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date: 15 January 2021

Stigma and Health/Risk Communicationfree

  • Rachel A. Smith, Rachel A. SmithDepartment of Communication, Arts and Sciences, College of the Liberal Arts, Pennsylvania State University
  • Xun ZhuXun ZhuDepartment of Communication Arts and Sciences, College of the Liberal Arts, Pennsylvania State University
  •  and Madisen QuesnellMadisen QuesnellDepartment of Communication Arts and Sciences, College of the Liberal Arts, Pennsylvania State University


Stigmas are profoundly negative stereotypes of a social group and its members that have diffused and normalized throughout a community. Being marked as a member of a stigmatized group does more than designate someone as different: stigmas denote people as discredited, devalued, and disgraced. Stigmas shape health and risk communication and are considered the leading—but least understood—barrier to health promotion.

Communication and stigmas are dynamically connected. Communication is critical to a stigma’s existence, spread, expression, coping, and elimination. Using mediated and interpersonal communication, community members are socialized to recognize and react to stigmatized people. People use communication to enact the devaluation and ostracism of stigmatized people, and stigmatized people use communication to cope with stigmatization. Stigmas also shape communication: stigmas compel non-marked persons to engage in stigmatization and ostracism of marked persons, reduce marked people’s disclosure and encourage secrecy, and shape the characteristics of personal and community networks. Last, campaigns have used communication to attempt to eliminate existing stigmas. The accumulating research, conducted from diverse assumptions about human behavior (cultural determinism, evolutionary, socio-functional), shows how easily and effectively stigmas may be socialized; how challenging they are to manage; how many facets of health and wellbeing are devastated by their existence; and how difficult it is to attenuate them.

While much has been uncovered about stigma, health, and risk, many questions remain. Among these include: How can one design messages that effectively alert the general public about imminent health threats and that successfully promote desirable behavioral changes without evoking stigma processes? How do different reactions to stigmatization influence targets and their social networks? What factors increase resistance or vulnerability to messages containing stigma-inducing content? How can one create an effective, reliable means to eliminate existing stigmas?


Stigmas are a significant barrier to health (Hatzenbuehler, Phelan, & Link, 2013; Smith, 2011) and risk management (Flynn, Slovic, & Kunreuther, 2001). Stigmas damage material, social, and psychological well-being (e.g., Barron & Hebl, 2010; Goffman, 1963; Hatzenbuehler et al., 2013; Markowitz, 1998; Miller & Major, 2000). Stigmas also have been shown to influence risk perceptions. For example, stronger perceptions of an infectious disease as stigmatized has predicted less personal susceptibility and greater optimistic bias (Smith & Morrison, 2006).


The word stigma comes from the Greek word stigmatos, meaning “mark of infamy” (Webb, 1883). This referred to the ancient Greek tradition of tattooing or burning marks on morally condemned members of society, such as slaves, criminals, and traitors (Goffman, 1963; Johnson, 2010; Jones, 1987). Over time, various definitions of stigma have appeared (Link & Phelan, 2001; Stafford & Scott, 1986). The term stigma has been used to refer to (a) marks, visible or invisible, indicating membership in a stigmatized group (e.g., Oxford Dictionary, 2015); (b) personal characteristics that identify someone as negatively deviant from others (e.g., Goffman, 1963; Thompson & Seibold, 1978); (c) profoundly negative feelings, toward and stereotypes of the disgrace of a particular social group and its members (e.g., Jones, Farina, Hastorf, Markus, Miller, & Scott, 1984), that have diffused and normalized throughout a community (Smith, 2007, 2011); or (d) experiences of being berated, humiliated, and ostracized (e.g., Sayce, 1998).

The first definition—stigma as a mark—emphasizes the signs of a stigmatized status, which we will refer to as stigmata in the rest of this chapter. We will consider both visible marks that may be affixed onto a stigmatized person by others (e.g., ritualized burn, yellow star, red letter “A”) or may be part of the person’s morphology (e.g., bodily feature) or actions (e.g., bodily tic). The fourth definition emphasizes the personal performance or communication of devaluation, which we will refer to as stigmatization, or structural inequities, which we will refer to as discrimination. The differences between the second and third definitions are more subtle. Both definitions consider stigmas as more than difference: stigmas denote people as profoundly discredited, devalued, and disgraced (Goffman, 1963). The second definition considers stigma as a taint on the social identity of a person (Crocker, Major, & Steele, 1998; Goffman, 1963); this perspective assigns a more psychological and sociological perspective to stigma. The third definition considers a stigma as an inter-group social cognition: a normalized, diffused, profoundly negative stereotype of a social group, thus focusing on the inherent dynamic connection between communication and stigmas (Smith, 2007). This definition emphasizes that stigmas are socially constructed and communicated in order to exist. If people enact stigmatization without the stigma in place, then they may be punished by their community for dehumanizing others. In contrast, if a stigma exists and people do not enact it (referred to as norm enforcement; Phelan, Link, & Dovidio, 2008), then they may be punished as traitors.

Link and Phelan (2001) argue that it is wise to allow for different definitions, as long as each scholar is clear about the definition they use. We agree. For this article, stigmas are defined as simplified, standardized images (i.e., stereotypes) of the profound disgrace of a social group that have diffused and normalized through a larger community (Smith, 2007).

Different Causal Explanations for Stigmas

The variability in the definition of stigma reflects its complex nature and the various epistemologies and foci that each discipline brings when they study stigma. Stigma scholarship differs in its primary assumptions about the cause of stigmas: culturally determined, evolutionary, or socio-functional.

