Stigma has been defined as “A mark of disgrace or infamy; a stain or reproach, as on one’s reputation.” Stigma is complex, operating both as a process and an outcome. It is a pervasive experience for its targets and often goes completely unnoticed by those who are unaffected. According to Bruce Link and Jo Phelan, stigma unfolds through a four-step process: labeling of human differences, stereotyping through the assignment of deviance, separation of certain groups, and finally status loss and discrimination. The fourth step results in power differentials between the empowered in-group and the disempowered stigmatized person.
Significant evidence demonstrates that stigma is an important and independent psychosocial risk factor for poor health. For example, stigma worsens health outcomes for chronic pain patients, people with epilepsy, those with cancer, and even patients recovering from myocardial infarction. Studies have shown lower levels of educational completion, lower income, and voluntary withdrawal from social opportunities among people who feel stigmatized. All these outcomes affect safety, wellness, and stress levels and are likely to exacerbate health inequities.
Although most people experience stigma via individualized, person-to-person encounters, stigma can also be exercised as a downstream manifestation of upstream structural and social phenomena, and thus can be viewed as one of the social determinants of health. Stigma is embedded in and sustained by the systems and organizations that govern daily life. One natural home for this kind of structural stigma is in laws, policies, and regulations, which hold substantial influence on societal operations and cultural norms. For centuries, powerful actors have used laws to mark out-groups as deviant and enforce status loss and other forms of social control on disempowered groups.
The key mechanism that makes law such a potent home for structural stigma is the enduring language itself, codifying stigma into day-to-day life. Because laws are infrequently reevaluated, amended, or removed, once formalized in law, structural stigma systematically affects vulnerable populations, with the potential to affect multiple generations. Legal language has material effects on people’s lives, manifesting in the daily operations of structures and institutions that shape health outcomes. The answers to “who can do what, to what extent, and with what money, through which resources?” are all defined in the active laws and policies that govern us.
Laws and policies are an often-overlooked yet critical component of the social determinants of health. For example, certain aspects of criminal law can directly affect a person’s insured status and ability to gain future employment, thereby affecting their health.
This brief has three goals: to illustrate how laws and policies mediate structural stigma through the example of substance use disorder (SUD) stigma; to explore potential mechanisms linking structural stigma in law to negative health outcomes, and therefore to health inequities for populations that are already marginalized; and to recommend an approach for revision of laws and policies that can significantly reduce structural stigma for targeted communities.
Case Study: SUD Stigma In Law
Addiction, subsumed under the more comprehensive category of SUD, provides an excellent lens with which to examine the emerging evidence on structural stigma in law. SUD affects a significant portion of the US population. For example, as of 2022, more than thirty-four million people regularly smoke cigarettes and almost fifteen million people have alcohol use disorder. Laws and policies are a natural habitat for structural stigma toward SUD. Everything related to substance use is heavily regulated, including which substances are legal, where they can be consumed, how they are sold, where people with SUD can be treated, and so on. As such, the types of policies and laws that house structural stigma against people with SUD are diverse, with assorted and far-reaching implications for health.
The experience of interpersonal stigma (as contrasted to structural stigma) by people with SUD is well-documented, as are the health-related effects of this experience. Patients who are stigmatized have lower functional outcomes during SUD treatment, are less likely to seek out treatment programs and less likely to complete them, and cite worsened self-perception and increased social isolation as deterrents to completing community-based rehabilitation programs. Patients who use drugs and who are stigmatized also have higher rates of high-risk injection practices and subsequent hepatitis C infection.
There is currently no peer-reviewed literature that demonstrates the impact of structural stigma in law against people with SUD; however, our team completed a recent pilot study for the state of California to evaluate and map SUD stigma in law. This pilot focused on the ten most populated and ten least populated counties in the state, along with the cities of Los Angeles, Sacramento, and San Francisco, as well as California state laws and regulations. An overview of our legal epidemiological methods is included as a supplemental appendix to this brief.
One hundred percent of the jurisdictions we evaluated had laws in place containing language that promotes stigma against people with SUD (see exhibit 1 for examples). By far the most common legal domain in which we found this language was employment law, with 86 percent of jurisdictions having at least one such stigmatizing provision. Approximately two-thirds (64 percent) of jurisdictions had legal findings that promoted stigma against people with SUD, and nearly half (43 percent) of jurisdictions had provisions promoting stigma against this group via nuisance law.
EXHIBIT 1 Example provisions demonstrating structural stigma against people with substance use disorder in California law
Charter provision providing that any civil servant may be suspended and removed for “drug addiction or habitual intemperance”
State statute noting that “Blacks” have infant mortality rates that are double the general population and that “substance abuse only exacerbates the problem”
Municipal ordinance providing that “use” and “possession” of a controlled substance can be grounds for eviction based on nuisance if it “creates an unreasonable interference with the comfortable enjoyment of life”
Source: Authors’ analysis, based on data from “Targeting Addiction Structural Stigma Embodied in Law.”
