2016 Janet Taylor Spence Award

Mark Hatzenbuehler

Columbia University

mailman.columbia.edu/people/our-faculty/mlh2101

Please briefly describe your research interests.

Psychological science has provided essential insights into how stigma operates to disadvantage those who are targeted by it. At the same time, stigma research has been criticized for being too focused on the perceptions of stigmatized individuals and the consequences of such perceptions for microlevel interactions. I have developed a new line of research expanding the stigma construct to consider structural forms of stigma, defined as societal-level conditions, cultural norms, and institutional policies and practices that constrain the opportunities, resources, and well-being of the stigmatized. Using a multimeasure, multimethod, and multidisciplinary approach, my colleagues and I have demonstrated that structural stigma has far-reaching health consequences for members of stigmatized groups, ranging from dysregulated physiological stress responses measured in the laboratory to premature mortality at a population level.

For instance, in one natural experiment, we examined mental-health outcomes among lesbian, gay, and bisexual (LGB) respondents who were assessed before and after several states passed constitutional amendments banning same-sex marriage. We found that LGB adults who lived in states that passed the constitutional amendments experienced a 37% increase in mood disorders, a 42% increase in alcohol-use disorders, and a 248% increase in generalized anxiety disorders in the 12 months following the bans. In contrast, LGB respondents living in states without these bans, and heterosexuals living in states with the bans, did not experience a significant increase in psychiatric disorders during the study period. In another study, we constructed a measure capturing the average level of antigay prejudice in a community. To do this, we took four questions on people’s attitudes towards gays and lesbians that had been repeatedly assessed in the General Social Survey across 14 years and aggregated these individual responses up to the community level, such that each community had an average prejudice score. This information on prejudicial attitudes at the community level was prospectively linked with mortality data via the National Death Index. We found that sexual minorities who lived in high-structural stigma communities — operationalized as communities with high levels of antigay prejudice — had increased mortality risk compared with 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: 4–20 years), which is similar to life-expectancy differences between individuals with and without a high school education.

The consistency of the associations that we have observed between structural stigma and health inequalities across numerous studies, and the ability to triangulate evidence across several methodological approaches, highlights the robustness of evidence for these relationships. Consequently, our work suggests that structural stigma represents a significant, but thus far largely underrecognized, source of social disadvantage for stigmatized populations.

What was the seminal event, or series of events, that led you to an interest in your award-winning research?

When I began searching for a way to study the health consequences of structural stigma, I confronted several challenges. First, there was a lack of structural-level measures of stigma because most stigma research had focused on the individual and interpersonal levels. Second, the few structural stigma measures that did exist, such as laws, often had no variation; for instance, the Defense of Marriage Act was a federal law, and therefore affected all LGB populations in the United States. Third, few large-scale data sets that included measures of stigmatized populations and provided geographic units of analysis (e.g., states) existed, making it difficult for researchers to link structural stigma variables. A confluence of fortuitous events made it possible for me to overcome these challenges. I had begun working with a nationally representative data set of US adults that was released just as I started graduate school, and it included a measure of sexual orientation, mental-health outcomes, and the state of residence of the respondents. At about the same time, the policy environment surrounding LGB populations was rapidly shifting; some states enacted laws that provided protections for LGB individuals (e.g., through hate-crime laws), while others promulgated stigma against these individuals (e.g., constitutional amendments banning same-sex marriage). It occurred to me, in one of those rare moments of inspiration, that I now had a measure of structural stigma (i.e., state policies) that had sufficient variation to detect an effect (should one exist), as well as a data set that provided the rare opportunity to examine a fairly basic, but heretofore unanswered, question: Would sexual orientation disparities in psychiatric morbidity be more pronounced in states with structural forms of stigma against gays, lesbians, and bisexuals (i.e., state laws that did not provide hate-crime or employment nondiscrimination protections for LGB individuals)?

My colleagues and I found evidence for this hypothesis, and the results were much stronger than we had anticipated. We found that sexual orientation disparities in some psychiatric disorders (i.e., dysthymia) were eliminated in low-structural stigma states; conversely, sexual orientation disparities in other disorders were nearly four times more likely to exist in high-structural stigma states. Importantly, we were able to control for experiences of interpersonal discrimination and demonstrated that structural stigma remained associated with psychiatric morbidity over and above stigma at other levels of analysis.

This finding raised several new questions that have guided my program of research over the past several years: Is an effect of structural stigma on health still observed using designs that permit stronger causal inferences (e.g., prospective, quasiexperimental)? Do different operationalizations of structural stigma produce similar results? Does structural stigma contribute to negative health outcomes other than psychiatric disorders? Is there evidence for plausible alternative explanations for the relationship between structural stigma and health (e.g., social selection)? Are relationships between structural stigma and health disparities evident in other stigmatized populations? What psychosocial factors moderate and mediate the relationship between structural stigma and health?

Tell us about one of the accomplishments you are most proud of within this area of research. What factors led to your success?

