List of Appendices
1.6. Research Ethical Clearance
2.2.4 The Concept of Stigma
Erwin Goffman (1963:13-14) said stigma referred to bodily signs designed to expose something unusual and bad about themoral status of the signifier. The signs were cut or burnt into the body and advertised that the bearer was a slave, a criminal, or a traitor – a blemished person, ritually polluted, to be avoided, especially in public places.” Stigma “is applied more to the disgrace itself than to the bodily evidence of it”. Goffman’s definition suggests that stigma is an “attribute that is deeply discrediting” and that reduces the bearer “from a whole and usual person to a tainted, discounted one” Goffman (1963:14) describes three different types of stigma: 1- Abominations of the body-the various physical deformities 2- Blemishes of individual character perceived as weak will, domineering or unnatural passions, treacherous and rigid beliefs, and dishonesty, these
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being inferred from a known record of, for example, mental disorder, imprisonment, addiction, alcoholism, homosexuality, unemployment, suicidal attempts, and radical political behaviors 3- Tribal stigma of race, nation, and religion, these being stigmas that can be transmitted through lineages and equally contaminate all members of the family.
People living with HIV&AIDS almost always are associated with the first two because of the physical manifestations of AIDS and the association of HIV with “deviant” and
“immoral” behaviors (particularly sexual “promiscuity” and intravenous drug use). In addition, many people living with HIV&AIDS are members of groups that are already marginalized such as sex workers, women, homosexuals, the young and the poor. This particular subset of individuals with HIV&AIDS experiences multiple stigmas, with the HIV stigma compounding pre-existing stigmas (known as double or compound stigma) (Parker and Aggleton 2003). HIV&AIDS stigma is then used to justify further marginalization of such people, further entrenching deeply rooted prejudices
Since Goffman, elaborated definitions have varied. For example, Crocker et al (1998:505) indicate that, “stigmatized individuals possess or are believed to possess some attribute, or characteristic, that conveys a social identity that is devalued in a particular social context”. Scott and Miller (1986: ix), support Crocker’s view and extend the definition of stigma as a “product of definitional processes arising from social interactions between those who acquire potentially discrediting conditions and the individuals with whom they interact.”These authors thus critique Goffman’s notion of stigma as an “attribute that is deeply discrediting” (Goffman, 1963:13). They argue that attributes themselves do not automatically qualify persons for stigmatization, but rather view stigma as a dynamic element within the processes of social interactions. People, they write, “qualify as stigmatized only within the context of a particular culture, historical events, or economic, political, or social situation” (Crocker 1998). Scott, Miller and Crocker raise three important points. First, stigma is not static. Second, it exists within a particular socio-historical and cultural context. Third, stigma is manifested during social interactions between those who acquire a potentially stigmatizing attribute and the people with whom they interact. As culture is in a constant flux, stigma evolves as culture changes. However, a question arises as to whether stigma can operate in the absence of social interactions. In other words, are social interactions a prerequisite for stigma to manifest itself? Stigma can be either “internal” or “external” (UNAIDS 2002a).
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External stigma refers to “actual experiences of discrimination. This may include the experiencing of domination, oppression, the exercise of power or control, harassment, categorizing, accusation, punishment, blame, devaluing, prejudice, silence, denial, ignorance, anger, a sense of inferiority, social inequality, exclusion, ridicule, resentment or confusion” (Policy Project 2003:4). Additionally, external stigma has a “powerful capacity to produce internalization and acceptance of inferiority by the oppressed group and justification of discrimination by the dominant group” (Policy Project 2003:5). Here we can speak of the internalized stigma, which is an indirect result of the stigmatization process. Internal stigma, on the other hand, is the “shame associated with HIV and AIDS and fear of being discriminated against. Internal stigma is a powerful survival mechanism to protect oneself from external stigma and often results in the refusal or reluctance to disclose HIV status or the denial of HIV and AIDS and unwillingness to seek help”.
Individuals, who possess a potentially stigmatizing attribute, or might acquire one at a later stage in life, are usually aware of the negative cultural perceptions and representations surrounding them, based on the preconceived ideas about their particular condition that reflects dominant cultural beliefs and attitudes (Oyserman and Swim 2001).
Deacon et al (2005), distinguish between Instrumental and Symbolic Stigma.
Instrumental stigma, he said, is intended discrimination based on risk perceptions and resource concerns. Symbolic stigma, he opines, relates to cultural or religious meanings expressed in religious or moral judgments, or in emotional responses. However, instrumental and symbolic stigma do not originate from the same social, cognitive, or emotional process, nor would the same intervention be appropriate. Symbolic stigma carries the weight of the religious, moral, cultural and social baggage associated with particular diseases, imbuing them with negative meanings that go so far beyond the instrumental concerns. In the language of religion, the infringement of cultural and social norms may be re-conceptualized as ‘sin’. Stigmatization varies in different cultures.
