Brief Report

The Human Face of Stigma in the Israeli Press: Representations of Physical Illnesses
Michal Soffer MSW, PhD*
The Charlotte B. and Jack J. Spitzer. Department of Social Work, Ben en-Gurion University of the Negev, Israel

Abstract
Purpose: This study examined the relationship between the degree of illness-related stigma and the representation of persons with severe physical illnesses in the Israeli press. Methods: A random sample of 478 published articles was drawn from three daily newspapers and two local newspapers over 12 months. The degree of illness-related stigma was measured using a scale developed for this study. Press representation was measured using content analysis. Results: Persons with very stigmatized illnesses tended to be women, to be unattached, shown as members of a marginalized ethnicity, and as involved in deviant occupations. Additionally, they were described in bare detail, not named, or portrayed as dangerous others. Conclusions: People with very stigmatized illnesses were symbolically annihilated, depicted as Others, and represented as an emblem of their illness. Implications: Changing press representations of persons with stigmatized illnesses is an essential step toward debunking illness-related stigma. Keywords: illness-related stigma, people with severe physical illnesses, press

Introduction
Illness-related stigma, a negative label given to an illness, is a specific type of social reaction to illness. Stigma is ascribed to medical conditions that are judged by society to be especially deviant and to defy salient social norms (Lupton, 2000; Scambler, 2008). The mass media are argued to be one of the most powerful social institutions in Western societies. They engage in the social construction of reality and serve as a socializing agent and a means of social control (Altheide & Snow, 1991; McQuail, 2005). The media are a central cultural site in which deviant definitions are
*Corresponding author: Michal Soffer, MSW, PhD, The Charlotte B. & Jack J. Spitzer Department of Social Work, Ben en-Gurion University of the Negev, P.O. Box 653, Beer-Sheva 84105, Israel. Tel.: +972-8-642-8132, Fax: +972-8-6472933. E-mail: msoffer@bgu.ac.il

produced and reinforced (Erickson, 1987). Therefore, it is not surprising that the media are often blamed for creating and perpetuating illness-related stigma (Corrigan, Watson, Gracia, Slopen, Rasinski & Hall, 2005; Caspermeyer, Sylvester, Drazkowski, Watson & Sirven, 2006). In spite of the fact that media coverage of illness is perceived to play a vital role in public reactions toward illnesses (Fishman & Casarett, 2006), most of the studies on press coverage of physical illnesses have focused on the type and quality of the information provided such as, for example, morbidity and mortality from the disease, prevention of the disease, risk factors, and treatment (see Kline, 2006). Such studies show that newspapers fail to provide accurate epidemiological data (cf. Kumanan et al., 2004; Iaboli, Caselli, Filice, Russi & Belletti, 2010; Williamson, Jones & Hocken, 2011; Williamson, Skinner & Hocken, 2011).

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Other research, mainly conducted on press representation of HIV/AIDS (cf. Lupton, 1994; Brodie, Hamel, Brady, Kates & Altman, 2004), but also, to a lesser extent, on cancer (e.g., see Seale, 2001; Clarke & Everest, 2006), and a few other illnesses (cf. Washer, 2006; Clarke, 2008; Lawrence, Kearns, Park, Bryder & Worth, 2008), provide some insight to the stigmatizing mechanisms that are used by the press, such as othering processes. Scant research has centered on stigma. Such studies were commonly focused on the language that was used in the press to describe the illness or, on rarer occasions, the person with the illness (see Caspermeyer et al., 2006; Anthony, Lozano-Calderon & Ring, 2009; Soffer & Ajzenstadt, 2010; Johnson, Henderson, Pedersen & Stonecipher, 2011). This exploratory study attempts to add to the literature on press representations of individuals with physical illnesses. As research in this field is negligible, we now turn to research concerning the stigmatization and representation of individuals with mental illnesses and disabilities in the press, which are a more studied phenomena (Kline, 2006). Ample research has been conducted on the representation of mental illness in the press as well as in other forms of mass media (sees e.g., Klin & Lemish, 2008). The role of the press in both producing and perpetuating stigma toward mental illnesses is a common finding (Corrigan, et al., 2005). Numerous studies have found that that people with mental illnesses were depicted in the press in a negative stereotypical manner, primarily as dangerous others who engage in violent and criminal behaviors (cf. Stuart, 2003, 2006; Blood & Holland, 2004; Corrigan, et al., 2005). It is noteworthy that this image has also been found in studies of press representations of infectious diseases, primarily HIV/ AIDS (see e.g., Lupton, 1999; Klin, 2001, 2008; Soffer & Ajzenstadt, 2010) but also, for example, gentile herpes (Roberts, 1997). In addition, perceptions of persons with disabilities as evil in the media and elsewhere are well documented (see e.g., Barnes, 1992. For a recent study of autism in the Australian press see, Jones & Harwood, 2009). The mass media is perceived to produce and perpetuate stigmatizing representations of people with disabilities (Wall, 2007). Various studies have relied on Clogstons (1990) typology of models of mass media representation of disability (see e.g., Haller, 1992; Clogton, 1994; Mick, 1996; Auslander & Gold, 1999; Wall, 2007), which was further expended by Haller (2000; unpublished results) (see e.g., studies by Haller, 1999; Haller, Dorries & Rahn, 2006; Power, 2006). Clogstons (1990) typology consists of three traditional categories and two progressive models. The former are the Medical, Social Pathology and, the Supercrip Models. The latter are

