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Basic and Applied Social Psychology
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“Discredited” Versus “Discreditable”: Understanding
How Shared and Unique Stigma Mechanisms Affect
Psychological and Physical Health Disparities
Stephenie R. Chaudoir a , Valerie A. Earnshaw b & Stephanie Andel c
a College of the Holy Cross
b Center for Interdisciplinary Research on AIDS, Yale University
c University of South Florida
Version of record first published: 04 Feb 2013.
To cite this article: Stephenie R. Chaudoir , Valerie A. Earnshaw & Stephanie Andel (2013): “Discredited” Versus
“Discreditable”: Understanding How Shared and Unique Stigma Mechanisms Affect Psychological and Physical Health
Disparities, Basic and Applied Social Psychology, 35:1, 75-87
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BASIC AND APPLIED SOCIAL PSYCHOLOGY, 35:75–87, 2013
Copyright © Taylor & Francis Group, LLC
ISSN: 0197-3533 print/1532-4834 online
DOI: 10.1080/01973533.2012.746612
“Discredited” Versus “Discreditable”: Understanding How
Shared and Unique Stigma Mechanisms Affect
Psychological and Physical Health Disparities
Stephenie R. Chaudoir
College of the Holy Cross
Valerie A. Earnshaw
Center for Interdisciplinary Research on AIDS, Yale University
Stephanie Andel
University of South Florida
In his classic treatise, Goffman (1963) delineates between people who are discredited—
whose stigma is clearly known or visible—and people who are discreditable—whose
stigma is unknown and can be concealable. To what extent has research in the past 50
years advanced Goffman’s original ideas regarding the impact of concealability on
stigma management strategies and outcomes? In the current article, we outline a
framework that articulates how stigma can “get under the skin” in order to lead to
psychological and physical health disparities. Further, we consider when and to what
degree concealability moderates these effects, creating divergent outcomes for the
discredited and discreditable.
Correspondence should be sent to Stephenie R. Chaudoir,
Department of Psychology, College of the Holy Cross, 1 College Street,
Worcester, MA 01610. E-mail: schaudoir@gmail.com
Does the stigmatized individual assume his different-
ness is known about already or is evident on the spot, or
does he assume it is neither known about by those pres-
ent nor immediately perceivable by them? In the first
case one deals with the plight of the discredited, in the
second with that of the discreditable. This is an impor-
tant difference.
— Goffman (1963, p. 4)
In his seminal work, the sociologist Erving Goffman (1963)
suggested that the experience of stigma differs based on the
concealability of the stigmatized attribute. The discred-
ited are individuals who have a stigma that is predomi-
nantly visible such as race/ethnicity, gender, or physical
disability. In contrast, the discreditable are individuals who
have a stigma that is predominantly concealable such as
mental illness, HIV infection, or sexual minority status.
Thus, these terms refer to the visual conspicuousness of
the stigmatized attribute.1
Although Goffman’s analysis largely focused on
examining differences in the experience of stigma, most
psychological research in the past 50 years hasn’t adopted
a similar approach. Instead, research has largely focused
on the causes and consequences of stigmatization among
either visible stigmas (e.g., race: Richeson & Shelton,
2007; gender: Murphy, Steele, & Gross, 2007) or conceal-
able stigmas (e.g., Quinn & Chaudoir, 2009; sexual orien-
tation: Beals, Peplau, & Gable, 2009) alone. Consequently,
there exist very few empirical studies (e.g., Frable, Platt,
& Hoey, 1998; Hatzenbuehler, Nolen-Hoeksema, &
1For purposes of this article, we categorize types of stigmatized
identities into discredited or discreditable categories based on whether
the attributes are typically visually conspicuous. It is important to note,
however, that some identities may be either discredited and visible or
discreditable and concealable depending upon specific time or social
context. For example, though we conceptualize HIV as a discreditable
or concealable stigma, physical symptoms of disease progression may
sometimes render the identity as visible (e.g., Stutterheim et al., 2011).
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76 CHAUDOIR, EARNSHAW, ANDEL
Dovidio, 2009) or theoretical analyses that directly
compare the experiences of visibly and concealably
stigmatized individuals.
In the current work, we apply Goffman’s (1963)
conceptualization of difference in order to understand
how concealability contributes to psychological and phys-
ical health disparities. Health disparities are differences in
health outcomes between groups that reflect social
inequalities (Centers for Disease Control and Prevention,
2011a). Psychological and physical health disparities have
been shown to occur among groups that occupy a lower
social status such as African Americans (Centers for
Disease Control and Prevention, 2011a; see also Adler &
Rehkopf, 2008; Schnittker & McLeod, 2005) and sexual
minorities (Centers for Disease Control and Prevention,
2011b; Marshal et al., 2011; Mayer et al., 2008).
We draw on research and theorizing across social
psychology (Adler & Rehkopf, 2008; Earnshaw &
Chaudoir, 2009; Hatzenbuehler, 2009; Pascoe & Smart
Richman, 2009; Schnittker & McLeod, 2005) and social
epidemiology (Berkman, 2000; Krieger, 2000) to present a
conceptual framework that captures how stigma “gets
under the skin” to affect psychological and physical health
disparities. The Stigma Mechanisms in Health Disparities
Framework, depicted in Figure 1, describes how public
stigma initiates a cascade of processes that ultimately lead
to disparate outcomes among stigmatized and nonstigma-
tized individuals. This cascade of processes begins with
public stigma, which is the relative degree of devaluation
associated with a stigmatized attribute (i.e., cultural
stigma; Quinn & Chaudoir, 2009). It encompasses a “com-
munity’s negative reaction to a stigma”—a reaction that
confers lower social status and power to those who pos-
sess the stigmatized attribute (Link & Phelan, 2001).
