Social miscues: understanding stigmas
First posted July 26, 2002
Sometimes, it's like a slap in the face. You're sitting comfortably in a movie theater laughing with the rest of the audience, and then there it is: a bad joke about psoriasis. Nothing else ruins the experience in quite the same way. In the recent movie Ghost World, the fact that one of the characters has psoriasis (National Psoriasis Foundation mail is found in the character's mailbox) is brought out to somehow explain why the character is a quirky social misfit.
In another bad example of the way psoriasis is often portrayed in mass culture, a recent article in the magazine LA Life insinuates that psoriasis is a "downfall" that occurs to Hollywood stars.
Having psoriasis joked about in movies or magazines is a far cry from being mistaken for a person with leprosy and being forced to wear bells, as people with psoriasis were centuries ago, but it boils down to the same thing: stigmatization. Indeed, the word "stigmatization" may carry a special significance for people with psoriasis—the archaic meaning of the word is a distinguishing mark burned or cut into the flesh, as of a slave or criminal.
According to a 1993 study published in the International Journal of Dermatology, about 20 percent of people with psoriasis experience obvious rejection because of their disease, most often while at the gym, pool, hairdresser or job.
"I often wondered if I was mentally unbalanced," says a 34-year-old member, "because my psoriasis affected my self-esteem so much. My girlfriend didn't want to talk about it and said I was just vain. I couldn't understand why I was feeling so much anger and frustration."
More recent research by social epidemiologists and psychiatrists tells us that, in fact, stigmatization does erode a person's self-esteem, and can lead to stress, a known trigger factor for psoriasis. One of the ways to overcome stigmatization, however, is to understand how and why it occurs and what can be done to counteract it.
Anatomy of a stigma
Stigma expert Bruce Link, Ph.D., a professor of epidemiology at Columbia University and a researcher at the New York State Psychiatric Institute, says stigmas come into existence when four interrelated "components" converge.
In the first component, people identify and label human differences. Obviously, in psoriasis, this difference is skin lesions. Secondly, people associate the differences with undesirable characteristics. In psoriasis, Dr. Link suggests, one of these characteristics is people's fear that the disease is contagious.
The third component necessary for a stigma is when people doing the stigmatizing separate people into "us" versus "them" groups. This involves some lowering of status. Children are generally placed into a separate group from adults and given a lower status, but people don't separate children into "us" and "them" groups in the same way healthy people do to people with diseases.
The fourth component involved in the existence of a stigma is discrimination. People discriminate against stigmatized people in various ways, such as not wanting to date them, eat in the same restaurant or swim in the same pool because of the stigma, according to Dr. Link. "For this to occur, there almost always has to be a power difference," Dr. Link said.
For example, people frequently apply the first and second component of stigmas to lawyers—jokes about lawyers mark them as different and associate undesirable qualities to them—but a stigma isn't attached to lawyers, because they are not a discriminated group in our society. "If people with psoriasis controlled the pool, they wouldn't get kicked out," he said.
As a society, we are so accustomed to attaching stigmas to things that we may assume it is a natural or valid process. Researchers have discovered we apply stigmas to scores of circumstances: urinary incontinence, exotic dancing, being in debt or being an ex-convict, to name a few. We have attached a "dangerous" stigma to people who have a mental illness such as schizophrenia, yet there is no proof that people with a mental illness are any more dangerous than others.
Where do stigmas come from?
In a word, stigmas arise from fear. "Every society has things they reject," says social psychologist Jo Phelan, Ph.D., a colleague of Dr. Link's at Columbia University.
The specifics may vary—what is rejected in one society may be accepted in another—but generally the reasons that stigmas occur are similar. People fear what they do not understand or that they could be like the person they stigmatize. Essentially, people attach stigmas to seek social distance from others, Dr. Phelan says.
Most research on stigmas involves understanding the stigmatization of people with mental illness. Similar to when people with psoriasis are stigmatized, humor is often used as a tool to stigmatize mental health patients, Dr. Phelan says. While humor can be a coping mechanism for dealing with chronic disease, in these instances, people are using humor to create social distance.
"When a person says they are going to see their therapist, someone will make a joke out of it," she says. "It's an expression of discomfort."
We gain knowledge of cultural stigmas early on as we are socialized into culture. Thus, our expectations are usually pre-set about what others—our friends, employees, neighbors or intimate partners—will think if we develop or bear something that is stigmatized in the culture. Those expectations can lead to fear of rejection. In turn, fear of rejection has been shown to lead to strained relationships with others, constricted social networks, a compromised quality of life, low self-esteem, depression and loss of work, according to Dr. Link.
Overcoming stigmatization
In a classic work titled Stigma (1963), Erving Goffman defined stigma as an "attribute that is deeply discrediting" and that reduces the person being stigmatized "from a whole and usual person to a tainted, discounted one."
Mr. Goffman further defined stigmas as being either "discrediting" or "discreditable." A discrediting stigma is one based on characteristics immediately apparent to others, while a discreditable stigma is based on factors that aren't immediately apparent to others. If people with psoriasis can conceal their disease, most often they are coping with a discreditable stigma.
According to social psychologists, people with discreditable stigmas cope in a number of ways. They may decide to tell no one about the stigma (total secrecy); or they may reveal it to selected individuals or only late in a relationship (selective concealment); or they may make the stigma public knowledge.
Most people choose the "selective concealment" strategy, which may be more therapeutic than total secrecy. Recent research suggests that attempts to conceal stigmas actually cause a person to focus on it more intently. For example, saying to yourself, "don't think about a white bear," makes exactly the thing you're trying not to think about pop into your mind, says Dr. Link. Focusing on the disease, or worrying about keeping it secret and withdrawing from social interactions because of it, can cause stress, he said. On the other hand, sharing information selectively with others can help overcome feelings of isolation.
Similarly, "selective telling" can serve to test the strength of a relationship. Telling people you are developing a relationship with about your psoriasis may make it possible for them not to be surprised by your skin, as well as allow you to gauge whether or not it is worth continuing the relationship.
Interestingly, because people who carry the weight of a discreditable stigma have extensive practice at "concealment," researchers suggest, the stigmatized are better than "normals" at detecting the discreditable in others.
Raising public awareness
Another way to counteract stigmas is to raise public awareness through education. Increasing awareness that psoriasis is a genetic disease, for instance, can decrease social stigmatization, especially the stigmatization parents of children with the disease often confront.
The National Psoriasis Foundation is an advocate for people with psoriasis and has protested inappropriate public jokes or cracks about psoriasis over the years with some success. In the early 1970s, the Psoriasis Foundation brought comedian Bob Hope up short for a bad joke that stigmatized people with psoriasis in a television special. Mr. Hope responded with an apology.
The National Psoriasis Foundation encourages people who have psoriasis to protest any public portrayals of psoriasis as comic or trivial, and notify the Foundation so the organization can protest as well. For more information, call 800.723.9166 or e-mail getinfo@psoriasis.org.
Posted on July 26, 2002