Social Science & Medicine 103 (2014) 1e6

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Introduction

Introduction to the special issue on structural stigma and health

Introduction Stimulated by the pioneering work of Goffman (1963), research into the causes and consequences of stigma has proliferated over the past five decades. Progress has been made in the construction of new concepts, measures, and methodological approaches that have illuminated how stigma works to the disadvantage of those targeted by it. The culmination of this intense scrutiny has created the capacity to more deeply understand this powerful human phenomenon, opening the possibility to address its unwanted effects. At the same time, in the midst of this growth and advancement, the stigma concept has been criticized on several fronts. One of the most consistent criticisms has been that stigma research is too individually focused (Link & Phelan, 2001; Parker & Aggleton, 2003). According to Oliver (1992), the central thrust of stigma research has been focused on the perceptions of individuals and the consequences of such perceptions for micro-level interactions, rather than on structural issues underlying stigma. In part to address this criticism, researchers have recently expanded the stigma construct to consider how broader, macrosocial forms of stigmadtermed structural stigmadmay also disadvantage the stigmatized. For instance, Link and Phelan’s (2001) influential conceptualization of stigma distinguished between discrimination at individual and structural levels and noted that the concept of structural stigma “sensitizes us to the fact that all manner of disadvantage can result outside of a model in which one person does something bad to another” (p. 382). Despite initial attempts to define (Link & Phelan, 2001) and measure (Corrigan et al., 2005) structural stigma, there has been limited empirical investigation of the extent to which structural stigma represents a risk indicator for adverse health outcomes among stigmatized individuals. This dearth of empirical research on structural stigma has led researchers to conclude that this under-representation represents “a dramatic shortcoming in the literature on stigma, as the processes involved are likely major contributors to unequal outcomes” (Link, Yang, Phelan, & Collins, 2004, pp. 515e16). Recent research, however, has begun to generate a tantalizing set of findings concerning the role of structural stigma in the production of negative outcomes for members of stigmatized groups, including individuals with mental illness (Evans-Lacko, Brohan, Mojtabai, & Thornicroft, 2012), sexual minorities (Hatzenbuehler, 2011), Blacks (Krieger, 2012), and individuals infected with HIV/ AIDS (Miller, Grover, Bunn, & Solomon, 2011). In one example of this work, Hatzenbuehler, Keyes, and Hasin (2009) coded states for levels of structural stigma surrounding lesbian, gay, and bisexual (LGB) individuals, operationalized as the absence of 0277-9536/$ e see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.socscimed.2013.12.017

policies that confer protection to gays and lesbiansdnamely, hate crime statutes and employment nondiscrimination policies that include sexual orientation as a protected class. The researchers linked this policy information to individual-level data on mental health and sexual orientation from a large nationally representative survey of U.S. adults. Sexual orientation disparities in mental health were lower in low-structural stigma states. For instance, sexual orientation disparities in dysthymia (a mood disorder) were eliminated in states with protective policies; however, LGB adults who lived in states with no protective policies were nearly 2.5 times as likely to have dysthymia as were heterosexuals in those same states. Results remained robust after controlling for demographic covariates and perceived discrimination, suggesting that structural stigma contributes to psychiatric disorders independent of individual stigma. These initial findings have shown the impact of structural stigma to be substantial and thereby indicated the need to understand it more thoroughly. To capitalize on the exciting advancements of this emerging line of research on structural stigma, we founded the Structural Stigma and Population Health Working Group at Columbia University, funded by the Robert Wood Johnson Foundation Health & Society Scholars program. We brought together an interdisciplinary group of psychologists, sociologists, social epidemiologists, and anthropologists to meet twice a month to advance and develop new approaches to theory, methods, and empirical evidence bearing on the role of stigma as a social determinant of population health. After meeting for over a year, our group came to the conclusion that bringing the “social” squarely back into the stigma conceptdand examining the impact of these structural forms of stigma on healthdrequired attention to several overlapping foci, including: (1) conceptualizing novel definitions of social/structural dimensions of stigma; (2) measuring and statistically modeling stigma as a structural determinant of health; (3) identifying relationships between structural and individual stigma in predicting health outcomes; and (4) designing interventions to reduce structural forms of stigma that create and perpetuate health inequalities. After pursuing these topics on our own, we invited several experts in the field of stigma, discrimination and health to a conference to discuss these topics further. This special issue “Structural Stigma and Health” emerged out of this larger discussion.

