Cumulative consequences of stigma: Possessing multiple concealable stigmatized identities is associated with worse quality of life

Stigma Toward Substance Dependence: Causes, Consequences, and Potential Interventions

Substance dependence is a prevalent and urgent public health problem. In 2021, 60 million Americans reported abusing alcohol within the month prior to being surveyed, and nearly 20 million Americans reported using illegal drugs (e.g., heroin) or prescription drugs (e.g., opioids) for nonmedical reasons in the year before. Drug-involved overdose rates have been steadily increasing over the past 20 years. This increase has been primarily driven by opioid and stimulant use. Despite its prevalence, drug dependence is one of the most stigmatized health conditions. Stigma has myriad negative consequences for its targets, including limiting their access to employment and housing, disrupting interpersonal relationships, harming physical and mental health, and reducing help-seeking. However, because research on stigma toward people with substance use disorders (SUDs) is relatively sparse compared with research on stigma toward other mental illnesses, the field lacks a comprehensive understanding of the causes and consequences of SUD stigma. Moreover, it remains unclear how, if at all, these factors differ from other types of mental illness stigma. The goal of this review is to take stock of the literature on SUD stigma, providing a clear set of foundational principles and a blueprint for future research and translational activity.

Shared social identity and media transmission of trauma

When an individual or group trauma becomes a shared public experience through widespread media coverage (e.g., mass violence, being publicly outed), sharing a social identity with a targeted individual or group of victims may amplify feelings of personal vulnerability. This heightened perceived threat may draw people to engage with trauma-related media because of increased vigilance for self-relevant threats, which can, in turn, amplify distress. We studied this possibility among two U.S. national samples following the 2016 Pulse nightclub massacre in Orlando, FL (N = 4675) and the 2018 Dr. Christine Blasey Ford and Judge Brett Kavanaugh Supreme Court Senate hearings (N = 4894). Participants who shared LGBT or Hispanic identities with Pulse massacre victims reported greater exposure to massacre-related media and acute stress. Participants who shared Dr. Blasey Ford's identities as a victim of interpersonal violence and a Democrat reported more hearings-related media exposure and acute stress. Indirect effects of shared single identity on acute stress through self-reported event-related media exposure emerged in both studies. Results for sharing dual identities with victims were mixed. These findings have implications for media use and public health.

Stigma as a barrier and sex work as a protective factor for HIV testing among trans women in Nepal

Stigma towards trans women in Nepal creates individual and system-level risks for HIV. A critical protective factor is access to HIV prevention. Research is needed to determine the impact of stigma on HIV testing among trans women in Nepal. We conducted a secondary analysis of data collected using respondent driven sampling in 2019 on HIV risk among trans women in Nepal. Data analysis was restricted to trans women who were HIV negative at testing through the parent study. Descriptive statistics, tests for bivariable associations between HIV testing and stigma variables, and binomial Poisson regression were conducted to examine HIV testing outcomes. There were 173 participants who tested negative for HIV in our sample. The majority were under age 35 (59%) and most had a grade school education or less (64.7%). No trans women were homeless and most rented a room (70.5%) or owned their home (19.7%). The majority were currently sex workers (57.8%). Almost all HIV-negative trans women had ever been tested for HIV (90.8%), but only 53.5% in the last 3 months. The most frequently cited reason for not having been tested was thinking they were at low risk for HIV (40.9%) and being afraid of receiving a positive test result (22.7%). HIV and anti-trans stigma were high across most measures, including that almost all (94.2%) believed that most people in Nepal would discriminate against people with HIV. And most participants thought trans women were not accepted in Nepali Society (65.9%). Most participants also reported high social support (70.5%). Social cohesion among participants varied, with most experiencing medium (41.6%) or high (33.5%) social cohesion. Just over half had high social participation (55.5%). Participants who reported current sex work had lower prevalence of not testing for HIV in the last 3 months (prevalence ratio, PR = 0.54, 95% confidence interval, 95%CI = 0.32-0.92, p = 0.02). Every one-unit increase in social cohesion was associated with 1.05 times the prevalence of not testing for HIV in the last 3 months (95%CI = 1.01-1.09, p-value = 0.02). Trans women who did sex work were more likely to be HIV tested while those who were more socially connected to peers were less likely to have recently been tested for HIV. HIV stigma may result in fear of social rejection from peers if one tests positive. Interventions that focus on addressing stigma within trans women's social networks and strategies to mitigate HIV stigma in society may result in increased frequency of HIV testing among trans women in Nepal.