Scholars presuming a cultural deterministic perspective often focus on the variation and emphasize the social construction of stigmas. Stigmas have been created about many different kinds of health conditions and social arenas (see review in Pescosolido, 2015). Over time, the social value of health conditions change. For example, obesity was a desired marker of social status and wealth historically, but it is stigmatized in some contemporary Western societies (e.g., Newman, 2014). The same condition may be stigmatized by one society, but not another. The stigma may appear in distinct forms within a community (Becker & Arnold, 1986), and sometimes the same condition receives stigmatization in one social context but not another (Crocker, Major, & Steele, 1998). In this perspective, stigmas are considered as embedded in moral judgments within cultural communities (Kleinman, 1988; Yang, Kleinman, Link, Phelan, Lee, & Good, 2007), creating and preserving social order (Foucault, 1977) and symbolic power (Bourdieu, 1987), and putting their stained character on public display (Johnson, 2010).

In contrast, other scholars have highlighted how stigmas are ubiquitous in human societies, globally and historically (Oaten, Stevenson, & Case, 2011; Smith & Hughes, 2014) and appear in other social species, from ants to chimpanzees (Goodall, 1986; Hughes & Cremer, 2007; Wilson, 2000). For example, chimpanzees rebuff other chimpanzees who violate norms of reciprocity (de Waal, 1989), maintain distance from chimpanzees who have the lost use of a limb due to polio (e.g., Goodall, 1986), and attack in-group chimpanzees who exhibit physical markers of a communicable disease (e.g., Goodall, 1986).

Two explanations have been associated with observed ubiquity: one is based in natural selection (individual survival and reproductive success); the other is based in group selection (group survival). The natural selection explanation considers stigmas as evolving as a defense against infectious diseases (Kurzban & Leary, 2001; Park, Schaller, & Crandall, 2007). For example, to survive, host species attempt to avoid members who are more likely to be infected with contagious pathogens (Kurzban & Leary, 2001), thus generating human repulsion from infection symptoms (e.g., weeping, pus-filled sores) and human attraction to signs of strong immunity, like facial symmetry. In fact, within the first hour of birth, human babies show preferences for facial symmetry (Johnson, Dziurawiec, Ellis, & Morton, 1991).

Another explanation for stigmas’ ubiquity is that they may provide a social defense for groups (Neuberg, Smith, & Asher, 2000; Smith & Hughes, 2014). For species that depend on group members for survival, stigmas may have evolved through group selection to protect group survival, by identifying and ostracizing members whose actions or characteristics interfered with essential group functions. For example, among social species that are prey for others, albinism is often stigmatized when it impedes the group’s ability to hide from predators (Slavík, Horký, & Maciak, 2015). Furthermore, group members will gain advantages if they “selectively avoid, reject, or eliminate other individuals whose behaviors are disruptive to group organization” (Brewer & Caporael, 1990, p. 240).

While many scholars acknowledge that stigmas have historical precedence and may have provided fitness advantages to groups in the past, there is debate over the utility of this old-brain adaptation in modern society. Indeed, some argue that modern conditions have eliminated advantages to stigmas and often provide serious costs to groups and health (Phelan, Link, & Dovidio, 2008; Smith & Hughes, 2014). Infectious diseases provide a good example. For most of human history, people lived in kin-based groups with infrequent inter-group interactions (in general, for mating). Ostracism from the group meant swift and certain death due to lack of resources and greater vulnerability to predators (Wilson, 2000; Smith & Hughes, 2014). Thus, it was unlikely that anyone ostracized for a contagious condition (e.g., a stigmatized infectious disease) could spread their infection to anyone else before they died. Stigmas in pre-modern times, then, served to limit the spread of infection and eliminate a reservoir for future infections. Stigmas were elimination strategies for group survival and, therefore, were not concerned with rehabilitating members. In modern times, conditions have changed: the human population increased, contact rates between humans have increased, and medical options have become available to treat infectious diseases. Smith and Hughes (2014) explain how these new conditions eliminate any fitness advantage provided by stigmas and, in fact, damage public health. Stigmas are ineffective at best and, at worst, often damage campaign strategies for managing other public health concerns, such as obesity (Vartanian & Smyth, 2013) and mental health issues (Rüsch & Thornicroft, 2014). To be clear, while we ascribe to a socio-functional perspective to stigma’s origins, we do not believe that it provides positive fitness advantages to modern human societies.

Related Concepts

All humans stereotype other people (Hamilton & Trollier, 1986). Stigmas evolve from stereotypes, which are defined as formulaic and simplified conceptions of a group and its members (Ashmore & Del Boca, 1981). Stereotyping is a normal result of cognitive abilities and limitations, social information, and experiences (Dovidio, Major, & Crocker, 2000). Thus, inherently, the concept of stigma overlaps with the concept of prejudice, which has been defined as antipathy based on faulty, inflexible, negative stereotypes of a group (e.g., Allport, 1954; Devine, 1989, 1995). Stigmas may differ from prejudice in whether the group is considered as less human (stigmas, but not prejudice; Phelan, Link, & Dovidio, 2008, see Haslam & Loughnan, 2014 for a review of dehumanization), and whether it must be diffused or not (stigmas must be diffused; prejudice does not). As with other stereotype-based phenomena, once learned, stigmas resist change, even when evidence fails to support them (Dailey, 1952). For example, people may allow exceptions for a person, (e.g., “He’s attractive for a [stigmatized group]”) without changing the base group-stereotype (e.g., Brewer, 1988).

In addition, stigma overlaps with discrimination (Crocker et al., 1998). Discrimination, or accumulated institutional practices that disadvantage people based on perceived membership in particular social entities (Herek, 2002), may occur without individual prejudice or stigma (Link & Phelan, 2001). Discrimination can appear in legal statutes or policies related to employment, criminality, access to health care, and less protection of privacy (e.g., Smith, 2011; see Herek, 2002 for a discussion).