the Minority/Civil Rights and the Cultural Pluralism Models. Haller (2000; unpublished results) has added one traditional model: Business Model, and two progressive models: the Legal and the Consumer Models, to the typology. Briefly and in general, progressive models stem from a rights approach and frame people with disabilities as a minority group which are entitled to equal rights. Traditional models portray disability and persons with disabilities as victims of their infliction and as objects of pity (the Medical Model, see also Haller, 1997; Soffer, Rimmerman, Blanck & Hill, 2010), deviant or abnormal (the Social Pathology Model), supercrips, that is, high-achieving individuals who set standards others fail to meet; or a fiscal burden (the Business Model, see also Haller, 1999). Other studies on the representation of people with disabilities have shown that people with disabilities are often depicted in the press (and elsewhere) in a stereotypical manner, primarily as victims, or what was also coined the pitiful handicapped (cf. Zola, 1993; Rimmerman & Herr, 2004; Soffer et al., 2010), as well as supercrips (Shapiro, 1993) or heroes (cf. Shapiro, 1994; Hardin & Hardin, 2004a, b, 2009). In sum, studies that have examined the representations of individuals with mental illnesses or disabilities have shown that the media symbolically annihilates them (Gerbner, 1972; Tuchman, 1978); they lack representation and are represented by condemning and trivializing images. Thus, we examined whether the stereotypes of victim, dangerous other, and hero, were linked to press coverage of persons with various degrees of stigmatized illnesses. First (2000) has argued that the quality of media representation lies in assessing whether the other is objectified not referred to by name and described in bare detail. Hence, to account for indicators of othering and objectification we also examined whether various individual sociodemographic, and other indicators of visibility, were connected to illness-related stigma.

Methods
Sample This analysis was part of a larger project conducted as part of a PhD dissertation, which is described elsewhere in detail (Soffer, in press; see also Soffer & Ajzenstadt, 2010). Briefly, we developed a random sample of articles from major Israeli newspapers and used the International Statistical Classification of Diseases and Related Health Problems (ICD-10, World Health Organization, 2007) and expert opinion to determine degrees of severity. The sample comprised of 478
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articles which mentioned an individual with a severe physical illness. Since twenty of the selected articles did not identify a specific illness, the degree of stigma could not be determined. This reduced our sample to 458 articles. Independent Variable: The 87 physical illnesses that were identified in our sample were rated by experts as to their stigma severity using a 3 point scale: (0) non-stigmatized, (1) somewhat stigmatized; and (2) very stigmatized. We calculated the average illness-related stigma scores for each illness and categorized them by their degree of stigma into the following groups: (1) illnesses with an average score greater than one were defined as very stigmatized (such as HIV/AIDS or leprosy), (2) illnesses with an average score between 0.5 and 0.99 were somewhat stigmatized (such as cancer or malaria), and (3) illnesses with an average score between 0.0 and 0.49 were nonstigmatized (such as heart disease or diabetes). Dependent Variables: All aspects of representation (sex, name, age, marital status, occupation, country of residence, ethnicity, nationality/citizenship, photograph, direct quote, and prevalent image) were assessed using a detailed coding protocol with inter-rater reliability confirmed. Data Analysis Quantitative content analysis of the 478 sampled articles was carried out by the researcher. Associations between variables were examined using (1) the 2 statistic and Fishers Exact Test, which are tests for dependency between categorical variables, (2) Cramers V to examine the correlations between categorical variables, and (3) standardized residuals. The latter were examined in order to determine which one of the cells in the table were the major contributors to the significance of the 2 or the Fishers Exact Test. For the purpose of this study we report cells which were characterized by standardized residuals that were <|1.64|. Cells that indicated a positive tendency are bolded in the tables below, while cells that indicated a negative tendency are both bolded and italicized.