Consistent with previous theorizing (Earnshaw &
Chaudoir, 2009), public stigma is manifested via a series
of stigma mechanisms that can be conceptualized to occur
at individual, interpersonal, and sociocultural levels. That
is, stigma-related phenomenon can be conceptualized to
occur within the individual target, interpersonal
interactions among dyads or groups of people, or across
societies or cultures. At each of these levels, stigma mech-
anisms elicit mediating processes—stress, health behav-
iors, and biological changes—or more proximal processes
that enable stigma to “get under the skin” and cause dis-
parities in mental and physical health. Further, at each
level, we consider Goffman’s (1963) perspective of differ-
ence (see Table 2): To what extent does concealability
affect the degree to which stigma “gets under the skin” to
affect psychological and physical health disparities?
INDIVIDUAL LEVEL
Stigma Mechanisms and Processes
Most psychological research examining stigma has
occurred at an individual level of analysis; it has tended
to adopt the perspective of the “target,” examining how
public stigma manifests itself within stigmatized individ-
uals (Crocker, Major, & Steele, 1998; Major & O’Brien,
2005). Self-stigma is a term that broadly refers to how
individuals respond to possessing a stigma (e.g., Pryor &
Reeder, 2011). These responses can be manifested as three
primary beliefs—anticipated, enacted, and internalized
stigma (Earnshaw & Chaudoir, 2009)—regarding how
the stigma relates to the broader social context.
Anticipated stigma refers to the degree to which individu-
als anticipate or expect to be the target of discrimination
or social rejection because of their stigma. Enacted
stigma refers to the degree to which individuals actually
have experienced discrimination in the past. Last, inter-
nalized stigma refers to the degree to which individuals
feel shame or self-loathing because of their stigma.
Anticipated and enacted stigma reflect stigma directed at
the self from others, whereas internalized stigma reflects
stigma directed at the self from the self. Each of these
individual-level stigma mechanisms have been associated
with poorer mental and physical health outcomes (e.g.,
Hatzenbuehler, Nolen-Hoeksema, & Erickson, 2008;
FIGURE 1 Stigma mechanisms in health disparities model.
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“DISCREDITED” VERSUS “DISCREDITABLE” 77
Mak, Poon, Pun, & Cheung, 2007; Pascoe & Smart
Richman, 2009; Quinn & Chaudoir, 2009).
Expectations and experiences of stigmatization can
be stressful. For example, female students who expected
to be devalued in a predominantly male math, science,
and engineering educational conference experienced
greater cardiovascular reactivity (e.g., faster heart rate;
Murphy et al., 2007) than women who did not expect to
be devalued. Past perceptions of stigmatization can also
exacerbate the effect of new stressors. For example,
perceived discrimination is related to dysregulation of
daily blood pressure trajectories and greater reactivity to
new social stressors among adult Black and White
participants (Smart Richman, Pek, Pascoe, & Bauer,
2010). In response to stigma-related stressors, individuals
may also be more likely to experience negative affective
states and utilize maladaptive coping strategies such as
alcohol use or rumination (Berkman, 2000; Hatzenbue-
hler, 2009), thereby facilitating greater overall psychologi-
cal distress. Over time, chronic exposure to stigma-related
stressors and activation of physiologic stress systems (i.e.,
sympathetic nervous system and hypothalamic-pituitary
adrenal axis) can contribute to allostatic load, or the
accumulation of physical “costs” or “wear and tear” on
the body from stress (for a review, see Ganzel, Morris, &
Wethington, 2010). Thus, stigma-related stressors can
undermine mental and physical health.
In addition, anticipated, enacted, and internalized
stigma may undermine health behaviors that optimize
health and well-being (e.g., disease screenings, diet, and
exercise) and increase health-compromising behaviors
that actively damage health (e.g., tobacco use, sexual risk
behavior). For example, people living with chronic
illnesses who anticipate stigma from health care workers
are less likely to access health care regularly (Earnshaw &
Quinn, 2012). Meta-analytic evidence suggests that
enacted stigma is associated with increased drug and
alcohol use, poor eating behaviors and attitudes, and
poor medical treatment adherence (Pascoe & Smart
Richman, 2009). Internalized stigma is further associated
with decreased adherence to therapy among people living
with mental illnesses (Eisenberg, Downs, Golberstein, &
Zivin, 2009), as well as drug use and sexual risk
(Hatzenbuehler, McLaughlin, & Nolen-Hoeksema, 2008;
Weber, 2008). Because these stigma mechanisms under-
mine the availability of self-regulatory resources (Inzlicht,
McKay, & Aronson, 2006; Inzlicht & Kang, 2010) and
activate feelings of powerlessness that undermine self-
efficacy (Cook, Arrow, & Malle, 2011), they can contrib-
ute to poorer health-related behaviors and disparities.
Discredited Versus Discreditable
Because of their visual conspicuousness, the discred-
ited are more easily identified as “tainted” relative to the
discreditable. Consequently, the discredited may be more
likely to expect and to actually experience individual-level
stigmatization relative to the discreditable. What evidence
exists to support this hypothesis?