Communication and Stigmas

Now that we have explicated stigma and its origins, and defined key concepts, we spend the rest of this article on the multiple, dynamic connections between stigma and health/risk communication. Communication shapes stigmas: communication is critical to creation of, spread of, coping with, and elimination of stigmas. Using mediated and interpersonal communication, community members are socialized to recognize and react to stigmatized people. People use communication to enact the devaluation and ostracism of stigmatized people, and stigmatized people use communication to cope with stigmatization. Stigmas also shape communication: stigmas compel non-marked persons to engage in stigmatization and ostracism of marked persons, reduce marked people’s disclosure and encourage secrecy, and shape the characteristics of personal and community networks. Finally, some interventions have used communication to attempt to eliminate existing stigmas. The next sections describe each of these connections in more detail.

Creating Stigmas

One common claim in stigma theories (e.g., Goffman, 1963; Link & Phelan, 2001; Pescosolido, Martin, Lang, & Olafsdottir, 2008; Smith, 2007) is that stigmas are socialized; that is, they are communicated to and among community members so that the public becomes socialized to recognize stigmatized people and to enact devaluation (Smith, 2007, 2011). Theoretically, stigmas should only be created when power differentials are possible (Link & Phelan, 2001, 2014). Beyond stating this boundary condition, little attention has been paid to why some messages (e.g., media stories, or interpersonal rumors) provoke stigma-related outcomes, while others do not (Corrigan, Powell, & Michaels, 2013; Pescosolido et al., 2008). An exception is the model of stigma communication (MSC) (Smith, 2007, 2011). The MSC explicates that community members must receive messages that teach them how to recognize people who pose threats to their community’s wellbeing and how to limit stigmatized people’s access to group resources and interactions with community members. Consequently, stigma communication needs to include content that quickly gains attention, encourages grouping and stereotyping, and provides emotional and cognitive motivations to engage in devaluation and discrimination. To achieve these message effects, efficient stigma communication includes four types of content: marks, labels, etiology, and peril.

Marks are the information about how to recognize members of the stigmatized group from written (e.g., branding or tattooing a label on someone, such as “thief,” Johnson, 2010) or nonverbal (e.g., yellow stars, or weeping sores) stimuli, also referred to as a stigmata. The most effective marks are observable, facilitate quick recognition, are easy to learn, and evoke emotions that trigger the behavioral response to remove someone from the situation. Johnson (2010) argues that the visibility of a mark may operate as a form of risk management, allowing people to avoid stigmatized persons. People can more easily categorize someone as a member of a stigmatized group when the mark is harder to conceal (Deaux, Reid, Mizrahi, & Ethier, 1995; Frable, 1993; Jones et al., 1984) and disgusting (Goffman, 1963; Jones et al., 1984). Disgust, in general, triggers an action tendency to avoid or reject the marked target and eventually to remove it from one’s presence (Mackie & Smith, 2002), as well as an evaluative tendency to make moral judgments about the “disgusting” person (Looy, 2004). Marks may be permanent attributes born on a person (e.g., birth mark), permanently affixed by others (e.g., branding scar), or temporarily affixed. For example, medical authorities in African countries provided certifications of clearance to people who have been cured for Ebola. However, these people have been prohibited from returning to their homes, and have experienced violence from their community (Davtyan, Brown, & Folayan, 2014). While the certification was likely intended as a positive indication of clearance, it may have become a stigmatizing mark.

Labels are words used to reference the stigmatized group. Labeling facilitates the process of considering the stigmatized group as a coherent, distinct entity. Bringing the group into existence (i.e., group entitativity) makes the group appear structured and its members homogeneous and subject to a common fate (e.g., Hogg & Reid, 2006). Group entitativity also encourages the development of stereotypes and stereotype-consistent interpretations of group members’ behavior (Hogg & Reid, 2006). The word selected for the group’s label can bring attention to the stigma by using the mark or stigmatizing condition in the label. A salient example can be found in the discussion of illnesses (Link & Phelan, 2001) as either conditions or labels (Link & Phelan, 2001). For example, syntactically, the statement “John has schizophrenia” signals that schizophrenia is separate from the person and is a condition that could happen to anyone. By putting John as a subject, it also emphasizes individuality, as opposed to over-generalizing a group of people by their characteristics. In contrast, the statement “I saw a schizophrenic in town today” applies a label and suggests that John is a member of a category of people called “schizophrenics,” who are different from most people in the society (for a detailed discussion on linguistic representation of AIDS-related stigma, see Kunda & Tomaselli, 2009). More derogatory versions, such as schizos, or terms, such as nuts or lunatic, may be used to emphasize the devaluation of the group. In American English, pronoun usage, us versus them (Devine, Plant, & Harrison, 1999; Link & Phelan, 2001; Morone, 1997), can also separate the stigmatized group from the rest of the community. Out-group entitativity and related social cognitions also facilitate group-level emotions, such as frustration with another social group based on one’s personal social identity, instead of frustration with a person (Seate & Mastro, 2015). Out-group-level emotions prompt people to appraise the environment and take actions toward an out-group on behalf of the groups with which they identify (Seate & Mastro, 2015). This, in turn, affects intergroup behaviors, such as ostracizing out-groups and segregation (Smith & Mackie, 2010).

