Social Science & Medicine 64 (2007) 15241535

Culture and stigma: Adding moral experience to stigma theory

Lawrence Hsin Yang
a,
, Arthur Kleinman
b
, Bruce G. Link
a
,
Jo C. Phelan
c
, Sing Lee
d
, Byron Good
e
a
Department of Epidemiology, Columbia University, 722 West 168th Street, Room 1610, NY, NY 10032, USA
b
Department of Anthropology and Social Medicine, Harvard University, USA
c
Department of Sociomedical Sciences, Columbia University, USA
d
Department of Psychiatry, Chinese University of Hong Kong, Hong Kong
e
Department of Anthropology and Social Medicine, Harvard University, USA
Available online 22 December 2006
Abstract
Denitions and theoretical models of the stigma construct have gradually progressed from an individualistic focus
towards an emphasis on stigmas social aspects. Building on other theorists notions of stigma as a social, interpretive, or
cultural process, this paper introduces the notion of stigma as an essentially moral issue in which stigmatized conditions
threaten what is at stake for sufferers. The concept of moral experience, or what is most at stake for actors in a local social
world, provides a new interpretive lens by which to understand the behaviors of both the stigmatized and stigmatizers, for it
allows an examination of both as living with regard to what really matters and what is threatened. We hypothesize that
stigma exerts its core effects by threatening the loss or diminution of what is most at stake, or by actually diminishing or
destroying that lived value. We utilize two case examples of stigmamental illness in China and rst-onset schizophrenia
patients in the United Statesto illustrate this concept. We further utilize the Chinese example of face to illustrate stigma
as having dimensions that are moral-somatic (where values are linked to physical experiences) and moral-emotional (values
are linked to emotional states). After reviewing literature on how existing stigma theory has led to a predominance of
research assessing the individual, we conclude by outlining how the concept of moral experience may inform future stigma
measurement. We propose that by identifying how stigma is a moral experience, new targets can be created for anti-stigma
intervention programs and their evaluation. Further, we recommend the use of transactional methodologies and multiple
perspectives and methods to more fully capture the interpersonal core of stigma as framed by theories of moral experience.
r 2006 Elsevier Ltd. All rights reserved.
Keywords: Stigma; Theory; Measurement; China; Moral experience; Mental illness; USA
Introduction
The construct of stigma has generated extensive
theoretical and empirical research, and as the
literature has expanded, so too has reasoning about
what the concept entails. We trace the development
of the stigma concept, paying particular attention to
an evolution in its denition from a construct
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doi:10.1016/j.socscimed.2006.11.013

Corresponding author. Tel.: +1 212 305 4747;

fax: +1 212 342 5169.
E-mail addresses: laryang@attglobal.net (L.H. Yang),
kleinman@wjh.harvard.edu (A. Kleinman), bgl1@columbia.edu
(B.G. Link), jcp13@columbia.edu (J.C. Phelan),
singlee@cuhk.edu.hk (S. Lee), byron_good@hms.harvard.edu
(B. Good).
largely grounded in the individual to one rooted in
social space. Next we examine theoretical models
describing how stigma affects people, focusing on
how these models have identied stigmas social
aspects. This examination of the limited manner in
which current denitions and theoretical models
address the social dimensions of stigma reveals a
need for an expanded conceptual lens that incorpo-
rates moral experience, or what is most at stake for
actors in a local social world. We provide several
examples of stigma as moral experience, focusing on
mental illness in China as an illustration of stigma
as a dynamic psychocultural process. We conclude
by describing the impact of current stigma theory
upon measurement, and detail how consideration of
moral experience will encourage innovative means
of measuring stigma.
Denitions of stigma
We rst examine how existing stigma denitions
have delineated this construct, with a particular
focus on how stigmas social elements have been
conceptualized. Goffman (1963), in his classic
formulation, denes stigma as an attribute that is
deeply discrediting and proposes that the stigma-
tized person is reduced from a whole and usual
person to a tainted, discounted one (p. 3). Goff-
man views processes of social construction as
central; he describes stigma as a special kind of
relationship between an attribute and a stereotype
(p. 4) and avers that stigma is embedded in a
language of relationships (p. 3). In Goffmans
view, stigma occurs as a discrepancy between
virtual social identity (how a person is character-
ized by society) and actual social identity (the
attributes really possessed by a person) (p.2).
Emphasizing Goffmans idea of stigma as an
attribute, Jones et al.(1984) use the term mark to
describe a deviant condition identied by society
that might dene the individual as awed or spoiled.
Although Jones et al. describe the stigmatizing
process as relationali.e., the social environment
denes what is deviant and provides the context in
which devaluing evaluations are expressedthese
authors also emphasize impression engulfment
a psychological process located within the indivi-
dualas the essence of stigma (p. 9).
Other social psychological formulations have
further located stigma as a characteristic of the
individual. Crocker, Major, and Steele (1998) also
dene stigma as occurring when an individual is
believed to possess what they describe as an often
objective attribute or feature that conveys a
devalued social identity within a social context.
