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Soc Sci Med. Author manuscript; available in PMC Jul 29, 2010.
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‘Face’ and the Embodiment of Stigma in China: The Cases of Schizophrenia and AIDS

Abstract

The majority of theoretical models have defined stigma as occurring psychologically and limit its negative effects to individual processes. This paper, via an analysis of how ‘face’ is embodied in China, deepens an articulation of how the social aspects of stigma might incorporate the moral standing of both individual and collective actors defined within a local context. We illustrate: 1) how one’s moral standing is lodged within a local social world; 2) how one’s status as a ‘moral’ community member is contingent upon upholding intrapersonal and social-transactional obligations; and 3) how loss of face and fears of moral contamination might lead to a ‘social death’.

We first draw from Chinese ethnographies that describe the process of human cultivation before one can achieve fully ‘moral’ status in society. We integrate findings from empirical studies describing how social exchange networks in China are strictly organized based on the reciprocation of favors, moral positioning, and ‘face’. We further ground these Chinese constructs within a theoretical framework of different forms of capital, and discuss the severe social consequences that loss of face entails. By utilizing the examples of schizophrenia and AIDS to illustrate how loss of moral standing and stigma are interwoven in China, we propose a model highlighting changes in moral status to describe how stigma operates. We suggest that symbolic restoration of moral status for stigmatized groups takes place as local-level stigma interventions. By analyzing the moral aspects of ‘face’, we propose that across cultures, stigma is embedded in the moral experience of participants, whereby stigma is conceived as a fundamentally moral issue: stigmatized conditions threaten what matters most for those in a local world. We further propose that stigma jeopardizes an actor’s ability to mobilize social capital to attain essential social statuses.

Keywords: China, AIDS, face, mental illness, discrimination, social capital, culture, stigma

Introduction

Current theoretical models have greatly advanced our understanding of how stigma affects people via a broad array of psychological processes and social mechanisms. Although these theories have generated much research by highlighting different routes by which stigma acts upon the individual, the great majority limit the negative effects of stigma to self-processes. Consequently, individual psychological processes are predominantly seen to mediate stigma’s effects, and negative outcomes result from how an individual copes with and responds to stigma (Parker & Aggleton, 2003).

Conceptual models have described stigma’s social elements in manifold ways which we outline briefly (for a full analysis, see Yang, Kleinman, Link, Phelan, Lee & Good, 2007). Social psychological models primarily deal with these aspects as a ‘social identity’ applied to an individual, situational stimulus that individuals respond to, or as cultural stereotypes (Crocker, Major, & Steele, 1998). Sociological models describe the social domains of stigma as occurring when objects in the social world obtain meaning through symbolic interaction (Goffman, 1963; Link, Cullen, Struening, Shrout & Dohrenwend, 1989), while other authors express these social dimensions as occurring through institutional, structural, and hegemonic forms (Corrigan, Markowitz & Watson, 2004; Parker & Aggleton, 2003).

While acknowledging the key roles that psychological and macrosocial forces play in stigma’s manifestation, currently missing from the literature is a deepened articulation of how the social aspects of stigma might incorporate the moral standing of both individual and collective actors as defined within a local context. This paper seeks to more deeply illuminate stigma’s social elements through examining how the cultural phenomenon of ‘face’, by representing a person’s moral standing in the community, leads to the embodiment of stigma in China. We seek to reveal through an in-depth analysis of ‘face’: 1) how one’s moral standing is lodged within a local social world; 2) how one’s status as a ‘moral’ community member is contingent upon upholding intrapersonal and interpersonal (social-transactional) obligations and; 3) how loss of face and accompanying fears of moral contamination might lead to a ‘social death’. We further examine how ‘face’ and moral status interact with stigma by examining schizophrenia and AIDS in China. Through our analysis, we present a conceptual model describing how changes in moral standing lead to negative outcomes in China, and provide culture-specific recommendations for combating stigma by restoring the moral status of individuals and families at the local level. We conclude by proposing that the face dynamic reveals novel ways of understanding stigma’s underlying nature across cultures—that stigma at its essence is a moral process (i.e., threatens what matters most for those in a local world) and that stigma jeopardizes an actor’s ability to mobilize network resources (or ‘social capital’) to attain essential social statuses.

‘Face’ as a Physical, Emotional, Social and Moral Process in Chinese Society

We utilize conceptual writings and empirical studies on ‘face’ and social exchange to advance understanding of stigma formation in local Chinese communities. We first draw from Chinese texts and ethnographies that describe the requisite process of human ‘cultivation’ before one can achieve status as a fully ‘moral’ person (Lau, 1984; Stafford, 1995). We then integrate findings from ethnographies and other empirical studies that describe how social exchange networks in China are strictly organized based on the reciprocation of favors, moral positioning, and ‘face’ (Fei, 1992; Kipnis, 1997; Yan, 1996). We further ground these Chinese constructs within a theoretical framework of the different types of capital articulated by Bourdieu (1986), particularly that of social capital (Szeter & Woolcock, 2004). We conclude this section by discussing the severe social consequences that loss of face entails for individuals and networks.

