On the Margins of the Periphery: Unassisted Childbirth and the Management of Layered Stigma

This article examines an unusual practice—unassisted childbirth—and the ways in which advocates and practitioners manage the stigma they are accorded. Given their “doubly deviant” status as not only women who birth at home but also as women who choose to give birth without professional assistance, these women provide a unique case for our theoretical understanding of stigma management. As members of homebirth social networks, the women must reckon with what I term layered stigma, the broad stigma of homebirth as well as the deeper in-group stigma within their deviant community that results from their rejection of midwives as appropriate care providers. By examining the dynamics of stigma management among practitioners of unassisted childbirth, I highlight the complex, situation-dependent nature of stigma and the impact of its management on women's sense of self.     

Identity Dilemmas: Toward a More Situated Understanding

When are identity dilemmas—when people possess identities that conflict with one another and both are potentially stigmatizing—most likely to occur? Are they the result of generic social processes? A review of some of the extant research on “identity work” suggests that historical “misalignments” of culture and stratification, which we refer to as “lag,” create the greatest potential for stigma and the reproduction of inequalities. Lag is exacerbated by complex, intersecting axes of hierarchy, and amplified as symbolic environments globalize and subcultures multiply. Articulating culture and structure reveals how power plays out in interaction, and highlights the omnipresence of struggles for treatment as “fully human.” We consider whether “alignment” is even possible when multiple dimensions of social location intertwine, compete, and collide. Following Schwalbe and Mason‐Schrock (1996), we argue that “subcultural” or collective identity work that brings new meanings into dominant cultural narratives may offer the greatest hope, but in the interim all coping strategies are costly.     

Telling Others How You Live—Refining Goffman's Stigma Theory Through an Analysis of Housing Strugglers in a Homeowner Nation

This article revisits Goffman's stigma theory from the perspective of housing studies. We elaborate on Goffman's approach by exploring how housing tenure can work as a proxy for moral character. We interviewed twenty‐seven people who are excluded from access to homeownership in two cities in Norway, which is a “homeowner nation.” These individuals are unable to enter the dominant “homeowner class” for different reasons, including drug‐dependency, mental illness, refugee background, low socioeconomic status; thus, they must access housing through other tenures; private renting or social housing. To many of them, housing becomes a stigma, in Goffman terms, an “undesired differentness.” Social housing is known to carry stigma in Norway. It was thus a paradox, that those with the softest differentness—private rental—were most likely to practice (Goffman:) “information control” over their housing situation. Goffman's theoretical apparatus, and his distinction between the discreditable and the discredited in particular, helped us make this paradox comprehensible. Through this analysis, refinements to Goffman's theory were discovered. We suggest that “multiple stigmas,” which was not seen clearly by Goffman himself, should be a key notion in stigma studies. We use this notion to distinguish between possible sub‐types to the discredited‐discreditable distinction.     

Cyclops Cave

Written in the post‐structural traditions of symbolic interactionism, Cyclops Cave is a biographic‐interview‐based and fact‐and‐fiction‐plotted ethnodrama of anti‐Semitism in Soviet higher education. This project is premised on the theories of the “social self”—namely, the “looking‐glass racialized self,” constructed by the dominant ethnic “supremacy,” and the theories of racial stigma as an outcome of the racialized “me” production. Showing the stigma experiences of former Soviet Jewish academics from 1970 to the 1980s, the play adds a new illuminative and self‐interpretive case of a race‐situated symbolic interaction and deconstructs the “root image” of Soviet anti‐Semitism through interpreting the informants' stigma incidents and interactional conflicts between their “selfhood” symbols.     

Demands and Devotion: Cultural Meanings of Work and Overload Among Women Researchers and Professionals in Science and Technology Industries

How do cultural meanings influence how people experience work‐life demands? Much research, especially quantitative research, on the effects of structural work and family conditions does not account for employees’ cultural beliefs about the meaning of work in their lives. This article uses unique survey data to investigate the effects of employee embrace of elements of the “work devotion schema”—a cultural model that valorizes intense career commitment and organizational dedication—on their sense of “overload,” an experience that includes feeling exhausted and overloaded by all one's roles, net of actual hours on the paid job and family responsibilities. We argue that by cognitively, morally, and emotionally framing work as a valued end, the work devotion schema reduces feelings of overload. Using a case of senior women researchers and professional service providers in science and technology industries, we find that those who embrace work devotion feel less overloaded than those who reject it, net of work and family conditions. However, this effect is curtailed for mothers of young and school‐aged children. We end by discussing implications for flexibility stigma and gender inequality.     