This identity is then socially constructed by dening
who belongs to a particular social group and
whether a characteristic will lead to a devalued
social identity in a given context. Like Goffman,
Crocker et al. propose that stigma at its essence is a
devaluing social identity (p. 505). Yet the authors
observe that stigma is not located entirely within the
stigmatized person, but occurs within a social
context that denes an attribute as devaluing. Also,
these authors cite briey the inuence of power
in determining ones susceptibility and possible
response to stigma.
These social psychological denitions agree that
stigma: (1) consists of an attribute that marks
people as different and leads to devaluation; and (2)
is dependent both on relationship and contextthat
stigma is socially constructed (Major & OBrien,
2005). In conjunction with the insights provided by
a perspective based on evolutionary psychology
(Kurzban & Leary, 2001), these conceptualizations
capture many important aspects of stigma. How-
ever, these frameworks have also been criticized as
neglecting the stigmatized persons viewpoint and as
focusing too narrowly on forces located within the
individual rather than on the myriad societal forces
that shape exclusion from social life (Parker &
Aggleton, 2003).
Out of these critiques, Link and Phelan (2001)
proposed a sociological denition of stigma as a
broad umbrella concept that links interrelated
stigma components. Similar to the social psycholo-
gical denitions, the rst four components of their
denitionlabeling, stereotyping, cognitive separa-
tion, and emotional reactions (added in Link, Yang,
Phelan, & Collins, 2004)identify social processes
that take place within the sociocultural environment
whose effects can be observed within the individual.
Yet the fth component of Link and Phelans
denitionstatus loss and discriminationalso
includes structural discrimination (when institu-
tional practices disadvantage stigmatized groups).
Also unique to the conceptualizations considered is
Link and Phelans idea that the stigma process
depends on the use of social, economic, and poli-
tical power that imbues the preceding stigma
components with discriminatory consequences.
Link and Phelans denition thus represents a
critical step towards viewing stigma as processual
and created by structural power. This becomes
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L.H. Yang et al. / Social Science & Medicine 64 (2007) 15241535 1525
further illustrated by Das, Kleinman, Lock, Mam-
phela, and Reynolds (2001) who, amongst others,
showed that the issue of power is often lodged in the
apparatus of the State, whose agents and agencies
can stigmatize entire groups.
Social components of the theoretical models of stigma
Just as stigma denitions have increasingly
articulated the construct as one based on social
processes, models of how stigma exerts its negative
effects have progressively emphasized its social
aspects. Examining models of stigma, including
identifying whether these models classify outcomes
as individualistic or social, further illustrates how
the social domain has been conceptualized in how
stigma works. In contrast to the paucity of stigma
denitions, there is a comparatively large literature
describing how stigma affects people; we review this
briey (for further reviews, see Hinshaw, 2005;
Major, McCoy, Kaiser, & Quinton, 2003; Schmitt &
Branscome, 2002; Stangor et al., 2003; Steele,
Spencer, & Aronson, 2002).
Several social psychologists have described stigma
as a situational threat; stigma results from being
placed in a social situation that inuences how one
is treated. Jones et al. (1984) conceptualized stigma
based on the processes of cognitive categorization
i.e., stigma takes place when the mark links an
individual via attributional processes to undesirable
characteristics that lead to discrediting. Subsequent
social psychological models further incorporate the
response of individuals to stigma. Crocker et al
(1998) included not only the role of social context in
shaping identity, but also how individuals cogni-
tively maintain integrity of the self and actively
construct social identity. Major and OBrien (2005)
integrate an identity threat modeli.e., a transac-
tional analysis of stress and coping strategies
enacted by the individual (Lazarus & Folkman,
1984)with stigma. The social elements of Major
and OBriens theory consist of the immediate
situational cues (which convey risk of being
devalued) and collective representations (knowledge
of cultural stereotypes) that inuence appraisal of
threat to ones well-being. At the heart of these
latter two formulations is the concept that stigma
predisposes individuals to poor outcomes by threa-
tening self-esteem, academic achievement, and
mental or physical health.
Other social psychologists have described stigma
as a specic application of stereotyping, prejudice,
and discrimination research (Ottati, Bodenhausen,
& Newman, 2005). Here, the social elements of
stigma consist of socially shared cognitive repre-
sentations that inaccurately associate individuals
with mental illness with certain negative character-
istics. Further, the negative emotional reactions
(prejudice) or negative behaviors (discrimination) of
stigmatizers can be seen to derive from social
others. Paralleling this community model, Corri-
gan and Watson (2002) present a social-cognitive
model of personal response to stigma that initiates
when individuals with mental illness know of the
negative cultural images that characterize their
group (self-stereotyping), which then leads to self-
prejudice and self-discrimination. Further, in deter-
mining the individuals personal response to stigma,
Corrigan and Watson identify social elements such
as collective representations (cultural stereotypes,
perceived social hierarchies, and sociopolitical
ideology) activated by cognitive primes (informa-
tion from the situation) that inuence whether the
stigma encountered is appraised as legitimate or
illegitimate. Like the other social psychological
models, Corrigan and Watson locate the primary
effects of stigma on the individuals emotional
response and self-esteem.