Etiology describes the cause(s) of a stigmatizing condition. To be most effective at inducing stigma-related outcomes, etiology content must suggest that a person voluntarily and actively decided to violate social responsibilities and engaged in taboo activities (Smith, 2007, 2011). Even without explicit etiology content, people make assumptions about why people do what they do and tend to make character-based assumptions about why people engage in negative actions or experience negative outcomes (e.g., Jones & Nisbett, 1971). Studies show that this attribution bias does not extend to all negative behaviors, but only to those that violate accepted norms of social morality (Trafimow, Bromgard, Finlay, & Ketelaar, 2005). These attributions, from explicit descriptions or inferences, may affect future interactions. Attribution theory (Jones & Davis, 1965) suggests that people assume that the choices of others remain consistent over time. If stigmatized people choose to hurt the group once, they are likely to do so again. Etiology content, then, assists with developing stereotypes about stigmatized people as morally flawed (Goffman, 1963; Jones et al., 1984) and undeserving of normal rights as a group member because they intentionally put others at risk. Etiology content evokes anger, which evokes a behavioral tendency to aggressively destroy or remove the target of their anger (Mackie & Smith, 2002).

Peril content highlights the danger that a stigmatized group poses to the rest of the community (Deaux et al., 1995; Frable, 1993; Jones et al., 1984). Peril content describes the danger the stigmatized group poses to the rest of the community (Smith, 2007). Drawing upon research in product hazards (DeTurck, 2002), peril content may include the source of the danger, recommendations to avoid dangerous people, and the consequences if one fails to avoid dangerous people (Smith, 2007). Peril, then, induces perceived dangerousness, which is the belief that the stigmatized group and its members are able and likely to harm the rest of the community by their presence and actions (Smith, 2007). Together, peril and etiology content locate the community threat in people (i.e., dangerousness of people), as a fundamental aspect of their character or action.

In the MSC, marks, labels, etiology, and peril content trigger cognitive responses, such as perceived dangerousness, responsibility, and group entitativity; and affective states, such as disgust, anger, and fear. The affective states not only trigger relevant stigma-related behaviors, but they also shape message processing (as discussed under “Marks”). The emotional evocativeness attracts attention to messages (Roskos-Ewoldsen & Fazio, 1992), attitude salience (Roskos-Ewoldsen, Yu, & Rhodes, 2004), increases elaboration about them (Fabrigar, Priester, Petty, & Wegener, 1998), and consequently has greater influence on people’s behavior (Roskos-Ewoldsen, 1997).

The MSC has been used as a framework to analyze the content of the stigma communication surrounding obesity (Anderson & Bresnahan, 2013), lung cancer (Bresnahan, Silk, Zhuang, 2013), HIV/AIDS (Zhuang & Bresnahan, 2012), physical illness, and autism (Bie & Tang, 2015) in newspapers and online forums (Wang & Liu, 2015) in multiple countries. The experimental tests (Smith, 2012a, 2014a) have brought additional insights into the mechanisms underlying how content evokes stigma-related outcomes, such as creating stigma beliefs, increasing support for regulating affected people’s lives, and increasing the likelihood of spreading the message to others.

Many questions about the mechanisms remain. For example, Goffman (1963) described three forms of stigma with regards to illnesses: (a) the illness’s biological manifestations (such as abscesses), (b) the blemish of one’s character, and (c) the choice to associate with groups already prone to infection or devalued within the community. The first form of stigma links to the MSC’s concept of marks; the second and third are variations in etiology. While Goffman made a point of distinguishing character flaws from intentional association with threatening, deviant people, these are often confounded or combined in current research; more research is needed to assess how and why forms of etiology evoke stigma-related processes differently.

These tests have also shown that some personal characteristics moderate these message effects. For example, people with stronger disgust sensitivity (Haidt, McCauley, & Rozin, 1994) and a more cynical worldview (Crandall & Cohen, 1994) have stronger stigma-related reactions to stigma communication. Chronic perceptions of vulnerability to disease (Faulkner, Schaller, Park, & Duncan, 2004) may also increase sensitivity to stigma communication.

Notably, in the context of health outbreaks, people may hold two different cognitions about threats to themselves or society: perceived dangerousness of the infected people and perceived threat of the health condition. Perceived threat aligns with Witte’s (1992, 1994) conception of health threats as the perceived severity of and susceptibility to the health condition. Dangerousness, then, focuses on people (Smith, 2014a), and disease threat focuses on the health condition. In studies of stigma appeals, dangerousness has been associated with multiple stigma processes, such as forming stigma beliefs (Smith, 2012a), supporting the isolation and removal of stigmatized people in policy (Smith, 2012a) and interpersonally (Smith, 2014a), and intending to share the stigma message with others (Smith, 2012a, 2014a). In Witte’s studies of fear appeals (e.g., Witte, 1994; Witte & Allen, 2000), disease threat, particularly severity (i.e., perceived significance or magnitude of the threat; Witte, Meyer, & Martell, 2001), has been positively associated with engaging in actions recommended by health personnel. Effective health messaging, then, may depend on distinguishing the message content that prompts perceptions of dangerousness versus disease severity.

How stigmas are created through communication is a rich, dynamic area of research. There is much for communication scholars to reveal about how stigmas are created in order to provide guidance on how to engage in health, risk, and scientific communication without creating new stigmas.

Interactions and Stigmatization

Goffman (1963) categorized people into three groups based on their association with and their reactions to stigmatized persons: the own, the wise, and normals. The “own” (p. 30) are those who share the stigma (i.e., these are my own people). The “wise” (p. 19) are not members of the stigmatized group, but are sympathetic to those who are. “Normals” (p. 5) are not classified with the stigmatized group and do uphold the stigma. Neither normals nor the wise are members of the stigmatized group. The stigma is not personally relevant for normals (Goffman, 1963), and they treat stigmatized people differently from others, typically through discrimination, social distance, and devaluation. Normals attribute imperfections and responsibilities to stigmatized persons (Goffman, 1963). In contrast to normals, the wise, through special situations or personalities, accept and are sympathetic to stigmatized people (Goffman, 1963). An empirical test of these categories (Smith, 2012b) revealed four groups, relabeled as the stigmatized (the own), stigmatizers (normals), and active and passive supporters. Goffman’s original category of the wise separated into two groups of supporters, who differed in whether they acted to challenge stigmatization (active) or not (passive).