Conceptualizing structural stigma As we note above, stigma researchers have emphasized the need to conceptualize and measure stigma as a social phenomenon with roots in social structures. This, of course, requires the articulation of

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what is meant by structural stigma. Structures have been defined as “organizing principles on which sets of social relations are systematically patterned” (Bonilla-Silva, 1997, p. 476). Drawing on prior conceptualizations, we define structural stigma as societal-level conditions, cultural norms, and institutional policies that constrain the opportunities, resources, and wellbeing of the stigmatized. This represents a broad working definition, but our first set of articles was tasked with developing more specific conceptualizations to address important lacunae and to offer further refinements to more clearly articulate core aspects of the construct. Each paper did this by engaging theoretical traditions in sociology that are focused on factors at the macro-level or the intersection of macro and micro levels but which have not been fully integrated into the study of stigma in general or structural stigma in particular. Feagin and Bennefield (2014) leverage theory and concepts from work in the area of “systemic racism” (Feagin, 2006, 2010) within sociology bringing insights from that tradition to bear to understand racial inequality in health and health care in the United States. The dimensions of racism that are of use in this endeavor, such as racial hierarchy, social reproductions of racial-material inequalities, and collective discriminatory practices, illuminate structural processes that powerfully affect racial disparities as experienced in the health domain. And as the article makes very clear, current manifestations of these phenomena are deeply embedded in historical processes, thereby sensitizing us to the importance of incorporating historical dimensions, which have largely been lacking in the study of structural stigma and health. This approach is consistent with recent empirical evidence showing that the highest mortality rates among Whites and Blacks in states with and without Jim Crow legislation in the decade between 1960 and 1970 occurred in Black populations within Jim Crow states; conversely, the lowest mortality rates occurred among Whites in these same states, suggesting that systemic racism benefits Whites while compromising the health of Blacks (Krieger, 2012). Phelan, Lucas, Ridgeway, and Taylor (2014) direct attention to another area of sociology, the so called “status characteristics tradition” (Berger, Rosenholz, & Zelditch, 1980; Ridgeway & Erickson, 2000) that is particularly well-known for its capacity to link macro and micro processes. In particular, Phelan and colleagues suggest that “status” as conceived in this tradition is an important, but overlooked, dimension of structural stigma, and they demonstrate how linking stigma to status characteristics theory can help embed the study of stigma in a social-structural framework. The authors discuss several parallels between status and stigma (e.g., in both, macro-level inequalities are enacted in micro-level interactions, which in turn reinforce macro-level inequalities), which reveals close parallels between stigmatization and status processes that contribute to systematic stratification by major social groupings. These conceptual intersections highlight the fact that stigma is not only an interpersonal or intrapersonal process, but also a macro-level process. The authors’ contribution underscores a central theme of this special issue: that stigma’s impact on health “should be scrutinized with the same intensity as that of other more status-based bases of stratification such as SES, race and gender, whose health impacts have been firmly established” (p. 15). Finally, Link and Phelan (2014) travel to the sociological theories of Bourdieu (1987, 1990) playing off his ideas about “symbolic power” and the utility of hidden, “misrecognized” processes in deploying power to achieve desired ends. Using these ideas, Link and Phelan introduce a new concept of “stigma power” to identify the macro-level factors that create social structures in which stigmatized individuals are exploited, controlled, or excluded. This concept points to the ways in which stigmatizers achieve their goals of keeping stigmatized individuals “down, in, or away”