Although the full scope of these social psycholo-
gical models are too intricate to review here, these
models have greatly advanced our understanding of
how an individuals stigmatized social identity is
constructed through cognitive, affective and beha-
vioral processes. Because these models derive from
social psychological theory, each focuses on current
social or situational determinants of stigma. Another
important emphasis is that stigmatized individuals
actively copei.e., through construal, appraisal or
other cognitive strategieswith stigmatizing circum-
stances. However, an analysis of these models reveals
that they primarily regard the social aspects of stigma
as a psychological variable (i.e., social identity as
applied to an individual), as an environmental
stimulus that the individual appraises or responds
to, or as societal or cultural stereotypes. Further,
these models restrict the range of coping responses to
the stigmatized individuals reactions (e.g., cognitive
coping strategies) and the harmful outcomes of
stigma to individual self-processes (e.g., psychologi-
cal well-being). These models suffer from limiting
conceptualization of the social to those environmen-
tal elements of stigma that impinge upon the
individual sufferer, who is then viewed as the primary
locus in which stigma processes take place.
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L.H. Yang et al. / Social Science & Medicine 64 (2007) 15241535 1526
Goffman (1963) did not appear to emphasize
such an individualistic focus when he described
stigma as a process based on the construction of
social identity. Rather, stigma occurs through what
Goffman terms a moral career (p. 32): when a
stigmatized person initially learns societys stand-
point and gains a general idea of what it might be
like to possess a particular stigma. Persons with
mental illness (a non-visible stigma) thus pass from
normal to discreditable status, and if they
disclose their condition, a discredited status.
Goffman describes transition from each status as
resulting from control of identity information.
Thus, in Goffmans view, stigma occurs as a new
social identity is assumed through interaction (i.e.,
re-identifying) with socially constructed cate-
gories.
Other sociological models have also regarded
stigma from a symbolic interactionist perspective.
Scheff (1966) proposed a labeling theory of
mental illness where the application of deviant
labels to individuals led to changed self-perceptions
and social opportunities. According to Scheff,
mental illness stereotypes are learned during socia-
lization and reinforced daily. Scheff proposes that
once fully inculcated, the stereotyped patient role
may then emerge as a master status due to its
highly discrediting nature (Markowitz, 2005). Uni-
form responses from others (such as social exclu-
sion) then block attempts to return to normal
social roles. Link, Cullen, Struening, Shrout, and
Dohrenwend (1989) elaborated upon Scheffs claim
that the labeling process was the primary cause of
symptomatic behaviors by formulating a Modied
Labeling Theory that proposed that labeling places
individuals with mental illness at risk for negative
outcomes that may exacerbate pre-existing mental
disorders. According to Link et al., expectations of
devaluation become personally relevant once ofcial
labeling occurs during contact with treatment.
Negative psychosocial consequences may stem from
beliefs of anticipated rejection or the individuals
response to stigma, which are then seen to increase
vulnerability to future psychiatric relapse.
Both Scheffs and Link et al.s models dene
stigma as operating primarily in the social sphere
the symbolic interactionist perspective proposes that
objects in the social world (persons and actions)
obtain meaning through social interaction (Mead,
1934). Thus, the meaning of behavior (and de-
viance) is continuously interpreted through utiliza-
tion of language and symbols. Social responses to
behaviors are shaped by shared cultural meanings.
Self-conceptions thus arise from perceptions of how
others view and respond to the self as a social object
(Markowitz, 2005). Role identities (e.g., being
mentally ill) form when self-conceptions result in
reied social positions that are accompanied with
behavioral expectations. Despite the emphasis of
these sociological models on the social and inter-
active bases of stigma however, research utilizing
these frameworks has largely continued to locate
stigmas effect within the individual stigmatizer or
recipient.
A subsequent framework proposed by Corrigan,
Markowitz, and Watson (2004) further expands the
social mechanisms of stigma by describing the
structural determinants of mental illness stigma
that arise from economic, political, and historical
sources. Intentional institutional discrimination
occurs when the decision-making group of an
institution intentionally implements policies that
reduce opportunities for a particular group (e.g.,
state legislatures restricting people with mental
illness from voting). A second type of structural
discrimination takes place when policies limit the
rights of people with mental illness in unintentional
ways. For example, societal policies that limit public
mental health care are typically motivated by
arguments that increased mental health coverage
would lead to prohibitively high health care costs.
What is key in structural discrimination is that the
decision to stigmatize does not take place at the
interpersonal level. Rather, discriminatory policies
exert their adverse effects via broader, systemic
forces.
1
Moral experience and stigma
Sociological approaches push us to conceive of
stigma as a social process with multiple dimensions.
Stigma is seen to be embedded in the interpretive
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1
One other perspective articulated with respect to HIV/AIDS
identies stigma in a broader framework of power and
domination and as central to reproducing structures of hegemony
and control. Parker and Aggleton (2003) draw from the work of
philosophers and sociologists such as Foucault (1977) and
Bourdieu (1977) who propose that forms of social control are
embedded in established knowledge systems that legitimize
structures of social inequality and thus limit the ability of
marginalized peoples to resist these hegemonic forces. These
authors argue that stigma is utilized by identiable social actors
who legitimate their dominant societal positions by maintaining
social inequality, and that stigma consequently occurs at the
convergence of culture, power and difference.