Mechanisms Linking Structural Stigma In Law To Health And Health Equity
Although the evidence base linking structural stigma in law to health outcomes is still developing, the through line is self-evident. Stigmatizing laws cause status loss, which can include loss of employment, thereby blocking access to health resources. Stigmatization interrupts significant social and psychological processes, reducing health-seeking behaviors and increasing both stress and social isolation for people seeking rehabilitation and treatment services. All these effects worsen the health of marginalized populations, and therefore contravene health equity.
Our pilot study of California law revealed three key legal domains in which structural stigma is particularly prevalent for people with SUD (exhibit 1). Here we describe the mechanisms by which language in each of these domains is likely to have health-harming consequences.
Notably, looking beyond people with SUD, structural stigma related to different conditions and groups will likely be found across a variety of legal domains, some more relevant to certain populations than others. One objective of legal epidemiological analysis would be to identify the domains relevant to a given stigmatized group so that targeted remedies may be implemented.
Employment restrictions have cascades of health-harming consequences for people with SUD and their families, beginning with loss of insured status. Many provisions include language that prevents employment or authorizes its termination for substance use. For example, Los Angeles Municipal Code section 6.04, pertaining to eligibility for employment as a civil servant, states: “The director of personnel…may refuse to accept an application or to examine an applicant…who is addicted to the use of intoxicating liquors or narcotics or habit-forming drugs.”
Termination of employment blocks meaningful access to SUD recovery services through two commonly used routes: employment-based treatment centers, which provide immediate care when opportunity windows to seek treatment are fleeting, and outpatient treatment centers, which are essential for people to maintain income, as many cannot afford to leave work for weeks of inpatient rehabilitation. In addition, loss of employment and barriers to future employment threaten income, housing, and food security, all of which are important social determinants of health.
Legal findings are nonoperative preliminary provisions in statutes and regulations that explain, clarify, justify, or provide context for the particular issue being addressed in the given law. They do not have force of law, but they are often used by courts in interpreting laws and offer important evidence of legislative intent. Legal findings that explicitly connect substance use to social harm often use broad and subjective language unsupported by data, formalizing the assignment of deviance in governing law. For example, San Francisco Ordinance Section 124 states that automatic public toilets are associated with “narcotics sales and use, and for disposal of hypodermic needles,” thereby rendering people “making legitimate use of automatic public toilets…intimidated and fearful for their safety.”
The extent to which legal findings drive structural stigma against vulnerable communities is unknown. Nevertheless, these laws likely exert a powerful signaling effect as to stigma. By integrating existing prejudices into legal language, such findings advise the approval of structural stigma.
Although there are often sound public health justifications for characterizing some kinds of substance use as a nuisance, nuisance law often explicitly assigns deviance to out-groups, promoting stigma. Nuisance law is inherently connected to property law, establishing its ability to upend safety among stigmatized communities by way of housing restrictions. For example, the Federal Housing Administration’s 1938 Underwriting Manual advanced racial segregation by specifically classifying Black neighbors as nuisances, speaking of mixed-race dwellings the same as it does stables and pig pens.
In another example, Los Angeles Municipal Code Sections 8.050.010 and 8.50.050 state: “Every building, place, land, or dwelling unit within the county of Los Angeles, maintained or used for the purpose of unlawfully selling, serving, storing, keeping, transporting, manufacturing, cultivating, or giving away any controlled substance, precursor, or analog…is a nuisance,” and “if the court finds that the person has engaged in the activities described [above, they] may be permanently barred from returning to or reentering any portion of the entire premises,” respectively.
Specific to SUD, nuisance law can limit community-based services such as sober living facilities, restricting accessible care.
There are two important takeaway concepts from the above discussion: first, laws are a high-yield reservoir of structural stigma, and stigmatizing laws should be identified, mapped, and ultimately revised; and second, sound theory and a small but growing body of research suggest that structural stigma in law has tangible health-harming consequences. These two conclusions are likely true for any vulnerable population, including people with SUD, transgender and nonbinary youth, minority racial and ethnic groups, people with HIV, and people with mental health conditions.
Mapping of stigmatizing legal language relies on surveillance techniques adapted from public health epidemiological methods. Legal epidemiology is the scientific discipline used to measure the law, create legal data sets, and disseminate findings about the state of the law. Trends emerging from the empirical legal data set can be used for legal analysis, providing a blueprint for antistigma efforts by identifying which laws should then be amended, revoked, or expunged.
Notably, legal language can be stigmatizing regardless of its intent. The ubiquitous nature of structural stigma against people with SUD is perhaps expected, given the intersection of SUD with public health measures and criminal law. Laws and regulations championed by public health experts aimed at combatting addiction often, by their very nature, fuel stigma. This is a critical consideration in the study of structural stigma: social harm enacted through structural stigma and social good from public health and safety laws are not mutually exclusive. Accordingly, even legal language intended to protect or support marginalized groups must be included in legal epidemiological and policy surveillance efforts to identify stigma.
Once structural stigma is mapped in law, remedies can be applied that broadly fall into three categories: stigma-promoting laws can be amended, stigma-promoting laws can be repealed, and additional antidiscrimination and stigma-reducing laws can be enacted and enforced.