Perceptions of racial essentialism and social identity threat

While past research documents essentialist beliefs’ (i.e., believing social groups have inherent, unchangeable traits) impact on prejudice, no research has explored if stigmatized groups perceive essentialism as indicative of bias. With a sample of participants diverse in race and sexual orientation, we document that endorsers of racial essentialism were perceived as more likely to be racist and also as more likely to be sexist and heterosexist, relative to nonendorsers (Studies 1–2). As some essentialist beliefs about sexual orientation are associated with progay attitudes, another experiment parsed out dimensions of racial essentialism (i.e., natural kind and entitative beliefs) and examined differences in White sexual minorities’ expectations of bias from this race-based cue. Findings indicate that both essentialism dimensions elicited identity threat with potential consequences for sexual minorities’ desire to conceal their sexual orientation; thus, we broaden conceptualizations of cues that elicit identity threat while exploring nuances of the impact of perceiver identity and essentialism type.

“Breaking Free”: A Grounded Theory Study of Atheist Women in the United States

Using a critical, grounded theory approach, we interviewed 31 atheist-identified women to ascertain the ways in which women develop and navigate an atheist identity and how their experience is influenced by patriarchal, hegemonic Christianity in the United States using a concealable stigmatized identity framework. Qualitative analysis resulted in six core categories: (1) Embracing Atheism as Liberation, (2) Escaping Christian Patriarchy, Challenging Atheist Patriarchy, (3) Low Identity Salience Provides Protection from Anti-Atheist Discrimination, (4) Expectations to Conform to Christian Norms, (5) Disclosure Requires Thoughtfulness and Purpose, and (6) Connecting with Other Atheists is Valuable and Elusive. Although atheist women experienced sexism within atheist communities that made connecting with other atheists challenging, participants viewed atheism as liberating them from religious patriarchy. Anti-atheist discrimination was common early in women’s atheist identity development, but not as frequent or salient over time. Rather, Christian hegemony and the expectation to adapt to Christian norms were more distressing than individual acts of anti-atheist discrimination. Therefore, concealment and disclosure were used to reduce personal discomfort and protect others’ feelings, rather than to avoid overt anti-atheist stigma. Integration with previous concealable stigmatized identity and atheism literature is discussed. In the interest of more equitable and healthy atheist communities for women atheists, community members and leaders are encouraged to dismantle patriarchy within secular organizations and center women’s voices and experiences. Clinicians and researchers can increase awareness of how hegemonic, patriarchal Christianity influences their professional work and the women they serve and eradicate such bias from their methods.

"It's not just the hit itself": the social practice of injecting drug use among gay and bisexual men in Australia

BACKGROUND

Injecting drug use is purportedly more common among gay and bisexual men (GBM) than the general Australian population. Approaches designed to support the wellbeing of people who inject drugs may not be effective for GBM who inject, due to divergent settings, substances, and/or symbolism. We sought to identify the critical elements shaping injecting among GBM as a social practice and the implications for health and psychosocial wellbeing.

METHODS

We conducted 19 in-depth interviews with GBM in Australia with lifetime experience of injecting drug use, adopting the Frameworks Method for data analysis. Framed by social practice theory, transcripts were coded to delineate the constituent material, competency, and meaning elements of GBM's injecting practices. We developed themes encompassing the dynamic interrelationship between practice elements and wellbeing aspects.

RESULTS

Of 19 participants interviewed (aged 24-60 years), 17 identified as gay, two as bisexual. Injecting histories ranged from 2-32 years; most injected methamphetamine (n = 18). Injecting involved the integration of sexual function with substances and injecting skills in dyadic/communal settings. Beyond traditional harm reduction aspects, 'safe injecting' concerned trustworthiness of fellow practitioners, preventing addiction, and maintaining a solid self-concept. Injecting occurred as a dyadic/communal practice, in which an uneven distribution of materials (substances, sexual capital) and competencies (self-injecting) influenced risk and power dynamics. Pleasurable meanings of belonging, desirability and self-actualisation - gained from communities of practice - conflicted with injecting-related stigma, social dependencies, and fear of harms to body, mind, and sense of self.