age, the actual age, sex, and the name of the person. As indicated by the standardized residuals, the age of individuals with non-stigmatized illnesses tended to be mentioned. When age was mentioned, the prevalent age group was 3545 years. Individuals with very stigmatized illnesses tended to be women and anonymous. Table 2 shows that reporting on marital status and occupation, the actual marital status, the occupation, and the country of residence were significantly correlated with the degree of illness-related stigma. As indicated by the standardized residuals, the marital status of persons with somewhat stigmatized illnesses tended to be mentioned. The table also shows that individuals with a very stigmatized illness tended to be unattached. The standardized residuals indicate that individuals with very stigmatized illnesses tended to be engaged in deviant occupations, such as drug trafficking, theft, and prostitution. Table 3 shows that, the degree of illness-related stigma correlated significantly with the persons ethnicity and the reporting of nationality. As indicated by the standardized residuals, persons with very stigmatized illnesses tended to be non-white or Sephardi Jews. The nationality of people with somewhat stigmatized illnesses tended to be reported. Table 4 shows that, the degree of illness-related stigma correlated significantly with the presence of a direct quote from the person, the number of identifying features reported (sex, name, age, marital status, country of residence, occupation, ethnicity, nationality, photograph and quote) and the image of the person. As indicated by the standardized residuals, individuals with somewhat stigmatized illnesses tended to be quoted more than others. Articles on very stigmatized illnesses tended to disseminate fewer pieces of information about the person and to portray patients as dangerous.

Discussion
We found that the degree of illness-related stigma correlated with several representations of persons with severe physical illnesses in the press. People with very stigmatized illnesses were symbolically annihilated, they were characterized mainly by the presence of condemning and trivializing images (Tuchman, 1978), notably as dangerous others (see similar findings, Lupton, 1999; Corrigan et al., 2005; Klin, 2008). Furthermore, we found that individuals with very stigmatized illnesses tended to be women, unattached individuals, members of minority groups, and people with socially deviant occupations. These findings suggest that persons with very stigmatized illnesses are portrayed

Results
Approximately half of the articles sampled (48.9%) dealt with non-stigmatized illnesses, 38.2% covered somewhat stigmatized illnesses, and 12.9% covered very stigmatized illnesses. Table 1 shows a significant correlation between the degree of illness-related stigma and the reporting of
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as the epitome of the other in Israeli society, as the embodiment of multiple marginalized and stigmatized identities. Ample documentation exists as to the perception of women as the second sex, and the other (de Beauvoir, 1949/1989). Women were found to be viewed as temptresses (DeWall, Altermatt & Thompson, 2005), evil (Noddings, 1991; Ajzenstadt, Soffer & Steinberg, 2010)and vectors of illness (Gilman, 1988). Similarly, singlehood is a stigmatized condition (Moran, 2004 2005), especially among women (see Hacker, 2001) and particularly in Israel. Familism was argued to be one of the central features of Israel, which centers on family values (Fogiel-Bijaoui, 1999). In accord with other studies (see e.g., Eichelberger, 2007), we found that very stigmatized illnesses were attributed in the press to non-Caucasian patients. In addition, the most stigmatized illnesses were associated with Sephardi Jews in Israel. Relying on Saids (1978) conceptualization of Orientalism, Shohat (2002) argues that Sephardi Jews are perceived as other, as culturally inferior to a hegemonic Ashkenazi ethnicity.

We found that persons with the most stigmatized illnesses were engaged in deviant occupations. Hence, they were others by means of their livelihood. Similar findings have been reported elsewhere, linking deviant lifestyle and behaviours to falling ill (cf. Clarke, 2006). However, our findings suggest that there is a tendency to link persons with very stigmatized illnesses to other forms of deviance, not merely to behaviors. Taken together our findings might suggest that stigma involves first and foremost, the mechanism of othering. Moreover, stigma is produced by multiple vectors of oppression and is a process whereby stereotypes and markers of marginalization work together to construct the other (see also Parker & Aggleton, 2003). In the Israeli society, danger, patriarchy, xenophobia, ethnic tensions, and deviant phenomena are involved in this moral process. The devaluation and objectification of such others seemed to be further constructed by the tendency to rob them of perhaps the most significant symbol of personhood and personal identity, namely, their given name. Moreover, presenting these individuals in a sketchy manner seemed to grant them less visibility as well as to symbolize that they are of small significance.

