Lecture notes – Frank Jacob
3rd October 2007
Webster’s dictionary defines stigma as a “mark of shame or discredit”. Goffman (1963) traces the origin of the word back to the ancient Greeks who used the word to describe cuts, or branding, made in the body to denote whether the person was a slave, criminal or a traitor.
It was a sign of disgrace and shame.
Goffman (1963) went on to argue that a stigma, or having a stigmatised condition is socially constructed, whereby the person is measured against what is considered to be “normal”. For example it is considered “normal” to have ones sight, therefore to be blind is “abnormal” and thus there is a stigma surrounding blindness.
Goffman suggests that stigma is, “an undesirable attribute that is incongruous with our stereotype of what a given individual should be” Goffman (1963, p.3.)
Goffman argues that when we meet another person we categorize them according them various attributes and characteristics that we consider to be normal for that category.
This categorization is made therefore on the social identity of the individual. Social identity is made up from a number of factors and may include e.g.:
• Physical appearance and activities
• Professional roles
• Concept of self
Hooper (1981) argues that anything changes the person’s social identity such a physical deformity creates a stigma.
Stigma according to Goffman is something that disqualifies a person from full social acceptance. When a person is not able to meet our expectations because their attributes are different or undesirable they become reduced from being acceptable to undesirable
Classifications: Goffman (1963)
1. Discredited: Visual clues, e.g. a wheelchair, shortness of breath, smell, clothes
2. Discreditable: No visual clues, therefore the discrepancy is hidden. E.g. Epilepsy, HIV positive, Schizophrenia etc. The dilemma then arises whether to tell or not.
Types of stigma: Goffman (1963)
1. Stigma of physical deformity: e.g. physical changes associated with ageing/disease process, obesity/size, colour etc. (N.b physical beauty, youthfulness, leanness is considered to be the norm, thus when one ages there is pressure to remain lean and slim).
2. Stigma of character blemish: e.g. mental illness, alcoholism/drug abuse, smoking, homosexuality, HIV, suicide. The point with this type of stigma is the assumption that the person is responsible for their “condition”, and should exercise self-control. As the individual is considered to wholly or at least partly responsible for their “condition” a moral judgement is usually linked to people with the “condition”.
3. Prejudice: Tribal in origin. Occurs when one group perceives features of race, religion, nationality, class of another group as deficient when compared with their own constructed norm.
Stigma is a discrepancy between what is desired and what is actual. The discrepancy spoils the social identity, isolates the person from societal and self-acceptance.
Saylor (2002) argues that feelings of shame and guilt are common feelings associated with stigma.
Guilt: emanating from self-criticism.
Shame: emanating from disapproval from others.
For example, an alcoholic mother may feel guilt in that she is unable to meet the needs of her children, and also experience the shame of condemnation for others for neglecting her children.
Illness as deviance
Scambler argues that when a person violates a set of laws, rules or social norms they and their behaviour and likely to be viewed as being deviant.
For example, consider how you may feel about the writing graffiti on the walls of the Radiography Department, or your house ---- You are likely to see it as an outrage and see the perpetrators and their behaviour as being completely unacceptable, or deviant, who need to be stopped, corrected and punished in some way.
Deviance therefore elicits an attitude in which the deviant is identified, and isolated and whereby some sanction is administered in order to bring the deviant back into line with the rest of the non—deviant society.
In Parsons (1951) proposed that for society to function optimally, we must all work to the best of our capability, and work (play the game) in co-operation with each other. Anyone who is considered lazy, or refuses “to play the game” is considered in some way to be a deviant, also any thing that hinders the normal, smooth functioning of a society is also unwelcome and is considered to be deviant.
Parsons took his argument to its logical conclusion and proposed that sickness should be considered a form of deviance, because it is disruptive and threatens the smooth running of any social group or society.
However as sickness happens to us all from time to time, and in many cases patients cannot be held responsible for their sickness, and cannot be blamed for their condition, ostracising and applying sanctions against the sick is inappropriate. Parsons therefore proposed that sickness has to be managed in a different way.
He suggested that firstly sickness has to be considered legitimate, and secondly that sick people have to play their part in trying to get better.
Parsons argued that one of the roles and functions that doctors and the health service fulfil is to diagnose and legitimise illness.
Consider two people who fail to turn up for work for two months. When questioned one says s/he has been suffering from a depressive illness, the other says s/he also has been suffering from a depressive illness and produces a sickness note from the GP to “prove it”.
One is considered to have a legitimate form of depression, the other is not.
