Stigma, discrimination and the health of illicit drug users
Introduction
To varying degrees, persons who use cigarettes, alcohol, and illicit drugs currently experience stigmatization in the United States, although illicit drug users are stigmatized to the greatest extent (Kallen, 1989). Among illicit drugs, not all are equally stigmatized. Use of drugs such as powder cocaine by the wealthy is often seen as a display of status, while use of heroin or crack cocaine, particularly among those who are poor or otherwise marginalized, is more stigmatized (Jones et al., 1984). The conferral of a deviant social status on illicit drug users may serve to discourage illicit drug use and the social ills that accompany the behavior. However, the stigmatization of illicit drug use may also adversely affect the health of those who use drugs in at least two ways.
Stigmatization may have a direct detrimental influence on mental and physical health stemming from exposure to chronic stress including experiences of discrimination (Krieger, 1999, Link et al., 1997, Minior et al., 2003, Young et al., 2005). Rejection by others and expectations of rejection may cause chronic stress and may lead to coping approaches that involve withdrawal and isolation, further harming mental wellbeing (Link et al., 1997). The level of stigma perceived by illicit drug users has been shown to persist even when drug use is reduced or ended, and remains strongly associated with mental health symptoms (Link et al., 1997). Ultimately, the persistent stress experienced from stigmatization and discrimination may influence physical health through hypothalamic-pituitary-adrenal axis and neuroendocrine processes (Taylor et al., 1997, Tsigos and Chrousos, 2002).
Stigmatization may also discourage illicit drug users from getting health care due to fear of poor treatment by health care providers or fear of trouble with the authorities (Cunningham et al., 1993, Link et al., 1997). Stigma has been identified as an important barrier to substance use, mental health, and general health care in many communities (e.g., HIV/AIDS positive, minorities) (Calsyn et al., 2004, Ojeda and McGuire, 2006, Reif et al., 2005). Research suggests that when they do seek care, substance users often experience discrimination in the health care setting and receive lesser quality care (Miller et al., 2001). Moreover, substance users may attempt to hide their drug use, the issue for which they may have the greatest need of care, in the health care setting (Kurtz et al., 2005). Thus as a barrier to care, stigma and discrimination may adversely affect both mental health and physical health by impeding entry into the health care system, reducing accurate reporting of health issues, and lowering the quality of care received.
While research on the health effects of stigmatization and discrimination among illicit drug users is nascent, there is a burgeoning literature on these topics, particularly discrimination, for other marginalized groups including racial and ethnic minorities, persons with HIV/AIDS, homosexuals, and persons with mental illness (Brown, 1993, Corrigan et al., 2004, Finch et al., 2000, Guyll et al., 2001, James et al., 1984, Kessler et al., 1999, Krieger and Sidney, 1996, Ren et al., 1999, Stuber et al., 2003, Surlis and Hyde, 2001, Williams, 1997). We draw on these literatures in our conceptualization of the elements of stigma and discrimination that may affect the health of illicit drug users.
Stigma, a concept introduced by Goffman, has been defined in a variety of ways over the past decades (Goffman, 1963). To frame stigmatization of drug use, we used a definition of stigma that encompasses behavior: “a characteristic of persons that is contrary to a norm of a social unit” where a norm is defined as a “shared belief that a person ought to behave in certain ways at a certain time” (Stafford and Scott, 1986). In this case, the characteristic is being an illicit drug user situated within a social context where drug use is frowned upon. Stigma is both a social process perpetrated by non-marginalized groups to achieve goals of exclusion and conformity, and a psychosocial process that marginalized groups must navigate and contend with. We are concerned with how drug users process stigmatized perceptions, experiences and interactions. The broader literature on social stigmatization delineates many possible responses to stigmatization. We distinguish two forms of stigma in relation to illicit drug use, which we label perceived devaluation and alienation (Link et al., 1997, Ritsher et al., 2003). Societal norms in the United States cast drug use as an unacceptable behavior, so many hold negative opinions about people who use drugs. Illicit drug users are seen as weak, immoral, and as causing a risk to society (Kallen, 1989). Perceived devaluation occurs when illicit drug users think that most people believe common negative stereotypes about drug users (Link et al., 1997). In contrast, alienation refers to the internalization of the views expressed in those stereotypes that drug users are marginal members of society (Ritsher et al., 2003). These two elements of stigma may be steps in a process through which illicit drug users to turn negative societal attitudes inward and to adopt negative self-characterizations (Link, 1987).