Table 1: Sex, Name, and Age, by the Degree of Illness-Related Stigma (n=458) Characteristic Sex Reported Yes No 2=3.15, df=2, p=0.21 Sex Male Female 2=8.94, df=2, p=0.011, Cramers V=0.14 Name Reported Yes No 2=8.72, df=2, p=0.013, Cramers V=0.14 Name Fully stated Initials, first name only, or an alias 2=5.74, df=2, p=0.06 Age Reported Yes No 2=15.21, df=2, p<0.001, Cramers V=0.18 Age Reported1 018 1934 3554 5564 65+ 2=24.63, df=8, p=0.002, Cramers V=0.21 Level of Stigma Total % ( n) 99.4% (475) 0.6% (3) 65.5% (311) 34.5% (164) 73.2% (350) 26.8% (128) 90.3% (316) 9.7% (34) 58.4% (279) 41.6% (199) 19.4% (54) 21.1% (59) 22.6% (63) 10.8% (30) 26.2% (73) Very % ( n) 100% (59) 0.0% (0) 57.6% (34) 42.4% (25) 61.0% (36) 39.0% (23) 80.6% (29) 19.4% (7) 47.5% (28) 52.5% (31) 17.9% (5) 28.6% (8) 28.6% (8) 0.0% (0) 25.0% (7) Somewhat % ( n) 100% (175) 0.0% (0) 61.1% (107) 38.9% (68) 80.0% (140) 20.0% (35) 93.6% (131) 6.4% (9) 53.1% (93) 46.9% (82) 11.8% (11) 23.7% (22) 34.4% (32) 11.8% (11) 18.3% (17) Non % ( n) 98.7% (221) 1.3% (3) 73.3% (162) 26.7% (59) 72.3% (162) 27.7% (62) 88.9% (144) 11.1% (18) 69.2% (155) 30.8% (69) 24.5% (38) 18.1% (28) 14.2% (22) 12.3% (19) 31.0% (48)

Notes: 1Even though one cell (6.7% of the cells) is expected a value smaller than 5, we can accept the value of 2 (Cochran, 1954).

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Table 2: Marital Status, Occupation, and Country of Residence, by the Degree of Illness-Related Stigma (n=458) Level of Stigma Characteristic Marital Status Reported Yes No 2=9.32, df=2, p=0.009, Cramers V=0.14 Marital status1 Married, has a partner Other 2=6.90, df=2, p=0.032, Cramers V=0.26 Occupation Reported Yes No 2=7.55, df=2, p=0.023, Cramers V=0.13 Occupation White collar Blue collar and unemployed Deviant occupation Fishers Exact Test=0.005 Country of Residence Reported Yes No 2=1.32, df=2, p=0.052 Country of Residence Israel Other 2=7.16, df=2, p=0.028, Cramers V=0.13 Total % (n) 23.0% (110) 77.0% (368) 71.8% (79) 28.2% (31) 54.4% (260) 45.6% (218) 82.8% (215) 14.5% (38) 2.7% (7) 98.1% (469) 1.9% (9) 64.6% (303) 35.4% (146) Very % (n) 16.9% (10) 83.1% (49) 60.0% (60) 40.0% (40) 49.2% (29) 50.8% (30) 75.9% (22) 10.3% (3) 13.8% (4) 96.6% (57) 3.4% (2) 59.6% (24) 40.4% (23) Somewhat % (n) 30.3% (53) 69.7% (122) 79.2% (42) 20.8% (11) 62.3% (109) 37.7% (66) 87.2% (95) 12.8% (14) 0.0% (0) 98.9% (173) 1.1% (2) 57.8% (100) 42.2% (73) Non % (n) 18.3% (41) 81.7% (183) 92.7% (38) 7.3% (3) 49.1% (110) 50.9% (114) 78.2% (86) 19.1% (21) 2.7% (3) 97.8% (219) 2.2% (5) 70.3% (154) 29.7% (65)

Notes: 1Even though one cell (16.7% of the cells) is expected a value smaller than 5, we can accept the value of 2 (Cochran, 1954).

