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November 2003 Stigma is as old as history. While the word dates back to ancient Greek times and refers to the physical mark made by fire or with knives on individuals or groups considered outsiders or inferiors, the concept appears universal. In different cultures and at different times, slaves, criminals and adulterers - or those suspected of being slaves, criminals and adulterers - have been branded or otherwise physically marked. The physical marks have gone, but stigma remains, based on one or more factors, such as age, caste, class, colour, disease, ethnicity, religious belief, sex and sexuality. Stigma is applied by society and borne or possessed by groups and individuals. By defining deviance and confirming exclusion, stigma reinforces social norms. We do not use the word stigma very much in English today. We have replaced it with the -isms - sexism, racism and so on. And it is not as universal as it once was; stigmas have weakened as society has fractured. Nonetheless, stigma remains and in many parts of the world is as strong as before. Think of caste in India, women in Islam and homosexuals in Africa and Jamaica. And think of HIV/AIDS throughout the world. At the heart of stigma lies fear - fear that those who are stigmatized threaten society. Underlying that fear is often ignorance - such as ignorance of the way of life of stigmatized groups, ignorance of the realities of sexual behavior or ignorance of the way in which diseases spread. Yet although the concept is negative, stigma can have positive consequences. Stigma can create a sense of community which gives individual members the motive to challenge the stigma. After centuries of stigma Indian dalits, once known as "untouchables", have found a common voice and are demanding human rights. And across the world, despite fierce opposition in many societies, gay men and women are fighting free of the stigma that burdens them. The corollary of stigma is discrimination. The original meaning of the word was to note differences. Over time, however, it has come to mean to perpetrate an unjust action or inaction against individuals who belong, or are perceived to belong to a stigmatised group. Discrimination tends to fall into two categories: legislative, which reflects stigma enacted in law or policy, and community, which reflects stigma in less formal contexts, such as the family, workplace or and social settings such as the local marketplace, sports center or bar. Stigma and discrimination are self-perpetuating. A stigmatised group suffers discrimination, while discrimination underlines and reinforces stigma. There are three components to discrimination: discriminatory (or prejudicial) attitudes, discriminatory behavior and discrimination. The first two (attitudes and behavior) apply to individuals within the social norm, while the last (discrimination) applies to the relationship between those within the social norm and those who are stigmatised.
Discriminatory attitudes, discriminatory behavior and discrimination are obviously closely connected, but one does not always lead to the other. Discrimination may occur when discriminatory attitudes and behavior are not present (for example, when good intentions have the opposite effect) Similarly, it is possible for someone to suffer stigma but not discrimination (for example when stigmatised individuals or groups are consciously treated no differently from other members of society) Stigma and discrimination are often confused. For example, a working definition used for a 2001 meeting on HIV/AIDS-related stigma defined it as "a real or perceived negative response to a person or persons by individuals, communities or society. It is characterized by rejection, denial, discredting, disregarding, underrating and social distance." In fact, this does not define stigma, but discrimination arising from stigma. Attempts to analyse stigma and discrimination have led to narrower definitions that may not be universally understood or accepted. Some authors distinguish between "felt" and "enacted" stigma. The former refers to the individual's own attitude about their condition and how they expect how others will react on learning of it. (Felt stigma has also been referred to as self-stigmatisation and as fear of stigma.) In contrast, enacted stigma is actual experience of stigma and discrimination. Felt stigma often comes before enacted stigma and may limit the extent to which the latter is experienced. For example, some people living with HIV/AIDS may conceal their serostatus; as long as they are perceived as HIV-negative, they do not experience acts of discrimination. By reacting to felt stigma, they can avoid enacted stigma. However, while the term felt stigma is useful in that it separates the stigma itself from the way in which stigma is anticipated, "enacted stigma" is confusing in that it appears to be no more than an alternative term for discrimination. If a contrast is necessary to show the impact of discrimination, "experienced stigma" might be a more appropriate phrase. Stigma has long been associated with disease, particularly diseases which, through their association with disfigurement and death, provoke strong emotional responses. In the past, individuals suffering from leprosy, cholera and polio have all suffered stigma and the discimination that ensues. As a fatal disease which can cause disfigurement such as wasting syndrome, HIV/AIDS-related stigma combines both these fears and other pre-existing stigmas, including sexual misconduct and, in some communities, illicit drug use. "People with HIV/AIDS are often believed to have deserved what has happened by doing something wrong. Often these 'wrongdoings' are linked to sex or to illegal and socially-frowned-upon activities, such as injecting drug use. Men who become infected may be seen as homosexual, bisexual or as having had sex with prostitutes. Women with HIV/AIDS are viewed as having been 'promiscuous' or as having been sex workers." (UNAIDS) As with other diseases, ignorance about transmission fuels HIV/AIDS-related stigma as individuals fear casual contagion and take inappropriate actions or inaction. "At work, in education, in health care and in the community, people may lack the education to understand that HIV/AIDS cannot be transmitted through everyday contact, and they may not know that infection can be avoided by the adoption of relatively simple precausetions. This lack of awareness can lead people to stigmatize and discriminate against those infected, or presumed to be infection, with HIV/AIDS." (UNAIDS) A consistent finding in US studies is that people who are misinformed about HIV transmission are almost twice to hold stigmatising attitudes as likely as those who were well informed. The study goes on to review the way in which HIV/AIDS-related stigma and discrimination are manifest in health services, and attempts which have been made to overcome them. For more information, click the cover top right.
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