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116
Fig. 9.1 Inuence between the interpersonal and individual levels of stigma
conceptualization approach incorporates mutual inuence, gender diversity, and
individual and contextual conditions that participate in exclusion processes. It also
takes into account signicant aspects of culture in Latin America that cannot be
isolated from the health conditions of the population.
Figure 9.1 illustrates the process of stigmatization. The norms, values, stereo-
types, and prejudices that are expressed through discriminatory behaviors are part
of a shared knowledge that is learned and legitimized by different social institutions.
This requires consideration of the mutual inuence between individual and macro-
social factors that shape the exclusion processes directed at different social groups.
However, this knowledge is not static, so interpersonal contact and the active par-
ticipation of people, groups, and institutions are fundamental to the generation of
new forms of knowledge and the approach to social phenomena.
9.3 Intersectionality andtheSocial Stigma ofPeople Who
Use Substances
From an intersectional perspective, it is possible to understand how social stigmati-
zation of people who use substances interacts with phenomena such as racism and
sexism. Various studies have documented that people who use substances who
belong to specic sexual diversity and ethnic groups tend to be treated inequitably
(Kulesza etal., 2016; Lipperman-Kreda etal., 2020; Nelson, 2021). For example, it
is more likely that an Indigenous, Black, or Hispanic person with addictions will be
sent to jail rather than to a health care institution for treatment.
J. Mora-Rios et al.
117
Various social groups participate in the stigmatization of people who use sub-
stances. For example, the media often present more sympathetic narratives of opioid
use in the white population, in contrast to the criminalization of people of color,
who are described as transgressors, irresponsible, and immoral. This leads to dif-
culties in entering the labor market except with precarious jobs and low wages, and
it promotes hatred and rejection of these people (Kulesza etal., 2016).
Gunn etal. (2018) explore the impact of stigma on drug users, particularly from
family and partners, and nd that women with a history of substance use, imprison-
ment, or behaviors associated with addiction are subject to multiple forms of dis-
crimination. These authors address the intersection of various stigmatizing factors
in the lives of women who have been incarcerated and have a history of sub-
stance use.
English etal. (2018) examine a group of Black. Latino, and multiracial men of
diverse sexual identities, who have historically been the object of stigma and dis-
crimination. Their interest was to explore the intersection of race, sexual orienta-
tion, and stigma and its relationship to substance use in these men. A principal
nding was that racial discrimination was associated with difculties for emotional
regulation in those who had been victims of attacks and hate crimes.
In a systematic review of qualitative studies on the subject, Meyers etal. (2021)
suggest that a qualitative intersectional approach considering stigmatized identities
is most appropriate for the analysis of complex issues such as substance use and
gender, and that these identities affect the health and well-being of people who use
substances. However, quantitative studies found no evidence of the impact of gen-
der on stigmatization, so the measurements used to address these issues may not
account for the complexity of stigmatization processes. However, qualitative studies
have documented that women using substances report double or triple conditions of
exclusion, due to cultural expectations that are linked to their gender expectation as
caregivers. Women who use drugs are considered transgressors, evil, selsh, and
promiscuous (Meyers etal., 2021; Walters etal., 2023). The physical, emotional,
economic, and sexual violence to which these women are subjected could be natu-
ralized, seen as a kind of punishment or consequence for not fullling their assigned
role (Lozano-Verduzco etal., 2016, Mora-Ríos etal., 2017: Gunn etal., 2018). In
addition to the social and cultural difculties they face, these women also experi-
ence discrimination within the health care system. Health care providers reproduce
these stereotypes, giving priority to their other health problems, which negatively
affects their health and well-being (Meyers etal., 2021).
Along the same lines, Kelly etal. (2021) found a marked relationship between
substance use disorder and suicide risk in people with diverse sexual orientations
and in specic ethnic groups (Hispanics, Blacks), in comparison with white hetero-
sexual adults. The suicide risk was higher in Black and Hispanic women. Finally, a
qualitative study (Ghasemi etal., 2021) found that stigmatization and discrimina-
tion against Afghan immigrants were related to the gender and migratory status of
the informants, which accentuated the inequality experienced by people who use
substances and prevented them from accessing treatment.