(Phelan, Link, & Dovidio, 2008). The authors demonstrate that individuals with mental illness exhibit concerns with staying in, feel propelled to withdraw and “stay away,” and are induced to feel downwardly placed. In this way, the stigmatized ensure that the outcomes that the stigmatizers might desire are enacted, but without the stigmatizers ever being involved in direct person-toperson discrimination. The concept of power has been central to sociological concepts of stigma (Link & Phelan, 2001; Parker & Aggleton, 2003), but this article provides new insights into how stigmatizers are able to ensure the outcomes they desire in insidious and under-recognized pathways that reinforce social structures in which stigmatized individuals are embedded. The articles in this section accomplish two central aims. First, they collectively highlight important gaps in current conceptualizations of stigma, which are almost exclusively individually focused. Second, these articles significantly advance this literature by offering several key concepts (both new concepts, as well as existing concepts that may be fruitfully applied to understanding the stigma process) that are absent from current conceptualizations of structural stigmadincluding stigma power, status, and systemic racism. Measuring and modeling structural stigma as a risk indicator for poor health Having defined and elaborated important components of structural stigma, we next turn to a series of articles that demonstrate novel ways of measuring this construct as it relates to health. Theoreticians of institutional racism (Ture & Hamilton, 1967) have noted that this form of racism is less overt and more difficult to identify than other forms (i.e., individual- and interpersonal-level racism). Similarly, structural stigma can be hard to capture, ensuring that it frequently remains hidden or “misrecognized” (Bourdieu, 1987, 1990). Part of the role of social scientists is therefore to develop measures of structural stigma to make the processes that underlie it less invisible and more manifest. Accomplishing this task, the papers in this special issue highlight a range of different measures of structural stigma that can be used in order to study the role of structural stigma as a social determinant of population health. In the first article, Hatzenbuehler et al. (2014) constructed a measure capturing the average level of anti-gay prejudice in the community (defined at the primary sampling unit level, which included metropolitan statistical areas and rural counties), using data from the General Social Survey. This information was prospectively linked to mortality data via the National Death Index. Sexual minorities who lived in highstructural stigma communitiesdoperationalized as communities with high levels of anti-gay prejudicedhad increased mortality risk compared to those living in low-structural stigma communities, controlling for individual and community-level covariates. This effect translates into a life expectancy difference of 12 years on average (range: 4e20 years), which is greater than life expectancy differences between individuals who do and do not complete a high school education (Muennig, Fiscella, Tancredi, & Franks, 2010). There was no association between geographic mobility since age 16 and mortality among sexual minorities, demonstrating that the results were robust to selection effects (i.e., they cannot be explained by healthier respondents moving to low-stigma communities). In the second article, Lukachko, Hatzenbuehler, and Keyes (2014) adopt a different approach to examining structural measures of racism, including political participation, employment and earning, economic autonomy, judicial parity, and disparities in incarceration. Data on structural racism at the state level was linked to individual-level data on myocardial infarction from the National Epidemiologic Survey on Alcohol and Related Conditions, a

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nationally representative survey of U.S. adults aged 18 and over. Blacks living in states with high levels of structural racism were generally more likely to report past-year myocardial infarction than Blacks living in low-structural racism states. Conversely, Whites living in high structural racism states experienced null or lower odds of myocardial infarction compared to Whites living in low-structural racism states. These results raise the provocative possibility that structural racism may not only harm the targets of structural stigma but also benefit those who wield the power to enact stigma and discrimination, consistent with theories put forward and/or elaborated on in this issue, including stigma power (Link & Phelan, 2014) and systemic racism (Feagin & Bennefield, 2014). In the third article, Taylor (2014) builds upon the work of Phelan et al. (2014) in this issue to consider biological sequelae of status processes. In particular, the author uses laboratory data to show that men who lose social influence among other men in a smallgroup setting exhibit a biological stress response, as measured by the hormone cortisol, which has been linked to health problems when chronically activated (McEwan, 1998; Sapolsky, 2005). Importantly, loss of social influence was not associated with a cortisol response among the other groups (men working with women; women working with men and women). Thus, men are uniquely physiologically responsive to the stigma of failed manhood in front of other men. Although heterosexual men are not a stigmatized group, failure of achieving manhood is highly stigmatized in certain social contexts. These results therefore have important implications for understanding ways in which structural forms of stigma that are salient in specific cultural contexts may contribute to deleterious stress responses among members of stigmatized groups, consistent with arguments made by Yang et al. (2014) in this issue (see below). Together, these papers complement and extend recent studies examining structural stigma and health (e.g., Hatzenbuehler et al., 2009; Williams & Collins, 2001). Corrigan et al. (2005) previously offered potential operationalizations of structural stigma, including “the policies of private and governmental institutions that restrict the opportunities of stigmatized groups” (p. 557). The articles in this special issue suggest several additional ways in which researchers can operationalize structural stigma in order to study its influence on the distribution of negative health outcomes among members of stigmatized groups. We demonstrate the predictive utility and generalizability of this approach through examining different stigmatized groups (race, sexual orientation), as well as multiple health outcomes (stress biomarkers, physical morbidities, mortality). We advance the extant literature by expanding the focus of stigma from individual measures of this construct (e.g., perceived discrimination) to considering the ways in which the structural conditions in which stigmatized individuals are embedded undermine their health and wellbeing. Linking macro and micro Even though these studies indicate that structural forms of stigma exert powerful, direct influences on the health of stigmatized individuals, it would be misleading to suggest that structures are unidirectional and static. To be sure, social structures actively shape individual- and group-level processes; at the same time, however, structures are themselves molded and altered by individual and interpersonal factors. Consequently, this section of the special issue considers various unexplored aspects of these linkages between macro and micro levels. Together, four articles pose a series of questions about relationships between structural and individual forms of stigma: (1) Are they truly distinct processes, or does structural stigma merely