Mazrui (1986:239), defines culture as “a system of interrelated values active enough to influence and condition perception, judgment, communication, and behaviors in a given society.” Furthermore, Airhihenbuwa and Webster (2004:5) refer to Hahn (1995) and emphasize “the role of culture and society in relation to sickness and healing, and highlight the use of language in the understanding of illness concept.” Additionally, they
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highlight Brody’s (1987) view that “one’s cultural belief system influences one’s social roles and relationships when one is ill” (Ibid:5). The approach that emphasizes the notion of stigma as a cultural and social construct critiques the view of stigma as an expression of individually held attitudes. This notion stresses the importance of historical, social and cultural contexts of stigma that influence the individual. Stigmatizing attitudes are, therefore, not a property of individuals, but they are shaped within a cultural context.
Hence, it is difficult to establish a definition of stigma within a particular framework and stigmatization varies in different cultures. Douglas (1966) talking about dirt said “dirt is essentially disorder, there is no such thing as absolute dirt, it exists in the eyes of the beholder…Dirt offends against order”. What we do with our bodies is a map of what we do with our society. Each society establishes its norms and values that define acceptable attributes and behaviors for its majority. It also defines instruments of social control in a form of laws to ensure adherence to such norms (Becker and Arnold 1986).Anyone that breaks a norm, is likely to be punished. Stafford and Scott (1986), propose that stigma is
“a characteristic of persons that is contrary to a norm of a social unit” where a “norm” is defined as a “shared belief that a person ought to behave in a certain way at a certain time.” The basic premise behind the notion of deviance and social control is that established norms reflect the views of the majority. However, it is disputable who composes the majority as well as whose interests the majority represent. According to Link and Phelan (2001), “stigmatization is entirely contingent on access to social, economic and political power that allows the identification of different-ness, the construction of stereotypes, the separation of labelled persons into distinct categories and the full execution of disapproval, rejection, exclusion and discrimination”. Parker and Aggleton (2003), in turn suggest that, “stigma can become firmly entrenched in a community by producing and reproducing relations of power and control. Stigma is used by dominant groups to legitimize and perpetuate inequalities, such as those based on gender, age, sexual orientation, class, race or ethnicity.” They argue further that the ability of the stigmatized individuals to resist is quite limited because of their marginal status.
According to Brandt (1998:148), “the way a society responds to problems of disease reveals its deepest cultural, social and moral values”. As Brandt continues, “the epidemic has been shaped not only by powerful biological forces, but by behavioural,
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social and cultural factors as well”.Quam (1990) points out that “the ascription of stigma to any condition arises out of the symbol system within a culture, and, like other symbolic acts, follows a logic within which relationships are more emotional than rational.” The dynamics of stigma are reflected in the history of diseases such as TB, leprosy etc. Blame, denial, and fear that accompany various diseases have formed a standard way of response towards the epidemics that were perceived as ‘deadly’ or
‘dreadful’, thus reinforcing stigmatizing responses. Doka (1997) explains, “TB was considered a mark of shame, a reminder of dark tenements and unsanitary conditions.”
Doka further explains that the stigma of leprosy “reaches back to biblical times when lepers were expelled from their communities, doomed to wander as the walking dead.
Having leprosy meant that one became socially dead.” Additionally, during the Middle Ages, Sontag (1979) writes, “the leper was a social text in which corruption was made visible; an exemplum, an emblem of decay.” What is particularly ‘interesting’ about leprosy is that, as with HIV&AIDS nowadays, it was defined in terms of ritual purity. As Douglas (1966) points out, “pollution is the result of our contact with ‘dirt’.” Douglas continues that dirt is “matter out of place. Dirt is the by-product of a systematic ordering and classification of matter, in so far as ordering involves rejecting inappropriate elements”. Thus persons classified to be “out of place” are then labelled as socially dangerous and treated as such. The question then is how HIV has and AIDS come to be identified in terms of ritual purity? Despite all the numerous works on the nature of stigma, much work needs to be done in the area of the underlying causes of HIV and AIDS stigma. Although many of these works inform us about the manifestations of stigma they fail to point out the causes behind the stigmatizing attitudes towards people living with HIV and AIDS. Are the attitudes from cultural or religious concerns? Are they informed by a religious affiliation? “Stigma and discrimination are social and cultural phenomena linked to the actions of whole groups of people, and are not simply the consequences of individual behavior” (Parker & Agletton, 2003).