10. Stigma and its Management at Goron Dutse Psychiatric Hospital in Kano

Mohammed Awaisu Haruna

The concept of stigma has been widely used and applied in many aspects of the social, economic, political, and even religious domains of human activities. For instance, Lewis (1998 ) mentioned the stigma of exotic dancing, Conrad (1981) discussed the social stigma of occupations, while Whiteford and Gonzalez (1995) examined the stigma of infertility. However, stigma is most popularly associated with different kinds of human disability or illnesses such as leprosy, blindness, crippling disabilities, dumbness, deafness, and so on. However, more forcefully, except for the stigma of AIDS (Gilmore & Somerville, 1994; Goldin, 1994; Marshall, Patricia, O’Keefe, & Paul, 1995; and Link, Bruce, & Phelan, 2001) in recent times, stigma is attached to psychiatric illnesses, which are most devastating to patients and their relatives (Corrigan & Pen, 1999; Phelan, Link, Steve, & Pescosolido, 2000). According to Page (1984, p. PAGE), the term stigma has for a long time remained “a relatively imprecise concept,” one that is as complex as the concepts of democracy, alienation, and poverty. This is because of the diverse meanings and interpretations of the term and its applicability to various aspects of human life. Similarly, stigma is regarded as:

A social process or a related personal experience characterized by exclusion, rejection, blame, or devaluation those results from an adverse social judgment about a person or group. The judgment is based on an enduring feature of identity attributable to a health or health related condition, and this judgment is in some essential way medically unwarranted. (Weiss & Ramakrishna, 2001, p. 3)

No matter what definition of stigma is in use, the term acquires its meaning through the emotions it generates within the person bearing the label as well as the feeling and behavior of those using the term towards him (Page, 1984). In this sense, stigma is regarded as a protective device, a response against danger or an adverse condition, also as “a means of strengthening or homogenizing a community and its values by actually or metaphorically purging the community of unwanted, undesirable or unproductive traits”. Therefore, stigmatized individuals possess (or are believed to possess) some attributes or characteristics that conveys a social identity that is devalued in a particular social context (Crocker, Major, & Steele, 1998, p. 505).

Finally, stigma can be “a means of social control of both the persons stigmatized and those who are not, by marginalizing or excluding them from a community, or by making them fear this, respectively”. Thus, attributing of stigma is fundamentally regarded as a problem arising from social interaction. Stigma “impairs the quality of life through concerns about disclosure, and it affects work, education, marriage, and family life” (Weiss & Ramakrishna, 2001, p. 3). This is evident in the case of the stigma of mental illness in regard to people who suffer from mental illness as well as their relatives and significant others. It is also evident in the use of determinations of mental competence as a mechanism for social control.

In discussing the phenomena of stigma in relation to mental patients, this paper has limited itself to the simple, but somewhat general meaning of the concept, which describes stigma as “the negative perception and behavior of so called normal people to all individuals who are different from themselves” (English, 1977, as cited in Page, 1984, p. 1). It is in this context that psychiatric patients are considered different from normal people, not simply because they are ill, but because their illness is one which is “discrediting,” in that the sufferer is, in an important sense, less than human because his actions and words are senseless. Of course, on this Foucult (1965) has argued that, on the contrary, there is a sense and a positive message and meaning in the words and actions of mental patients, which the so-called normal people fail to understand by not trying to capture and grasp the message.

It is Goffman (1963, pp. 14-15) who first distinguished the “discreditable” and the “discredited.” The former is composed of invisible characteristics, which are only “potentially stigmatizing,” while the later contains visible attributes. Once a person is diagnosed as psychiatrically ill and is as a result hospitalized, he becomes potentially vulnerable to stigmatization and, for this reason, he takes all necessary measures to conceal the unwanted identifier or regulate the spread of information on his damaged identity or status. Thus, psychiatric patients, including other categories of disabled people, employ various strategies for the concealment of abnormality (Edgerton, 1971; Matza, 1969; Goffman, 1963; Bury, 1991).