For purposes of theory-building, we depict an ideal case of the formation of ‘moral persons’ in China. However, this social dynamic, and that of ‘face’, are currently being contested and reconstructed. The transition to a market economy-- including an emergent private sector, new foreign investment, and imported cultural media (films, music)-- have greatly reshaped traditional Chinese society (Yan, 2003). The influx of Western norms and values has led to evolving conceptualizations of filial piety for contemporary Chinese (Li Lieber, Nihira & Mink, 2004); additionally, kinship has been supplanted by familiarity ties as the main medium to build social networks (Yang, 1994). However, the notion that unique cultural patterns of modernization in Asia (or “Easternization”; Marsella & Choi, 1993) occur suggests that China might retain important psychological, social, and cultural structures even in the face of rapid technological and economic advancement. Further, individual psychological processes enable preservation of traditional Chinese orientations while simultaneously allowing adaptation to societal change (Yang, 1998). Hence, we assert that attaining ‘moral’ status and upholding face will remain salient to modern-day Chinese, even as these values are transforming as a function of modernization. To the degree these dynamics become attenuated in the years ahead may limit their future influence yet still not remove their legitimacy as core cultural orientations.

Different Roads of Identification Leading to Adult (Moral) Status

Stafford (1995) in his ethnography of childhood education in Angang (a fishing village in southeastern Taiwan), describes how children must undergo extensive cultivation before being recognized as having adult status. The popular view of children is that they are not yet full persons (chengren or adult, literally translates as ‘completed persons’; Stafford, 1995, p. 19). Most importantly, children are not regarded as fully-formed morally. Stafford explains how children learn ‘everyday’ morality transmitted through family life and ‘ordinary’ morality through formal education. Accordingly, Stafford describes the socialization of Chinese children as first being a natural process that emphasizes certain types of identification and second, a ‘Confucian’ process in which children achieve status as full-fledged human beings through learning and self-cultivation.

The community immerses the child in a compulsory educational process to learn established cultural patterns and to conform to social roles that organize interpersonal life (Fei, 1992). Morality is transmitted as ‘ordinary knowledge’ and appears ‘not to be taught’. Perhaps most powerfully embedded within everyday life, parents and children are obligated to provide for one another. Parents first raise children. Children then perform filial obligations through a series of family transactions (a ‘learning environment’). Adherence to filial obedience becomes so ingrained that it is perceived as something which simply ‘should be done’ (yinggai zuode) (Stafford, 1995, p. 82). To not provide food for one’s parents merits public scorn- e.g., a common taunt in rural Taiwan is to mock a useless person as a ‘rice pot’- i.e., they only eat rice and do not produce it (to feed parents) (Stafford, 1995, p. 96). This obligation to keep parents well-fed continues even after death (through religious offerings to their spirits; Kipnis, 1997). If this duty is neglected, these spirits are thought to become hungry ghosts who must be placated by the general community. Further parental obligations include producing offspring to continue the lineage, providing lifetime financial support, and performing rituals to ensure that support is sustained in the next life. This process is thus an “…immersion in a system of total support (economic, social and spiritual),” and placement into “…an eternal chain of filial children” (Stafford, 1995, p. 86). Yan (2003) has shown that these filial obligations are weakening, at least in Northern China; nonetheless, they remain ideals, albeit less effective ones.

In contrast to everyday immersion in morality, schools utilize texts that convey distinct moral rules. Confucian philosophy, which is commonly transmitted through school texts, states that commitment to learning (i.e., achieving cultural competence and literacy), or self-cultivation, is essential to the process of properly becoming human. A fifth-grade textbook in Taiwan entitled, “Studying and Being a Person” (Qiuxue yu zuoren), emphasizes that these two values are inseparable. Modern Taiwanese textbooks teach a version of traditional Chinese morality emphasizing a moral continuity from xiao (filial obedience) extending to zhong (loyalty/patriotism). Indeed, Tu (1987) states that “the original Confucian intention…is the moralization of the person in human relationships” (p.71).

Through the everyday and formal teaching of morality, children learn how to engage in properly ordered human relationships. Fei (1992) underscores that to become a true adult is to be connected to others and to uphold obligations as defined by one’s social relationships; failure to do so is “to be less than human” (p.25). Thus, participating in reciprocal familial obligations, achieving cultivation through education, and becoming a full member of a community constitute achieving good, adult or ‘moral’ status.