Anticipated stigma. To some extent, anticipated
stigma appears to affect the discredited and the discredit-
able similarly. A large body of research suggests that the
stigmatized are subject to a number of detrimental
psychological outcomes due to identity threat—situational
concern that one will be socially devalued (for a review,
see Schmader, Johns, & Forbes, 2008). Although most of
this research has focused on visible stigmas such as race
and gender, similar effects have been observed for
concealable stigmas such as mental illness (Quinn,
Kahng, & Crocker, 2004). Similarly, chronic expectations
of stigmatization have been related to greater psychologi-
cal distress among both visible and concealable stigmas
(Chan & Mendoza-Denton, 2008; Quinn & Chaudoir,
2009). For example, women who had a history of abortion
reported greater distress at a 2-year follow-up to the
extent that they expected stigmatization and felt the need
to keep their identity concealed (Major & Gramzow,
1999). There is also evidence that anticipated stigma is
related to poorer health outcomes among concealable
stigmas (Cole, Kemeny, & Taylor, 1997; Quinn &
Chaudoir, 2009), though this possibility has not been
examined among visible stigmas. Thus, to the extent that
the discredited and discreditable feel that they are vulner-
able to social devaluation, they may experience similar
vulnerabilities for psychological and physical health
disparities.
Enacted stigma. Some recent evidence suggests that
the frequency of enacted stigma is similar for individuals
with visible (i.e., African American race) and conceal-
able (i.e., sexual minority status) stigmas (Cook et al.,
2011; Hatzenbuehler et al., 2009). In both of these daily
diary studies, researchers examined the association
between stigma and well-being among African American
and sexual minority participants. These studies demon-
strate that in the course of about 1 week, there were no
differences in how frequently people felt stereotyped in
everyday social interactions (Cook et al., 2011) or how
frequently they experienced stigma-related stressors
(Hatzenbuehler et al., 2009).
In contrast, other evidence suggests that individuals
with visible stigmas may experience greater enacted
stigma than those with concealable stigmas. Rather than
compare two separate groups of visible or concealable
stigmatized individuals, Stutterheim and colleagues
(2011) focused on examining a single stigmatized iden-
tity that can be either visible or concealable: HIV-positive
status. As HIV infection progresses, side effects of
antiretroviral medications—such as lipodystrophy, or
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78 CHAUDOIR, EARNSHAW, ANDEL
abnormal distribution of fat—can cause HIV status to
become visible. In this sample, visibility of HIV status
does appear to affect stigma-related outcomes. People
living with visible symptoms of HIV report greater
enacted stigma and psychological distress but lower self-
esteem and social support, compared to people living
without visible symptoms of HIV (Stutterheim et al.,
2011).
What might explain this conflicting pattern of results?
One possibility is that this pattern may be attributable to
the types of samples utilized across these studies, which
likely differ in the degree of cultural stigma associated
with them. The studies demonstrating that there were no
differences in rates of enacted stigma involved African
American and sexual minority participants (Cook et al.,
2011; Hatzenbuehler et al., 2009), whereas the study
demonstrating differences involved only HIV-positive
participants (Stutterheim et al., 2011). One advantage of
utilizing the same stigmatized identity and measuring its
visibility is that it rules out cultural stigma—or severity
of social devaluation associated with the identity—as a
potential confounding variable. Thus, the association
between visibility and enacted stigma in the HIV sample
is attributable only to visibility and not to differing levels
of cultural stigma that maybe associated with different
types of identities. In this way, it’s unclear whether the
null results found in the former studies (Cook et al.,
2011; Hatzenbuehler et al., 2009) are attributable to
concealability per se, or differing levels of cultural stigma
associated with African American ethnicity and sexual
minority status.
Regardless of whether there are differences in the
frequency of enacted stigma, research does suggest that the
psychological consequences of enacted stigma on people
with visible and concealable stigmas is different. Feeling
stereotyped was related to greater behavioral inhibition—
feeling less able to express oneself freely—among individu-
als with concealable stigmas relative to individuals with
visible stigmas, and this association was mediated by iden-
tity centrality (Cook et al., 2011). Similarly, Hatzenbuehler
and colleagues (2009) found that after experiencing stigma-
related stressors, individuals with concealable stigmas
reported greater social isolation and less social support
than individuals with visible stigmas. The association
between stigma-related stress and psychological distress
was mediated by social isolation/social support. Together,
this research suggests that concealability may not necessar-
ily affect the frequency of stigma-related events but rather
the effectiveness of coping strategies utilized to address the
demands of these stressors.
Internalized stigma. Goffman (1963) theorized that
stigmatization would lead to internalized stigma: “The
stigmatized individual tends to hold the same beliefs
about the identity that we do. [This may cause him] to
agree that he does indeed fall short of what he really
ought to be. Shame becomes a central possibility” (p. 7).
Since Goffman’s original writings, researchers have
demonstrated that internalized stigma can lead to nega-
tive psychological outcomes for some, but not all,
stigmatized individuals. Because group-based compari-
sons and attributions for discrimination can provide
self-protective benefits (Crocker & Major, 1989), indi-
viduals with visible stigmas such as race, gender, and
physical disability are less likely to experience psycho-
logical detriments because of their stigmatized status.
Yet research examining concealable stigmas such as
HIV/AIDS (Earnshaw & Chaudoir, 2009) or sexual
minorities (Hatzenbuehler, McLaughlin, et al., 2008;
Meyer, 2003) continues to demonstrate that internalized
stigma is a reliable predictor of important outcomes
such as greater psychological distress, greater participa-
tion in health-compromising behaviors, and lower physi-
cal well-being. Further, some research findings offers
direct evidence to suggest that the discreditable do, in
fact, demonstrate lower self-esteem (Frable et al., 1998)
and greater internalized stigma than the discredited (cf.