L.H. Yang et al. / Social Science & Medicine 64 (2007) 15241535 1527
engagements of social actors, involving cultural
meanings, affective states, roles, and ideal types. A
social dialectic of interpretation and response
effectively ensures that marginalization is perpetu-
ated, since others respond to a stigmatized indivi-
dual as someone already burdened with shame,
ambivalence, and low status. Macro-social structur-
al forces also compound marginalization by limiting
in advance the possibilities of other kinds of
interactions or responses. These approaches are a
large part of the reason that stigma is so prominent
now and insights from this work are being used to
address stigma in peoples lives. We seek to build on
this body of work and to provide a new set of ideas
that will contribute a novel perspective to the study
of stigma.
Anthropological or ethnographic approaches to
stigma also emphasize its social dimensions,
although these approaches impel us to even more
deeply and robustly consider how stigma is
embedded in the moral life of sufferers. This
approach adopts the concepts of a broader perspec-
tive on the social dimensions of illness (Kleinman
1988), social suffering (Kleinman, Das, & Lock
1997), and violence and trauma (Das et al., 2001).
Here, the focus is on lived or social experience,
which refers to the felt ow of engagements in a
local world. A local world refers to a somewhat
circumscribed domain within which daily life takes
place. This could be a social network, an ethno-
graphers village, a neighborhood, a workplace
setting, or an interest group. What denes all local
worlds is the fact that something is at stake. Daily
life matters, often deeply. People have something to
gain or lose, such as status, money, life chances,
health, good fortune, a job, or relationships. This
feature of daily life can be regarded as the moral
mode of experience. Moral experience refers to that
register of everyday life and practical engagement
that denes what matters most for ordinary men
and women (Kleinman, 1997, 1999, 2006). Early
recognition of a moral component to stigma is
found in the important contributions of Goffman
(1963), Scott (1969), and Erikson (1966).
Building on other theorists notions of stigma as a
social, interpretive, or cultural process, anthropol-
ogists have pushed us to conceive of stigma as a
fundamentally moral issue in which stigmatized
conditions threaten what really matters for suf-
ferers. In turn, responses arise out of what matters
to those observing, giving care, or stigmatizing;
here, what matters to these social interlocutors can
allay or compound conditions. In addition to
compounding the experience of illness, stigma can
intensify the sense that life is uncertain, dangerous,
and hazardous. Stigmatizing someone is not solely a
response to sociological determinants or a deeply
interpretive endeavor played out in a cultural
unconscious. It is also a highly pragmatic, even
tactical response to perceived threats, real dangers,
and fear of the unknown. This is what makes stigma
so dangerous, durable, and difcult to curb. For the
stigmatized, stigma compounds suffering. For the
stigmatizer, stigma seems to be an effective and
natural response, emergent not only as an act of
self-preservation or psychological defense, but also
in the existential and moral experience that one is
being threatened. Here the dialectics that dened
the sociological approach can be seen to be
deepened or thickened. Responses are not only
determined by cultural imperatives, meanings, or
values, but refer to a real world of practical
engagements and interpersonal dangers. Both the
stigmatizers and the stigmatized are engaged in a
similar process of gripping and being gripped by
life, holding onto something, preserving what
matters, and warding off danger. If recipients of
stigma nd that what is held to be most dear may be
seriously menaced or even entirely lost, these threats
are also felt by non-stigmatized others and may lead
them to respond to the threat embedded in the
stigmatizing situation by discriminating against and
marginalizing others.
From a cross-cultural perspective, stigma appears
to be a universal phenomenon, a shared existential
experience (Link et al., 2004). Yet we must be
careful not to collapse all forms of discrimination
into a formulaic idea of stigma. Historically,
Foucault (1977) and others (Farmer, 1992; Gussow,
1989; Shell, 2005) have demonstrated that stigma
varies in degree and quality in distinctive epochs
owing to different administrative and legal dis-
courses. Across cultures, the meanings, practices,
and outcomes of stigma differ, even where we nd
stigmatization to be a powerful and often preferred
response to illness, disability, and difference. A
review of the research literature in China, for
example, would lead one to conclude that stigma
exerts its negative effects in a similar way to other
communities. First, people with psychiatric illness
are perceived, within their communities, as unpre-
dictable and dangerous. In one study (Tsang, Tam,
Chan, & Cheung, 2003), nearly 50% of 1007 Hong
Kong community respondents described people
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L.H. Yang et al. / Social Science & Medicine 64 (2007) 15241535 1528
with mental illness as quick-tempered and a
signicant proportion (28.9%) agreed that this
group is dangerous no matter what. In another
study, nearly 70% of 320 schizophrenia outpatients
in Hong Kong (Lee, Lee, Chiu, & Kleinman, 2005)
agreed that promotion at work would be affected
and 59.7% anticipated their partner leaving him/her
if the mental illness was revealed. This expectation
of rejection in turn shaped patients coping
responses. Over 50% of Lee et al.s (2005) sample
deliberately concealed mental illness from co-work-
ers and friends. From such studies we learn how
people in a variety of cultures can anticipate
discrimination, shunning, and bias when it comes
to their illness experiences.