Fundamental Characteristics of Chinese Social Organization

Fei’s classic text (1992) written from a Chinese anthropologist’s viewpoint, describes Chinese society as consisting of “webs woven out of countless personal relationships” (p. 78). These overlapping arrangements of expandable, individually-centered networks connect each member of society in multiple ways with varying degrees of attachment (King, 1994). A network’s size is established by the authority of each individual center; the greater a person’s prestige, the denser his or her web of horizontal and vertical network relations. These networks are highly elastic and expand or contract in response to changes in an individual’s social power. “Inner” networks consist of family and kinship ties1 which overlap with sets of “outer networks” (e.g., classmates, friends of friends, and people from the same region). The projection of closely defined kinship relations often occurs among intimate non-family members, who are treated as ‘practical kin’ (Yang, 1994).

Fei further emphasized the importance of adherence to rituals- by developing self-restraint through rituals, moral character is then cultivated. Only after achieving self-control can one extend into outer circles of interpersonal relationships. Control thus takes place from the inside spreading outward- if one upholds one’s morality followed by his or her close relations (i.e., family), then the state and entire world will be in order. In Confucian tradition, Chinese lineage networks thus become “the medium through which all activities <and social structures> are organized” (Fei, 1992, p .84).

Correction immediately takes place when failure to learn any of these obligations occurs. Any individual’s failure to act appropriately implies that the associated social circle (e.g., parents, teachers, even an entire village) has not provided proper guidance. Everyone in a network supervises the actions of others and these standards of obligation are internalized as following one’s heart and mind. Again, recent research in China suggests that connections are becoming more pragmatic, but that they still retain their structuring influence in social life (Yan, 2003)

Reciprocity, ‘Guanxi’, ‘Renqing’ and ‘Face’

Reciprocity, particularly among family members and then society, thus is viewed as a core principle that governs everyday social behavior in China. Yang (1957) first defined the Chinese principle of reciprocity (bao) as the basis for social relations. Giving gifts (liwu) can be viewed as “the intersubjective medium of social transactions in local moral worlds” (Kleinman & Kleinman, 1991, p. 277). Gift-giving constitutes guanxi, or the boundaries of one’s network of social connections as defined by the flow of gift exchange. Guanxi was initially viewed as personal strategies used to construct ‘particularistic ties’ (Jacobs, 1979) and subsequently was expanded to include elements of personal feeling that accompany instrumental intentions (Walder, 1986).2 More recently, Yan (1996) further incorporated the centrality of moral duties to fulfill obligations as well as affective and economic involvement. Guanxi networks thus function as the objective foundation of each individual’s local world and consist of relationships that are continually reproduced through purposeful human efforts.

Deciding who to accept favors from demarcates one’s range of obligations (and membership in another’s guanxi web; King, 1994). Even sharing food with non-kin may be seen as public acknowledgement of having guanxi; in China, public banquets are explicit mechanisms to produce and hold onto extrafamilial guanxi (Yang, 1994). Counterbalancing such material exchange, the direct embodiment of human feelings, or ganqing, also plays a particularly strong role in guanxi formation. Thus, publicly weeping at a funeral is a way of claiming relationship to the deceased and his or her family (Kipnis, 1997).

Also critically intertwined with the fundamental concepts of reciprocity and guanxi is the key social norm of renqing, or “a system of ethics based on commonsense knowledge” of society (Yan, 1996, p .21), where interpersonal relations consist of both moral and emotional components. In everyday social practice, renqing can be understood as the exchange of favors- by repaying an owed favor with a bigger favor, others owe that person future favors. Obligations must eventually reach a balance between parties, although to actually settle accounts fully is to end a relationship, because if favors are not owed, no further communication is needed (Yang, 1994). However, renqing is not simply a matter of understanding reciprocity but also embodies the following overlapping concepts: 1) understanding basic emotional responses in everyday social situations; 2) moral duties associated with gift-exchange; 3) a type of exchangeable social resource (i.e., favor) and; 4) one’s guanxi networks (Yan 2003). Renqing is based upon the notion of sharing (zhanguang or “to share the light”); one is morally obligated to share social resources with network members, which is expressed in and gives meaning to everyday gift-giving.

Renqing is based upon one’s social ‘face’ (mianzi), or embodiment of social power in the interpersonal field (Hwang, 1987). Renqing first depends on mianzi- one must initially possess sufficient mianzi to face others and to create social networks. Renqing also reflects mianzi- e.g., at formal ceremonies (weddings, funerals), social status is exhibited by the number of guests and by the financial and emotional offerings provided, thus embodying the entirety of social connections that a family possesses. Accordingly, social-transactional dynamics (renqing) are inextricably intertwined with one’s social status or mianzi.

More recent conceptualizations further link the construct of moral face, or lian, with the deeply-embedded moral obligations located in the everyday economy of reciprocity and social exchange. For example, Yan (2003) states that, “One’s failure to fulfill the obligation of reciprocity, or to show no consideration for others’ feelings and emotional responses, is regarded as an immoral act” (p. 39). Accordingly, moral face consists of the group’s evaluation of a person’s moral reputation, record for fulfilling social exchange obligations, and status as a good human being (Yan, 1996). Lian can thus be seen as reflecting one’s moral status in the local world and consisting of internal and external prohibitions for moral behaviors.3 The awareness of moral face guides participants’ actions in social exchange and injects a moral discourse to social life.