Several of my studies have been used in amici curiae briefs in cases on status-based discrimination. One of the highlights was having the work cited in several briefs submitted for Obergefell v. Hodges, the Supreme Court case that legalized same-sex marriage nationwide last year. It was professionally gratifying to have my work used to inform public-policy debates. It also was personally rewarding to see the research have a positive impact on the LGB population in places like Tennessee, where I grew up and where the state had historically silenced LGB individuals’ self-expression and stigmatized their identities.

What contributions, or contributors, to psychological science do you feel have had a major impact on your career path?

Robert Frost once said, “I am not a teacher, but an awakener.” I have had the great fortune to be mentored by three people who awakened in me a passion for my work. As a doctoral student in clinical psychology at Yale University, I approached Susan Nolen-Hoeksema about working with her. Even though my interests were fairly tangential to hers, she immediately welcomed me into her lab. Her generosity and capacious knowledge of the field helped me find my footing. Jack Dovidio joined the social psychology department just when I decided to blend models and theories from clinical and social psychology to understand the mental-health consequences of stigma, providing further evidence for the importance of luck in the research endeavor. I took a seminar on stereotyping and prejudice with Jack and was hooked. His creativity and ability to quickly home in on the most important questions continue to inspire me. I could not have conjured a more perfect mentorship team in graduate school; Susan’s and Jack’s probing intellect and love of learning were infectious and were matched only by their incredible dedication to mentoring their students. Susan tragically passed away 3 years ago, but her legacy lives on in the lives of all of us who benefited so tremendously from her talent and support.

My third mentor is Bruce Link, who was my postdoctoral and early career mentor at Columbia University. Bruce is a sociologist (we won’t hold that against him) and a leading expert in the field of stigma. Like Jack and Susan, he is a deep thinker and a fierce advocate for his mentees. Bruce nurtured my inchoate interest in structural stigma, and his early encouragement of my ideas gave me the confidence to pursue and expand them. He emboldened me to stretch and ask bigger and broader questions about the role of stigma as a source of disadvantage. Bruce once told me that every time he thought he had a new idea about stigma, he reread Erving Goffman’s work and found some version of it there. I feel the same about Bruce.

There are several factors that have contributed to my success. First and foremost: my dad always told me to surround myself with people who are smarter than I am, and that has proven to be very sage advice.  My mentors— have shaped my thinking in fundamental ways, and their support at crucial points in my career gave me the confidence to pursue my ideas. My collaborators, many of whom are from other disciplines (including medical sociology and psychiatric and social epidemiology), have provided inspiration and good counsel. There are too many to name, but I’m especially grateful to Bruce Link, Jo Phelan, John Pachankis, Katie McLaughlin, and Kerry Keyes. I have wonderful colleagues in the Department of Sociomedical Sciences at Columbia University. My office is right next door to two sociologists and an anthropologist, and I routinely interact with health psychologists, historians, and political scientists. This interdisciplinary setting has undoubtedly contributed to the kinds of questions I ask and the manner in which I pursue answers to them. Finally, at the risk of this turning into an Academy Award speech, you simply can’t do good work without a foundation of love and support. I clearly won the lottery with an incredible family, partner, and friends.

What questions do you hope to tackle in the future?

At first glance, it may appear that research on structural stigma falls outside the purview of psychologists, who tend to study individuals and groups rather than social structures. However, research is beginning to indicate why structural stigma is important to psychological science, and the questions I want to pursue hopefully will provide further evidence for this claim. For example, influential theories of stigma at the individual and interpersonal levels posit structural-level sources for stereotypes and stigma-related stressors (e.g., self-stigma, concealment), but they do not explicitly interrogate such sources by locating variation and testing their impact. This is due in part to the fact that, until recently, the field lacked the measures and data sets necessary to incorporate structural stigma into psychological research on stigma. With the advent of new measures and data structures that permit the examination of structural stigma, it is now possible to conduct novel tests of existing theories about the causes and consequences of stigma processes that have long been the traditional focus of psychological science. Our recent research, for instance, has suggested that individual-level stigma processes may be generated in part by structural forms of stigma. Using data on country-level structural stigma (e.g., laws and policies related to sexual orientation discrimination) across 38 countries in Europe, we showed that sexual-minority men living in high-structural stigma countries were more likely to conceal their sexual orientation (i.e., an individual-level stigma process) than were those in low-structural stigma countries; in turn, concealment was associated with greater HIV risk behaviors among men living in high-structural stigma countries. Examining direct and synergistic relationships across different levels of stigma not only will open up previously unexplored areas for research on stigma, but also will suggest new ways of thinking about how to change and ultimately reduce stigma related health disparities.

What does winning this award mean to you both personally and professionally?

It’s very humbling to receive this award. I am a big admirer of many of the past recipients, so it is quite an honor to join their ranks. As someone who studies stigma and discrimination, I am particularly honored to receive an award named after Janet Taylor Spence, who was such a pioneer in confronting and addressing gender bias and discrimination. It is validating to have my work acknowledged in this capacity. There were times when I felt as if my focus on broad social structures was too far afield to be considered psychological science, so I’m grateful that the committee has recognized that this work has important implications not only for understanding basic psychological processes, but also for applied psychological science.