9 Stigma, Discrimination, andSubstance Use: AnIntersectionality-Based Approach
118
9.4 Intersectionality, Stigma, andSubstance Abuse
inLatin America
In Mexico, a number of authors have proposed intersectional analyses of addiction.
Núñez (2019) critiques regulatory and prohibitionist frameworks that have crimi-
nalized drug use and advocates instead for public policies that consider intersection-
ality and a perspective of gender and other identities. In a narrative review,
Torres-Lorenzo etal. (2022) highlight the importance of including intersectionality
and a gender perspective in addressing violence and substance use in women.
In a mixed methods study we carried out in Mexico City (Mora-Rios etal.,
2017), we inquired about the experiences of stigma and discrimination related to the
use and abuse of substances from the perspective of people with substance use dis-
order, family members, and health providers. All informants diagnosed with sub-
stance abuse disorder reported being the object of stigma and discriminatory
practices as a result of their use at some point in their lives, primarily by their fami-
lies and health personnel, and consisting mainly of criticism, hostile attitudes, and
blame for their use. Discriminatory practices were described in unregulated self-
help groups (AA), mainly physical and verbal aggression. Family members
expressed feelings of guilt, shame, anger, helplessness, and hopelessness, so they
preferred to isolate themselves or avoid meetings, anticipating rejection. Health care
providers, in addition to recognizing stigma as a problem present in all types of care
services, mentioned providers’ lack of training in addiction and mental health issues
and the apathy of mental health institutions, as well as the lack of recognition of
health care personnel working in this area.
9.5 Social Context, Vulnerability, andEmerging Problems
Migrants as a group face particular conditions of vulnerability is. Mexico has a
signicant ow of migrants, both of citizens and foreigners traveling to the United
States in search of better living conditions. Substance use is an additional problem
among this population during its journey to the United States. Migrants also face
unemployment, discrimination, insecurity, poverty, social isolation, separation from
family networks, and exploitation, which further complicate their situation.
Opioid use is an emerging problem in the states close to Mexico’s border with
the United States. Many of the people affected are Central American and African
migrants deported by the United States, some of them born with withdrawal syn-
drome because their mothers used drugs during pregnancy. These people, in their
conditions of vulnerability, are captured by groups dedicated to trafcking in sub-
stances including opioids, methamphetamine, and fentanyl. They lack resources,
are in poor health conditions, and lack access to care services. Other no less impor-
tant challenges are faced by older adults, victims of violence by crime, and terror-
ism and forced displacements by drug trafckers.
J. Mora-Rios et al.
119
As part of the effort to eradicate stigma and discrimination with respect to addic-
tion, it is necessary to implement a different paradigm, one that is dialogical, due to
the complexity of the phenomenon. It must involve different social groups, people
who use substances, family members, health personnel, decision makers, and civil
society, all of whose testimonies and experiences are key to modifying attitudes
toward people who use substances.
While in the traditional paradigm efforts are focused on reducing stigma by
improving accessibility to care services, a new paradigm should be oriented toward
recovery, agency, and inclusion. It should ght for access to minimum supports,
such as housing, employment, and care services. This is one of the main challenges
in reducing stigma toward people who use substances: to have clean, adequate facil-
ities, so as not to perpetuate the idea that these facilities are designed for punish-
ment. In Latin America, community interventions are increasingly being carried out
to address stigma, using participatory strategies which have given good results, but
it is necessary to evaluate the impact of these interventions, and such evaluation
remains a challenge.
As for health care professionals, it is necessary to provide additional training and
support, as they are limited in their work by a lack of resources and a burden of
administrative activities that interfere with patient care. It is essential to establish a
commitment with the main actors involved in the health care process. Political will
is required, adopting a more comprehensive vision that includes mental health and
addiction as a key focus of the well-being of the population, to face the complexity
of the problems linked to the care process. It must be part of a broader social com-
mitment, with an inclusive and open view of the sociocultural diversity of the popu-
lation and a more human approach.
9.6 Final Considerations
In this study, an intersectionality paradigm allows us to understand in a more com-
plete and nuanced way the experiences of people who use substances. Intersectionality
refers to the dynamic relationship between social determinants, the subject, and
their context. In this sense, it alludes to the presence of multiple conditions that seri-
ously affect people, generating their social exclusion, and that are part of their social
context.
