Crushing It

What prevents people from seeking help?

For some, it’s a lack of resources—usually time or money. Others may not even be aware that help is available.

Sometimes, people postpone seeking help for a totally different reason, namely, that they’re worried about how they’re going to be treated by the health-care system. They worry about stigma.

“Stigma is something that we deal with every single day,” says Dr. Eileen de Villa, Toronto’s Medical Officer of Health. “Toronto, like many other areas, is grappling with the intertwined challenges of homelessness, pervasive mental illness, and untreated addiction.”

She hosted an event called Diverse Dialogues: Stigma & Breaking Barriers in Toronto in May as part of the annual Charles Hastings Lecture series.

Dr. De Villa calls this an unprecedented “triple crisis” that demands a solution from all three levels of government, listing stigma as one of the major roadblocks in the path to addressing this crisis.

“People say ‘If only they could get their act together’ or ‘If only they had made better life choices,” says Dr. de Villa, “but addiction is a complex disease, not a moral failing,” she says.

Types of stigma

“Stigma creates a web of shame, fear of judgment, and isolation,” she continues. “The fear of criminalization makes it far less likely that someone will seek help and, when they finally do work up the courage to seek out help, the discriminatory attitudes they can face within our health-care system don’t support the path to recovery.”

And, as Dr. de Villa points out, this is just one of the ways in which stigma impacts our population.

What, exactly, is stigma? Well, it’s as complicated as it is pervasive. At face value, most of us know that stigma is in the same family of words as “stain,” “scar,” and “mark of shame,” and generally means something along the lines of “an unfair belief about a person or a group of people.”

Current research frames stigma as the presence of a socially undesirable characteristic which signals ‘otherness’ according to research from the Mental Health Commission of Canada (MHCC). That research focuses on four types of stigma, explains MHCC president and CEO Michel Rodrigue, who was part of Toronto Public Health’s Diverse Dialogues event.

There is individual stigma which is largely about internalizing negative messages. The second is interpersonal stigma, which, he says, can arise in relationships with friends, family, and colleagues.

Structural stigma encompasses organizational rules, policies, procedures, laws, and cultural norms that perpetuate and increase stigmatization. Intersectional stigma, which happens when stigma related to mental health or substance use overlap with other forms of inequities.

Thanks to a growing body of research that’s built up a taxonomy of stigma, it’s been easier to identify the ways that stigma, particularly structural and intersectional stigma, have been used to marginalize populations.

Lived experiences with stigma

“Stigma does not exist without marginalization and discrimination,” explains Dr. Notisha Massaquoi, assistant professor in the Department of Health and Society at the University of Toronto Scarborough, who spoke at the event and participated in the panel discussion. “Stigma is a core and essential tool within anti-Black racism.”

Dr. Massaquoi says we can’t separate stigma from other tools of oppression, notably erasure and invisibility, but also marginalization and isolation. Stigma serves to distract us from systemic barriers to health and has a profound negative impact on the health of the population.

“Stigma undermines every aspect of the health-care cascade,” says Dr. Massaquoi, “It undermines diagnosis, it undermines treatment, it undermines equitable access to care, and it undermines successful outcomes.”

Before working at the university, Dr. Massaquoi worked in public health, first as a service provider for continental African people in Toronto newly diagnosed with HIV. That was in the late 1980s, before medical treatment was available. She says that every day, she hoped nobody would walk through her door because every client she saw would pass away within a year.

“When we did get medication, when AZT (a type of anti-HIV retroviral drug) first arrived in Canada, what I saw were the effects of stigma,” she recalls. “African people were blamed for bringing HIV to Canada and stigmatized in terms of being accused of having unusual sexual practices. All kinds of stigmatizing labels were given to this community.”

That led to people losing their jobs. And, Dr. Massaquoi adds, if they were discovered to be HIV-positive, health-care providers dropped them from their rosters. Toronto’s Black community was the last to access medication.

Sometimes discrimination comes from structural barriers that are difficult to perceive, such as the lack of HIV/AIDS clinics in parts of the city with large Black communities, even though the incidence of HIV infection is higher in those populations. That disparity is finally being addressed now, but it persisted for years.

Other times, though, discrimination and stigma in the medical system is blatant and undeniable.