Parsons therefore sees the role of the doctor as the gatekeepers to health care and the legitimizers sickness.
However consider what your reaction would be on learning that the person who had been suffering from the certificated depression, had spent the two months on a skiing holiday. Or that s/he had flushed the prescribed anti-depressant tablets down the toilet.
The chances are that the authenticity of the depression would questioned, as it would not be considered appropriate behaviour for a person who is on the “sick” to go on a two-month holiday. Or it would be considered that the person is not behaving appropriately by going against the doctors prescribed medical regimen.
Parsons argues that in order for the patient to claim the right “to be sick” they have to fulfil various responsibilities and conform to the sick role. By adopting the sick role the patient can then expect various benefits.
Obligations of the sick-role
1. The sick individual must want to get better and get out of the sick role as soon possible.
Patients who indulge in forms of self-harm are therefore viewed suspiciously. Consider your feelings towards the patient who smokes, or the alcoholic who goes out on bender and wakes up in a hospital bed.
Additionally people who do not seem to be helping themselves to recover or are seen to be always using sickness as a reason not to work are also viewed negatively.
Therefore people in this category are seen as hypochondriacs, and wasters.
1. The sick individual must comply with the medical regimen in order to get better.
The person, who flushes the anti-depressants down the toilet is viewed suspiciously because s/he is not compliant, and again is wasting the time and resources of the health service. Their entitlement to care is questioned.
Rights of the sick role
If the person does fulfil their obligations they can expect their sickness to be legitimised and for them to receive the care they require:
1. The sick individual is entitled to exemption from everyday activities and responsibilities', providing medical practitioner legitimises the sickness.
1. The sick individual can expect assistance from, or dependence on, others whilst they are sick.
Consider your feeling towards the following
A colleague who is off sick seen shopping for clothes in an expensive clothes store
A patient who is due to be discharged home, refuses to change into his clothes and goes “missing” from the ward when the taxi comes.
A colleague continually takes two or three days sick every month, but refuses to make an appointment to see his/her doctor.
A barium meal is booked at 9.am for a patient who has been told they must not eat from midnight. The patient informs you s/he has bacon and eggs for breakfast in the hospital canteen.
Good Patients and Bad patients
With the sick role there are expectations upon the patient in respect of how they should behave.
Parsons's theory indicates that patients are expected to adopt a passive role, where they are quiet, pleasant and co-operative.
It is argued that physicians/health professionals are the gatekeepers to health care and they legitimise sickness, by making a diagnosis. The diagnosis therefore itself “creates the condition”, and, depending on the diagnosis there may be far-reaching implications for the patient and his/her relatives.
What do you think it would mean if you or a close relative were given the diagnosis of cancer, or heart disease, etc.
However, not only does the diagnosis clarifies, and identifies the range of signs and symptoms the patient has been presenting with, it also identifies the patient with the disease. The diagnosis therefore becomes the label.
When you are in the clinical placement, see how many times a patient is identified by their disease. – For example Mr Jones’s identity becomes replaced by his disease or by the technical procedure that is to be performed. So he becomes “this morning’s bowel resection”, or he is “this afternoon’s barium enema”, or simply he is known as the CA (carcinoma) of the bronchus in cubicle 12.
Thomas Scheff (1966) argued that diagnosis of some conditions, which also carry a stigma, have far-reaching consequences and determine how other people perceive and behave towards people with a particular condition.
Scheff suggested that the diagnosis of certain mental illnesses, such as schizophrenia, is tantamount to putting a label on that person. Subsequently people seek to avoid (in case its catching), and marginalise people with this kind of label, and the psycho-socio problems of people for example with schizophrenia largely emanate from how they are marginalised and ostracised by the rest of society.
Consider which other conditions that carry a label:
AIDS, Sexually transmitted diseases, Cancer, Epilepsy, Drug/Alcohol addiction,
Basically labelling is the pre-cursor to a self-fulfilling prophesy.- If you adopt the attitude that a particular person is stupid, or unworthy, then they behave accordingly.
Scambler argues that stigmatising conditions have a stereotyping effect upon the patient. A person who is blind may be perceived to be less able to engage in mainstream society, may be in need of more support, and should be admired (patronised) for their achievements. In other words the patient conforms to a cultural stereotype about that condition in the following ways:
1. They may concur with the stereotype
2. They isolate themselves from “mainstream” to protect themselves 3. Adopt a façade of compliance for convenience sake
4. Make others pay for their condition (for example by begging) 5. Actively resist the stereotype
Larson (1977) asked groups of health professionals to look at a picture of a fictitious patient.