In addition to the burdens of stigmatization, those who use illicit drugs experience discrimination. In the United States, drug use is illegal and has been increasingly dealt with as a criminal problem rather than a health problem that could be prevented and treated (Conyers et al., 2003). There are certainly no protections afforded illicit drug users in areas such as housing or employment. Experiences of discrimination can range from major exclusions to put-downs and slights (Krieger, 1999). Drawing on the literature, we define drug use discrimination as experiences of rejection and unequal treatment attributed to drug use (Krieger, 1999, Link et al., 1997).
When illicit drug users face stigma and discrimination, like other marginalized groups they may respond in ways that may either exacerbate or mitigate these stressors. There are emotional responses, psychological attributes and behavioral strategies of stigmatized individuals that may lessen or exacerbate the effects of stigma and discrimination (Crocker and Major, 1989). For example, speaking out against stigma and discrimination may in certain contexts mitigate stigma. Not all responses to contend with stigma and discrimination are constructive. Feelings such as anger, strategies to conceal one's drug using status, or withdrawal from social interactions may be ineffective in mitigating and may exacerbate the effects of stigma and discrimination on health (Link et al., 1997).
Perceived devaluation, alienation, and experiences of discrimination represent a matrix of different dimensions of stress plausibly experienced by illicit drug users. In this study we examined the association of each of these dimensions with standard measures of physical and mental health. We hypothesized that perceived devaluation, alienation and discrimination would each be associated with poorer mental and physical health. Further, we hypothesized that when the stigma and discrimination measures were examined together, each would maintain an independent association with physical and mental health so that their combined effects would be greater than their individual effects. Finally, we hypothesized that constructive responses to stigma and discrimination would be associated with better mental and physical health while unconstructive responses will be associated with poorer mental and physical health.
This is one of the first studies to examine the associations of both stigma and discrimination with the health of illicit drug users. Despite the essential link between the constructs of stigma and discrimination, extant research has rarely examined their associations with health simultaneously (Meyer, 1995). Moreover, because perceived devaluation and alienation are both based on the perspective of the stigmatized individual, the distinction between the two is typically overlooked. Thus, examining these three constructs together may give new insight into their relative and combined associations with health.
Section snippets
Sample
Study participants were recruited from the New York City neighborhoods of East Harlem, Central Harlem, and the South Bronx. Persons 18 years of age or older who reported using cocaine, crack, or heroin in the past 2 months were eligible for participation. We recruited participants using street outreach techniques between August 2000 and January 2001. Outreach workers approached drug users on the street, placed advertisements in service agencies, and distributed pamphlets to interested persons;
Results
We recruited 1008 drug users for participation in the study. Over 70% of respondents were between 35 and 54 years old, and 64% were male. The sample was predominantly of minority race/ethnicity with 50% African American and 42% Latino respondents. Approximately half of respondents had completed high school (51%) and over 70% earned $10,000 or less in the past year. All respondents had used drugs in the prior 2 months, with 62% reporting sniffing cocaine, 67% smoking crack, 63% sniffing heroin,
Discussion
We set out to study the associations of stigma and discrimination with the physical and mental health of illicit drug users by specifying and testing hypotheses related to a stress processes. The results partially supported our hypotheses, showing that some discrimination and stigma measures were associated separately and in combination with poorer mental and physical health. Alienation (i.e., internalization of the belief that drug users are marginal members of society) and experiences of
Conclusion
Using theoretically based measures of stigma and discrimination due to illicit drug use, we found that marginalized drug users not only experience high levels of stigma and discrimination, but that these experiences are multi-faceted and are associated with poorer mental and physical health. Studies that include only one measure of discrimination or stigma may be underestimating the importance of this source of stress for the health of illicit drug users.
Undoubtedly, the increasing
Acknowledgements
This work was funded by grant DA14219-02S1 and DA 017642 from the National Institute on Drug Abuse, Cooperative Agreement R18-CCR22983-01 from the Centers for Disease Control and Prevention, and by a grant from The Robert Wood Johnson Foundation. We would like to thank Dr. Bruce Link for assisting with instrument development for this study, Drs. David Vlahov and Stephanie Factor for their role in the establishment of this study.
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