Stigma as a Fundamental Cause of Population Health Inequalities

Mark L. Hatzenbuehler, PhD, Jo C. Phelan, PhD, and Bruce G. Link, PhD


Am J Public Health. 2013;103(5):813-821. 

In This Article

Abstract and Introduction


Bodies of research pertaining to specific stigmatized statuses have typically developed in separate domains and have focused on single outcomes at 1 level of analysis, thereby obscuring the full significance of stigma as a fundamental driver of population health. Here we provide illustrative evidence on the health consequences of stigma and present a conceptual framework describing the psychological and structural pathways through which stigma influences health. Because of its pervasiveness, its disruption of multiple life domains (e.g., resources, social relationships, and coping behaviors), and its corrosive impact on the health of populations, stigma should be considered alongside the other major organizing concepts for research on social determinants of population health.


Growing evidence shows that the stigma associated with multiple circumstances (e.g., HIV, mental illness, sexual preference) both disadvantages the stigmatized and is a major source of stress in their lives.[1] If stigma is a significant source of stress and social disadvantage, one might expect it to have substantial effects on population health, similar to other social determinants, such as socioeconomic status (SES), social relationships (i.e., social support), and racism or discrimination.[2] We argue that stigma is in fact a central driver of morbidity and mortality at a population level.

Although the literature on stigma and health has grown dramatically, its full power and significance remain somewhat obscured because bodies of research pertaining to specific stigmatized statuses have generally developed in separate domains. For example, we have literatures focused on the health implications of HIV stigma,[3,4] mental illness stigma,[5,6] and sexual orientation stigma,[7,8] which proceed on separate tracks. In addition, studies have tended to examine single outcomes (e.g., associations between stigma and self-esteem) at 1 level of analysis (typically at the individual level, without attention to structural conditions).[9] The field of population health would greatly benefit from a synthesis of these disparate literatures and from the development of a theoretical framework that provides insights into the processes that generate health inequalities among members of stigmatized groups. Such a discussion is both worthwhile and timely, in light of the potential insights a stigma framework can provide the field of population health.