Cook et al., 2011; Hatzenbuehler et al., 2009). Together,
these findings suggest that internalized stigma negatively
affects psychological outcomes, though this is most likely
to occur among concealable stigmas.
INTERPERSONAL LEVEL
Stigma Mechanisms and Processes
Public stigma further shapes the way in which stigma-
tized individuals experience their social lives via mixed
dyadic social interactions, social support, and social
network features. Goffman’s writings paid significant
attention to how public stigma affects the nature of mixed
dyadic social interactions (i.e., interactions between
stigmatized and “normal” individuals). For example, he
wrote that when stigmatized and “normal” individuals
interact, social interactions “can become tense, uncer-
tain, and ambiguous for all participants, especially the
stigmatized one” (Goffman, 1963, p. 41). Indeed, research
in the past 50 years has demonstrated that mixed inter-
personal interactions between the stigmatized and
nonstigmatized can be awkward and strained (for a
review, see Hebl, Tickle, & Heatherton, 2003). These
mixed dyadic social interactions may act as situational
stressors that undermine health (Trawalter, Richeson, &
Shelton, 2009). For example, interracial interactions
between Black and White Americans are often anxiety-
provoking experiences that elicit cardiovascular reactivity
and other markers of physiological stress (e.g., Lepore
et al., 2006). In addition, mixed dyadic social interactions
characterized by stigma may undermine health behaviors.
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“DISCREDITED” VERSUS “DISCREDITABLE” 79
In the context of interracial patient–provider interac-
tions, expectations or actual occurrence of stigmatization
can lead to a host of deleterious outcomes that have
direct effects on health disparities, including lower rates
of adherence to treatment protocols, lower rates of access
to and maintenance of care, and increased mistrust of the
medical field, in general (for reviews, see Dovidio et al.,
2008; Smedley, Stith, & Nelson, 2003).
In addition, public stigma may shape characteristics
of social networks that surround stigmatized individuals.
Social networks are simply the collection of friends,
family, coworkers, and others with whom a given person
typically interacts (Scott, 1988). Public stigma affects the
composition of social networks by facilitating greater
homogeneity of the types of people within the network.
Namely, fear of stigma-by-association—or the tendency
for social devaluation to transfer from a stigmatized
target to persons who are associated with the target—
may limit the number of nonstigmatized individuals
within the social network (McLaughlin-Volpe, 2006).
Greater homogeneity of social networks may involve
trade-offs for stigmatized individuals. On one hand, stig-
matized individuals can derive a number of self-esteem
benefits from their group membership to the extent that
they feel that they are part of a larger group (Tajfel &
Turner, 2004). On the other hand, belonging to a larger
disadvantaged group may block individuals’ access to
information, social opportunities, and resources that
benefit their health (Berkman, 2000).
Further, public stigma affects the degree to which
stigmatized individuals experience social support. Social
support is typically conceptualized and measured in two
primary ways: perceived social support, and received
social support (for a review, see Uchino, 2009). Perceived
social support refers to the degree to which individuals
feel that they can access interpersonal support from
others (Sarason, Sarason, Shearin, & Pierce, 1987),
whereas received social support refers to the degree to
which individuals utilize or exchange support in specific
situations of need (Bolger & Amarel, 2007; Cobb, 1976).
Thus, whereas perceived support is typically conceptual-
ized and measured as an individual difference variable,
received support is typically conceptualized and measured
as a state or situation-specific process. Social support is a
strong predictor of optimal adaptation to stress and
better health behaviors (for a review, see Uchino, 2009)
and can therefore lead to improved health among stigma-
tized individuals.
Discredited Versus Discreditable
Dyadic social interactions. In his original writings,
Goffman emphasized that dyadic social interactions
between the stigmatized and nonstigmatized could be
strained, awkward, and uncomfortable, especially for
those whose stigma is visible. In the past 50 years, most
psychological research has examined mixed social inter-
actions among visible stigmas such as racial minorities
(Richeson & Shelton, 2007) or individuals with physical
disabilities or deformities (Kleck & Strenta, 1980), with
limited examination of mixed social interactions among
concealable stigmas such as sexual orientation or
mental illness (for reviews, see Hebl et al., 2003; Quinn,
2006). How does concealability affect experiences of
dyadic social interactions? Although the ability to “pass”
appears to be adaptive for the quality of social interac-
tions, it does appear to come at some psychological cost
for individuals with concealable stigmas. As Quinn
(2006) reviewed, individuals with concealable stigmas
are likely to be doing extra “cognitive work” during
mixed social interactions to keep their identities
concealed. Thus, although the social interactions may go
more smoothly for individuals with concealable stigmas,
they are likely to be more preoccupied with thoughts
about their identities (Smart & Wegner, 1999) and their
partner’s perspective (Frable, Blackstone, & Scherbaum,
1990). Thus, concealability appears to afford a relative
trade-off: Better social interactions and lower social
evaluative threat come at the expense of greater cognitive
detriments.
In therapeutic or clinical contexts, this trade-off may
have more serious consequences for well-being.
Although concealability is likely to create better social
rapport in the social interaction, it may compromise the
quality of treatment provided. For example, an individ-
ual who conceals her mental illness from her medical
provider may develop better rapport with her provider
because she doesn’t have to worry that she is being
socially devalued by her provider, and her provider’s
behavior won’t be affected by this knowledge of her stig-
matized attribute. However, because she hasn’t disclosed
this information to her provider, the provider doesn’t
have access to the full range of information that is
needed to build an effective treatment protocol. Given
that antidepressants prescribed to treat mental illness
can create adverse reactions when coadministered with
many painkillers (Sansone & Sansone, 2009) and other
pharmacological treatments, omission of this important
information could limit the efficacy of her treatment.
