Internalizing Stigma Is Bad For Your Health

No matter what form it takes—from eye rolls and snide comments to outright job discrimination—fat-shaming is bad for both physical and mental health. But what if the fat-shaming comes from within?

Researchers call this internalized stigma. “Internalized stigma is when you accept those negative characterizations, labels, perceptions that others hold, and you apply them to yourself, and therefore you blame yourself,” explains Bulent Turan, an assistant professor of psychology at the University of Alabama-Birmingham. “You have guilt and shame and, most importantly, you feel inferior.”

This internalization is a kind of byproduct of prejudice, and it shows up only after some level of outside stigmatization. Someone who is publicly ridiculed for being fat, for instance—a fairly common experience—might then go home, stand in front of the mirror, and berate herself for being fat, ugly, and lazy, buying in to the very criticisms that caused such pain in the first place. And that process of self-blame can damage health on a number of levels.

“In some cases, internalization is a stronger predictor of adverse health consequences than the actual experience of stigma itself,” says Rebecca Puhl, deputy director for the Rudd Center for Obesity & Food Policy at the University of Connecticut. Those include physical consequences like higher blood pressure and cortisol levels, psychological effects like depression and low self-esteem, and behavioral changes including higher levels of binge eating and disordered eating.

A 2017 study of obese adults found that the more they internalized weight stigma, the more likely they were to have metabolic syndrome—high blood pressure, triglycerides, blood glucose, and “bad” cholesterol—raising their risk of heart attacks and strokes. Those with the highest levels of internalized stigma were three times more likely to have metabolic syndrome and six times more likely to have high triglycerides or be on cholesterol medications than those with the lowest levels.

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People who internalize the societal stigmas around obesity avoid going to the doctor and don’t get routine screenings and check-ups. They also tend to exercise less and show lower levels of self-efficacy, or the belief that you can accomplish a specific task; one 2017 study looking at people who had intentionally lost weight found that those who internalized weight stigma were far less likely to keep the weight off than those who did not.

Not everyone internalizes stigma, of course. Another person who is the target of fat-shaming might react by getting mad or lashing out at the bully. But in general, the more culturally acceptable the prejudice, the more likely people are to apply it to themselves. “When social stigma goes unchallenged it becomes easier to internalize it,” Puhl says. In addition to obesity, people who are stigmatized for conditions like HIV status and mental illness—which are often thought to include an element of personal choice—are more likely to blame themselves, Puhl says. Media, health-care professionals, and the culture at large often reinforce such beliefs.

“With other forms of stigma you have a lot more outspoken outrage against it,” explains Rebecca Pearl, lead author on the study and an assistant professor of psychology in psychiatry at the University of Pennsylvania’s Perelman School of Medicine. For example, she says, racial stereotypes and gender bias are more likely to inspire pushback than, say, obesity or HIV status. And while members of some stigmatized groups bond with their group—LGBTQ pride, for example—people with higher body weights often do not, making them more vulnerable to internalizing stigmas against them.

Via what exact means self-stigma damages health is still unclear, though researchers have identified a number of likely pathways. Internalized stigma can lead to a physiological stress response, raising cortisol levels, blood pressure, levels of C-reactive protein, and other biomarkers that affect cardiometabolic risk. “Stigma is a stressor—for some people it’s a chronic stressor,” Puhl says. “And having to live with this stressor can impair emotional, behavioral, and even physiological resources, all of which can impair health.”

Psychological factors also contribute. For instance, studies have found links between self-stigma and health-promoting behaviors. “When people believe they’re lazy and lack willpower, they may be less confident in their ability to make healthy food choices, to try a different kind of exercise, and that may be a pathway by which we’re seeing associations between stigma and poor health,” Pearl says.

A 2016 study found that people who are stigmatized for being HIV-positive—or, interestingly, who expect to be stigmatized—and who bought in to those stigmas were less likely to take their medications, maybe because they are also less likely to disclose their HIV status to others. “You don’t want to take the medications in front of others, who then might realize your status,” says Turan, the lead author on the study. But not taking the medications as prescribed can mean more viral load, and in turn can make the difference between living a relatively normal life and developing full-blown AIDS.

Fear of having to disclose can keep patients from getting medical or dental care. Even subtle outside judgments—a look from the dentist’s receptionist, for example—can lead to self-blame and skipped medical appointments. “There is still a lot of stigma in the health-care system,” Turan says.

Researchers are just beginning to think about ways to address these effects. “Right now, initiatives that directly target internalized stigma are really scarce,” Puhl says. One potential strategy is awareness. Often people think they need to be hard on themselves to bring about positive changes; they might castigate themselves as lazy or ugly or stupid because they think it will motivate them to exercise more. Pearl suggests instead that people reflect on whether this internal process of blame is actually helping them achieve their goals or making them feel worse. “And be aware of the research showing that generally that’s not so helpful for people in the long run,” she suggests. “Individuals can challenge the stereotypes they have about themselves.”

Other strategies include educating doctors and other medical professionals about the dangers of internalized bias, a process Puhl describes as an uphill battle. Doctors need to understand that weight stigma does not lead to better outcomes for their patients. “Any kind of plan they have or whatever they’re working on with their patients,” she says, “stigma will make that more difficult if not impossible.”

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