The Goron Dutse Hospital

The Goron Dutse Hospital is located in Kano, Nigeria just within the famous traditional city walls in Goron Dutse quarters and is only a short walk from the Goron Dutse hill from which the hospital derives its name. During the colonial era, the building was originally constructed for use as a dormitory for elementary school students; later, in the 1950s, it was used as a place for keeping the criminally insane. The Native Authority maintained the institution as a mental infirmary until 1976 when the Ministry of Health took over its administration and introduced some changes in institutional operations. The name was changed from Mental Infirmary to Asylum by the Ministry of Health, which provided doctors, nurses, health assistants, social workers, and other support staff. The male compound has 11 active rooms and 33 beds. The female’s has 8 rooms and 24 beds. There is an isolation room. The A Ward has 23 beds with blankets and mattresses. There is a total number of 35 nursing staff in the hospital, 25 are males and 10 female. Doctors, however, do not tend to stay very long in the service of the hospital. Accordingly, consistent care is largely in the hands of the trained psychiatric nurses, some of whom have been serving in the hospital for quite a long time.

Methodology

The data used for this paper were collected from Goron Dutse as part of the data collected for a Ph.D. Thesis (Haruna, 1997). Various methods of data collection were triangulated to enrich the data collected. The fieldwork took nine months. Observation was used. The daily activities of the hospital staff, patients, and their relations within the hospital setting were observed. Medical consultations and diagnostic conversations between doctors and nurses on the one hand and patients and their relatives on the other were tape-recorded. An in-depth interview was conducted with 35 nursing staff, 10 support staff, and 74 relatives of patients as well as one Psychiatrist and one General Practitioner. In addition, medical records and patients’ prescriptions were examined.

Stigmatizing Hospital Staff

In Goron Dutse and, by implication, the other psychiatric and mental hospitals in Nigeria, stigma is attached not only to the patients in the hospital, but also to the staff who look after them. A number of their friends, for example, jokingly regard them also as tababbu (slightly abnormal) because they work and intermingle with psychiatric patients. However, this is a stigma with a difference. It is a joke and typically without significant adverse consequences. The stigma tends to die out and does not lead to ostracization or condemnation. This stigma is momentary and easily brushed aside as well as being unchallenging to the status they have as workers in the medical field. Nevertheless, and as discussed by Haruna (1997), there are still a significant number of people in Nigerian society who believe that mental illness is the product of sorcery or evil spirits and should properly be the province of traditional healers. Hence, medical men perceived to be dealing with an illness that is beyond their skills and understanding. It may be this tension that is, perhaps, the source of the joke mentioned above, and which has an affinity with (and echoes) the saying that “the friend of a thief is also a thief;” likewise those who associate or work with the insane are also insane.

Unlike other doctors and nurses, but like the patients’ relatives who are also affected, psychiatric nurses and doctors suffer to some extent from occupational stigma because of their association with the patients. This has been compounded by the practice of employing ex-patients as staff. This was explained and stressed by one of the nurses who mentioned that some of the ex-psychiatric patients secured jobs at the center through connections. Their parents seek and obtain jobs for them because they feel secure if the ex-patients work and remain in the hospital. This brings the ex-patients very close to the medical care staff even while they bring stigma to other staff of the institution.

Not all of these staff are entirely trustworthy or suitably trained and, indeed, a number of them have been involved in certain malpractices when dealing with patients’ relatives. The penalties for such transgressions can be quite severe in that such people are treated like some of the patients who misbehave, that is, by confinement and detention in the wards. One of the nurses explained that they detain their junior staff who misbehave in the compound and give them an injection as a means of teaching them to behave well.

In these kinds of situations, the nurses use medicine as a means of controlling the behavior of ex-patient staff. It is what Szasz (1972,) calls a means of “social tranquillization.” This kind of punishment is meted out mostly to the ex-patients who constitute part of the employees in the hospital. It contributes to the low status with which many of the other staff are regarded by the wider society.

However, the stigmatization phenomena, as it is manifested in the hospital setting, goes beyond the junior staffs, because even some of the nurses who misbehave in ways that are considered inappropriate by others are also stigmatized. Through an informal discussion, one of the senior staff described one of the nurses as an “experienced person who has spent many years in the hospital and who knows a lot but sometimes behaves abnormally like the patients by climbing to the top of the roof, as some of the patients do”. The staff member is simply suspecting the nurse’s behavior to be indicative of some level of mental abnormality.