Face and Guanxi as Symbolic and Social Capital

Before discussing how loss of face affects participants in their local worlds, we use theoretical constructs set forth by the late French sociologist Pierre Bourdieu in his analysis of the mechanisms by which dominant classes reproduce structures of power, to deepen understanding of the social constructs of guanxi, renqing, and face. We specifically identify how these Chinese constructs might map onto different forms of capital that are accumulated, and traded, within societies. We do so to further ground these indigenous Chinese concepts within a deep and systematized social analytic framework and to locate these constructs as local examples of what might represent more universal processes.

Capital is broadly conceptualized by Bourdieu as materialized and convertible ‘social energy’ in the form of living labor or accumulated labor in an objectified state (Bourdieu, 1986). Face- both moral (lian) and in particular social face (mianzi)- can be seen to function as forms of symbolic capital. Such capital (e.g., mianzi as ascribed status accumulated via effort or clever interpersonal manuevering) is represented symbolically because it is set within the known ‘logic’ of the world, is not perceived as capital per se, and is instead recognized as a legitimate form of competence. The possession and use of these forms of symbolic capital are necessary to access and to mobilize network resources (e.g., ideas, information, money, favors), or social capital.

Analogous to guanxi within Chinese societies, social capital is comprised of social obligations (“connections”), and is defined by Bourdieu (1986) as “the aggregate of the actual or potential resources which are linked to possession of a durable network…or to membership in a group” (p.248). The entire social capital held by an individual is determined by the size of the network of connections that can be accessed and by the volume of the total capital possessed by each network member.4 Each member derives status from their potential access to the collectively- owned capital. The core ‘credential’ that allows individuals membership into guanxi (or social capital) networks in China is cultivation and maintenance of moral face (lian). Once guanxi is established, the amount of social face (mianzi) one possesses then determines the total network resources that can be mobilized. According to Bourdieu, and exemplified by guanxi webs in China, networks of social capital are based on the material and/or symbolic exchanges which act to maintain and reinforce them. Being a member of a guanxi network, and thereby establishing and reproducing social capital to secure material or symbolic profits, is based on endless acts of sociability and series of exchanges (of gifts, feelings, and words).

Utilizing frameworks that further delineate attributes of social capital reveal that guanxi contains both components of ‘cognitive’ (i.e., perceptions of trust, reciprocity and support) and ‘structural’ (i.e., extent of network links or activity) social capital (Harpham, Grant &Thomas, 2002). Further, guanxi ties may also comprise ‘bonding’ (cooperative relations between group members who share similar social identities) and ‘bridging’ (social relations that span across distinct socio-demographic groups, such as class) types (Szreter & Woolcock, 2004). At these formulations’ root, however, is the view that social capital is as an ‘accumulation of trust’ that results from individuals’ willingness to cooperate with one another via norms of reciprocity that facilitate collective action (Putnam, 1993). Such trust in Chinese groups forms the prerequisite for social capital to be transformed into economic capital (i.e.., goods that can be directly changed into money; Bourdieu, 1986) or the direct ‘social energy’ of others, which is why face is so prized, and safeguarded, in everyday usage.

Loss of Face and its Effects on Individuals and Networks

Loss of face (e.g., among those who violate key reciprocity norms) greatly affects an individual’s access to social capital and closely parallels how stigma works in Chinese society. The motivation to preserve face often causes adherence to moral obligations over economic considerations. To gain a reputation for not participating in gift-exchange would result in losing community trust and becoming isolated without adequate guanxi, which is felt as greatly embarrassing. Accordingly, a popular saying in a Northern Chinese village states, “Suili (obligatory, expressive gift-giving) is as urgent as putting out a fire. It can’t wait. A man cannot have a firm position in front of others if he fails to follow the rules of gift-giving and escapes his duties. (Yan, 1996; p. 76)”

Because obligations of reciprocity are cultivated since childhood, to publicly neglect such obligations is to lose moral face (lian). To lose lian (diu lian) represents the community’s condemnation for immoral behavior, and signifies “a serious infraction of the moral code of society” (Hu, 1944, p.46). To enact such behavior is to act atrociously and to be morally bankrupt, resulting in a depreciation of character.5 Loss of lian results in potential community ostracization- for instance, isolation during important rituals such as funerals. Consequently, the mere threat of sanctions typically leads offenders to reform their behavior (Fei, 1992).

Loss of lian also brings immediate shame to the offender. Affect is essential to moral face; a person’s aspirations to become a moral person are based on feelings of shame (chi- Lau, 1984). To lose lian is to experience real dread that is felt even more strongly than physical fear (Hu, 1944). Yan (1996) provides an example of an elder brother in rural China who failed to live up to a wedding gift-giving ritual (the most important gift-exchange event); having exhausted his money on earlier gift-giving rounds, he became filled with unbearable shame and fled the wedding.