Stigma-reducing laws can include condition and population-specific statutes, such as the authorization of needle exchange programs in the case of SUD. Which of these remedies is most appropriate for resolving structural stigma in law is an empirical question, the answer to which will vary across jurisdictions and legal domains. In addition, the above remedies only arise after stigma exists in law; additional attention should be devoted to strategies for preventing stigma from being codified into law, for which mapping will also be useful.
Nevertheless, the examples listed in exhibit 1 provide several opportunities for legislative redress. The San Francisco Charter could be amended to remove the language permitting adverse employment action for addiction. The anti-Black stigma in the legal findings of California Health and Safety Code 11781 should be repealed in its entirety. And if there are legitimate public health goals of the nuisance law provision in the City of Los Angeles Municipal Code, additional antidiscrimination provisions can be enacted to signal that persons who use drugs cannot automatically be excluded from the relevant public accommodation.
More generally, we suggest three high-priority areas for action: increasing policy makers’ awareness of structural stigma in law and its impacts, review and revision of stigmatizing employment law, and review and revision of stigmatizing legal findings.
Public Health Professionals Must Increase Policy Makers’ Awareness
To dismantle structural stigma in law, lawmakers must first be aware of the problem. Health experts can translate the literature to make population-based studies personal through their anecdotal, lived experience with patients. Once policy makers understand the harmful role structural stigma plays, experts can use legal epidemiology and policy surveillance techniques to identify language requiring legislative or policy action.
Policy Makers Should Immediately Review And Revise Stigmatizing Employment Laws
Federal and state policy makers possess legal authority to review existing laws and policies for health impact. Although there are likely to be a variety of legal domains that should be evaluated for language that stigmatizes a given population, employment law should be prioritized because of its significant impact on health and its position as an important locus of discrimination and punitive action. California’s 2004 Mental Health Services Act provides a model for review and response to problematic laws. The Mental Health Services Act required multilevel stakeholder participation, resulting in the development of a ten-year strategic plan to reduce mental health stigma. The plan established statewide committees “to evaluate existing laws and regulations for any embedded discriminatory provisions and gaps; and develop corrective strategies to address these problems.” Importantly, the committees’ work also identified employment as a domain that frequently advances stigma toward persons with mental illness, prompting state agencies to issue position statements and legal opinions to reduce stigmatizing employment laws.
In addition to eliminating such stigmatizing laws, policy makers can use policy mapping techniques to enact or strengthen antidiscrimination provisions within employment and other domains of law. This kind of legal revision requires coalition building with stigmatized communities to create shared policy decision making. This is especially true when stigmatizing laws have underlying public health implications and are intended to protect public safety and well-being.
Policy Makers Should Immediately Review And Revise Stigmatizing Legal Findings
As noted, legal findings signal what is deemed acceptable or that which is shameful and condemned. These powerful signaling effects justify deeply rooted prejudices and legal responses in the operative provisions that follow. Courts also rely on these findings when interpreting laws. Findings therefore have real effects in sanitizing stigma against vulnerable populations and are important targets for policy intervention.
A more precise understanding of how laws perpetuate stigma is a necessary first step in improving health and health equity for the most disadvantaged communities. More specifically, improved understanding of how employment and nuisance laws perpetuate stigma and intensify other social determinants of health is needed to develop a targeted approach for the dismantling of structural stigma for people with SUD, and likely a broad range of other stigmatized groups. Impact analyses are needed to quantify the magnitude of health impact that results from strategic categories of law and to guide high-yield revision of stigmatizing laws across a variety of health conditions, demographics, or social contexts.
Last, the true weight and impact of legal findings is unknown. Given the dearth of scholarship on the role of findings in courts’ decision-making process, and their capability of advancing stigma, descriptive analysis of findings’ impact is warranted.
Stigma causes incalculable human suffering. It intensifies harm against the most vulnerable and marginalized communities. Stigma, driven by upstream factors connected to social control, is an inherently structural phenomenon. Because laws are common and powerful mediators for structural stigma, they are critical levers for antistigma work.
Policy attention is needed urgently at the state, county, and municipal levels to evaluate legal language that intensifies addiction and other types of stigma. Our own findings likely represent the tip of the iceberg related to the infiltration of addiction stigma in law. These kinds of analyses can have impact far beyond a single-disease paradigm, as evaluation methods can be adapted to assess structural stigma in law for virtually any health concern or exposed population.
All briefs go through peer review before publication. The authors thank the Center for Public Health Law Research at Temple University for technical assistance in legal epidemiology methods, as well as Lindsay Wiley, Mark Hatzenbuehler, and Tara Ramanathan Holiday for their review of construct model and background memo for TASSEL. Written by Sarah Hemeida, assistant professor in the Department of Family Medicine and scholar at the Farley Health Policy Center at the University of Colorado Anschutz Medical Campus, Denver, Colorado; Hallie Conyers-Tucker, JD candidate at Seattle University School of Law, Seattle, Washington; Lina Brou, clinical instructor in the Department of Family Medicine at the University of Colorado Anschutz Medical Campus; and Daniel Goldberg, associate professor at the Center for Bioethics and Humanities at the University of Colorado Anschutz Medical Campus.