I commence with a confession. As compelling as I find the argument that stigma is a fundamental cause of health inequities,1 and as much as I believe (obviously) that intersectionality is an indispensable critical lens for health equity research,2 I am not convinced that intersectional stigma is the right concept to advance more equitable HIV treatment and prevention outcomes. The incongruity of this confession is not lost on me. In addition to my role as a guest editor of this special supplement of AJPH, I am also a principal investigator of an intersectional stigma project funded by the same National Institute of Mental Health (NIMH)3 initiative that sourced this supplement. My primary opposition is that intersectional stigma, at least as currently conceptualized, obscures interlocking oppressive social-structural systems such as structural racism, sexism, and heterosexism (to name some) that more accurately explain why, four decades into the HIV/AIDS epidemic in the United States, we can foresee the end of the epidemic for relatively more privileged groups such as White sexual minority men but not Black and Latino sexual minority men or cisgender and transgender women.
In 2018, the NIMH’s Division of AIDS Research parenthetically defined intersectional stigma as “multiple stigmatized identities” when it “cleared” the concept,3 paving the way for funding for many of the projects in this supplement. Alas, there are at least three problems with this individualistically focused definition. Problem 1 concerns the use of the term “stigma” rather than discrimination. In an insightful 1998 article, British disability activist Liz Sayce deftly articulated the problem: Different conceptual models point to different understandings of where responsibility lies for the “problem” and different prescriptions for action. For instance, by using the term “racism” we focus our attention on collective and individual perpetrators of discrimination. If instead, we construe the problem in terms of the stigma of being black, our attention shifts to the self-image and perceptions of the black individual.4(p332)
To its credit, NIMH’s Division of AIDS Research now uses intersectional discrimination as well as stigma (see Goodenow and Rausch, p. S273). Nonetheless, intersectional stigma still implicitly directs attention to “multiple stigmatized individuals”—those marginalized at multiple intersections of racial/ethnic and sexual and gender minority status—as if the intersections themselves, not the historical legacy of interlocking structural oppression based on those intersections, were the fundamental cause of HIV inequities.
A second problem is that fixating on “multiple stigmatized identities” reifies and privileges the passive vantage point of stigmatizers, a hallmark of White supremacy. Thus, there are stigmatized people, but alas no people, systems, or structures, enacting the stigma or being held accountable for doing so. Reminiscent of the book Racism Without Racists,5 this nonagentic worldview has implications for HIV research and intervention. People with the power to stigmatize, such as health care providers who fail to prescribe preexposure prophylaxis (PrEP) to people of color, are rarely a focus of HIV intersectional stigma research, nor are the effects of stigmatizing structures such as criminal HIV exposure laws that disproportionately affect Black sexual minority men, for example. As a case in point, most of the articles in this supplement focus almost exclusively on intersectional stigma from the target’s perspective, not the enactor’s. Consequently, there is a sizable knowledge gap about structural and interpersonal intersectional stigma to inform interventions to stop intersectional stigma and discrimination at the source.
Third, although centering the experiences of people marginalized by intersectional discrimination is foundational to critical frameworks such as intersectionality and critical race theory, focusing squarely on “multiple stigmatized identities” absent the structures that perpetuate the stigmatization reifies Erving Goffman’s notion of stigma as “an attribute that is deeply discrediting.”6(p3) In this formulation, stigma is a birthright, an immutable stain that defies time, geography, and social and political intervention. There is nothing intrinsically wrong with being a Black or Latino cisgender woman and/or a sexual or gender minority person. People historically marginalized at specific minoritized intersections are not a problem in need of intervention; the policies, laws, and interpersonal practices that discriminate against them, however, are. Emphasizing “multiple stigmatized identities” over the structures that stigmatize functions to “reinforce the intractability of inequity, albeit in a more detailed or nuanced way.”7(p12)
Consider the problem documented in recent national surveillance data that HIV has decreased for White sexual minority men but not for their Black and Latino counterparts,8 or consider empirical evidence that, despite health insurance, Black and Latino sexual minority men were significantly less likely than their White counterparts to be aware of, have access to, or use PrEP.9 These problems are not solely rooted in Black and Latino sexual minority men’s internalized stigma, the precursor of which is still structurally racist, heterosexist, and classist policies, laws, and practices. In the context of HIV prevention, more pragmatic concerns supersede. Take again the example of PrEP. You don’t buy PrEP over the counter like aspirin; PrEP must be prescribed. Neither the source of nor the solution to the problem of PrEP access resides primarily in the individual’s internalized intersectional racism and heterosexism. Multilevel solutions, such as training and enforcement of policies that require health care providers to provide the same level and quality of HIV prevention care provided to White patients to all patients, and structural interventions, such as Medicaid expansion to cover PrEP, provide a more promising and equitable route to ending the HIV epidemic than conventional individualistic approaches, no matter how nuanced.
Exclusively individualistic conceptualizations of intersectional stigma miss a vital opportunity to leverage intersectionality for what it is, a social justice project,10 not simply a tool for innovative research and scholarship. Like studying how fire burns rather than extinguishing it when it does burn, implicitly rooting intersectional stigma within individuals, rather than in oppressive social structures and processes that seed the stigma in the first place, will not advance the knowledge most needed to inform interventions for problems that are foundationally social-structural. Seismic gaps in knowledge exist about structural stigma,1,11 particularly intersectional structural stigma—knowledge that is desperately needed to inform effective multilevel (e.g., interpersonal, community, structural) interventions to eliminate inequitable HIV outcomes.
Michele Tracey Berger, the Black feminist scholar who coined the term “intersectional stigma” based on her research with women of color living with HIV, conceptualized intersectional stigma to describe how HIV stigma aligned with the “structural realities of race, class, and gender.”12(p24) Notably, identity was not a focus of Berger’s definition. It is telling that until this special supplement, Berger’s groundbreaking work was absent from most of the discourse and research on the topic. This invisibility is part and parcel of the history of Black women’s intellectual contributions, one that has birthed campaigns such as CiteBlackWomen (https://www.citeblackwomencollective.org). Had the HIV field initially listened to (and cited) Berger’s work with its attention to structural intersectionality and commitment to intersectionality as critical praxis, we might be closer to achieving HIV equity than we now find ourselves. Albeit more nuanced, intersectional stigma work that implicitly locates the problem within “multiply stigmatized individuals,” not the oppressive social structures that create and maintain intersectional stigma and discrimination in the first place, will help end the US HIV epidemic for White people, such as those with class privilege or those who do not inject drugs, but not racialized people at diverse intersections, those for whom, 40 years into the HIV/AIDS epidemic, equitable HIV prevention and treatment outcomes remain elusive.
ACKNOWLEDGMENTS
This editorial draws on ideas prompted by my National Institute of Mental Health–funded intersectional stigma research with Black sexual minority men (grant 1 R21 MH121313-01).
CONFLICTS OF INTEREST
The author has no conflicts of interest to declare.