Since lian signifies the community’s confidence in one’s moral character, severe loss of lian places the individual and family in a despised and isolated position. Those who fail to cultivate guanxi networks are assigned a severely disadvantaged status, a solitary state viewed as ‘disastrous’ (Kipnis, 1997). To represent the ‘social death’ linked to such persons (and their associates), Northern Chinese terms use ‘death’ (si) as a modifier (e.g., sipi- “dead skin”, sixing- “dead characters”) to describe the closed opportunities of such individuals’ social networks (Yan, 1996). One especially illustrative term-- si menzi--means “dead (closed) doors”. By contrasting the popular phrase of using one’s connections to obtain resources, or “going through the back door” (zou homen; King, 1994), si menzi is a metaphor that describes a relationship leading to no further resources. Not only are si menzi without a guanxi network (or from Bourdieu’s perspective, without social capital), they are also seen as “not knowing how to be a human being” (buhui zuoren) in their lack of knowledge in conducting basic human relations (Yan, 1996, p.103). These individuals face severe social sanctions and isolation from their local world.

The use of ‘death’ to describe individuals with whom one derives no benefit and risks moral contamination illustrates another critical facet of Chinese social life--that danger is felt to be highly contagious. Exposure to inauspicious (bujili) circumstances (e.g. funerals) endangers one via malicious influences (e.g., ghosts, which are a part of Chinese popular culture) and pollution of associated networks. For example, families who have recently experienced a death are isolated by the community for some time, and even those who merely attend a funeral will not be invited to happy events (e.g., weddings) due to fears of spreading bad luck or moral contamination (Stafford, 1995).

These examples highlight an essential aspect of guanxi networks- that designating people as friends means categorizing others as enemies. Guanxi-building is as much about utilizing strategies of exclusion and distancing as it is about internal sharing- e.g., a boss (laoban) will not allow those perceived as too low in status to banquet with him (Kipnis, 1997). Others note that face does not imply equal status but instead “…functions as a site from which hierarchical communication is possible” (Zito, 1987, p. 119). How guanxi, renqing, and face come to be constructed thus powerfully reflect local processes of inclusion, exclusion, and power in China.

‘Face’ and Schizophrenia in China

To illustrate how the experience of stigma is interwoven with loss of face and moral standing, we discuss two stigmatized conditions- schizophrenia and AIDS- in China. Sociopolitically, China’s delay in passing a national mental health law that clearly delineates the legal rights of people with mental illness and guarantees access to treatment (Shan, 2007) contributes to negative stereotyping, anticipated devaluation, and discrimination reported by people with schizophrenia across multiple life domains (Yang et al., 2007). Yet the traditional viewpoint that cultivation of restraint is integral to moral character further shapes how mental illness stigma is felt. In Confucian thought, one must learn to control oneself before exerting social influence (Lau, 1984). Partly due to public beliefs in China that people with mental illness act dangerously and unpredictably (Phillips & Gao, 1999), we propose that such persons are viewed as not fully cultivated and thus incompetent to participate in social life. People with psychiatric illness are thought to exhibit a ‘moral bankruptcy’ that relegates them to a moral level of not fully ‘adult’ status. Etiological beliefs of mental illness further assign a moral ‘defect’ to sufferers and families (Yang, in press); popular Chinese beliefs imply that having mental illness in this lifetime entails moral wrongdoing in a prior life (Stafford, 1995). That people with schizophrenia are not regarded as fully competent morally is depicted by suicide surveys in rural China not counting such individuals (Wu, 2005).

Because of perceived incompetence- that a person with schizophrenia will embarrass the family and lower their moral status- families and health professionals express stigma via infantilizing responses. This attitude is evident among 63% of a sample of Beijing psychiatric hospital nurses who agreed that people with mental illness “…need the same kind of control and discipline as a young child” (Sevigny, Wenying, Peiyan, Marleau, Zhouyun, Lin et al., 1999). Accordingly, Chinese psychiatric hospital patients have been made to sing songs and dance like children in a classroom (Pearson, 1995). Further, emotional attitudes of family members towards schizophrenia patients are predominantly those of emotional overinvolvement and overprotectiveness rather than outright criticism and hostility (Yang, 2003). This and related forms of discrimination lead to undermining of the patient’s self-confidence (endorsed by >88% of subjects in a Beijing patient sample; Phillips & Gao, 1999). Such infantilization leads to loss of aspirations, which contributes to concrete practical losses such as failure to achieve marriage and employment. Accordingly, people with schizophrenia in China have employment rates roughly half that of their age group, are almost twice as likely not to get married, and experience divorce rates nearly ten times the population norm (Phillips, 1993). To not marry and not have children is viewed as a further “…move towards achieving non-personhood” (Stafford, 1995, p. 28).