The greatly pejorative stereotypes in China also
appear to contribute to frequent direct discrimina-
tion. Over a majority (60%) of 1,491 family
members of schizophrenia patients in Mainland
China reported experiencing moderate or severe
effects of stigma on the patient (Phillips, Pearson,
Li, Xu, & Yang, 2002), and a signicant percentage
(44.5%) among the outpatients in Lee et al.s (2005)
study also reported being laid off after disclosing
their mental illness. Hence, the empirical research
among Chinese individuals with mental illness
demonstrates types of discrimination, rejection and
loss of self-worth that converge with stigma
reported in European and North American popula-
tions (Phelan, Bromet, & Link, 1998; Wahl, 1999).
Yet the above conclusion provides an incomplete
understanding of how stigma effectively margin-
alizes both individuals and entire social groups in
China. A more comprehensive formulation can be
reached by understanding how stigma threatens the
moral experience of individuals and groups, such
that responses arise out of feelings of danger,
uncertainty, and preservation. For example, what
is most at stake for the mentally ill in China is often
the ways that stigma can devastate the moral life of
a family (Phillips et al., 2002). Kinship ties are
burdened where an individual is viewed as a
temporary part of a timeless structure whose
descendents have the responsibility to extend and
make this structure prosper (Kleinman & Kleinman,
1993). Stigma in Chinese society quickly moves
from affected individuals to his/her family, largely
due to shared etiological beliefs about mental illness
that assign a moral defect to sufferers and their
families (Yang & Pearson, 2002). Family members
suffer so much from stigmatizing attitudes that
59.6% of Lee et als (2005) outpatient sample
reported that family members wished to conceal
the illness and 41.1% reported unfair treatment
towards family members. Stigmatizing the family
thus threatens to break the vital connections
(quanxi wang) that link the person to a social
network of support, resources, and life chances.
Especially threatened are the material and social
opportunities for the patient to marry, have
children, and perpetuate the family structure.
Something crucial is missed when stigma is seen as
affecting the individual only; in these examples from
Chinese society, stigma is most grievously felt as its
conditions reverberate across social networks, such
that both the entire network is threatened or
devalued and the individual sufferer is shunned,
banned, or discriminated against within that net-
work as a defensive response. The end result for
individuals with mental illness and their families in
China can be a kind of social death that threatens
the very existence, value, and perpetuity of the
family group.
The concept of moral experience and its applica-
tion to stigma is not limited to cross-cultural
settings. Overarching core values in the US de-
marcate individuals as full participants in social
life or de-legitimate others as not quite integrated.
Since de Tocqueville (1832 (1990)) analysis of
democracy and American values in the early
1800s, the notion of individualismwhere an
individuals freedom to exercise choice and self-
reliance is obtained through sufcient education
and fortune to chart ones lifehas been classied
as supremely American. Since American society
does not maintain hereditary wealth or class
distinctions, de Tocqueville also identied labor as
ythe necessary, natural and honest condition
and even held by the whole community to be an
honorable necessity (pp. 152153). Such values
have persisted to comprise present-day ofcial
American values of tolerance, equality of opportu-
nity, individual initiative, and freedom that have
become embedded in US education and socializa-
tion (Selznick & Steinberg, 1969). Violation of these
core values leads to moral sanctions; such indivi-
duals are cast as the moral othere.g., unem-
ployed welfare recipients are characterized as
undeserving persons reliant on overly generous
government benets (Morone, 1997). In its most
potent form, moral judgments can shape the
denition of rights, the distribution of prestige,
and the dispensation of social welfare benets in
the US (Morone, 1997, p. 998).
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How such core lived values are affected in the
lived experiences and moral lives of sufferers
depends not just upon the particular illness, but
also upon the concrete setting, social network, or
situation of care in which the sufferer lives. For
example, recent rst-break schizophrenia patients
in a particular locale will have different things at
stake than chronic patients who at a later illness
and life stage may require family or govern-
ment assistance for everyday living. An initial
psychotic break will likely emerge in adolescence
or early adulthood; illness onset greatly compro-
mises ones ability to meet developmental demands
essential to achieving self-reliance, such as complet-
ing school, nding employment, and living inde-
pendently. Psychiatric hospitalization may
especially threaten the patients emergent sense of
individual freedom as many basic rights and
liberties may be suspended. If, as Erikson (1963)
argued, the key developmental task of early adult-
hood is to establish intimate bonds of love and
friendship, which may be powerfully felt as desires
for peer acceptance and normality, then this
ambient individualist culture is further contested
by the very practical setting in which people come of
age. For rst-break schizophrenia patients, then,
stigma arises and is felt most directly in these
essential life domains. At very early stages of
development, personal growth, and socialization,
what matters most is threatened not by an intrusion
but by denition. The ambivalence of an uneven,
difcult, and threatened development would be part
of the socialization itself, such that stigma comes to
dominate the moral experience of the sufferer,
threatening the process of achieving a balance
between self-reliance and retaining a sense of
normalcy.