Thus, concealability can pose a serious and direct threat
to mental and physical health by affecting the social
information available for use (Chaudoir & Fisher, 2010).
In addition, concealing may hurt the development of
social rapport in therapeutic or treatment contexts
under certain circumstances. Concordance between
patient and provider can lead to improved treatment for
patients with both visible (Smedley et al., 2003) and
concealable (Davidson et al., 1999) stigmas. If patients
or providers conceal their stigma, however, such rapport
cannot be achieved. In this way, concealability may
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80 CHAUDOIR, EARNSHAW, ANDEL
further threaten health by limiting opportunities for
connecting over shared experiences.
Social network homogeneity. Fundamentally, con-
cealability means that the discreditable have a much harder
time identifying and interacting with people who share their
stigmatized attribute. For example, in a survey study of
perceptions of psychological marginality, individuals with
concealable stigmas reported feeling more unique and
perceiving less similarity with other people relative to indi-
viduals with visible stigmas (Frable, 1993). Thus, to the
extent that psychological marginality is a proxy for the
composition of larger social networks, these data might
suggest that individuals with concealable stigmas are less
likely than individuals with concealable stigmas to have
homogenous social networks that include other similarly
stigmatized individuals.
What are the consequences of having a social network
that doesn’t readily include people who share the stigma-
tized attribute? Given that people rely on visible social
cues to infer belongingness (Murphy et al., 2007; Walton
& Cohen, 2007), the discredited may chronically experi-
ence lower sense of belonging, lower self-worth, and
greater internalized stigma because they are less likely to
see similar others in their day-to-day lives. Indeed, a daily
diary study found that individuals with concealable
stigmas reported greater negative affect, greater social
isolation, and lower self-esteem than those with visible stig-
mas (Frable et al., 1998). Although they felt more socially
isolated, when individuals with concealable stigmas did
have the opportunity to be around “similar” others, they
experienced a temporary boost to their well-being.
Individuals with visible stigmas did not experience a similar
“boost,” possibly because they are more accustomed to
interacting with “similar” others in their day-to-day lives.
Further, as other scholars have noted (Pachankis,
2007; Quinn, 2006), concealability acts as a barrier to
forming a group identity with similar others and prevents
the use of group-based coping responses. Although indi-
viduals with visible stigmas can utilize group-based
coping resources in the face of stigma-related stressors
(Crocker & Major, 1989), these processes are largely
unavailable to the discreditable. For example, a daily diary
study revealed that individuals with a visible stigma (i.e.,
African Americans) reported greater identity centrality
than individuals with a concealable stigma (i.e., sexual
minorities; Cook et al., 2011). Further, when made to feel
stereotyped in their everyday interactions, sexual minori-
ties felt lower in power than African Americans, a pattern
of effects that was mediated by identity centrality. Thus,
this evidence would suggest that because individuals
living with concealable stigmas may be less able to cultivate
a strong sense of identity centrality relative to individuals
living with visible stigmas, they might be more vulnerable
to deleterious effects of stigmatization.
If the discreditable cannot rely on group-based coping
resources such as identity centrality, social support, or
collective self-esteem, what can they rely upon in times of
stigma-related stress? Converging evidence suggests that
the discredited may be more likely to utilize avoidant or
otherwise ineffective coping strategies—such as substance
abuse, rumination, and social isolation—in order to cope
with stigma-related stressors (Hatzenbuehler et al., 2009).
Indeed, in a daily diary study, individuals with conceal-
able stigmas reported greater social isolation and less
social support than individuals with visible stigmas after
experiencing stigma-related stressors (Hatzenbuehler
et al., 2009). The tendency for individuals with conceal-
able stigmas to socially isolate themselves and feel less
social support mediated the association between stigma-
related stress and psychological distress. Thus, these data
suggest that when individuals with concealable stigmas
engage in socially isolating coping responses, they risk
exacerbating their levels of distress. Thus, whereas visible
stigmas can utilize a wide array of approach and avoid-
ance-focused coping resources (e.g., Major & O’Brien,
2005; Miller, 2006), our review suggests that the discredit-
able are less able to utilize approach-focused coping
resources and processes that visible group membership
affords. Given that stress is one of the primary mediating
processes by which stigma “gets under the skin,” the
discreditable are at a distinct disadvantage in coping with
stigma related stressors.
Social support. How does concealability affect the
social support that is available to and utilized by stigma-
tized individuals? Although there is no direct evidence
examining this question among perceived social support,
there is some evidence to suggest that concealability
affects whether social support is actually utilized in
response to stigma-related stressors. In a daily diary study
conducted by Hatzenbuehler and colleages (2009),
individuals with either a visible stigma (i.e., African
American race) or a concealable stigma (i.e., sexual
minority status) tracked their exposure to stigma-related
stressors and their utilization of social support and
feelings of psychological distress. They found that sexual
minority participants reported greater social isolation
and less utilization of social support than African Americans
after experiencing stigma-related stressors. In fact,
African Americans actually utilized more social support
on days that they experienced stigmatization, relative to
days without these stressors. Further, the greater tendency
for sexual minorities to socially isolate themselves and
utilize less social support mediated the association
between stigma-related stress and psychological distress.