Stigmatizing Psychiatric Patients

Stigma extends beyond these particular transgressions to outpatients’ attendance at the hospital. For many, attendance is a discrediting experience and one that they try to conceal from others. Some, even when attending, will pretend to be going elsewhere then sneak onto the hospital premises. Some relatives try as much as possible to avoid frequenting the hospital or refuse to escort outpatients for routine consultations. There is tremendous cultural pressure on the mentally ill to avoid disclosing their sickness. Indeed, while the Federal Government has officially and sympathetically recognized the conditions of various categories of the disabled and instructed all government ministries to provide jobs for at least three disabled people per department, these vacancies tend to go to the blind, the crippled, the deaf, and the dumb among others (Hassan, 1992) Rarely, if ever, do these positions go to ex-psychiatric patients. In this respect, they are treated like ex-convicts. This situation is a case of official stigma and compels ex-patients to resort to hiding their status as best as they can, such as by not recording it on application forms or disclosing it at any interview. Relatives who can afford private treatment are often motivated by the fear of the stigmatizing effects of publicity on the whole family.

Seeking Assistance and the Fear of Stigma

Stigma is the biggest factor inhibiting relatives seeking assistance from the hospital at the onset of illness. They prefer other forms of treatment and come to the hospital as the lowest preference. One of the nurses pointed out that in a number of cases, parents or relatives hardly bring the patient to the hospital at the early stage of the problem; they prefer boka or traditional medicine-men. According to the nurse, the fear of stigma is always associated with the Goron Dutse Hospital because treatment is cheap and available and, as a result, patients and their relatives come as a last resort.

Thus, it is a widespread belief among the hospital staff that patients are first taken for a traditional or religious treatment and only then to a general hospital, after which they are finally taken to the psychiatric hospital if there is no improvement (Haruna, 1997). Many of the patients, or their relatives, disclosed that they sought treatment from somewhere else before coming to the hospital. One of the patients who suffered from puerperal psychosis disclosed that she was taken to three different traditional healers for treatment.

Another patient suffering from epilepsy was also observed at Goron Dutse Hospital during the fieldwork. According to one of the patient’s relations, the man had been suffering from epilepsy for ten years, but was never taken to any hospital for treatment. He disclosed that the patient was taken to Borno for Qur’anic education; there he received some traditional treatment before coming to the hospital.

Although it is evident, as indicated by the doctor, that it is difficult to get detailed information from patients and their relatives on their relationship with traditional and religious healers. Nonetheless, some of them did disclose to the hospital authorities and so the information that they had consulted such healers before coming to the hospital was recorded on their cards. Out of 129 patient records, 59 of them indicated that the patients had previously sought assistance from healers. Women are widely believed to be in the fore in patronizing such healers, either with permission from their husbands or secretly. In fact, it appears that most of the men who consult traditional healers do so on the advice or influence of their mothers and/or their wives. During the period of hospital treatment and the after-discharge treatment, one of the greatest dangers faced by patients is that of a relapse, which could be due to a number of reasons.

Stigma Management

Goffman (1963) pointed out that stigma represents discrediting attributes between individuals’ virtual (assumed) and actual (real) social identities. Since it is believed that stigma spoils, damages, and taints the image of the stigmatized persons, various attempts are made to control or manage the discrediting attributes. However, it is worth noting that the mechanisms of managing stigma are not limited to the stigmatized individuals but also the falsely accused persons (Blinde & Taub, 2000). The strategy used to manage any type of stigma depends largely on the degree to which the attribute is visible or perceivable to others. According to Goffman (1963), people with a potential deviant stigma can be categorized into the discreditable, those with conceived deviant traits, such as ex-convicts and secret homosexuals who manage themselves to avoid deviant stigma; and the discredited, those who cannot hide their deviance, such as the obese, and the physically handicapped or ex-convicts and secret homosexuals who have revealed their deviance (Adler & Adler, 2000).

Forms of Stigma Management

There are a number of stigma management and control techniques that are used by stigmatized persons and organizations in many societies. It is mainly managed through individual adaptation to deviant stigma and group or collective effort. Most discreditable people manage their stigma by passing as “normal” in their daily lives, hiding their deviance from other members of the public. Other means of passing as normal include the use of identifiers and avoiding contacts with stigma symbols. Stigmatized persons also manage and control stigma by leading a double life, maintaining two different lifestyles with two different groups of people, one that knows about their deviance and one that does not.