CONCLUSION

Injecting is a heterogenous practice, including among GBM. Shifting configurations of its composite elements influence GBM's perceptions and experiences of pleasure, risk, and harms. Efforts to support their wellbeing should take a dyadic/communal approach and seek to rectify the uneven distribution of material and competency elements in these settings.

Stigma and Quality of Life among People Diagnosed with Mental Disorders: a Narrative Review

INTRODUCTION: The anti-psychiatric movements that emerged in the early 1960s led to the appearance of stigma in psychiatry. The misunderstanding of the concept of mental disorder, the negative way in which associated hospitalization was perceived, the inclination to treat patients through psychological therapies, and the criticism of pharmacological treatment led to the discrediting of psychiatry. AIM: The current paper aims to review the available literature regarding the impact of stigma on the quality of life of people diagnosed with mental disorders. MATERIAL AND METHODS: A narrative review of relevant literature published between 1999 and 2021 was conducted. The authors analysed studies found on PubMed and the Web of Science electronic databases. The search terms combined two overlapping areas with keywords such as "stigma" and "mental disorders". A descriptive analysis was employed to synthesize the obtained data. RESULTS: Stigma continues to be an important challenge to the management of health conditions in people with mental disorders. A lack of comprehension may give the impression that all psychiatric patients are aggressive and are unable to function adequately. Such stigmatizing beliefs and habits have proven to be very difficult to change. CONCLUSIONS: Due to the stigmatization and repulsive attitudes in society, patients are reluctant to be linked to any form of mental disorder or to be seen as having any contact with mental health professionals. This undermines the beneficial effects of treatment, resulting in a poor quality of life and diminished socio-occupational functioning.

Psychosis in transgender and gender non-conforming individuals: A review of the literature and a call for more research

Epidemiological studies have described higher rates of psychotic disorder diagnoses in transgender, as compared to cisgender, individuals. With the exception of this work and a small number of published case studies, however, there has been little consideration of gender diversity in psychosis research or clinical care. In this paper, we will review and critically evaluate the limited literature on gender diversity and clinical psychosis and articulate the critical need for more work in this field, more specifically on the following areas and how they bear on clinical care: 1) diagnostic biases; 2) how chronic non-affirmation and bias, gender dysphoria, and other gender minority stressors may operate as trauma and can contribute to clinically significant psychotic symptoms; 3) the potential impact of gender-affirming care, such as hormone therapies, on mental health and barriers for receiving such care in transgender and nonbinary individuals; and 4) culturally-sensitive and gender-affirming approaches for addressing psychosis. Finally, we consider ways in which researchers may engage in ethical, gender-affirming, and accurate approaches to better address gender identity in psychosis research. We hope that such research will aid in the creation of clinical guidelines for understanding, diagnosing, and treating psychosis in gender diverse individuals.

Navigating Stigma Trajectory and Mental Health Among Young Adults Living with Perinatal HIV in New York City

Perceived HIV stigma and mental health are fluid across the lifespan for people living with perinatally-acquired HIV (PHIV). The process of navigating discredited identities over time in the context of other life demands potentially exerts a toll on the mental health of adolescents and young adults living with PHIV (AYAPHIV). Based on data from a longitudinal study in New York City examining mental health and health risk behaviors among 182 AYAPHIV, we examined if increased perceived HIV stigma predicted mental health, future orientation, HIV-disclosure, and healthcare transition over time (2003-2018). Findings from linear mixed-effects modeling indicated that older age predicted poorer mental health, less future orientation, more HIV-serostatus disclosure, and adult medical services utilization. Perceived stigma was the only significant predictor of mental health and mediated the association between age and mental health-highlighting the importance of addressing stigma across development for AYAPHIV while addressing systems that perpetuate them.