These data suggest that when individuals with conceal-
able stigmas actively engage in socially isolating coping
responses and fail to utilize social support, they risk exac-
erbating their levels of distress.
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“DISCREDITED” VERSUS “DISCREDITABLE” 81
Overall, these findings echo the aforementioned
conclusions regarding the impact of concealability on
well-being. In times of stress, individuals with conceal-
able stigmas are simply less able to identify others who
can provide essential social support. This represents a key
difference in the experience of stigma—one that has
significant consequences for well-being.
SOCIOCULTURAL LEVEL
Stigma Mechanisms and Processes
Individual beliefs and interpersonal processes are both
nested within broader sociocultural phenomena. We
focus on three ways in which sociocultural-level phenom-
ena, or characteristics of social contexts, influence the
health of people living with stigmatized identities:
hazardous environmental conditions, health care access
and quality, and public policy.
Members of stigmatized groups are differentially
exposed to hazardous environmental conditions that
threaten their health. Neighborhoods, schools, and
workplaces remain largely segregated based on race and
socioeconomic status within the United States and else-
where. Within these segregated environments, racial
minorities and individuals of low socioeconomic status
and are regularly exposed to greater amounts of toxic
substances and pollutants (Krieger, 2003; Schnittker &
McLeod, 2005), greater violence (Krieger, Waterman,
Chen, Soobader, & Subramanian, 2003), and greater
exposure to infectious diseases including syphilis, gonor-
rhea, chlamydia, and tuberculosis (Krieger et al., 2003).
These hazardous environmental conditions result in
biological changes that undermine the health of stigma-
tized individuals. The greater amounts of toxic sub-
stances and pollutants that racial and ethnic minorities
are exposed to within segregated living and working envi-
ronments put them at greater risk of cancer and other
chronic health conditions (Krieger, 2003; Schnittker &
McLeod, 2005). The greater violence that occurs in disad-
vantaged neighborhoods puts people of low socioeco-
nomic status at increased risk of experiencing bodily
harm and death (Krieger et al., 2003). Unsafe working
conditions further threaten bodily injury and death
among people of low socioeconomic status (Adler &
Rehkopf, 2008).
Further, members of stigmatized groups often have
less access to quality health care than members of non-
stigmatized groups. There are a variety of reasons for
this. For example, rates of uninsurance are higher among
racial and ethnic minorities (Lurie & Dubowitz, 2007). In
addition, racial minorities are more likely to live in neigh-
borhoods where there are fewer physicians and where
physicians are less likely to be board certified (Williams &
Jackson, 2005). The hospitals in these neighborhoods
also provide poorer emergency care, including greater
transportation time to the hospital and low-quality care
(Williams & Jackson, 2005). Further, racial minorities
presenting with disease symptoms or characteristics are
often treated less aggressively by providers (Smedley
et al., 2003). Decreased health care access and quality
prevents stigmatized individuals from adopting positive
health behaviors and therefore leads to poor health.
Finally, public policies often disadvantage members of
stigmatized groups and may ultimately shape their mental
and physical health. Examples include policies that
restrict people living with HIV/AIDS from accessing
medical and dental care, attending schools, entering
countries, and joining certain employment sectors
(Earnshaw & Kalichman, 2013). Other policies designed
to fight the “war on drugs” stereotype current drug users
as “criminals” and “junkies” in an attempt to prevent
people from using drugs (Tempalski et al., 2007). Further,
policies that ban same-sex marriage and the adoption of
children by sexual minorities delegitimize or discredit
same-sex relationships (Weber, 2008). These policies may
undermine health by preventing stigmatized individuals
from adopting positive health behaviors (e.g., regular
medical and dental care, use of clean injection equip-
ment) and increasing their psychological distress
(Hatzenbuehler, 2011; Hatzenbuehler, McLaughlin,
Keyes, & Hasin, 2010).
Discredited Versus Discreditable
Health care access and quality. In response to
striking evidence of racial and socioeconomic disparities,
a great deal of attention and ameliorative efforts have
been focused on increasing quality and diversity of health
care providers and resources in order to reduce these gaps
(Betancourt, Green, Carrillo, & Ananeh-Firempong,
2003). To what extent does concealability affect these
gaps in health care and access and efforts to reduce them?
At present, it seems that these gaps disproportionately
affect visible stigmas such as race. However, emerging
evidence is beginning to document gaps in care among
some concealable stigmas. Many areas of the country
provide limited access to health providers who are trained
to provide effective care services to treat mental illness
and mental health issues that are unique to individuals
with concealable stigmas such as homosexuality, sexual
assault, and drug or alcohol addiction (e.g., Mayer et al.,
2008). At the same time, evidence pointing to inferior
health outcomes among sexual minorities (Wolitski,
Stall, & Valdiserri, 2008) and people living with mental
illness (Atdjian & Vega, 2005) continue to accumulate.
Concealability affects health care access and quality to
the extent that it focuses greater attention on visible
relative to concealable stigmas. The gaps in health care
access and quality may that are distributed on the basis
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82 CHAUDOIR, EARNSHAW, ANDEL
of race and socioeconomic status may, in fact, be sub-
stantially greater than those distributed based on sexual
orientation, mental illness, chronic illness, or any other
number of concealable stigmas. But, the available data do
not provide clear evidence to fully understand the extent
to which stigma affects health care access and quality in
these domains. Thus, although the largest gaps and efforts
to reduce these gaps focus on race and socioeconomic
status, it remains unclear whether this is because gaps in
health care access and quality do not occur or whether
there are too few data to adequately examine this
possibility.