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represent the aggregate effects of individual forms of discrimination? (2) Do synergistic relationships exist between individual and structural stigma, such that structural stigma potentiates the impact of individual stigma on health? (3) How do stigmatized individuals respond to and cope with structural forms of stigma? The fifth article in this section addresses another question relevant to macro-micro relationshipsdnamely, what are the individual- and interpersonal-level mechanisms through which structural stigma influences health? Angermeyer, Matschinger, Link, and Schomerus (2014) provide important evidence that structural and individual forms of discrimination are, in fact, distinct processes. Their study examined how attitudes towards allocating financial resources to the care of people with depression (measure of structural discrimination) developed over the last decade in Germany, compared to the public’s desire for social distance from individuals with depression (measure of individual discrimination). The proportion of respondents who opposed cutting money from the treatment of patients with depression tripled, suggesting that structural forms of stigma decreased over the study period. In contrast, over the same time, the public’s desire for social distance from persons with depression remained unchanged. Further, analyses indicated that the increase in the public’s opposition to funding restrictions was similar across all levels of social distance, providing further evidence that structural discrimination was unrelated to levels of individual discrimination. These results corroborate existing theories of stigma positing that structural and individual discrimination are distinct constructs (Link & Phelan, 2001; Meyer, 2003). Because existing research tends to treat structural and individual stigma in isolation, there has been very limited investigation of their interrelationships, with rare exception (e.g., Gee, 2008). To address this gap, the study by Pachankis, Hatzenbuehler, and Starks (2014) examined whether stigma at the individual level, namely gay-related rejection sensitivity, interacts with structural stigma (in the form of state policies and attitudes) to predict substance use among young sexual minority men. Rejection sensitivity interacted with structural stigma, such that those who were high in sensitivity to status-based rejection and lived in high structural stigma states had elevated rates of drinking. This paper is among the first to suggest that individual forms of stigma interact with structural stigma to predict important health behaviors among members of a stigmatized group. Adopting a very different methodology, Hansen, Bourgois, and Drucker (2014) utilize ethnographic data to further demonstrate interactions between social structures and individual responses to stigma. In their case study, the authors examine structural and policy changes in the welfare state, which have led to the increasing medicalization of poverty, as individuals are required to receive diagnoses of permanent disability to receive social security insurance. Similar to other (quantitative) studies in this special issue, Hansen and colleagues document multiple negative consequences of these newer, structural mechanisms for enacting stigma, including negative side effects of medications that must be taken to qualify for disability support, the inability to pursue employment for fear of losing disability payments, and “backlash stigma.” At the same time, the authors also uncover surprising ways in which poor people are able to neutralize the stigma of receiving disability payments; within these local contexts, the ability to gain benefits is seen as a “marker of competence and social responsibility,” underscoring that “the perception of a stigma varies by the structural level or field from which it is viewed” (p. 82). This research highlights critical, yet under-recognized relationships between individual and structural stigma, which are dynamic, contextual, and continually evolving. In so doing, it articulates a key theme of this special issue by linking “local, interpersonal strategies for