Due to moral contamination, people with mental illness are excluded from participating in renqing, or basic human reciprocity. For example, Hong Kong respondents are overwhelmingly more likely to agree that it “…would not be wise to show any favors” (thus indicating inclusion in one’s guanxi web) to a person with schizophrenia when compared with non-Chinese British respondents (Furnham & Chan, 2004). Stigma in China also quickly moves from the individual to his/her family, which threatens to break the vital connections (‘quanxi wang’) linking families to social networks of resources and life chances. For example, over a majority (54.3%) of 1,491 relatives of schizophrenia patients in China reported experiencing at least some adverse effects from stigma (Phillips, Pearson, Li, Xu & Yang, 2002). The entire social network is further viewed as inauspicious or contaminated, often leading to the expulsion of the offending individual and family to protect the remaining network. Not surprisingly, between 59–69% of patient samples in Hong Kong and Beijing report that stigma leads families to deny or hide the mental illness (Lee, Lee, Chiu & Kleinman, 2005; Phillips & Gao, 1999), resulting in delays and non-adherence to psychiatric treatment ( Lee, Chiu, Tsang, Chui & Kleinman, 2006).

‘Face’ and AIDS in China

The moral weight associated with HIV/AIDS stigma in China is greatly compounded by views common across cultures that immoral behaviors give rise to HIV-positive status. That these moral components supersede even concerns of illness infection is suggested by Mak and colleagues (2006) in their Hong Kong study which revealed much greater stigma in the general population towards HIV/AIDS when compared with tuberculosis and SARS (Mak, Mo, Cheung, Woo & Cheung, 2006). Such moral judgments commonly focus on behaviors perceived to be associated with HIV, such as drug use, commercial sex, or homosexuality. For example, in a separate Hong Kong sample, a significant proportion believed that people with HIV/AIDS were sexually promiscuous (Lau & Tsui, 2005). Further, in a study of pregnant women from Yunnan Province (the province with the highest reported prevalence of HIV), nearly half felt that AIDS was solely a disease of “low class and illegal people” (Hesketh, Duo, Li & Tomkins, 2005). These perceptions are fueled by Chinese media depictions of HIV/AIDS patients as acting in criminal and immoral ways (i.e., as intentionally infecting others; Jing, 2006).

Because of severe moral contamination from such behavior, lian is immediately threatened through depreciation of moral character resulting in potential social exclusion of individuals and families. Since 80% of all HIV/AIDS cases occur in rural regions, the impacts of losing moral face may remain particularly strong (He & Detels, 2005). Moral judgments give rise to stigmatizing community beliefs, with up to 75%–81% of subjects in Yunnan Province endorsing at least some social distance towards people with HIV/AIDS (Hesketh et al., 2005). Because HIV/AIDS stigma also morally stains family members, family ties become threatened, resulting in relatives routinely discriminating against patients- nearly half of a Hong Kong patient sample reported at least a moderate level of discrimination from relatives (Lau et al., 2003). A study of the Dai ethnic minority in rural Yunnan province further revealed beliefs of family contamination in that the bodies of drug abusing (and frequently HIV-positive) family members were buried in separate graveyards so that their evil spirits would not infect ancestors and offspring (Deng, Li, Sringernyuang & Zhang, 2007). Extreme discrimination towards relatives who remain linked to sufferers frequently occurs- e.g., (uninfected) children of HIV/AIDS patients being repeatedly refused schooling (Jing, 2006).

Another area where moral condemnation powerfully impacts people with HIV/AIDS is the healthcare system. Although initially slow to respond, the Chinese government has since initiated free healthcare and prevention programs-- such as the “Four Frees and One Care” policy-- to curb the virus’ spread (He & Ketel, 2005). Despite generally strong legislation that protects confidentiality and guarantees access and equality of treatment, stigma continues to take place during healthcare practice (Yang et al., 2005). That stigma occurs interpersonally despite legislative protection illustrates how loss of moral standing remains key. For instance, doctors in southern China have contested treatment of HIV/AIDS patients as “a waste of medicine on a lowly <or morally contaminated> individual” (Jing, 2006, p. 167). Similar views were endorsed by one health professional sample in Yunnan Province- 30% were “unwilling” and 81% “preferred not” to treat HIV-positive patients (Hesketh et al., 2005). These attitudes also contribute to differential treatment based on practices including (often uninformed) HIV-testing that results in denying treatment services for HIV-positive patients in Beijing hospitals (Yang, 2005).

Fear of loss of face has greatly discouraged individuals from seeking HIV testing; holding stigmatizing beliefs have been associated with decreased likelihood of seeking voluntary HIV-testing (Liu et al., 2005). Effective HIV treatment is further delayed by initial self-treatment through pharmacy visits, subsequent help-seeking at private clinics to protect privacy, finally leading to treatment at public hospitals or STD clinics despite their better quality and lower cost (Lieber et al., 2006). Consequently, of the estimated 840,000 HIV infections in China, only 6% have been tested and recorded (Wu, Keming, & Cui, 2004). Rather than risking intense community (and familial) rejection, the vast majority of those infected remain unaware of their disease status, thus greatly fostering medical noncompliance and transmission opportunities. Undetected cases constitute a growing public health threat in China as reported HIV infections increased from 30% in 2000 to 122% in 2003, and if left unchecked, could grow to 10 million by 2015 (Hesketh et al., 2005; Wu et al., 2004).