Pregnant Women's Experiences of Crisis Pregnancy Centers: When Abortion Stigmatization Succeeds and Fails

There is broad consensus that abortion is stigmatized, but the role of interpersonal interaction in this process is underspecified. I examine interviews with 25 women in the United States who visited crisis pregnancy centers (CPCs)—antiabortion organizations that offer one‐on‐one “prolife counseling”—for how and when interactions matter for abortion stigmatization. I identify two primary ways CPC counselors stigmatized abortion and describe variation in their impact: counselors' efforts were “successful,” were misrecognized as ideologically‐neutral, or were resisted. The findings demonstrate the importance of women's current consideration of abortion and preexisting beliefs for understanding how interpersonal interactions contribute to abortion stigma.     

Briefly Noted

The biennial International Drug Policy Reform Conference, sponsored by the Drug Policy Alliance and held Nov. 7–9 in St. Louis, Missouri, was full of varying sessions on harm reduction and reform — 45 of them in all. An article by Filter editor Will Godfrey summed up his perspective — he was the only print reporter so far to have covered the entire conference. We asked him what his feeling was about the prospects for treatment and harm reduction working together, as they have in the past. “There's plenty of friction, but there can and should be rapprochement between the harm‐reduction and traditional treatment communities,” he told ADAW. “Many people in the harm‐reduction movement pursue traditional recovery, and there are treatment folks who support harm reduction. All should be trying to save lives and empower people. Harm reductionists' legitimate concerns about mainstream treatment include its coercive or controlling deployment, its frequent eschewal of evidence‐based practices and its promotion of abstinence at the expense of stigmatizing people who use drugs. Treatment advocates often overlook that most people who use drugs are fine. And in any case, everyone must be free to choose their own path.” But the fact that two approaches — one more radical than the other — coexist still is bound to make some treatment providers uncomfortable. After all, some of the speakers said that even supervised consumption sites are unfair to drug users, who have no need to be “supervised,” and instead should be free to use drugs. All viewpoints were there. “There's constant debate in the harm‐reduction movement about working to change systems that inflict harm from the inside, versus calling for radical reforms from the outside,” said Godfrey. “I think both approaches are simultaneously necessary.” Not everyone saw the conflict. “I have to say that I didn't see an anti‐public health movement there at all,” Maia Szalavitz, who is writing a history of harm reduction and is respected in both harm reduction and some, at least, treatment camps, told ADAW. “There has always, of course, been tension between activists and researchers and between people who want to fight within the system and those who want to tear it all down.” For the Filter article, go to https://filtermag.org/drug‐policy‐reform‐movement/ .     

NAATP guidebook not only for residential care

The National Association of Addiction Treatment Providers (NAATP) has released its draft guidebook for minimum standards for members (see ADAW, April 22, https://onlinelibrary.wiley.com/doi/10.1002/adaw.32334 ). NAATP is not only for residential treatment providers, however. “Our position at NAATP is that we are a membership association for providers along the entire continuum and that, while residential holds an important place in our work and is our historical foundation, our membership is in no way limited to residential,” NAATP Executive Director Marvin Ventrell told ADAW last week. “Even apart from our membership, we intend our resources, including ethics and the guidebook, to reach and guide the entire continuum. It is true that some of the guidelines have application more or less relative to type of care, but as a whole it should be viewed as a provider guide, not just a residential provider guide.” We regret any confusion. The field — and prominent organizations within it — is changing.     

Briefly Noted

It's not every day that a nationally known “rehab” offers methadone. Recovery Centers of America (RCA) has opened its second medication‐assisted treatment (MAT) clinic — Bravo Medical — that does just this. “MAT is a vital tool in the battle against opioid addictions,” said Melissa Bishop, RCA national director of MAT, last week. “But many people are still afraid to learn more about it because of the stigma attached to this form of treatment.” The public is invited to tour the clinic on Oct. 16 from 12–2 p.m. At this event, families of loved ones from the southern New Jersey and Philadelphia area can tour the Somerdale, New Jersey, facility; see how medication is administered; and learn about the effectiveness of MAT. RCA offers MAT at its inpatient treatment centers and at stand‐alone MAT facilities such as Bravo Medical and the Trenton Healthcare Clinic. RCA offers methadone and buprenorphine. New Jersey State Medicaid is accepted at Bravo Medical and the Trenton Healthcare Clinic.     