Individuals also manage stigma through the deliberate and voluntary self-disclosure of the deviance, especially if concealment fails. This is done by the victims when they become fed up with maintaining the secrecy. It is also done for preventive and therapeutic reasons, although disclosure may lead to rejection or further rejection. Davis (1961) pointed out that some non-deviant persons normalize their relationships with deviant persons by refusing to acknowledge the deviant trait. Although it is the deviants who normalize their relationship with non-deviants through deviance disavowal—they present their stigma in a positive way in the form of joking and humor (Turner, 1972). In an attempt to normalize, some of the stigmatized persons confront the stigma and make sure the discrediting attribute loses its stigmatizing capability. This is achieved through the redefinition of stigma and the reeducation of the normal (Elliot, Ziegler, Altman, & Scott, 1990).

There are a number of voluntary and non-governmental organizations and associations of stigmatized individuals that are known worldwide. The associations include those of prostitutes, such as Call Off Your Old Tired Ethics (COYOTE), the Gay Liberation Front, the Gray Panthers, the Alcoholics Anonymous, the Overeaters Anonymous, the Narcotics Anonymous, and Gamblers Anonymous. The primary functions of some of these groups is to provide support for their members that include social and recreational activities, dispersing legal or medical information, and providing services such as shopping, meals, or transportation. These groups are known as expressive groups and are apolitical in that they help their members adapt to their social stigma rather than evade it. They also provide an avenue for deviants to get together in the company of each other and seek for common solutions to their common problems (Jennes, 2000). For example, COYOTE acts as a leading voice in the prostitutes’ rights movements in the United States. It advocates the repeal of all existing prostitution laws, the reconstitution of prostitution as a credible service occupation, and the protection of prostitute rights as legitimate workers.

Other groups are known as instrumental groups that, in addition to expressive functions, also engage in political activism, which is called tertiary deviation—stigmatized persons reject the societal conception and treatment of their stigma and organize to change the social definitions (Kitsuse, 1980). The members struggle to change other peoples’ negative perception of their deviant status in question. Some of these organizations include AIDS organizations, the National Organization for Women, and the Disabled in Action. Anspach (1979) described how handicapped individuals and former mental patients used political activism to counter the prevailing negative societal beliefs and assumptions about them and, in so doing, enhanced their own self-conceptions. (Jones, Farina, Hastorf, Markus, Miller, & Scott, 1984, p. 153). This kind of collective action by stigmatized groups “may take the form of banding together with fellow targets…withdrawing from one’s social environment and embracing another and redefining an attribute of the self that was previously considered to be negative as positive” (Jones et al., 1984, p. 153).

Gay/Bisexual men with HIV/AIDS use reactive, intermediate, and proactive strategies for the management of stigma. The reactive strategies include concealment, selective disclosure and personal attribution strategies. As for the intermediate strategies, some of the Gay/bisexual men use gradual disclosure, selective affiliation strategies, discrediting the dis-creditors and challenging moral attribution. Finally, the protective measures used to manage stigma include pre-emptive disclosure, public education strategies and social activism. All of these strategies are used to manage the stigma of HIV infections (Siegel, Lune, & Meyer, 2000).

Stigma Management for Goron Dutse Patients

The management of stigma for Goron Dutse Hospital patients is not fully developed or organized as is the case in the United States and Europe, where voluntary organizations, some individuals, and the victims become actively involved in the control and management of stigma. In the case of Goron Dutse patients, it is mainly the responsibility of both the patient and his significant others to manage and control it. It is more of a family affair and, therefore, regarded as a collective responsibility because stigma affects not only the patient but also his relatives. Thus, the various strategies used to manage and control stigma include:

• Hospital Visits: Patients’ significant others, especially parents and close relatives, are expected to pay regular visits to the patients during the period of hospitalization. In the case of a married female patient, her spouse and children are required to be with her during visits. It is believed that this kind of visit decreases feelings of alienation and stigmatization on the part of the patient and helps to convince the hospital management that parents and relatives do not in any way abandon the patient or shun their family responsibility. While some relatives pay regular visits, others visit patients due to enforcement by the hospital management. Hence, regular visits serve as a strategy that discourages stigma that sometimes emanates from a patient’s family and relatives. It allows the patients to develop a feeling of being loved and cared for by his or her significant others and other closed associates.
• The Provision of jobs: The provision of jobs for the discharged patients is one way through which stigma is managed and controlled. Some of the patients that were self-employed or employed by the government prior to their sickness and hospitalization are encouraged by their families and relatives to resume working. Those who were employed by the government are also encouraged to return to their places of work. Those who have no jobs at all are supported by families and often become self-employed. This reduces the societal conception of them as liabilities. Thus, employment provides a new status, increases acceptability, and reduces rejection. In the Hausa society, it is generally believed that “an empty mind is the devil’s playground.” This is one of the reasons why keeping ex-mental patients occupied constitutes an important stage in the process of gradual transformation and reintegration of the patients from abnormality to complete normality. Nevertheless, this process takes a long period of adjustment.
• Presentation: A Positive presentation of the self by the ex-mental patients is another technique of stigma management that assists the psychiatric patient to win the confidence of others and in the process changes their perception of him. This is usually initiated by concerned parents and relatives who ensure that he or she appears as normal as is possible in public places, in terms of dressing, the choice of words, and the general use of language while interacting and communicating with the ‘normals’.
• Concealment: This is the least preferable stigma management approach, but the most commonly used. Parents and relatives usually restrict the victim’s movement within the household and, if there is a progress towards normalization, his freedom of movements is increased within the wider environment. Otherwise, they move him to a different environment until he fully normalizes. They try as much as possible to conceal deviant status or stigma by transferring the victims to other relatives who live far away. This enables the victim to change environment, adjust and begin a new life somewhere and is returned to his family only as a normal person.

Although other categories of stigmatized disabled persons that include the blind, lepers, the dumb, and the deaf among others do have associations that serve and protect their interests, such associations are never formed by ex-mental patients because of the fear of being identified with a group of stigmatized individuals. This is not limited to the Kano ex-mental patients, as noted elsewhere by Link and Phelan (2001) who said that stigmatized mentally ill people are not likely to band together in fighting stigma because they typically “avoid collective settings for fear of being associated with a stigmatized group” (Link & Phelan 1987, p. 25).

Conclusion

Stigma has a number of negative effects. These include both social and economic isolation of the patients even after treatment and discharge from the Goron Dutse Hospital. It was noted that sometimes the stigma affects parents and the hospital staff that treat and look after the patients. This one of the major reasons why parents initially seek for treatment else-where before turning to the hospital as the last option. Attempts to reduce and manage stigma is mainly the responsibility of the family and the patients. Some of the families do that by securing a job for the patient or providing him with a small capital to make him self-employed. A positive and clean appearance is another means of stigma management and reduction that increases one’s chances of being accepted by members of the public, thus giving him or her the opportunity to inter-act with the “normals.” Concealment is the most frequently used to restrict the movement of discharged patients until the family become satisfied that the ex-patient’s behavior is normal, and he or she is responding to gradual integration in the community. However, there are no organized groups or associations of ex-psychiatric patients that could assist in the management and reduction of stigma.

Recommendations

To overcome the problems of stigma as faced by psychiatric patients and their relatives in Nigerian society in general and Kano in particular, the three tiers of government and non-governmental organizations should support patients, their relatives, and hospital personnel in order to improve upon their management techniques. The following recommendations may be considered:

• The attention of philanthropists and non-governmental organizations in our society should be called upon to donate in cash or kind to the types of hospitals that treat psychiatric patients.
• Halfway homes should be established for the gradual rehabilitation and reintegration of treated and discharged patients before they are allowed to join the wider society.
• The governments at Federal, State, and Local levels should provide jobs or training to have ex-patients self-employed. This could be achieved if the governments experiment with community-based treatments for non-chronic patients who are less likely to benefit from incarceration in the hospital.
• Lastly, there is the need to change from the predominant treatment regime of chemotherapy by introducing other more useful forms of treatment. For example, occupational therapy for recovered patients should be introduced, as this will make them more self-reliant.

 References

Anspach, R. (1979). From stigma to identity politics: Political activism among the physically disabled and former mental patients. Social Science and Medicine, 13A, pp. 765-773.

Bury, M. (1991). The sociology of chronic illness: A review of research and prospects. Sociology of Health and Illness, 13(4), pp. 451-468.

Conrad, S. (1981). Social stigma of occupations: The lower grade workers in service organizations. Gower, England: Aldershot.

Crocker, J., Major, B., & Steele, C. (1988). Social stigma. In D. T. Gilbert & S. T. Fiske (Eds.). The handbook of social psychology (2nd ed., pp 504-553). Boston, MA: McGraw-Hill.