Social interactions between stigmatized and non-stigmatized persons are effortful, difficult situations (e.g., Goffman, 1963; Smith & Hipper, 2010; Thompson & Seibold, 1978), characterized by negative emotions, stress, and intense impression-management activities (Goffman, 1963). For example, participants interacting with confederates bearing facial marks, versus non-stigmatized confederates, produced fewer words, had less eye-contact, and showed stronger cardiovascular reactivity (Blascovich, Mendes, Hunter, Lickel, & Kowai-Bell, 2001). Goffman (1963) argued that these tensions and efforts, in part, lead stigmatized and non-stigmatized persons to avoid each other. Avoidance is often imperfect, and stigmatization may occur.

Stigmatization is defined as verbal or nonverbal communication that expresses the devaluation of the target based on their membership in a stigmatized group (Quesnell, 2015). As the definition suggests, stigmatization is viewed as a social, dynamic, and interactive process that shapes and is shaped by the behavioral interplay between stigmatizers and targets (Archer, 1985). Stigmatization behaviors fall into two broad categories: depreciation and distancing. Depreciation refers to intentional verbal and nonverbal communication expressing devaluation of someone based on a social identity, delivered by stigmatizers to their targets. Communication acts in this category include name calling, verbal and physical aggression (Puhl, Luedicke, & Heuer, 2011), and more subtle acts, such as some forms of teasing and advice (Quesnell, 2015). For example, in a qualitative study, an obese interviewee reported being advised to lose weight by her doctor despite the fact that she was seeking treatment for an unrelated uterine concern (Cossrow, Jeffery, & McGuire, 2001). Distancing, in contrast, are nonverbal acts to create physical or social space between stigmatizers and their targets. Communication acts in this category include ignoring, avoiding (Mehrabian, 1967), and ostracizing (Williams, 2007). At the societal level, stigmatization may appear as segregation (Williams & Gerber, 2005) or genocide (Woolf & Hulsizer, 2005). The ways people enact stigmatization and the effects of different forms of stigmatization have received the little consideration, and they deserve future attention.

When stigmatization occurs in interpersonal interactions, typically the actor is not a member of the stigmatized group, but occasionally a stigmatized person will stigmatize a target with the same devalued social identity (Goffman, 1963). Such within-group stigmatization may be a result of the actor internalizing the stigma and believing that members of the stigmatized group deserve such treatment (Herek, Gillis, & Cogan, 2009; Puhl, Moss-Racusin, & Schwartz, 2007). Those who have yet to be marked as members of the group (referred to as “passing,” Goffman, 1963) may also be trying to avoid detection or a courtesy stigma.

Courtesy stigma (also see Mehta & Farina, 1988 for associative stigma; Neuberg, Smith, Hoffman, & Russell, 1994 for stigma by association) is an ironic term that describes a phenomenon in which communities do the “courtesy” of extending people who associate with stigmatized persons (e.g., supporters) the same stigma and stigmatizing experiences. Courtesy stigma, then, is due to one’s voluntary or family association with stigmatized people rather than due to the possession of stigmatizing attributes (Smith, 2014b).

It is not clear which mechanisms are at play with courtesy stigma, but four possibilities have been discussed in the literature: betrayal, balance, contagion, and presumed similarity. People choosing to be friends with stigmatized persons, by providing some level of sympathy or support, can be seen as betraying their community. The balance theory perspective (Heider, 1958) suggests that liking someone who likes a stigmatized person, but not liking the stigmatized person, may create an undesirable state of unbalanced cognitions. One way to restore the balance is to stigmatize associates of the marked person (see Neuberg et al., 1994 for empirical evidence). Association can also invite judgments as to whether friends have the potential to acquire the stigmatized health condition, as if stigmas were a social contagion. For example, people in the proximity of a stigmatized person may become targets: in one study, an average-weight male job applicant who sat next to an overweight female applicant experienced devaluation in a job interview (Hebl & Mannix, 2003). Association can also invite assumptions that the associate shares the same character flaws or immorality as the stigmatized group. For example, social workers who provided services for sex workers have been assumed to bear a history of sex work simply because of their job (Phillips, Benoit, Hallgrimsdottir, & Vallance, 2012). Courtesy stigma can extend to people who live with, work with, are related to (Peterson, Cohen, & Smith, 2013; Smith, Wienke, & Coffman, 2014), or have occasional interaction with stigmatized persons (Pryor, Reeder, & Monroe, 2012). Supporters targeted by courtesy stigma experience many of the same negative consequences as the stigmatized people they support, such as lower self-esteem and higher stress (Mak & Kwok, 2010; Struening, Perlick, Link, Hellman, Herman, & Sirey, 2001). In addition, courtesy stigma can create turnover in health and service professions associated with stigmatized groups (Pryor et al., 2012).

Coping with Stigmatized Conditions

People want to avoid being targets of stigmatization (Herek, 2007). People who have conditions that label them as members of a stigmatized group anticipate judgments of responsibility, being labeled, and potential devaluation and discrimination. Consequently, potential targets engage in coping strategies aimed at preventing negative reactions and influence (Barreto, 2014; Herek, 1996; Link, Phelan, & Hatzenbuehler, 2014; Miller & Major, 2000; Smith, 2007; see involuntary responses to stigma in Miller & Kaiser, 2001). In this section, we briefly summarize theoretical models focused on coping with stigmas.