“Becoming a Parent Changes Everything”: How Nonbeliever and Pagan Parents Manage Stigma in the U.S. Bible Belt

Despite the increasing visibility of secularism and alternative religions in the United States, few have paid attention to the relationship between family roles and religious identity outside of mainstream Christian denominations. Guided by insights from theories of identity work, I compare stigma management strategies by two religiously marginalized groups. Based on participant-observation, in-depth interviews, and textual analysis, I show how nonbeliever and Pagan parents in the Bible Belt respond to perceived threats to their moral identities as “good parents.” Nonbeliever and Pagan parents manage their spoiled identities by engaging in defensive othering amongst subordinates, a form of stigma management, to distance themselves from discrediting stereotypes—specifically the “militant atheist” and the “hedonistic Pagan.” I demonstrate that access to greater financial and cultural capital (nonbeliever parents) allows for reliance on defensive othering to massage interpersonal relations, whereas access to low levels of financial and cultural capital (Pagan parents), prompts the need to rely on defensive othering as a matter of survival. Becoming a parent changes the dynamic of stigma management for individuals; pushing individual parents away from social justice activism and ultimately undercutting broader social movements for equality.     

USPSTF recommends screening for illicit drug use in adults

Last week, the United States Preventive Services Task Force (USPSTF) recommended screening for “unhealthy drug use” by asking questions — not by drug tests — in adults. There is a proviso: “Screening should be implemented when services for accurate diagnosis, effective treatment, and appropriate care can be offered or referred.”     

The Importance of “Empty Gestures” in Recovery: Being Human Together

What do clients/patients want or value from their encounters with healthcare providers? Based on ethnographic research conducted with individuals suffering from drug addiction and mental health issues, this article argues that clients/patients treasure “everyday” or “human” interaction with medical staff. Everydayness is accomplished through three generic social processes: **co‐silence, inclusion in back‐stage activity, and physical dramatizations of authenticity. These processes and other ordinary interactional strategies for “being human together” should be seen as vital tools for recovery.     

Briefly Noted

Last month, the American Society of Addiction Medicine (ASAM) released a plan for advocacy, focusing on strengthening the addiction treatment workforce and standardizing the delivery of treatment. “We need comprehensive solutions to address such a complex problem,” said Paul H. Earley, M.D., ASAM president, in releasing the plan. “With the Advocacy Roadmap as our guide, ASAM will continue to advocate for equitable access to and coverage for evidence‐based addiction treatment services, increased funding for addiction research, and better education among professionals and the public to challenge the stigma and discrimination surrounding individuals with addiction.” Noting that there are still challenges in the field of addiction treatment, Earley said progress has been made, adding that “ASAM remains dedicated to treating addiction compassionately and effectively and, by doing so, saving lives.” There are 6,000 physician members of ASAM. For the “roadmap,” go to https://www.asam.org/docs/default‐source/advocacy/asam_report_feb2020_final.pdf?sfvrsn=f73f51c2_2 .     

Social Anxiety in Obese Youth in Treatment Setting

The aim of this study was to determine the prevalence of social anxiety in obese children treated in a weight management clinic. We hypothesized that social anxiety would positively correlate with obesity, and that “extremely obese” patients would have significantly higher rates of social anxiety when compared to “obese” patients. Information was collected at a multidisciplinary treatment clinic for obese youth during the first clinic visit. The social anxiety scale was administered (including parent-report and self-report scales for both elementary and adolescent versions) and demographic data was obtained. Social anxiety was found to be significantly positively correlated with BMI percentile. In addition, “extremely obese” patients had significantly higher social anxiety scores than “obese” youth at least for elementary-age youth. Trends in gender differences and racial differences in this obese pediatric clinical sample were consistent with results found in community samples. Social anxiety and obesity were found to be positively correlated in this pediatric clinic-based population. For elementary-age patients, “extremely obese” patients were at greater risk than “obese patients” for social anxiety and its various symptoms—fear of negative evaluation, social avoidance/distress in new situations, and social avoidance/distress in general. Results for adolescents were less clear. Clinical implications of these results were discussed. Limitations of this study, and directions for future research were also discussed.     

