible for how we respond to them.

Ultimately, it comes down to this: Do we choose to respond with prejudice? Or do we choose to do so with kindness? It is through our response where we can start to combat stigma, and build a more compassionate and inclusive society.

Resources

  • Community Health Assessment Team (CHAT) – Visit www.chat.mentalhealth.sg
  • Institute of Mental Health (IMH) 24-hour Helpline – Tel: 6389 2222
  • Oogachaga (a support community for LGBTQ individuals and families) – Visit https://oogachaga.com
  • The Greenhouse Community Services Limited (a substance addiction recovery centre for marginalised communities) – Visit https://thegreenhouse.sg/our-centre

Dr Rayner Tan is a Postdoctoral Fellow at the University of North Carolina at Chapel Hill Project-China in Guangzhou, China, and a Visiting Research Fellow at the Saw Swee Hock School of Public Health, National University of Singapore and the National Centre for Infectious Diseases in Singapore.

Dr Martin Chio is Adjunct Associate Professor at the Saw Swee Hock School of Public Health, National University of Singapore & Duke-NUS Medical School.

References

  1. Goffman, E. (1963). Stigma: notes on the management of spoiled identity. Englewood Cliffs, N.J.: Prentice-Hall.
  2. Dotter, D. L. (2004). Creating deviance: An interactionist approach: Rowman Altamira.
  3. Tan, G. T. H., Shahwan, S., Goh, C. M. J., Ong, W. J., Wei, K.-C., Verma, S. K., . . . Subramaniam, M. (2020). Mental illness stigma’s reasons and determinants (MISReaD) among Singapore’s lay public – a qualitative inquiry. BMC psychiatry, 20(1), 422. doi:10.1186/s12888-020-02823-6
  4. Shafie, S., Subramaniam, M., Abdin, E., Vaingankar, J. A., Sambasivam, R., Zhang, Y., . . . Chong, S. A. (2021). Help-Seeking Patterns Among the General Population in Singapore: Results from the Singapore Mental Health Study 2016. Administration and Policy in Mental Health and Mental Health Services Research, 48(4), 586-596. doi:10.1007/s10488-020-01092-5
  5. Corrigan, P. (2004). How stigma interferes with mental health care. American psychologist, 59(7), 614.
  6. Tan, R. K. J., Kaur, N., Kumar, P. A., Tay, E., Leong, A., Chen, M. I. C., & Wong, C. S. (2019). Clinics as spaces of costly disclosure: HIV/STI testing and anticipated stigma among gay, bisexual and queer men. Culture, Health & Sexuality, 1-14. doi:10.1080/13691058.2019.1596313
  7. Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychological Bulletin, 129(5), 674-697. doi:10.1037/0033-2909.129.5.674
  8. Tan, R. K. J., Low, T. Q. Y., Le, D., Tan, A., Tyler, A., Tan, C., . . . Wong, M. L. (2021). Experienced Homophobia and Suicide Among Young Gay, Bisexual, Transgender, and Queer Men in Singapore: Exploring the Mediating Role of Depression Severity, Self-Esteem, and Outness in the Pink Carpet Y Cohort Study. LGBT Health, 8(5), 349-358. doi:10.1089/lgbt.2020.0323
  9. Tan, R. K. J., Wong, C. M., Chen, M. I. C., Chan, Y. Y., Bin Ibrahim, M. A., Lim, O. Z., . . . Choong, B. C. H. (2018). Chemsex among gay, bisexual, and other men who have sex with men in Singapore and the challenges ahead: A qualitative study. International Journal of Drug Policy, 61, 31-37. doi:https://doi.org/10.1016/j.drugpo.2018.10.002
  10. Tan, R. K. J., Phua, K., Tan, A., Gan, D. C. J., Ho, L. P. P., Ong, E. J., & See, M. Y. (2021). Exploring the role of trauma in underpinning sexualised drug use (‘chemsex’) among gay, bisexual and other men who have sex with men in Singapore. International Journal of Drug Policy, 97, 103333. doi:https://doi.org/10.1016/j.drugpo.2021.103333