Modified labeling theory (MLT) (Link, Cullen, Struening, Shrout, & Dohrenwend, 1989) argues that people are socialized to associate stigmatized groups with stereotypes, to devalue stigmatized people, and to discriminate against them. Labeled people use these socialized stereotypes to form expectations about how others may devalue them and discriminate against them (Goffman, 1963). People want to avoid being targets of stigmatization (Herek, 2007) and consequently employ coping strategies aimed at preventing negative reactions (Link, 1987; Link et al., 1989, also see Miller & Major, 2000). The MLT identifies five coping orientations through which people respond to stigma: secrecy (concealing labeling information), withdrawal (avoiding potential stigmatization), education (offering information to correct stereotypes), challenge (confronting stigmatizing behavior), and distance (rejecting one’s own connection with a stigmatized group). MLT contends that people may use a mixture of these responses if social stigma becomes personally relevant via labeling. MLT takes a cognitive perspective that focuses on the individual (Link, Yang, Phelan, & Collins, 2004). Further, MLT “predicts that perceived devaluation discrimination should have no impact on social or psychological functioning in people who have never been officially labeled” (Link et al., 1989, p. 523). But what happens when the labeled person discloses his or her situation to a confidant? Does the confidant advise the labeled person to engage in withdrawal, secrecy, or education? The next theory attempted to address this dyadic perspective to coping.

Label Management

Drawing upon communication privacy management (Petronio, 2002), courtesy stigma (Goffman, 1963), and stigma communication (Smith, 2007), label management theory (LM) (Smith & Hipper, 2010) is a dyadic communication version of MLT that makes predictions about the advice confidants give to their labeled loved ones about how to use the strategies outlined in MLT to cope with labeling. LM applies only to cases in which the labeled person has disclosed their labeling condition to an unlabeled confidant; it does not apply to unintended disclosures. When a person discloses his or her labeling condition to an unlabeled confidant, the two become co-owners of this information (Petronio, 2002; Petronio, Sargent, Andea, Reganis, & Cichocki, 2004). Co-owners share the knowledge of the discloser’s labeled status, regulation of this knowledge, and its consequences. Confidants consider the label, its stereotypes, and potential consequences in similar fashion to those bearing the label, because this is socialized among all members of a community (Link et al., 1989; Smith, 2007). If people disclose a characteristic or behavior that would allow them to be labeled as a member of a stigmatized group, the listener is likely to believe that the discloser has identified a problem. This communication act, disclosure of a problem, may reasonably lead the listener to believe that the discloser wants advice (Goldsmith, 2000). People often respond to another person’s distress by telling this person how to act, feel, and think (e.g., Feng & Burleson, 2008; MacGeorge, Graves, Feng, Gillihan, & Burleson, 2004). Consequently, instead of presuming that labeled persons come up with these coping strategies without assistance, LM argues that confidants may advise labeled persons to engage in particular coping strategies (e.g., withdrawal, secrecy, or education) to help the labeled person to avoid future problems and potentially to avoid being targeted by a courtesy stigma.

Stigma Management Communication

MLT and LM explain how perceived stigma and its relevance predict engaging in broad categories of communication strategies to cope, and how these coping strategies shape many aspects of wellbeing. The theory of stigma management communication (SMC) (Meisenbach, 2010) provides insights into the nuanced range of communication behaviors used in interactions. SMC asserts that communication strategies are selected based on people’s attitudes about a stigma’s personal relevance and their attitude toward challenging others’ perceptions of the stigma. The strategies include, but are not limited to, accepting, avoiding, evading responsibility, reducing offensiveness, denying, and ignoring or displaying. For example, when people accept the public expectations of stigma and its applicability to themselves, they may engage in a “no comment” tactic or use humor to indicate their passive acceptance of stigmatized status. When targets of stigmatization challenge public opinion but accept personal applicability, they may “defer agency or control away from the stigmatized individual” and/or reduce stigma’s offensiveness to others (Meisenbach, 2010, p. 282).


Coping often demands disclosure, defined as the sharing of personal information with others (Derlega, Metts, Petronio, & Margulis, 1993). Whether intentional or unintentional, disclosure of one’s health condition is a way to seek support for it and, if relevant, to manage the stigma associated with it. For those with concealable stigmatized conditions (also referred to as invisible stigmas; see, e.g., Ragins, Singh, & Cornwell, 2007), disclosure may be a particularly critical aspect of coping (Chaudoir & Fisher, 2010). Communication includes many models of disclosure, and a few, such as the disclosure decision-making model (Greene, 2009), explicitly include stigma as one of many considerations shaping whether someone discloses their health condition to another. These models predict a tension: while the benefit of disclosure is receiving support, the risk is receiving stigmatization. Perceived stigma discourages disclosure to friends, family (Derlega, Lovejoy, & Winstead, 1998), coworkers (Ragins et al., 2007), and health providers (Lienemann, Siegel, & Crano, 2013). This tension is real: a meta-analysis (Smith, Rossetto, & Peterson, 2008) of the studies of people living with HIV disclosing their diagnosis showed that disclosure was positively related to more social support, but the effect was small and was not stable across studies. Stigma, in contrast, predicted less social support and fewer disclosures. In addition, Thompson and Seibold (1978) found little evidence that stigmatized people who disclose their stigmatizing condition, versus those who do not, will be more accepted by non-stigmatized others.