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managing identities and social value to larger institutional processes of the state, the exercise of power, class relations, and cultural and ideological impositions of meaning and value” (p. 77). The article by Yang et al. (2014) uses a mixed-methods approach to investigate ways in which structural forms of stigma and culture interact to produce adverse mental health outcomes among Fuzhonese immigrants diagnosed with major mental illness (psychotic-related disorders) in New York. The authors focused on one form of structural discriminationdnamely, unequal access to affordable mental health servicesdand documented how this aspect of structural stigma obstructs cultural values that are particularly important to Fuzhonese immigrants (i.e., the accumulation of financial resources in order to fulfill essential social goals like marrying and extending the family lineage), which in turn exacerbate mental health disparities. Further, Yang and colleagues suggest at least two ways in which structural and individual-level factors related to stigma interact. First, the authors indicated that one mechanism linking structural discrimination to poor mental health among the Fuzhonese immigrants was the internalization of discrimination, which led to a reduced capacity to advocate for changes in the health care system. This suggests that individual forms of stigma (e.g., self-stigma) may mediate the relationship between structural stigma and poor health. Second, the authors discussed ways in which individuals who were able to participate in cultural values that “matter most” (Yang et al., 2007)dnamely, employmentdcould resist stigma, suggesting that structural and individual factors interact to either potentiate or mitigate negative health outcomes among the stigmatized. Similar to the paper by Hansen, this research further illustrates the ways in which structure, local cultural processes, and stigma are highly contextual in nature and are mutually co-implicated. In the final article in this section, Smart-Richman and Lattanner (2014) identify potential individual-level mechanisms linking structural stigma to poor health outcomes. Drawing on theoretical contributions from articles in this special issue by Link and Phelan (2014) on stigma power and by Phelan et al. (2014) on stigma and status, the authors argue that power and status, as indicators of structural stigma, disrupt inhibitory and disinhibitory mechanisms that contribute to adverse health outcomes among members of stigmatized groups. For instance, according to the authors, low power encourages a heightened attunement to social threats, negative affect, careful and controlled cognition during decision making, and socially constrained behavior, all of which are associated with acts of inhibition and, in turn, with adverse health outcomes. The contribution of this article is its key insight that greater attention to power and statusdand their effects on inhibitory and disinhibitory processesdpromises to generate new understandings of the pathways through which structural stigma affects health. Stigma research has tended to proceed level-by-level (individual, interpersonal, structural), which has led to an underappreciation of the ways in which different forms of stigma interrelate. The articles in this section take an important first step in moving away from treating various forms of stigma in isolation and instead toward integrating stigmas across levels of analysis. Collectively, they provide preliminary evidence from several stigmatized statuses (sexual orientation, mental illness, poverty) and different operationalizations of structural stigma (policies, attitudes) that (a) macro- and micro-forms of stigma jointly interact to create health and (b) individual forms of stigma represent potential mechanisms linking structural stigma to heath. Reducing structural stigma In the preceding sections, we further developed the relatively new concept of structural stigma, provided evidence that it differs