The focus on moral experience also allows a
reconceptualization of how the so-called others
constitute the world of stigma. These are the ones
doing the stigmatizing, but they can also be
members of a peer group, social network, or system
of care (e.g., parents, doctors). The anthropological
approach sees all of these people as inhabiting
shared social space. Not just positioned differently
within structures of stigma, status, and prestige,
they are bound together in getting things done, in
the practice of addressing illness and stigma. What
matters most to all these others interlaces with
what matters to sufferers.
The anthropological focus on moral experience
further contributes to the study of stigma by
framing this process as a sociosomatic one. The
embodiment of sociosomatic processes is especi-
ally well-exemplied in the Chinese experience
of face and its loss. Face represents ones moral
status in the local community. One has face,
receives face, and gives face to respected
others. When Chinese experience loss of face,
they quite literally report the experience of humilia-
tion as an inability to face others, as a physical
crumbling of facial expression, a way of being
faceless. Here, stigma is not just a discursive or
interpretive process but a fully embodied, phy-
sical, and affective process that takes place in the
posture, positioning, and sociality of the sufferer.
This linking of values to physical experiences
is termed moral-somatic. Among Chinese, this
physical sensation is inseparable from the emo-
tion of humiliation, and that emotion in turn is
directly tied to the social state and the moral value
of being discredited (or discreditable). The linking
of values to emotional states can be described as
moral-emotional. The face complex is located
simultaneously among physicalemotionalsocial
cultural domains, or a sociosomatic reticulum
(Kleinman, 1996; Kleinman & Kleinman, 1991).
Stigma is such a closely related example that it
may work through the same interconnection of
physicalemotionalsociocultural bodies, at least
among Chinese.
Writings about stigma in the European and
North American traditions of social thought
have not adequately attended to its moral dimen-
sions. Yet, we can today read Goffman as having
had very much in mind moral status and its
vicissitudes. We recommend that moral experience
be brought back into denitions and models of
stigma as a reticulum spanning the person (body-
self-affect), the sufferers social network and condi-
tions, and what is most at stake for sufferers and for
their local world. Stigma, we hypothesize, threatens
the loss or diminution of what is most at stake, or
actually diminishes or destroys that lived value. Put
differently, engagements and responses over what
matters most to participants in a local social world
shape the lived experience of stigma for both
sufferers and responders or observers. The focus
on moral experience allows us to adequately
understand the behaviors of both the stigmatized
and those doing the stigmatizing, for it allows us to
see both as interpreting, living, and reacting with
regard to what is vitally at stake and what is most
crucially threatened.
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Implications of previous stigma theory on
measurement
Stigma theories exert a direct inuence on
measurement by determining the content of stigma
assessments and thereby identifying what lies within
the stigma construct. Further, each stigma model
calls for the administration of measures to specic
populations (e.g., Corrigan and Watsons (2002)
theory of personal response to stigma requires
sampling people with mental illness) to test its
theory. In our view, the individualistic focus among
prior stigma models has contributed to a predomi-
nance of survey research conducted among certain
groups. Our view is corroborated by an extensive
methodological review of 109 stigma studies con-
ducted from 19952003 (Link et al., 2004), which
illustrates an emphasis on survey methodology
(xed questions followed by Likert response scales);
60% of studies utilized survey methods, constituting
the most frequently used methodology. Survey
instruments with xed-item responses are especially
suited to assessing stigma dimensions located within
the individual (see Link et al., 2004, p. 517, Table 3).
In terms of study populations, because existing
stigma theories highlight the effect of community
attitudes towards the individual, this has resulted in
the most frequent sampling of general population
groups (47% of studies; see also Link et al., 2004,
p. 518, Table 4). To a lesser degree, studies that
examine theories of how individuals experience and
respond to stigma have also resulted in a signicant
proportion of studies that sample people with
mental illness, constituting the second-most
sampled group (22% of studies). These methodolo-
gical and sampling biases have resulted in an
inordinate focus on individual actors as the sole
source and recipient of stigma.
In contrast, several of the sociological models
suggest a more social, or less individualistic, view
of the stigma process by emphasizing societal
forces and larger-scale units of measurement. For
example, Corrigan et al.s (2004) formulation of
structural discrimination emphasizes measure-
ment of collective and macro-level units (e.g., how
government insurance systems may limit mental
health benets) as the aggregate of individual
units. This structural view focuses on larger-scale
systems and promotes more complex assessment of
stigma variables that captures both macro- (e.g.,
structural discrimination) and micro (e.g., loss of
job opportunities)-level sources of stigma. From
this perspective, increased side effects from con-
ventional antipsychotic medications that are pre-
scribed due to cost-saving guidelines, adverse
experiences during psychiatric hospitalization that
privilege social control over patients, and dispro-
portionate allocation of funds towards staff salary
as opposed to medical supplies (including medica-
tions) in Hong Kong constitute valuable areas for
stigma measurement (Lee, Chiu, Tsang, Chiu, &
Kleinman, 2006).