In some cases, people may prefer to disclose their information indirectly (e.g., without clearly or explicitly stating the information; An & McDermott, 2014) or anonymously (Rains, 2014). Interestingly, people find anonymous testimonials of stigmatization more credible than identified ones. Less attention has been paid to the ways in which third parties disclose stigmatized conditions, such as recommenders mentioning students’ disability in their letters of recommendation (Vidali, 2009). While disclosures may be thought of as discrete events, duration varies, and greater breadth or depth of personal information may be shared over multiple interactions (Chaudoir & Fisher, 2010). The initial disclosures, and how they are received, may be particularly important because they shape future disclosures: in one study (Chaudoir, 2009), those who experienced more positive reception of their initial disclosure of a stigmatized condition (being diagnosed with HIV) reported more social support and were more likely to disclose six months later.

Coping Consequences

Link and Phelan (2014) theorized an ironic feedback loop: stigma prompts people living with illnesses to adopt coping strategies, which in turn enhances the power of stigma to dominate the minority, enforce the norms of the majority, and ostracize stigmatized people. As they concluded, “This leads to our pessimism about individual-based coping or resistance—the actions of single individuals are very unlikely to change the power difference between stigmatized and stigmatizing groups” (Link et al., 2014, p. 60). Only a few studies have empirically tested the effectiveness of stigma coping strategies (Barreto, 2014; Link et al., 1991); more research is needed. At the personal level, coping can affect stress and social networks. The relationship between secrecy and stress is well documented (e.g., Pennebaker, Hughes, & O’Heeron, 1987). Continuing our focus on communication, in the next section we will outline what has been learned about the consequences of stigma for interaction patterns and network structures.

Interaction Patterns and Networks

Stigma has long been considered as a trigger of “network crisis” (Lipton, Cohen, Fischer, & Katz, 1981, p. 144). As noted earlier, MLT (Link, 1987; Link et al., 1989; also see LM, Smith & Hipper, 2010) posits that the social networks of stigmatized people shrink in size and quality as stigmatized people avoid interactions with anyone who is not already known to be a supporter and as non-stigmatized persons actively avoid interactions with stigmatized persons (Puhl & Brownell, 2003; Strauss & Pollack, 2003). In line with these predictions, multiple studies have documented that people living with a stigmatized health condition have smaller social networks (Lipton et al., 1981; Link et al., 1989; Lennon, Link, Marbach, & Dohrenwend, 1989). Stigmatized persons’ restricted networks have been associated with lower income, more unemployment, and lower self-esteem (Link, 1987).

Anticipated or experienced stigmatization has also been associated with lower quality support (Lipton et al., 1981). The networks of stigmatized people provide fewer types of social support (Link et al., 1989), such as only providing advice, helping with tasks, or providing emotional support. Furthermore, stigmatized people may have a weaker ability to gain support from their network members (Perry & Pescosolido, 2015). Sometimes people turn to online support, which may give the stigmatized person more control over the interaction. Interestingly, for those turning to online health support-groups, stronger stigma has been associated with a stronger preference for support from less-known persons (Wright & Rains, 2013). While less-known persons may carry less risk in a given conversation, close contacts tend to provide more reliable support and remain in one’s support network for longer. Unfortunately, stigmatized persons’ networks have higher membership turnover (Perry & Pescosolido, 2012; Sasovova, Mehra, Borgatti, & Schippers, 2010). Thus, in order to avoid stigmatization, stigmatized people may rely on fewer people, who can provide fewer forms of support and may be less reliable.

From a community network perspective, the diagnosis of a health condition may encourage people to participate in social groups to seek social support or to manage their health conditions; as a result, they will be embedded in the community’s network. On the other hand, the diagnosis of a stigmatized health condition may encourage people to avoid or be pushed out from the main community, and as a result they will appear at the periphery of community’s network. These claims were empirically supported with HIV stigma in a community in southern Africa (Smith & Baker, 2012). The empirical study of how stigmas shape personal, group, and community networks is an active area of inquiry, which should reveal many insights in the future.

Anti-Stigma Communication Efforts

Due to the significant, negative consequences of stigma, there has been much effort to find ways to eliminate existing stigmas; unfortunately, there is not a reliable, consistent means by which to do so. In a meta-analysis, Corrigan, Morris, Michaels, Rafacz, and Rüsch, (2012) grouped the existing studies into three categories: protest, education, and contact. Protest efforts typically employ shame appeals, in which advocates highlight an instance of stigmatization and its injustice, and shame those responsible for enacting it. For example, a recent anti-obesity public service announcement “Rewind the Future” (Children’s Healthcare of Atlanta, 2013) was identified as stigmatizing people who are overweight (Azevedo & Vartanian, 2015). Since its release, the ad and its creators have been criticized by advocates in media outlets (e.g., Alter, 2014). While the protest approach has been associated with anecdotal evidence of policy makers or companies changing, removing, or apologizing for their offending activities, the meta-analysis of Corrigan and colleagues found that protest efforts do not systematically reduce stigma-related attitudes (e.g., dangerousness), emotions (e.g., anger), or behaviors (e.g., avoidance). In fact, sometimes it increases these outcomes (e.g., Corrigan, River, Lundin, Penn, Uphoff-Wasowski, Campion, et al., 2001; Penn & Corrigan, 2002). Educational activities typically address beliefs involved in a stigma and try to change these beliefs by providing factual information disconfirming it (Corrigan et al., 2012). These campaigns often convey that people who are stigmatized are not responsible for their conditions, do not pose a danger, or are not fundamentally different from many others in the society. For example, the “Time to Change” campaign used a quote from a mental illness patient (“1 in 4 people like me have a mental health problem”) on its flyers (Henderson, Corker, Lewis-Holmes, Hamilton, Flach, Rose, et al., 2012). Other versions use opinion leaders to share information (e.g., Rice, Wu, Li, Detels, & Rotheram-Borus, 2012). The evidence shows that education interventions have small, persistent effects on reducing existing stigma beliefs, attitudes, and behaviors (Corrigan et al., 2012; Corrigan, Michaels, & Morris, 2015). Contact efforts (Corrigan et al., 2012) draw on research in reducing intergroup prejudice through interpersonal contact (Allport, 1954) between stigmatized and non-stigmatized people. Reviews of contact interventions show that very specific conditions are necessary for them to be effective (e.g., Pettigrew & Tropp, 2000). Meta-analytically, contact interventions have been associated with reducing stigma beliefs and behavior, but not emotions (Corrigan et al., 2012). Interpersonal contact seems to be more effective than mediated approaches, and the effects may be short-lived (Corrigan et al., 2015). Notably, while Corrigan and colleagues (2012) found that contact was more effective in reducing stigma than education across all of the studies, education (versus contact) was more effective for reducing the stigma beliefs of adolescents. The challenge of contact interventions is that they are logistically complex and resource intensive (Watson, Corrigan, & Kosyluk, 2014). While most efforts have targeted the public overall, it may be more useful to target critical groups, such as those who provide care and access to it (Watson et al., 2014).


