Thanks for inviting me to speak. So, I’m going to briefly talk about the social organization of stigma. And give three examples of women, including trans-women living with HIV in Canada. One stigma and clinical outcomes, violence and depression, and factors of mental health.
As a stigma is socially organized, and manifests in structural levels, individuals, Harlan so beautifully talked about, there are social constructions of stigma that are organized and shaped by history, such as colonization, as well as slavery, geography, politics, culture, and gender norms. So, the way that people experience different forms of stigma and discrimination vary based on all of these different factors.
And so, i know a few people have already talked about intersectionality, I also want to prephase this common behaviorally reflected statement, which is often quoted, which talks about racial, sexual, heterosexual and class oppression as being interlocking. If you haven't read this statement, it’s actually fantastic, it’s just a few pages long.
So i started thinking a lot about intersexuality and stigma about 10 years ago, about 21 focus groups of people living with HIV, and what really became clear was this intersection of sex work stigma, racism, homophobia, transphobia, sexism, and gender discrimination, drug-use stigma, we could add many different forms of stigma.
And, what I’m talking about today is a little bit about measurement of these different forms of stigma, and how stigma is socially organized from an intersectional perspective. Some experiences of marginalization are shared, but there are systematic differences. For example, racial profiling incarceration, in Canada systematically produced on racial categories for indigenous people, as well as other racialized people, specifically black Canadians.
And gender, largely structures segregation in occupations, and contributes to a current pay-gap. And of course, there’s intersections within gender and race. So, some people have said “well we should just create one short scale to measure intersectional stigma”, and there’s a lot of different debate in the field. But actually, someone who tried this said “there is not one way you can measure stigma that captures the way that racism operates, the way that sexual stigma homophobia operates, the way that sexism operates, the way that classism, the sex work stigma, like how can you capture all of that with one scale? Actually, this was a recent article that said “it doesn't work, you can try this discrimination scale, but our experiences are different”.
So, I’m going to give you three really brief outlines in my brief time.
So, the first one is looking at clinical outcomes of different forms of stigma among women with HIV. And so, health behaviour theories are not that helpful for looking at long-term adherence. Is stigma and the way intersex with race, class and gender, among other sexual orientation and gender identity differences, is this the missing piece? We know that there is overrepresentation because of these disparities and inequities among African and black women, and indigenous women, and I’m focusing on women with HIV because this is the data that I’m presenting. So we looked at this, and this is a complicated figure, but basically what we’re looking at here is HIV stigma, racial discrimination, and gender discrimination, and we found that they’re connected. And what are the pathways to depression, and via access to support and other resources. And what are the pathways from depression to actual clinical outcomes, CD4 count and bioload.
And what’s interesting is, we have all this power as researchers, depending on how we look at things. And so, we looked at it a different way. We said what happens if we just looked at the combination of these different forms of stigma, and the same pathways?
And so, the thing that we found that was interesting, is here, as I mentioned not all the ways that stigma operates isn’t the exact same based on different types of stigma. For example, you see gender discrimination has pathways to depression, and HIV stigma only one. And here when you look at a combined factor of different forms of stigmas, there’s much stronger pathways, which suggests synergy between the different forms of stigma, and the impact on mental health. And I just want to note that half of the sample had depression symptoms, and one reported severe depression.
And so, I also was curious about pathways from stigma to violence. And so, there was only data available at one time point in the top left, at HIV stigma, racial discrimination and gender discrimination, and we found pathways to recent violence in the past 3 months and pathways to depression. And so over time we looked at pathways from HIV stigma, to past three-month violence, to depression, over time, and we also looked at the interaction between HIV stigma and recent violence, still among women living with HIV in Canada.
And what we found was that there’s an interaction with violence and HIV stigma. When someone has experienced violence and higher stigma, they're much more likely to experience depression. And we also found that there is this accumulating health risks of stigma, violence and depression. And if you just leave here with one thing from this talk, 20% of women in this national study of HIV positive women reported past 3-month violence from anybody, at Time 1, and 25% at Time 2. That’s ⅕ and ¼ over the span of 5 years, violence against women with HIV is a pervasive problem.
So finally, the last example I’m going to give you is around stigma, tobacco use, and depression. So we know that people with HIV have higher rates of smoking than HIV negative persons. In the US it’s estimated at around 35% for women with HIV, which is double the national prevalence. So, there’s this model called the stress and coping model of substance use. So, some people have said, especially with LGBTQ folks, perhaps higher rates of smoking is about managing stress from stigma. This has actually not really been examined with HIV positive women.
And why does this matter? There’s actually harmful impacts that are specific to people living with HIV who smoke, and are pregnant, so there’s an increased risk of pregnancy loss. So, this is just one example why smoking might matter for women with HIV. And this has not been looked at longitudinally.
And so we looked at three ways of survey data, and we actually measured associations over time between HIV stigma and mental health, and looked at “does smoking tobacco moderate the pathway from HIV stigma to depression”. And the answer is yes, it does. Which is really important if we’re going to be designing smoking cessation problems, without understanding that it’s actually helping people cope with the stigma that they experience, we want to add racism and sexism into the next round of analysis.
And so, what does all of this mean? So this is probably the most important slide. First, stigma is intersectional from what we’ve been measuring. Racial, gender, and HIV stigma are separate from one another, but they also have shared, different and synergistic pathways to social and health outcomes. Two stigma is embodied, it produces stress that is associated with depression, violence, tobacco use and all the other factors and health outcomes i mentioned. And three, stigma can exacerbate pre-existing gender and health disparities. And the depression rate that we found, and we already know that there is a higher rate of depression among women than men, and among women with HIV, what we noted was that depression was 4.3 fold higher, and this is the severe depression, than the approximate 6% national prevalence of depression. It’s a little hard to compare because of the different ways they were measured. And gender-based violence is associated with stigma, and the tobacco use we found was 3.5 times higher for HIV positive women than national Canadian’s prevalence.
And so, think about all of these things in your research, and thanks, and I want to acknowledge the PI’s where this data is from, as well as an amazing PhD student who did the analysis.