from, yet interacts with, stigma at other levels of analysis, and documented that it has a corrosive impact on the health of populations. Interventions are therefore needed to reduce the negative health sequelae of structural stigma. In this final section, we include four articles that focus on various aspects of interventions as they relate to structural stigma. The first article provides a comprehensive review of the literature on multi-level interventions to reduce stigma (Cook, PurdieVaughns, Meyer, & Busch, 2014). Despite a relative dearth of interventions at the structural level, this article notes that such interventions hold great promise for reducing structural stigma and its negative consequences for population health. One of the central contributions of this paper is documenting how a multilevel perspective brings greater focus to the ways that factors at different levels of a system might facilitate or impede the success of interventions at other levels. For instance, the authors note that stigma interventions at the individual or interpersonal level may, over time, “cascade up” to change social structures. Although interventions at different levels may often be complementary, the article by Corrigan and Fong (2014) suggests that structural and individual interventions can, at times, have competing goals. This tension not only leads to different foci for intervention targets, but may also undermine collective efforts to reduce stigma. The authors also suggest a cautionary tale for structural interventions, citing certain unintended consequences of structural approaches for reducing stigma. For instance, population approaches to reduce mental illness stigma often emphasize the biological nature of mental illness (as a way of challenging the myth that individuals are to blame for their illness). A recent meta-analysis with data from 8 countries across 16 years (Schomerus et al., 2012), however, indicated that while there has been an increase in the endorsement of the belief that mental illness is genetic at a population level, stigma towards people with mental illness was either unchanged or had gotten worse. The authors raise this point not as an indictment of structural interventions per se, but rather as an admonishment to the field to carefully evaluate the impact of structural interventions to ensure that they reduce, rather than intensify, stigma. These previous two articles are conceptual pieces that offer important insights into the development and evaluation of structural interventions. The next article by Reid, Dovidio, Ballester, and Johnson (2014) considers how structural forms of stigma might impact existing individual-level interventions to reduce their effectiveness. The authors obtained data on Whites’ attitudes towards Blacks from the American National Election Studies, which were linked to a previously published meta-analytic database with information on effect sizes from HIV prevention interventions targeted toward African Americans. Results indicated that interventions improved condom use only when communities had relatively positive attitudes toward African Americans (similar effects were observed with a different measure of structural stigmadnamely, residential segregation). In providing some of the first empirical evidence that structural stigma serves as an important, yet understudied, moderator of intervention effectiveness, this article suggests potential explanations for why individual-level interventions may not gain much traction in certain social contexts that are characterized by high levels of structural stigma. Developing structural interventions remains a public health priority, but there are numerous obstacles to the creation and implementation of such interventions, including that key health constituentsdfor instance, the medical professiondhave historically been trained to intervene only at the level of the individual. In their article, Metzl and Hansen (2014) propose one strategy for overcoming this barrier through introducing “structural competency” in medical school education. This concept moves the field

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beyond the more familiar term of “cultural competency” to incorporate greater structural awareness in clinical training. The authors propose several core tenets of structural competency, including students’ observation of, and participation in, structural interventions. This article represents one way that individual-level interventions can be modified to address structural pressures and exigencies that constrain and/or promote the health of the stigmatized. In sum, the articles in this section accomplish several goals, including: (a) reviewing existing interventions at multiple levels; (b) documenting that structural forms of stigma moderate individual-level interventions; (c) describing ways to implement structural awareness in health care settings that have traditionally focused on individual interventions; and (d) considering potentially conflicting goals of structural and individual interventions. Future directions We believe these articles will fundamentally change how the field currently conceptualizes, measures, and ultimately attempts to reduce structural stigma. At the same time, these articles have raised several important questions for future inquiry. We highlight three, while recognizing that this is far from an exhaustive list of potential research questions emanating from this work. Our set of articles identified multiple conceptualizations of structural stigma, including community-level attitudes, social policies, status, and culture. These are important instantiations of structural stigma, but represent an incomplete list. Additional work is therefore needed to identify novel components of structural stigma that were not included here. For instance, recent research on spatial stigma (Keene & Padilla, 2013; Kelaher, Warr, Feldman, & Tacticos, 2010), has demonstrated that this is an understudied mechanism by which geographic places not only contribute to the health of their residents, but also to social inequality more broadly. Further, research is needed to develop additional measures of structural stigma. Recent research, for example, has taken advantage of newer technologies, including racially-charged Google search terms, to capture state-level variation in racist ideology. These technologies, which can be aggregated to different levels of analysis (e.g., county, state), predict important outcomes, including voting patterns (Stephens-Davidowitz, 2013) and Black/White disparities in all-cause mortality (Chae et al., submitted for publication). Although these studies have provided important insights into novel measures, there has been no attempt to develop a comprehensive structural discrimination measure and to evaluate its psychometric properties, an important avenue for future inquiry. In addition to expanding current conceptualizations of structural stigma, future studies are needed to strengthen causal inferences regarding the relationship between structural stigma and health. Studies in this special issue used multiple methods, including cross-sectional survey data, longitudinal studies linked to administrative data, and laboratory based research. Each has their relative strengths and weaknesses for establishing causality, but the field would clearly benefit from greater attention to such issues. Recent studies have used quasi-experimental designs to evaluate the health consequences of structural stigma. For instance, one study took advantage of a natural experiment to examine changes in the prevalence of psychiatric disorders among LGB respondents who were assessed before and after 16 states passed constitutional amendments banning same-sex marriage during the presidential elections in 2004 (Hatzenbuehler, McLaughlin, Keyes, & Hasin, 2010). Results indicated that LGB adults who lived in states that passed same-sex marriage bans experienced significant increases in psychiatric disorders in the 12 months following the passage of the bans; LGB adults in states without these bans did not