A Stigma Model for China

Based on our conceptual analysis and review, we propose a three-layered model (see Figure 1) to conceptualize how societal features of stigma and changes in moral status result in adverse local outcomes in China:

Figure 1
A Stigma Model for China

Societal Factors Influencing Stigma

The top layer of our model consists of societal-level factors. Like other models, we have identified public conceptions (i.e., cultural stereotypes, social hierarchies and sociopolitical ideology- Corrigan and Watson, 2002) and institutional forms of stigma (i.e., structural mechanisms that arise from economic, political and historical sources- Corrigan et al., 2004) as macrosocial factors that determine stigma’s effects in China. Within these structural forms, we highlight the concept of “field”, or structures of capital which Bourdieu (1986) defines as, “…the unequal distribution of capital” (i.e., economic, cultural, and social) and, “…the power to impose the laws of functioning of the field most favorable to <current structures of > capital and its reproduction” (p. 246). From this perspective, how different capital is distributed at a given time represents the configuration of the social world, determining the specific effects of capital as well as the potential success and profits from social-exchange practices. Including this construct highlights how stigma powerfully affects individuals’ capacities to mobilize social capital (i.e., network resources) in China.

Changes in Moral Aspects of Stigma

The second layer consists of changes in the moral aspects of stigma- specifically, losing face or the ‘symbolic capital’ needed to access network resources. Although loss of face occurs simultaneously and inseparably from subjective and collective aspects of stigma, the positioning of moral components as intermediary emphasizes their central role in determining stigma. The potential mediating role of face is further suggested by Mak and colleagues (2007), who report the inadequacy of an attributional model alone in explaining self-stigma among Hong Kong HIV-patients (Mak, Cheung, Law,Woo, Li & Chung, 2007).

Although loss of face exhibits features identifiable from other stigma conceptualizations (Jones, Farina, Hastorf, Markus, Miller & Scott, 1984)- e.g., perceptions of responsibility (that AIDS patients engage in risky behaviors), peril (moral contamination can be transmitted), and concealability (face can be preserved if the stigmatized status remains unexposed), losing face remains phenomenologically distinct from any of these classifications. The precise mechanisms by which a stigmatized condition might lose face in a local setting (e.g., through the above stigma dimensions or local meanings such as those attached with perceived ancestor misbehavior) remain a critical area of investigation.

Changes in Subjective, Collective, and Interpersonal Aspects of Stigma

Because face constitutes a ‘total social phenomenon’ (Mauss, 1967), our third layer comprises three separate but interrelated levels consisting of stigma’s effects on actors in a social world. At the subjective (or individual) level, we propose that stigma is moral-emotional as values-- or moral states-- are linked to affect. Becoming discredited within a moralistic system leads to discrete emotional conditions (e.g., humiliation) as loss of lian (or moral standing) among community others is powerfully felt as shame or humiliation. Further, we assert that stigma is moral-somatic. Societal values are linked to one’s physiology as loss of face has somatopsychic expression. Such physical manifestations have been revealed as one’s face ‘crumbling away’ or as a way of being ‘faceless’ (Kleinman & Kleinman, 1993).

At the collective level, we conceive that stigma occurs between family members and network associates. Loss of lian spans collective experience, as the resulting shame creates a “magnetic field of human emotion” felt by a group which also shapes the individual’s heart-mind (xin; Sun, 1987). For example, public disclosure of an individual’s shame creates a collective subject among those sharing that shame. This collective humiliation can be conceptualized as an interactive process-- with the words, gestures, meanings and feelings occurring between actors (or ‘intersubjective space’-Yang et al, 2007) as essential to stigma as the feelings within each actor.

The interpersonal level of stigma includes all individual-to-individual forms of discrimination, including social distancing and rejection. Our analysis highlights physician and family member stigma as particularly salient in China. In addition, loss of guanxi or social capital- i.e., loss of social opportunities to achieve desired social statuses such as marriage, and diminished access to material resources (via social exchange networks)- also constitutes a crucial aspect of interpersonal stigma. Because loss of face compromises one’s moral standing in a local community and access to social resources, stigma is further seen to directly threaten the interpersonal engagements that define what is most at stake for ordinary Chinese in everyday life (Kleinman, 1998).

Anti-Stigma Interventions in China- ‘Restoring’ Face

With this formulation, we propose to combat stigma via the restoration of face for individuals and families. Rather than recommending macro-level strategies, we instead focus interventions on the local contexts related to moral status. We utilize previous empirical work regarding anti-stigma strategies to inform such interventions (Corrigan, 2005; Thornicroft, 2006; see pioneering work by Phillips & Gao, 1999); however, additional research is needed to tailor our recommendations to specific conditions and locales.