Although current stigma research appears to
acknowledge the psychosomatic quality of stigma,
little research has actually examined this topic. The
same can be said of the interpersonal aspects of
stigma. They are often included in studies but all too
infrequently are prioritized. Hence, with a few
interesting exceptions, most current research is
limited by its methodological emphasis on indivi-
dual psychological processes as well as collective
biases.
Contributions of moral experience to stigma
measurement
Several useful questions for research emerge from
considering moral experience in relation to stigma
processes:
Stigma spans physical emotional social cultural
domains
By threatening what is at stake in the social
world, stigma endangers what is most valued in
ones innermost being. By proposing a means by
which the social world (values) crosses over into the
self (subjective experience of bodily states and
emotions), our framework incorporates how stigma
has psychobiological manifestations that occur out
of awareness and that stigma takes place in
intersubjective space. We propose that stigma has
the following characteristics:
Stigma is sociosomatic
Norms and emotions are linked by mediating
processes, which occur simultaneously through
moral-somatic and moral-emotional forms. In mor-
al-somatic processes, ones bodily states are linked
with ones experience of societal norms and
valuesi.e., the experience of the social world
may be transduced to physiology. This process is
illustrated by neurasthenia patients in China who
embodied the tremendous social upheaval of the
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Cultural Revolution as dizziness, headaches, fatigue
and exhaustion (Kleinman, 1988). With stigma,
distinct physical experiences may occur with loss of
social position. For example, Chinese report dis-
crete physical sensations (e.g., crumbling of facial
expression), representing real dread that is experi-
enced even more strongly than physical fear (Hu,
1944).
With moral-emotional processes, social values are
concurrently linked with an individuals experience
of emotions. Symbolic forms of stigma, such as
language and cultural images, connect the social
world of values to the inner world of feelings.
Chinese social life exemplies this process, where
social connections are intertwined with affective
dynamics in everyday interaction (renqing guanxi
the feeling of moral relationships). In this context,
the loss of social standing and weakening of social
ties resulting from stigma become inseparable from
feelings of overwhelming shame, humiliation and
despair.
While prior stigma theories have identied how
societal valuations of mental illness are linked with
the labeled individuals emotions (e.g., Link et al,
1989), our theory also emphasizes that stigma is
moral-somatic. Although other stigma theories
imply that physical processes within the stigma-
tized individual occur through affect or involuntary
stress responses (e.g., Major & OBrien, 2005),
our theory also identies that stigma may be felt
and sensed in the individuals bodily state yet not
consciously acknowledged. This process is de-
picted by people with mild mental retardation
who preserve self-esteem and a sense of normality
by adamantly rejecting the label of mental retarda-
tion and its implied lack of basic competence
(Edgerton, 1993). Edgerton describes these elabo-
rate attempts to pass as normal and denial of ever
being labeled mentally retarded as assuming a
protective cloak of competence. Yet despite this
apparently successful use of denial, such people
continue to fundamentally sense or feel their
difference and intellectual decits. How societal
norms of devaluation come to be physically felt,
even if consciously disavowed, may also occur
among people with mental illness who nd the
consequent shame too horrible and intolerable to
acknowledge.
Stigma is intersubjective
Stigma occurs among interpersonal communica-
tion and lived engagements. By taking place both
outside and inside a person, stigma is a social and
subjective process. Thus, stigma can be viewed as
interpersonal, or relational in nature. We further
suggest that much of stigma occurs in the inter-
subjective space between people at the level of
words, gestures, meanings, feelings, etc., during
engagement with what matters most. To utilize the
Chinese example, when severe mental illness occurs,
shame engulfs each family member as well as the
patient. Collectively, they may be ostracized from
social networks and experience reduced social
status. Yet can the experience of shame be
accurately understood as residing in each aficted
family member? Or can it also be understood as
being located in the intersubjective spacein the
interpersonal actions and communications that
signal recognition of shamebetween patients and
their closest family members?
We thus recommend a shift from solely assessing
stigma within the individual towards gauging
interpersonal, or transactional, forms of stigma.
Such a shift becomes essential if, as described above,
intolerable shame may be disavowed by individuals
when directly queried. Indeed, prior stigma research
has utilized transactional analyses, such as evaluat-
ing behavioral interactions between a perceiver
and (falsely and unknowingly labeled) psychother-
apy client (Sibicky & Dovidio, 1986). We are not,
however, encouraging research approaches that use
deception. We suggest returning to such observa-
tional, or transactional, methodologies to more
fully capture stigmas interpersonal aspects. This
approach may aid examination of how structural
discrimination works, as this type of stigma often
consists of everyday, subtle forms of social interac-
tions.
Stigma threatens what matters most
Stigma takes on its character of danger by
threatening interpersonal engagements and what is
most at stake. This perspective directly contributes
to stigma measurement because what is most at
stake for participants in a local world is empirically
discoverable. How stigma threatens moral standing
can be ascertained by eliciting the actual words used
by informants to describe their stigma experiences.
Further, one may inquire how those words relate to
informants reports of what is most at stake and
how stigma affects these lived values in everyday life
activities.