Different groups were presented with the same picture, but the disease, and occupation, and seriousness of the condition were changed. Some groups were shown the patient to have a high status job and a disease with an acceptable disease. (e.g. A 52 year old man, a vicar, with an inguinal hernia [non serious condition])
Other groups were shown the patient to have a low status job (or no job) with a socially unacceptable disease. (e.g. a 52 year old man, claiming social security, with cirrhosis of the liver [an alcohol related, serious disease]).
The health workers were asked to rate the two patients, and they consistently rated the patient who was of a lower social status, , in more less favourable terms. He was seen as being more dependent, passive, unintelligent, unmotivated unsuccessful, lazy, careless and unreliable.
Similarly patients with a socially unacceptable disease, were seen as being more sensitive, rigid, and resistant, that those who had an acceptable disease.
Lives at home with parents
Alcohol consumption: social drinker at weekends
Diagnosis: Termination of pregnancy (3rd time)
How do you feel about this patient?
| |Strongly agree |Agree |Unsure |Agree |Strongly agree | | |Very sympathetic | | | | | |No sympathy at all | |She’s Responsible for| | | | | |She’s a victim | |condition | | | | | | | |I wouldn’t want to | | | | | |I would want to | |support & comfort her| | | | | |support & comfort her| |Deserves the best of | | | | | |Undeserving of care | |care | | | | | | | |Drain on NHS | | | | | |Legitimate use of NHS| |resources | | | | | |resources | |Irresponsible person | | | | | |Responsible person |
Lives at home with parents
Alcohol consumption: social drinker at weekends
Diagnosis: Head neck and arm injuries after an assault
How do you feel about this patient?
| |Strongly agree |Agree |Unsure |Agree |Strongly agree | | |Very sympathetic | | | | | |No sympathy at all | |She’s to blame for | | | | | |She’s a victim, and | |her condition | | | | | |is not to blame. | |I wouldn’t want to | | | | | |I would want to | |support & comfort her| | | | | |support & comfort her| |Deserves the best of | | | | | |Undeserving of care | |care | | | | | | | |Drain on NHS | | | | | |Legitimate use of NHS| |resources | | | | | |resources | |Irresponsible person | | | | | |Responsible person |
Encountering patients with stigmatising conditions.
Davis (1964) found that physically handicapped people typically go through three stages when meeting strangers.
1. Fictional acceptance: They find they are ascribed some stereotypical identity and are accepted on that basis. In other words a person with a limb missing is accepted as an amputee. 2. Breaking through: The person with the condition force the stranger to interact with them on the basis of who they are (not as the condition). 3. Consolidation: The person with the condition has to maintain and sustain their definition of themselves as normal over time.
Scambler (1989) proposed there were three aspects to a patient’s perspective, when encountering health care professionals.
1. Felt Stigma: patients had a sense of shame and apprehension at meeting with discrimination 2. Rationalisation: Patients had a need to make sense of what was happening to them, in order to restore some kind of order to their lives. 3. Action strategy: Patients felt the need to develop some kind of coping strategy.
What in fact the medical staff were only interested in was the “rationalisation” side of the patient’s perspective. In other words the medical staffs were only interested in finding a diagnosis, and were not concerned about how the patient may feel about the condition or how they were going to cope with it.
Most of the research concerning the reaction of health professionals to stigmatised people, suggests their reactions and behaviour is very much the same as non-health care professionals.
Where a person does not conform to social stereotypes, or the norms of behaviour, they are likely to be marked out, marginalised and treated as not being legitimate member of society, in other words they bear a stigma.
Certain stigmas can be hidden to a certain extent until they are declared or are uncovered. However some stigmas, especially those that are visual, like certain a chronic illness are not all too apparent.
Some illnesses and diagnoses produce a label, which have far-reaching effects upon those who bear it.
In order to control illness, physicians act as the gate keeping to health care. Patients are obliged to conform to the prescribed treatment and act in a way that will speed their recovery, otherwise they too are likely to be stigmatised and marginalised within the health care system and beyond.
Scambler G. (2002) Sociology Applied to Medicine Ch 13.Saunders. London
Lubkin, I. M. and Larsen , P. (2002) Chronic Illness: Impact and Interventions. Ch 3. Jones and Bartlett. Boston.
Goffman, E. (1963) Stigma: notes on a spoiled identity. Prentice-Hall. New York.
Jeffrey R. (1995) Normal Rubbish: deviant patients in casualty departments. In . Davey, et al (Eds) Health and Disease: a reader (2nd ed) p.345-351. Open University Press. Buckingham