Stigma is a major driver of population health inequities. As a result, many communities who experience stigma work to reduce or challenge stigma. Efforts to reduce stigma include advocacy to shift policies, laws, and professional practice, and providing education and facts to the public, media, and care providers. In the wake of increasing attention from researchers and policy makers towards stigma, Martin, Lang & Olafsdottir (2008) presented a framework focused on the micro, macro, and meso sources that shape stigma enacted at the interpersonal level.

Martin, Lang & Olafsdottir’s framework focuses on interpersonal interactions that stigmatize people living with “conditions that engender prejudice and discrimination”. Known as the Framework Integrating Normative Influences on Stigma (FINIS), this tool identifies tangible aspects in the creation and maintenance of stigma. In this blog, we’ll review how this framework connects to the stigma experienced within gay men’s communities.

Framework Integrating Normative Influences on Stigma

FINIS is grounded in the stigma literature, and was developed using the case of people with mental illness. The authors’ intent is that this framework be adapted for use with other stigmatized populations. Thus, while being gay is not a condition or an illness, it is an identity that “engenders prejudice and discrimination” in Canada today. Many of the factors identified within FINIS are relevant to our understanding of stigma within gay men’s communities, whether we discuss the stigma related to being gay, living with HIV, or any other personal characteristic.

Micro Level

At the micro level, this framework highlights three key sets of factors – the social characteristics of the person who is stigmatized, the characteristics of the illness, and the social psychological context of the individuals involved:

• Social characteristics of the person who is stigmatized: everyone holds multiple, simultaneous social locations and personal characteristics (one tenet of intersectionality), which impact how they are perceived. Martin, Lang & Olafsdottir present research that suggests the more socially devalued statuses the person who is stigmatized holds, the more likely people they interact with will “endorse stigmatizing responses”
• Characteristics of the illness: knowledge or lack thereof about an illness, the extent to which it can be perceived through interaction, and how likely it is to be passed, factor into how individuals respond to a specific condition
• Social psychological context for the person enacting stigma: researchers disagree as to how conscious or unconscious stigmatizing attitudes are, and believe that this has implications for how stigma is enacted, along with the degree to which people who enact stigma experience anxiety about interacting with stigmatized groups
• Social psychological context for the person experiencing stigma: the degree to which an individual knows they belong to a stigmatized group (awareness), the concern they feel about either fitting into, or disrupting, expected stereotypes (stereotype threat), and difficulty in interpreting feedback as positive or negative (attributional ambiguity)

These micro level factors shape the ways in which stigma plays out within gay men’s communities. For example, characteristics of HIV/AIDS – notably, concern about how easily it could be passed, and the visibility of AIDS symptoms at the onset of the epidemic – have shaped stigmatizing responses to HIV for decades. These stigmatizing responses are true despite shifts in our knowledge of HIV: Ibanez-Carrasco (2012) argues that while “the stigma of being gay and having brought HIV upon oneself has been rationally dismantled, [it] is still lodged in our collective psyche.”

Macro Level: History & Culture

Martin, Lang & Olafsdottir identified two factors that shape stigmatizing responses at the macro level: the media and the cultural and historical context within the community. For these authors, the cultural and historical context “provides an overarching ideology by categorizing stigmatized groups and providing clues to appropriate responses” (Martin, Lang, & Olafsdottir, 2008, p. 6). Looking at even the simplest timeline of the rules, policies, and laws that have governed interactions between authority figures (the state, medical professionals) and gay men, the impact of macro level factors is evident within a Canadian context.

The first peoples that lived in Canada had cultural norms and practices that embraced more sexual and gender diversity than the social norms violently enforced by European settlers. Since the subsequent institution of a European legal and moral framework, Canada has considered homosexuality a religious sin, a criminal offence, and a mental illness. While professional bodies no longer list homosexuality as a mental illness (see my blog on medical approaches to gay men’s health), the damaging attitude that homosexuality is an illness, or can be fixed or cured unfortunately still persists.

Meso Level

The last category discussed within the FINIS is meso factors: personal connection to a stigmatized individual, and the treatment system available for people living with a stigmatized condition. In some ways, the personal connection to stigmatized groups is intuitive, and this is the raison d’être of National Coming Out Day in the USA. However, this factor puts the onus on people who are stigmatized to come out, and act as educators, a role which can be difficult, and in some cases, unsafe.

As discussed briefly above, and more fully on my blog on medical approaches to gay men’s health, the second meso level factor, the treatment system, has played a role in shaping the stigma that impacts gay men historically. In some (mostly urban) parts of our country, health services specific to gay men have emerged in recognition that providers working with gay men benefit from having a robust understanding of gay communities. This is one example of a strategy the health system uses to aim to rebuild a positive relationship with gay men’s communities after decades of identifying being gay as an illness. The principle of “greater/meaningful involvement of people with HIV” (GIPA/MIPA) also has factored into policy and practice decisions about the healthcare provided to people living with HIV.

Conclusion

It is important to note that this blog does not review the evidence that would or would not empirically validate each of these factors as applied to gay men’s communities. Yet, lived experiences would suggest that many of these factors are at playing in shaping how stigma shows up. This framework complements our understanding of pathways through which stigma impacts our health reviewed in the last blog, and provides ideas about points of interventions. While this framework as presented by the authors first focused on people living with mental illness, it can be broadened and applied to the stigma that is both experienced and perpetuated by gay men. As a tool in our practice, this framework highlights the breadth of factors that impact the health and wellbeing of gay men as it relates to stigma.

Further Reading

Ibanez-Carrasco, Francisco – 2012. Making the AIDS Ghostwriters Visible in Sexuality in Education: A Reader. Erica Meiners & Therese Quinn, Eds. Chapter 28, pp. 307-320. New York: Peter Lang Publishers.

Martin, Jack, Lang, Annie & Olafsdottir, Sigrun – 2008. Rethinking Theoretical Approaches to Stigma: A Framework Integrating Normative Influences on Stigma (FINIS). Social Science & Medicine 67(3): 431–440. http://www.ncbi.nlm.nih.gov/pubmed/18436358