Stigma is a signicant source of stress and social disadvantage for people who
use substances, and it has a signicant effect on their well-being. It represents an
additional burden that intersects with other conditions, creating double and triple
disadvantages. Studies show that there are certain vulnerable groups, especially
women, who are exposed to violence when they transgress the gender expectation
that they be caregivers. However, it is essential to investigate more fully the resources
of this population in facing adversity, and to assume a more reective and critical
positioning to address the questions of stigma and discrimination in the defense of
their rights. It is necessary to go beyond centering the problem on blaming people
9 Stigma, Discrimination, andSubstance Use: AnIntersectionality-Based Approach
120
who use substances and their families, who are the ones who suffer directly the
consequences of substance abuse (Orford etal., 2005).
In low- and middle-income countries, it is essential to expand research on addic-
tions from an intersectional perspective to inuence the development of public pol-
icy that assumes a greater commitment to the care of the most vulnerable parts of
the population, to make their needs visible, and to implement specic culturally
relevant actions that contribute to social inclusion.
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9 Stigma, Discrimination, andSubstance Use: AnIntersectionality-Based Approach
Part II
Social Stigma, Gender, Family Contexts
and Drug Use
125© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2025
T. Mota Ronzani (ed.), Social Stigma and Drug Use,
https://doi.org/10.1007/978-3-031-94813-8_10
Chapter 10
Stigma, Prejudice, andMedia: Impact
ontheCare ofRelatives ofPeople Who Use
Drugs
JoannaGonçalvesde AndradeTostes-Bianchetti, TelmoMotaRonzani,
RodrigoGoycoleaMartinic, andPollyannaSantosda Silveira
10.1 Stigma andDependence: TheConceptual andCultural
Bases ofThis Relationship
The process of stigmatization has been extensively studied, both theoretically and
empirically, and is commonly dened as the interplay of labeling, stereotype attri-
bution, social separation, status loss, and discrimination, reinforced through power
dynamics (Hatzenbuehler etal., 2013; Link & Phelan, 2001). In this process, indi-
viduals or groups are devalued and socially excluded due to characteristics per-
ceived as deviant (Corrigan & Watson, 2002).
The relationship between stigma and dependence is complex and deeply rooted
in conceptual frameworks and cultural perceptions. Stigma constitutes a form of
social disqualication that signicantly impacts identity and access to treatment
(Gnanapragasam etal., 2023). Cultural perceptions shape stigma, as societal disap-
proval often leads to self-stigmatization among individuals with substance
J. G. de AndradeTostes-Bianchetti
Postgraduate Program in Psychology, Universidade Federal de Juiz de Fora,
Juiz de Fora, Brazil
e-mail: joanna@tostes.org
T. M. Ronzani (*)
Department of Psychology, Universidade Federal de Juiz de Fora, Juiz de Fora, Brazil
e-mail: telmo.ronzani@ufjf.br
R. G. Martinic
Escuela de Terapia Ocupacional, Facultad de Odontología y Ciencias de la Rehabilitación,
Universidad San Sebastián, Santiago, Chile
e-mail: rodrigo.goycolea@uss.cl
P. S. da Silveira
Faculty of Psychology, Universidade Católica de Petrópolis, Petrópolis, Brazil
126
dependence (Nearchou etal., 2024). Such cultural factors contribute to negative
portrayals of people who use drugs, reinforcing stigma and hindering social reinte-
gration (De Shalit etal., 2024; Gnanapragasam etal., 2023).
Different models of dependence inuence public stigma. For example, biological
explanations can attenuate stigma by framing dependence as a medical problem
rather than a moral failure (Siddiqui & Rutherford, 2023). Some direct conse-
quences of stigmatization are the development of social exclusion strategies with
punishment systems or social barriers, hindering access to basic human rights.
Classic examples include prejudices related to class and race, as well as the exclu-
sion of marginalized groups, such as people labeled as “mad” or “addicts” (De
Shalit etal., 2024; Ronzani etal., 2016).
Stigma in healthcare settings exacerbates global health inequities, crossing eco-
nomic, social, and cultural borders (Monteiro & Villela, 2013). In this eld, many
individuals who would benet from available treatments, improving symptoms and
disabilities, refrain from seeking help or discontinue treatment prematurely due to
the anticipated social consequences (Ronzani, 2018). Among the elements that can
explain this low participation in mental health programs, perhaps the most impor-
tant are the effects on the social environment (Ronzani, 2018). Thus, if on the one
hand the condition of deviant social status of drug users can serve to discourage use,
on the other hand, stigmatization can affect the health of those who use illicit drugs.