Edgerton, B. R. (1971). The clock of competence: Stigma in the life of the mentally retarded. Berkeley, CA: University of California.

Elliot, C. G., Ziegler, H. L., Altman, B. M., & Scott, D. R. (1990). Understanding stigma: Dimensions of deviance and coping. In C. D. Bryant (Ed.). Deviant behavior (pp. 423-443). New York, NY: Hemisphere.

English, R. W. (1977). Correlates of stigma towards physically disabled persons. In R. P. Marinelli & A. E. Dell Orto (Eds.). The psychological and social impact of physical disability (pp. PAGES). New York, NY: Springs.

Falk, G. (2001). Stigma: How we treat outsiders. Amherst, MA: Prometheus Books.

Davis, F. (1961). Deviance disavowal: The management of strained interaction by the visibly handicapped. Social Problems, 9, pp. 120-132.

Gilmore, M. & Somerville, M. A. (1994). Stigmatization, scapegoating and discrimination in sexually transmitted diseases: Overcoming “them” and “us.” Social Science Medicine, 39(9), pp. 1339-1358.

Goffman, E. (1963). Behavior in public places: Notes on the social organization of gatherings. New York, NY: The Free Press.

Goldin, S. C. (1994). Stigmatization and AIDS: Critical issues in public health. Social Science Medicine, 9, pp. 1359-1366.

Haruna, M. A. (1997). The management of mental illness in a Nigerian hospital. (Unpublished doctoral dissertation). Lancaster University.

Hassan, A. H. (1992). The problems of the destitute: An overview and some solution. In A. H. Yadudu (Ed.). The conception and implementation of a social policy: Kano state experiment (pp. 137-145). Kano, Bayero University.

Jennes, V. (2000). The Collective Stigma Management of Prostitutes. In P. A. Adler & P. A. Adler (Eds.). Constructions of deviance: Social power, context and interaction (3rd ed.). Wardsworth, NJ.

Jones, E., Farina, A., Hastorf, A., Markus, H., Miller, D., & Scott, R. (1984). Social stigma: The psychology of marked relationships. New York, NY: W.H. Freeman.

Kitsuse, J. (1980). Coming out all over: Deviants and the politics of social problems. Social problems, 28, pp. 1-13.

Lewis, J. (1998). Learning to strip: The socialization experiences of exotic dancers. Can. J. Hum. Sexuality, 7, pp. 51-66.

Link , B. G. ( 1987). Understanding labeling effects in the area of mental disorders: An assessment of the effects of expectations of rejection. American Sociological Review, 52, pp. 96-112.

Link, G. B. & Phelan, C. J. (2001). Conceptualizing stigma. Ann. Rev. Social. 2001, 27, pp. 363-387.

Marshall, A. P., O’Keefe, & Paul, J. (1995). Medical students’ first-person narratives of a patient’s story of AIDS. Social Science and Medicine, 40(1), pp. 67-79.

Matza, D. (1969). Becoming deviant. Englewood Cliffs, NJ: Prentice-Hall.

Page, R. M. (1984). Stigma. London, England: Routledge.

Adler, P. A. & Adler, P. A. (Eds.). (2000). Constructions of deviance: social power, context and interaction (3rd Edition). Wardsworth, NJ.

Phelan, J. C., Link, B. G., Steve, A., & Pescosolido, B. (2000). Public perception of mental illness in 1950 and 19996: What is mental illness and is it to be feared?. Journal of Health and Soial Behavior, 41, pp. 188-207.

Siegel, K., Lune H. & Meyer, I. H. (2000). Stigma management among Gay/Bisexual men with HIV/AIDS. In P. A. Adler & P. A. Adler (Eds.). Constructions of deviance: social power, context and interaction (3rd ed.). Wadsworth, NJ.

Szasz, T. (1973). The manufacture of madness: A comparative study of inquisition and the mental health movement. London, England: Paladin.

Turner, R. H. (1972). Deviance avowal as neutralization of commitment. Social Problems, 19, pp. 308-321.

Weiss, G. M. & Ramakrishna, J. (2001). Interventions: Research on reducing stigma. Retrieved from http://www.stigmaconference.nih.gov/WeissPaper.htm

Whiteford, M. L.& Gonzalez, L. (1995). Stigma: The hidden burden of infertility. Social Science Medicine, 40(1), pp. 27-36.