Table 3: Ethnicity and Nationality/Citizenship, by the Degree of Illness-Related Stigma (n=458) Level of Stigma Characteristic Ethnicity Reported In full Implied Neither stated nor implied 2=6.88, df=4, p=0.14 Ethnicity1 Non-Israeli Caucasian Other Israeli Ashkenazi Jew Sephardi Jew Israeli and non-Israeli Arab 2=17.78, df=8, p=0.023, Cramers V=0.19 Nationality/Citizenship Reported In full Implied Neither stated nor implied 2=9.90, df=4, p=0.042, Cramers V=0.10 Nationality/Citizenship Israeli (Jew) Other 2=1.97, df=2, p=0.37 Total % (n) 4.2% (20) 49.4% (236) 46.4% (222) Very % (n) 5.1% (3) 44.1% (26) 50.8% (30) Somewhat % (n) 6.3% (11) 53.7% (94) 40.0% (70) Non % (n) 2.7% (6) 46.9% (105) 50.4% (113)

18.8% (48) 9.8% (25) 41.0% (105) 21.1% (54) 9.4% (24) 5.6% (27) 77.4% (370) 16.9% (81) 54.7% (217) 45.3% (180)

6.9% (2) 20.7% (6) 31.0% (9) 34.5% (10) 6.9% (2) 1.7% (1) 76.3% (45) 22.0% (13) 45.7% (21) 54.3% (25)

25.7% (27) 9.5% (10) 43.8% (46) 14.3% (15) 6.7% (7) 5.7% (10) 83.4% (146) 10.9% (19) 53.2% (83) 46.8% (73)

17.1% (19) 7.2% (8) 43.2% (48) 18.9% (21) 13.5% (15) 7.1% (16) 72.8% (163) 20.1% (45) 57.0% (102) 43.0% (77)

Notes: 1Even though two cells (13.3% of the cells) are expected a value smaller than 5, we can accept the value of 2 (Cochran, 1954).

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Table 4: Photograph, Direct Quote, Number of Identifying Features, and Image, by the Degree of Illness-Related Stigma (n=458) Level of Stigma Characteristic Photograph Yes No 2=5.00, df=2, p=0.082 Direct Quote Yes No 2=7.31, df=2, p=0.026, Cramers V=0.13 Number of Identifying Features 13 46 710 2=19.95, df=4, p=0.001, Cramers V=0.15 Image1 Victim Dangerous Hero No negative image 2=22.76, df=6, p=0.001, Cramers V=0.16 35.1% (168) 64.9% (310) 24.5% (117) 75.5% (361) 25.7% (123) 57.3% (274) 16.9% (81) 56.1% (268) 4.4% (21) 3.8% (18) 35.8% (171) 25.4% (15) 74.6% (44) 25.4% (15) 74.6% (44) 42.4% (25) 45.8% (27) 11.9% (7) 44.1% (26) 13.6% (8) 5.1% (3) 37.3% (22) 41.1% (72) 58.9% (103) 31.4% (55) 68.6% (120) 18.9% (33) 56.6% (99) 24.6% (43) 58.3% (102) 1.7% (3) 6.3% (11) 33.7% (59) 34.8% (78) 65.2% (146) 19.6% (44) 80.4% (180) 25.4% (57) 61.2% (137) 13.4% (30) 56.7% (127) 3.6% (8) 1.8% (4) 37.9% (85) Total % (n) Very % (n) Somewhat % (n) Non % (n)

Notes: 1Even though two cells (16.7% of the cells) are expected a value smaller than 5, we can accept the value of 2 (Cochran, 1954).

There were several limitations to this study. We used a new measure of illness-related stigma that was designed for this study. Secondly, we were unable to assess causality using our survey design. Press images may reflect stigmatized views or create them. Future studies would need to address these issues. Nonetheless, our study has several implications. The study is a first attempt to create a measurement to assess negative and stigmatizing press coverage of individuals with severe physical illnesses. As such, it can provide an initial step toward a general theory of illness-related stigma in the press that is not bound to a specific type of illness, but rather may apply to physical illnesses in general. It has been argued that the media exposes its audience to a wide variety of people. At times, the mass media are claimed to be the sole source of information about people (Harris, 2009). Additionally, research shows that the media are a central source for medical and health-related information for the general public (cf. Shuchman & Wilkes, 1997; Niederdeppe et al., 2007).

The information concerning persons with stigmatized illnesses, as our study shows, is entrenched with moral meanings. Newspaper articles were found to give science a human face (Henderson & Kitzinger, 1999). The human faces of stigmatized illnesses are not pure science but rather a cautionary tale to the Israeli public. Press coverage of stigmatized individuals sets and reinforces the moral boundaries of the Israeli society. It separates the right from the wrong, the deviant from the normal, the deserving from the undeserving (see Soffer & Ajzenstadt, 2010). This is not surprising as journalists reproduce images that reflect socio-cultural norms (Cohen & Young, 1973; Lester, 1980). In light of these findings and arguments it is imperative to change press coverage of people with stigmatized illnesses. The humanness of those who unwittingly are tainted with stigma should be restored. The findings therefore, stress the significance of working to educate journalists as well as the general public to change the cultural and moral meanings of stigmatized illnesses.

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