Drawing on practice reflections from Multicultural Health & Support Service (MHSS) projects with international students, people who inject drugs, newly arrived migrant and refugee communities, and people living with chronic hepatitis B, Daniel Reeders (Senior Project Worker, MHSS) discuss similarities and differences in how disease stigma operates in CALD communities. This presentation was given at the AFAO Positive Services Forum 2012.

1. Presentations of stigma in
CALD clients in Victoria: themes
from critical reflective practice
Daniel Reeders B.A., LL.B. (Melb)
Senior Project Worker
Multicultural Health & Support Service
Centre for Culture, Ethnicity & Health
danielr@ceh.org.au | 03 9342 9713

2. About MHSS
• Statewide service working with African and
Asian communities around blood-borne viruses
and sexually transmitted infections (BBV/STI)
• A program of the Centre for Culture, Ethnicity
and Health (www.ceh.org.au/mhss).
Acknowledgments & Disclosures
I am drawing on findings from projects funded by
Victorian Government Department of
Health, Gilead Sciences, Bristol-Myers
Squibb, and the Cancer Council of Victoria.

3. Scope
• Written for relevance to positive services
staff, focused on clients rather than
communities
• Looking at stigma for migrants/refugees in
Australia, quite different in countries of origin
• Not stating essential truths about other cultures;
I‟m sharing from my own learning process
moving from positive health to CALD BBV, and
my perspective is partial and relative – as much
about Western health professional culture as
any refugee or migrant cultural background.

5. what is stigma
Goffman (1963)
• mark or attribute
• deeply discrediting
• particular social interaction

6. what is stigma
Link & Phelan (2001)
1. Labelling of differences
2. Stereotyping of those labelled
3. Categories allowing separation of us / them
4. Status loss, discrimination, unequal outcomes
5. Enabled by power relations
Parker & Aggleton (2003)
• Stigma enables power relations & social order

8. what stigma is not

9. what stigma is not
“Our principal findings show, firstly, that moral or
social stigmatisation does not in any simple way
derive from fear, ignorance or inaccurate
beliefs but that it is also established and
continually reinforced by official campaigns
addressing HIV/AIDS.” (Gausset et al, 2012)
• Stigma is not ―just‖ anything.

11. stigma in Western culture
• Having HIV is a secret you choose to disclose
• Stigma can be resisted by speaking
up, refusing to be silenced, „reclaiming‟
identity, forming community within the category
• This implies stigma applies to one layer of
identity, and it is changeable over time

12. stigma in Asian communities
“If someone was a carrier of such disease it would
mean: be careful when you come near me as I
am an outlaw. Therefore no one would want to be
in such situation and deprived of all protection
and rights.”
• Vietnamese man, quoted in McNally & Dutertre,
2006, p158.

13. stigma in Asian communities
“I am afraid that people will rang kiat me.
Everyone is the same, and they think the same
about the illness. It does not matter how many
thousand people have HIV/AIDS within the
populations of more than 60 millions, I would say
that only zero percent will accept people living
with HIV/AIDS.”
• “Pailin”, Thailand woman living with HIV, quoted
in Liamputtong, Haritavorn & Kiatying-Angsulee
2009, p158.

14. relative differences
Compared to Western cultures, stigma in these
quotes is
• permanent
• fundamental
• contagious
• paradigmatic
Closer to Goffman (1963) „spoiled identity‟.
Takehome — the stakes are much higher for a
CALD PLHIV contemplating disclosure.

16. sources & methods
Across our projects the same 7 themes co-occur when
key informants, clinicians and support workers talk
about CALD clients facing stigma. Projects include:
• Double Trouble: CALD MSM sexual health
• International Students‟ Sexual & Reproductive
Health Needs Analysis
• Cultures of Care in Emerging Communities
• SRH Needs of Newly-Arrived Refugees
• Hepatitis B is Family Business (campaign)
Methods were thematic and discourse
analysis, triangulation of reflective practice & literature

17. “7S” model of stigma presentation
• Stigma
• Shame
• Silence
• Secrecy
• Stress
• Sleeping problems
• Somatisation

18. stigma(s)
Migrants and refugees are always dealing with
multiple overlapping sources of stigma.
HIV stigma in countries of origin may be lower
than it is in Australia, where it is always intensified
by migrant and refugee stigmas, even for CALD
people living without HIV.

19. shame
Shame is bodily and emotional but also social.
“Shame is the intensely painful feeling or
experience of believing we are flawed and
therefore unworthy of acceptance and
belonging.” (Brown, 2007)

20. silence
Silence refers to paralysis of all kinds of
action, not just speech and other forms of
expression.
―(Shame) produces a generalised silence because
any topic could accidentally reveal the underlying
premise – and through the suspicious inspection
of every utterance produced by this
fear, everything that is said comes to stand
for, and be linked with, the hidden secret. It
becomes a truth that is impossible not to
express, so that silence becomes the only safe
option.‖ (ISSRH report, forthcoming)

21. secrecy (or shiftiness)
This is a correlate of silence. To clinicians it can
seem like the person is hiding something.
―Where our focus on confidentiality tries to
address a simple, rational fear of onward
disclosure, shame-induced silence is different – it
is a loss of trust in your ability to control what you
mean when you speak.‖ (ISSRH report)

22. stress, sleep, somatisation
• CALD clients living with stigma will be dealing
with significant amounts of stress
• CALD clients in distress often present with
sleeping problems or somatisation – what a
Western patient might present in mental and
emotional terms may be translated into a bodily
malady, often stomach upset.

24. summary
Developing culturally competent accounts
• In addition to the social and structural aspects
of stigma, CALD clients/patients challenge
positive services to describe, recognise and
understand the affective, expressive and
bodily dimensions of stigma experience.
• The focus in Western postmodern cultural
theory on the changeability of identity may lead
us to underestimate the permanence and
fundamentality of stigma in CALD communities;
Goffman got it right with „spoiled identity‟.

25. summary
Implications for service providers
• “What‟s the point of treatments? I can never
recover my position and relationships with the
community.”
• Refusing referrals because, in our health
system, you have to continually retell your story
(and interpreters may register as an audience).
• Clients can become „clingy‟ – but ongoing
relationship with the same provider and small
group strategies can be incredibly meaningful:
acceptance and belonging.

26. contact details
For questions, references, copies of papers
cited, please e-mail danielr@ceh.org.au