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experience an increase in psychiatric disorders during the study period. These and other approaches (e.g., time-series analyses) can be used to further explore the structural stigma-health association. Finally, research is needed to document the mechanisms linking structural stigma to poor health outcomes. Richman and Lattanner (2014) identified putative pathways in their article in this issue (related to inhibitory and disinhibitory processes), but few of these mechanisms have been explicitly linked to structural forms of stigma and therefore represent important targets for future inquiry. Additionally, several papers in the special issue suggested additional pathways that may be further studied. For instance, in sensitivity analyses, Hatzenbuehler et al. (2014) showed that suicide, homicide/violence, and cardiovascular diseases were substantially elevated among sexual minorities in high-structural stigma communities, suggesting that violence and stress-related pathways may explain relationships that were observed between structural stigma and health. Further, work by Link and Phelan (2014) indicated several psychosocial mechanisms (e.g., stigma consciousness, isolation, low self-esteem) through which structural forms of stigma power may exert negative health consequences for stigmatized individuals. Additional studies are needed to test these and other pathways in order to elucidate the manifold ways in which structural stigma operates to compromise health. Conclusions This issue collectively underscores the point that stigma occurs at multiple levels, ranging from intrapersonal (e.g., self-stigma) to interpersonal (e.g., person-to-person discrimination) and finally to structural (e.g., state-level policies that differentially target the stigmatized for social exclusion) levels. This is not a new conceptdindeed, others have recognized the multi-faceted nature of stigma and related constructs (e.g., Jones, 2000; Link & Phelan, 2001; Meyer, 2003). But our special issue both extends and adds greater texture to this prior literature. We conclude by highlighting five key ways that we have accomplished this. First, one set of articles suggests greater refinement in the definition of structural stigma, in particular pointing to the central roles that both power (Link, Feagin, Lukachko, Richman) and status (Phelan, Taylor) play in causing, maintaining, and perpetuating structural forms of stigma. Second, articles by Hatzenbuehler, Lukachko, Reid, and Pachankis offer new operationalizations of structural stigma and show that linking such measures to existing, ongoing, and new health datasets can illuminate previously unrecognized ways in which structural stigma powerfully shapes the health of the stigmatizeddeven affecting life and death. Third, rather than treating individual and structural forms of stigma in isolation, several articles in our issue indicate that focusing on direct and synergistic relationships between these two forms of stigma opens up new avenues for research (Pachankis, Hansen, Angermeyer) and for interventions (Cook, Corrigan, Metzl), although researchers need to devote particular attention to ways in which multi-level interventions may, at times, be operating at cross-purposes. Fourth, it is clear that structural stigma is not a static process, nor is it invariant across social contexts. Articles in this issue (Yang, Hansen, Reid, Hatzenbuehler, Pachankis, Taylor, Lukachko) attest to the importance of considering the social and cultural contexts under which structural forms of stigma are most likely to be health compromising. Finally, the articles in our special issue were conducted across countries (US, Germany, China), disciplines (anthropology, psychology, sociology, social epidemiology), stigmas (sexual orientation, mental illness, race), and outcomes (myocardial infarction, substance use, mortality), which speaks both to the potential generalizability and reach of structural stigma,

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Mark L. Hatzenbuehler* Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, USA Bruce G. Link Department of Epidemiology, Mailman School of Public Health, Columbia University, USA E-mail address: [email protected]. * Corresponding author. E-mail address: [email protected] (M.L. Hatzenbuehler).

Available online 25 December 2013