Chronic exposure to stigma-related stress can worsen health outcomes or decrease
the quality of care received (Ahern etal., 2007).
The consequences of stigma in its interface with health become even more wor-
rying, considering that they are not limited to the attribution of negative character-
istics to certain individuals, but rather reduce opportunities for access to information
and services that offer health care, enabling a more dignied life, and end up further
increasing health disparities (Ferreira etal., 2014; Ronzani & Furtado, 2010). In
addition, studies have identied among those who internalize stigma, feelings of
guilt, hopelessness, distress, self-reproach, and depression. These variables, in turn,
are pointed out as associated with a more restricted social network, anticipation of
rejection in social situations and the resulting social isolation, including unemploy-
ment (Tsang etal., 2010; Vauth etal., 2007).
10.2 Social Determinants, Stigma, andDrug Use
The interaction between social determinants, stigma, and drug use is complex and
multifaceted. Social determinants, such as socioeconomic status, education, and
mental health signicantly inuence drug use behavior and attitudes toward depen-
dence. Stigma exacerbates these challenges, leading to discrimination and restricted
access to treatment. Fundamental factors such as housing, employment, and educa-
tion shape individuals’ mental health and substance use patterns (Gnanapragasam
etal., 2023).
J. G. de AndradeTostes-Bianchetti et al.
127
Health disparities are dened as the differences between the health proles of
subgroups of the population, encompassing outcomes on physical and mental
health. These disparities range from self-perceived health status to mortality rates,
from psychological well-being to severe mental disorders (Hatzenbuehler etal.,
2013). However, there needs to be a deeper understanding to overcome descriptive
and depoliticized discourses, considering that the differences between these health
proles may not have any relation to social injustice, but they can also highlight it
in a pronounced way (Ronzani etal., 2023). The hegemonic medical model often
reinforces medicalization as a universal solution while obscuring the ideological
and social control mechanisms that regulate behaviors and disorders (Delgado &
Imedio, 2011).
It is undeniable that changing the macrosocial structures in health in short peri-
ods of time is unfeasible, especially when it needs to be carried out in conjunction
with actions from various other sectors. However, incremental strategies must be
developed to facilitate communication between healthcare providers and users, as
well as to create spaces to sensitize and train health professionals. It is necessary to
discuss stigma and its impact on production, maintenance, and confrontation of
social inequalities and health inequities (Massignam etal., 2015).
Monteiro and Villela (2013) suggest that the specic contexts in which stigma
operates are linked to its greater or lesser success. When more egalitarian interper-
sonal relationships are established in these contexts, there is a tendency for the
production and diffusion of stigma to be less expressive and, therefore, signicant
improvements can be obtained in health promotion strategies and in reducing dis-
parities. Implicit biases show that people who inject drugs, especially those from
ethnic minority origins, are more likely to be associated as deserving of punishment
and not help, indicating the presence of implicit beliefs related to the stigma of
dependence (Kulesza etal., 2016).
From this understanding, the sphere of care should include understanding the
history of substance use and the relationship between individuals and groups
inserted in a certain sociocultural context. Drug use is analyzed within an interac-
tion between drug–individual–environment, capable of giving real meaning to the
problems related to this consumption (Ronzani, 2018). Although drug use is present
in various social classes and in different contexts, some determinants increase the
social or disease burden in relation to this use. That is, there is not a simple and
direct cause and effect relationship. Some of these social determinants already
related to drug use in the literature are poverty, race, gender, unemployment, hous-
ing, education, malnutrition, among others (Ronzani etal., 2023). Understanding
these determinants allows us to glimpse the social vulnerability of substance con-
sumption, in order to optimize the planning of actions and care for users (McCormack
etal., 2015; Ronzani etal., 2023).
Although social determinants play a fundamental role in inuencing drug use,
stigma remains a signicant barrier to effective treatment and support. Addressing
these interrelated issues requires comprehensive public health and education strate-
gies to reduce stigma and improve access to care.
10 Stigma, Prejudice, and Media: Impact on the Care of Relatives of People Who Use…