Hazardous environmental conditions. To date, most
research suggests that differential exposure to hazardous
environmental conditions (e.g., pollution, carcinogens,
violence, health-compromising commodities) is contin-
gent upon race and socioeconomic status (Adler &
Rehkopf, 2008; Krieger, 2003; Schnittker & McLeod,
2005). The current evidence, therefore, appears to suggest
that these stigma mechanisms disproportionately affect
individuals with visible stigmas. However, to date, little
research has directly examined whether these hazardous
environmental conditions might also disproportionately
affect outcomes for individuals with concealable stigmas.
One possibility is that many of the same social and
governmental influences that contribute to segregation
among race and socioeconomic status might also contrib-
ute to segregation among concealable stigmas. For exam-
ple, sexual minorities may be more densely populated in
regions of the country or cities that are more accepting of
sexual diversity. Certain government policies and social
services also contribute to greater segregation. Policies
such as those that provide affordable housing for indi-
viduals with severe mental illness, chronic illness, or HIV
can also contribute to greater density of concealable stig-
mas in particular areas. Although this segregation may
enable individuals with concealable stigmas to find
greater social support from similar others, it can also lead
to greater marginalization. To the extent that hazardous
environmental conditions disproportionately affect these
areas, concealable stigmas may be subject to similar
detriments.
Public policy. Public policies, guidelines, and laws
serve to formalize the values and expectations of a given
society. As such, public policies play an important role in
promoting values and behaviors that express acceptance
and prohibiting values and behaviors that express bigotry.
Although some federal policies such as the Americans
with Disabilities Act provide equal protection for visible
(e.g., physical) and concealable (e.g., mental illness)
disabilities (U.S. Department of Justice, 2011), most
federal policies such as Title VII of the Civil Rights Act,
the Equal Pay Act, and other laws enforced by the U.S.
Equal Employment Opportunity Commission primarily
afford protection against discrimination and prejudice
for the discredited (e.g., prejudice based upon race, gender,
age; U.S. Equal Employment Opportunity Commission,
2011).
Although federal laws do offer some degree of protec-
tion against prejudice, the discredited are also more likely
to be subject to additional policies that may compromise
this protection. For example, the U.S. Department of
Defense’s enforcement of “Don’t Ask, Don’t Tell” policies
encourage a military culture that views and treats sexual
minorities as inferior and may, therefore, contribute to
greater victimization of sexual minorities in the military
(Burks, 2011). Similarly, sexual minority students who
attend schools that have not incorporated sexual diversity
curriculum and antibullying training into their curricu-
lum are 20% more likely to have attempted suicide rela-
tive to students who attend schools with these policies
and programs (Hatzenbuehler, 2011). Similar policies are
also related to greater stigmatization and mental and
physical health risks among people living with HIV/
AIDS. Until 2010, U.S. laws prohibited HIV-positive
foreigners from traveling within the U.S. (“Medical
Examination of Aliens,” 2009). Furthermore, state laws
that prohibit individuals from engaging in sexual acts
without disclosing their HIV status serve to legitimize
stigmatization of HIV and undermine public health
efforts aimed at reducing the transmission of HIV
(Galletly & Pinkerton, 2006). Thus, to the extent that
policies encourage or fail to discourage prejudicial
behaviors, they facilitate environments that may further
stigmatize the discreditable. In these ways, the discredit-
able frequently experience less federal protection against
prejudice and discrimination relative to the discredited.
CONCLUSION
Goffman’s (1963) original treatise assumed that the
stigma management experiences of the discredited and
discreditable diverge in fundamental ways. Yet, over the
past 50 years, social psychological and epidemiological
research has focused the vast majority of its attention on
understanding stigma mechanisms (for reviews, see
Crocker et al., 1998; Major & O’Brien, 2005; Pascoe &
Smart Richman, 2009) and health disparities (Adler &
Rehkopf, 2008; Berkman, 2000) among visible stigmas
such as race, gender, and physical disability. Comparatively
less attention has focused on understanding stigma
mechanisms (for reviews, see Pachankis, 2007; Quinn,
2006; Quinn & Earnshaw, 2011), and almost no attention
has focused on understanding health disparities among
concealable stigmas such as sexual orientation, HIV/
AIDS, and mental illness. And, as outlined in Table 1,
very few studies have directly compared stigma mechanisms
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“DISCREDITED” VERSUS “DISCREDITABLE” 83
among visible and concealable stigmas to examine how
concealability affects outcomes. Thus, 50 years later, a
relative paucity of research exists that allows researchers
to directly examine whether and to what degree conceal-
ability creates divergent experiences and outcomes for
stigmatized individuals.
The framework proposed herein provides a conceptual
“roadmap” that can guide the next generation of stigma
researchers to understand two critical elements: (a) how
stigma “gets under the skin” to affect mental and physical
health disparities, and (b) when and to what degree
concealability moderates these effects. The current frame-
work marries social psychological approaches that have
traditionally focused on individual and interpersonal
mechanisms with social epidemiological approaches that
have traditionally focused on sociocultural mechanisms.
It is, therefore, a unified framework that crosscuts disci-
plinary boundaries and explicitly positions the study of
stigma mechanisms and processes within a broader socio-
cultural milieu that is consistent with Goffman’s original
theoretical approach. Work from Brondolo, Love, Pencille,
Schoenthaler, and Ogedegbe (2011) on the association
between racism and hypertension underscores the impor-
tance of adopting such a multilevel approach to the study
of stigma and health disparities. Our framework positions
public stigma as the most distal causal agent of health
disparities. Whereas existing conceptual approaches to
studying health disparities give little or no consideration
to the role of stigma (e.g., Adler & Rehkopf, 2008;
Berkman, 2000; cf. Krieger, 2000), our framework calls
attention to public stigma as a vital social determinant of
health and health disparities.