The first appearance of stigma in an outlet associated with the National or International Communication Associations (NCA, ICA) was written by Thompson and Seibold in 1978. They noted that interactions between stigmatized and non-stigmatized persons had received little attention in communication research, and one could argue that this lack of attention has persisted for almost forty years. Indeed, stigma has received relatively little attention in communication outlets associated with NCA, ICA, regional groups, or interdisciplinary outlets such as Health Communication and the Journal of Health Communication. Since Thompson and Seibold’s article, only 101 articles have been published in these outlets with forms of the word stigma (e.g., stigma, stigmatized, stigmatization, etc.) in their abstract.

There are concerns about stigma research, such as tensions over who should study stigmas. Scholars who do not belong to stigmatized groups may fail to understand the lived experiences of those who do belong to stigmatized groups, and may favor their a priori concepts and fail to adjust their scholarship to those insights (see Link & Phelan, 2001 for a review). While studies vary in their focus on stigma at the level of a person, social entity, or society (e.g., Link & Phelan, 2001; Pescosolido, 2015), the published work on stigma often has an individualistic focus (Link & Phelan, 2001): there is more work on persons than relationships or structural issues, even though these were central parts of the original scholarship (e.g., Fiske, 1998; Goffman, 1963). This person-centered research has also focused more on personal attributes that identify people as part of a stigmatized group (Link & Phelan, 2001) than on marks others affix to stigmatized targets (Fine & Asch, 1988).

Most of the research on stigmas has used non-experimental designs. It is complicated, experimentally and ethically, to conduct experimental studies of stigma creation or reduction, as well as to examine interactions between stigmatizers and stigmatized people. Some scholars have used fictitious conditions (e.g., Smith, 2012a, 2014a) to avoid accidentally creating or strengthening a stigma about a real condition when there is not a reliable means to eradicate existing stigmas. The problem with fictitious conditions is that they may not be strong enough to evoke a response to stigma. Most studies on stigmatization are non-interactive, relying on self-report and attitudinal studies (Hebl & Dovidio, 2005). Some scholars have attempted to use virtual reality to avoid assigning people or confederates to experience stigmatization (e.g., Dotsch & Wigboldus, 2008).

Questions for Future Studies

While much has been uncovered about stigma, health, and risk, many questions remain, such as: How can one design messages that effectively alert the general public about imminent health threats and successfully promote desirable behavioral changes without evoking stigma processes? How do different reactions to stigmatization influence targets and their social networks? What factors increase personal- and community-level resistance or vulnerability to messages containing stigma-inducing content? Are there ways to stop emerging stigmas from spreading? While scholars have paid attention to the ethical and legal implications of stigma, what are the social implications for the stigmatized and their supporters? Finally, how can one create an effective, reliable means to eliminate existing stigmas?

Further Readings

  • Crocker, J., Major, B., & Steele, C. (1998). Social stigma. In D. Gilbert, S. T. Fiske, & G. Lindzey (Eds.), Handbook of social psychology (4th ed., pp. 504–553). Boston. MA: McGraw Hill.
  • Goffman, E. (1963). Stigma: Notes on the management of spoiled identity. Englewood Cliffs, NJ: Prentice-Hall.
  • Heatherton, T. F., Kleck, R. E., Hebl, M. R., & Hull, J. G. (Eds.). (2000). The social psychology of stigma. New York: Guilford.
  • Herek, G. M., & Glunt, E. K. (1988). An epidemic of stigma: Public reactions to AIDS. American Psychologist, 43, 886–891.
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  • Link, B. G., & Phelan, J. C. (2001). Conceptualizing stigma. Annual Review of Sociology, 27, 363–385.
  • Smith, R. A. (2007). Language of the lost: An explication of stigma communication. Communication Theory, 17, 462–485.
  • Smith, R. A. (2011). Stigma communication and health. In T. L. Thompson, R. Parrott, & J. Nussbaum (Eds.), Handbook of health communication (2d ed., pp. 455–468). New York: Taylor & Francis.
  • Meisenbach, R. J. (2010). Stigma management communication: A theory and agenda for applied research on how individuals manage moments of stigmatized identity. Journal of Applied Communication Research, 38, 268–292.
  • Thompson, T. L., & Seibold, D. R. (1978). Stigma management in “normal”-stigmatized interactions: Test of the disclosure hypothesis and a model of stigma acceptance. Human Communication Research, 4, 231–242.
  • Williams, K. D. (2007). Ostracism. Annual Review of Psychology, 58, 425–452.


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