SAMHSA urges treatment programs to test for HIV

Last month, the federal Substance Abuse and Mental Health Services Administration (SAMHSA) called on public health and substance use disorder (SUD) treatment providers to help make sure patients who are negative for human immunodeficiency virus (HIV) stay that way, and that those who are HIV‐positive are tested, receive antiretroviral treatment and stay “adherent” to the treatment. The directive came in the form of a “Dear Colleague Letter” from SAMHSA Director Elinore F. McCance‐Katz, M.D., Ph.D., assistant secretary for mental health and substance use for the Department of Health and Human Services.     

“We are not strippers”: How Belly Dancers Manage a (Soft) Stigmatized Serious Leisure Activity

Most stigma research examines people who engage in deviant activities or possess visible and permanent discredited attributes, which lead to “hard” or severe consequences. Existing leisure studies focus on the benefits of leisure pursuits. Less attention is paid to the potential costs associated with serious leisure, such as “soft” stigma. The snubs and slight embarrassments resulting from soft stigma may jeopardize the rewards people receive from participating in leisure, such as a sense of identity, self‐worth, and pride. Using interviews with seventy‐four female belly dancers, most of whom belly dance as a form of “serious leisure,” this article examines how dancers manage perceptions that they are erotic dancers. Results show that dancers use an interesting set of stigma management techniques and new forms of some existing management strategies to simultaneously protect themselves and enhance the reputation of the group. Implications for how people negotiate soft stigma associated with serious leisure are discussed.     

Claiming Competence: Biographical Work among Victim‐Advocates and Counselors

Advocates and counselors at agencies that assist victims of domestic violence and sexual assault argue that they are especially suited to help their clients develop safe and practical strategies to protect themselves from further abuse. Yet the backstage of these agencies can depict a reality of confusion, doubt, and sometimes fear—especially when clients’ cases do not go according to plan. Data collected from in‐depth interviews and participant observation over fourteen months show how advocates and counselors engaged in “biographical work” (Gubrium and Holstein 2000) to construct coherent and consistent narratives as competent service providers in the aftermath of their clients’ unanticipated outcomes. Calling on different discursive strategies accessible to them according to their position within the agency, both groups were able to interpret negative results as beyond their responsibility. However, the counselor's rhetoric of “professionalism” proved more effective in this regard compared with the advocates’ “empowerment.”     

Can Health Care Reform End Stigma Toward Mental Illness?

This article addresses the destigmatization of mental health through health care reform by incorporating antistigma efforts—a destaining of mental illness—through prevention and early intervention in community-based programs that would be mandated and funded through the auspices of Patient Protection and the Affordable Care Act (ACA). Mental health care policies under the ACA and the Mental Health Parity Act are briefly described, following a definition of mental health stigma and its impacts. Recommendations for statutory mandates in stigma reduction at the community and federal levels and guidelines for mental health/behavioral health providers form the article’s conclusion.     

Briefly Noted

We asked Jerry Rhodes, former top executive at CRC (now Acadia) and a leader in opioid treatment program management, what he thinks of methadone as a medication to be used in primary care to treat opioid use disorder (OUD), as some people — including former Office of National Drug Control Policy Director Michael Botticelli — recommended last year (see ADAW, July 16, 2018). “I take issue with that,” said Rhodes. “Methadone is a dangerous drug in an unregulated environment,” he told ADAW. Buprenorphine is prescribed this way, but “buprenorphine is a relatively safe drug, and methadone isn't,” he said. A veteran of many battles over methadone, including the near‐elimination of opioid treatment programs, Rhodes told ADAW that “you don't give unfettered access to methadone” to patients with OUD. “Be careful what you wish for” is his advice. This has the potential to cause harm, he said. “Only people who don't understand the history of its utilization would recommend this.”     

“They Treat us Like Pests:” Undocumented Immigrant Experiences Obtaining Health Care in the Wake of a “Crackdown” Ordinance

This article presents findings from a qualitative study of Latino immigrant experiences seeking health care services in the wake of an anti-immigrant “crackdown” ordinance similar to Arizona's SB 1070. Prince William County, Virginia's 2007 “Rule of Law” ordinance escalated law enforcement efforts that targeted this population for deportation and ordered staff to ensure that no one receive social services other than those required by federal law. This article sought to answer the questions: (1) Were undocumented immigrants able to obtain health care? (2) How do immigrants characterize their experiences with health providers? Data were gathered via semi-structured interviews (n = 57) with Latinos in a low-income neighborhood. Analysis of Spanish-language narratives found that many were dissuaded from seeking care because of high costs as well as lack of familiarity with the health care system. Others perceived that they were treated with insensitivity or outright hostility—and believed this treatment was a deliberate effort to discourage them from seeking help.