The current work is also the first to directly consider
how concealability might moderate the effect of stigma
on mental and physical health disparities. Does stigma
affect visible and concealable stigmas in fundamentally
different ways? Our framework outlines areas of both
similarity and difference (see Table 2). In examining the
potential moderating effect of concealability, our analysis
reveals areas where gaps in research knowledge are most
severe. Given that much of the comparative work has
focused on only a few types of visible identities (e.g.,
TABLE 1
Quantitative Studies That Directly Compare Visible and Concealable Stigmas
Article Study Design Features Type of VS and CS Examined Major Findings
Boarts, Bogart, Tabak,
Armelie, & Delahanty,
2008
N = 57
Longitudinal study
(baseline, 3 months)
VS: African American race
CS: HIV status, sexual minority
Lifetime enacted stigma reported at Time 1 was
related to lower adherence to antiretroviral
medications at Time 2 for VS, but not for CS.
Cook et al., 2011 N = 64
Experience-sampling
study (7 days)
VS: African American race
CS: Sexual minority
Feeling stereotyped was associated with lower
feelings of power and greater behavioral
inhibition among both VS and CS. Feeling
stereotyped was related to greater inhibition
among CS relative to VS, and this effect was
mediated by greater identity centrality among VS.
Frable, 1990 N = 88
Cross-sectional study
VS: African American race,
overweight, acne
CS: Sexual minority, rape victims,
incest victims
CS were more likely to adopt a partner’s perspective
and remember features of a social interaction
than were VS.
Frable, 1993 N = 142
Cross-sectional study
VS: Obese, facial scars
CS: Sexual minority, epileptic,
juvenile delinquents, incest
victims
CS felt more unique and marginal than people with
VS.
Frable et al., 1998 N = 86
Experience-sampling
study (11 days)
VS: African American race,
overweight, stuttering
CS: Sexual minority, eating disorder,
low socioeconomic status
Overall, CS reported greater negative affect and
lower self-esteem than VS. CS had greater social
isolation than VS. CS felt better when they were
around “similar” others relative to dissimilar
others and nonsocial situations.
Hatzenbuehler et al.,
2009
N = 50
Experience-sampling
study (10 days)
VS: African American race
CS: Sexual minority
After experiencing stigma-related stressors, CS
reported greater social isolation and less social
support than VS. Greater social isolation/less
social support mediated the association between
stigma-related stress and psychological distress.
Stutterheim et al., 2011 N = 667
Cross-sectional study
VS: People living with visible
symptoms of HIV
CS: People living without visible
symptoms of HIV
People living with visible symptoms of HIV report
greater enacted stigma and psychological distress,
but lower self-esteem and social support,
compared to people living without visible
symptoms of HIV.
Note. VS = visible stigma; CS = concealable stigma.
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84 CHAUDOIR, EARNSHAW, ANDEL
African American ethnicity, obesity) and only a few types
of concealable identities (e.g., sexual minority status,
HIV), it remains unclear to what extent our conclusions
generalize to the heterogeneous range of visible (e.g.,
physical disability, age) versus concealable identities (e.g.,
mental illness, addiction, sexual traumas). Thus, future
research that examines elements of the framework among
a wider range of identities will help to establish the gener-
alizability of the current hypotheses.
A number of additional future research directions will
also help to expand upon the current framework. For
example, future research could examine the extent to
which other stigma-related dimensions such as controlla-
bility or peril (Jones et al., 1984), identity-related dimen-
sions such as centrality or salience (Quinn & Chaudoir,
2009), or the presence of multiple stigmatized attributes
(e.g., Berger, 2004) might further modify the processes
outlined in the current framework. In addition, future
research could also consider how individual stigma mech-
anisms (anticipated, enacted, internalized stigma;
Earnshaw & Chaudoir, 2009) develop and change over
time and whether concealability moderates these develop-
mental trajectories.
Although the discreditable have received significantly
less empirical attention relative to the discredited, we see
that this gap is most pronounced at the sociocultural level
where very few studies have examined how hazardous
environmental exposure, health care access and quality,
or public policies affect the discreditable. Although this
gap reflects the fact that psychologists’ research tends to
examine stigma from individual or interpersonal rather
than social or ecological perspectives, future work that
directly examines whether or to what degree concealability
affects disparities via individual, interpersonal, and
sociocultural phenomena can close these gaps in research
knowledge.
In these ways, we argue that research that advances the
study of concealability will play a critical role in develop-
ing both theory and practical strategies designed to lessen
the burden of stigmatization. Understanding the extent
to which the processes by which stigma “gets under the
skin” differ for people with visible and concealable
stigmatized identities is critical for adapting treatments,
interventions, and policies to improve the health of
stigmatized individuals and ultimately eliminate health
disparities—a significant and persistent national priority
(U.S. Department of Health and Human Services, 2000,
2010). Thus, research that advances the study of conceal-
ability will examine Goffman’s original proposition of
“difference” and utilize it—50 years later and beyond—to
improve the lives of those who are socially devalued.
ACKNOWLEDGMENTS
We thank Lisa Rosenthal for comments on an earlier
draft of this article.
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TABLE 2
Comparison of Stigma Mechanisms Between Visible and Concealable Stigmas
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