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Anthropology and moral theory contribute to the
examination of stigma by articulating (e.g., through
highly focused ethnography) where critical stigma
processes exert their harmful effects. In particular
contexts, stigma processes may occur during key
times that inculcate patients (and family members)
into stigmatized careers. These critical periods
are likely to be interconnected among practical,
everyday engagements with commonly held forms
of status or power in local worlds, which may
consist of other than economic or political types.
For example, one study in Hong Kong reported that
family members in addition to sharing the shame of
mentally ill individuals, also may perpetuate stigma
towards the patient (Lee et al., 2005). Lee et al.
hypothesized that family members fears of social
contamination and losing facea social status
needed for interpersonal actionmotivated rela-
tives to stigmatize (and sometimes abandon) their ill
family members. For a newly labeled Chinese
individual, potentially traumatizing interactions
with closely bonded family members may initiate
patients into a stigmatized role. Further, actions
from health care professionals that convey a
devalued status to patients are increasingly recog-
nized as pivotal in stigma generation, particularly
during initial psychiatric hospitalization (Lee et al.,
2006).
Upon identifying the stigma processes that
threaten what makes life matter, these areas can
then be targeted for anti-stigma intervention and
evaluation of such programs. This perspective
markedly contrasts with most anti-stigma inter-
ventions to date, which have sought to modify
public opinions through psychoeducation and have
examined public attitude change as the primary
outcome (Hinshaw & Cichetti, 2000). Although
stigma may share features across contexts, what is
most at stake in local settings constitutes the
receptive eld that shapes how stigma is felt. Rather
than prescribing interventions without knowledge
of their local effects, focused interventions based on
observation of the everyday lives and the actual
difculties that stigmatized individuals face may
better address how stigma threatens what is
fundamentally at stake. Accordingly, the World
Psychiatric Association has recently shifted its
efforts to reduce stigma in over 20 countries from
staging public attitude campaigns that had small
and transient effects to tailoring interventions to the
local stigma experiences of psychiatric patients
(Sartorius & Schulze, 2005).
Measuring stigma requires multiple perspectives and
measures
To fully describe how stigma affects what is most
valued for local stakeholders, it becomes essential to
obtain perspectives from multiple participants who
comprise that social space. Multiple informants
become necessary because stigmatized individuals
may possess inadequate awareness of how commu-
nity members view their condition. Second, stigma-
tized individuals may not disclose concerns
regarding stigma because it may be felt as too
threatening. Although not immune to such inu-
ences, close family members may be more attuned
to and willing to report stigma experiences. How-
ever, the stigmatized individuals (and family
members) perspective remains essential because
community members may also withhold stigmatiz-
ing attitudes due to concerns of correctness or
social desirability. In terms of moral experience
theory, these other social actors are also vitally
intertwined with the practical everyday engage-
ments over what matters most to sufferers.
The use of multiple vantage points and meth-
odologies may reveal different or complementary
perspectives on how stigma threatens to diminish
what is held as most dear by local participants.
Ethnographic methods (e.g., participant observa-
tion) are especially suitable because: (1) many
stigma-related topics may initially be avoided and
may only emerge with prolonged ethnographic
contact; (2) ethnographers may observe what
conicts with what is explicitly stated by informants
and; (3) other key informants perspectives (e.g.,
family) are considered essential. However, investi-
gators may utilize an array of methodologies to
supplement ethnography. For example, how do
individuals reports of what matters most during
stigma experiences compare with focus group
reports, ethnographic interviews with community
members, survey data, and the use of vignettes
depicting stigmatized conditions with local groups?
One such strategy would be to use quotes on stigma
derived from patient interviews as a stimulus to
elicit community members reactions. The commu-
nity members responses may then conrm, dis-
conrm, or elaborate upon how stigma is seen to
diminish what is most valued to patients in a local
world. Eliciting perspectives from stakeholders in
differing social positions regarding how stigma
threatens the labeled individuals moral standing
may be especially suited to investigate how multiple
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L.H. Yang et al. / Social Science & Medicine 64 (2007) 15241535 1533
devalued statuses (e.g., being poor or an ethnic
minority) interact to exclude individuals from a
local worlds meaningful everyday activities. And
the same sort of research may make the evaluation
of stigma intervention programs more relevant to
the local realities people negotiate.
Conclusion
Consideration of the practical engagements of
preserving what matters most can greatly enliven
our understanding of how stigma pervades the life
worlds of the stigmatized. From the vantage of
moral experience, both the stigmatized and stigma-
tizers are seen as grappling with what makes social
life and social worlds uncertain, dangerous, and
terribly real. We hope that future use of this concept
and its methodological applications to examine
stigma will further illuminate how stigma is
fundamentally tied to moral and existential experi-
ence, and how efforts to value or prevent stigma
may be enhanced by including this universally
human, if culturally inected, condition.
Acknowledgements
Preparation of this manuscript was supported in
part by NIMH grant K01 MH 73034-01 which has
been awarded to the rst author. The authors would
like to thank Kim Hopper and Janice Jenkins for
their insights and critiques of this manuscript.
Further, the authors would like to thank Peter
Benson for contributing insights to the framing of
moral experience.
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