To address the physical and emotional consequences caused by loss of moral status, we recommend what might be termed “re-moralization” counseling that presumes that stigmatized individuals and families have lost moral face (i.e., are ‘demoralized’) and consequently excluded from exchange networks (or face this danger). The first component of counseling seeks to counteract internalized stigma (or ‘self-stigma’; Corrigan & Watson, 2002) and the emotional embodiment of humiliation by replacing notions of moral depreciation (i.e., being of ‘outcast’ or not ‘full’ adult status) with conceptions that even those with chronic illnesses are capable of upholding community obligations and contributing productively to society (Lau & Tsui, 2005). Techniques from therapies to modify cognitive schemata might productively facilitate such change (Corrigan, 2005). To rebuild individuals’ abilities to partake in social exchange, a second component involves ‘coaching’ strategies to reach desired vocational and interpersonal outcomes (e.g., employment, dating; Thornicroft, 2006). Rebuilding moral status, or possessing a “trustworthy and loyal” character, was regarded as important by >80% of a sample of Beijing and Hong Kong employers (Tsang, Angell, Corrigan, Lee, Shi, Lam et al., 2007). Such “remoralization coaching” consists of occupational support to rapidly locate and maintain competitive employment and advice regarding how to cope with common forms of job-related discrimination. Employment will provide individuals the capacity to reciprocate with others and to access social channels that are prerequisite to finding a spouse. Additionally, nuanced strategies of ‘selectively disclosing’ (i.e., occurring on different levels by place, setting or behavior; Corrigan, 2005) a stigmatized status to employers, and potential romantic partners, constitutes a crucial element of this approach.

We also recommend that these “remoralization” strategies are implemented via multiple-family groups which have been used to successfully treat schizophrenia in China (Xiong, Phillips, Hu, Wang, Dai & Kleinman, 1994).6 The first goal is to legitimize the idea that powerful forms of stigma occur among family members (Lau et al., 2003; Lee et al., 2005) and to examine possible stigmatizing responses within each family. Counteracting perceived threats to relatives’ moral standing due to associative or “courtesy” stigma (Goffman, 1963) acts to reduce discriminatory attitudes towards the patient as well as the family’s ‘collective shame’. Mobilizing family cooperation facilitates patient recovery, as relatives aid in the disclosure process, daily activities, financial and medical assistance, and psychological support (Li, Wu, Wu, Sun, Cui & Jia, 2006).

After reinforcing intrafamilial solidarity, treatment then might shift to legitimizing extrafamilial discrimination felt by families (Lee et al., 2005), which is reframed as a form of unjust treatment (Fei, 2005). Along with a clinician, a suitably-trained family member ‘consultant’ (Phillips & Gao, 1999) could co-lead each multiple-family group, and role model successful adaptation to the stigmatizing circumstance. Sharing between families of coping experiences is viewed as a mobilization or empowerment strategy (Corrigan, 2005), whereby shameful feelings are transformed into increased self-worth and enhanced moral standing. Communicating feelings between families also produces embodied ganqing, or human emotion, which reconstitutes a complementary guanxi web to share favors and exchange resources with (Kipnis, 1997) before reentry is renegotiated into one’s primary guanxi network. The reduction of intra- and extra-familial stigma, mobilization of family commitments, and rebuilding of guanxi networks results in raised moral standing, trust, and reciprocity among individuals- constructs linked with facilitating social networks and positive perceptions of health among rural Chinese (Yip, Subramanian, Mitchell, Lee, Wang & Kawachi, in press).

To counter physician stigma, we propose state and local government-sponsored dialogues between people with stigmatized conditions and healthcare professionals to change disempowering attitudes entrenched in healthcare (Corrigan, 2005; Phillips & Gao, 1999). These formal, face-to-face dialogues would provide a non-confrontational forum to discuss how physician actions contribute to the loss of patients’ and family members’ moral status (e.g., infantilization pertaining to schizophrenia). These discourses should target current providers and in particular medical students to counteract stigmatizing attitudes while not fully-formed (Thornicroft, 2006). To maximize efficacy of this contact-based intervention (which has the most empirical support in reducing stigma), stigmatized individuals who moderately disconfirm group stereotypes should be involved in ongoing dialogues that exhibit: 1) equal status between groups; 2) common goals; 3) cooperative efforts and; 4) authorized sanction (Corrigan, 2005). Although substantial cultural barriers (i.e. low government priority towards stigmatized individuals; also, few AIDS and schizophrenia advocacy groups exist; Phillips & Gao, 1999; Jing 2006) work against implementing this approach, initial trials might be developed as experimental interventions at research-affiliated hospitals and subsequently disseminated more broadly.

Face Applied to a Cross-Cultural Understanding of Stigma

Revealed through our analysis of face in China and unacknowledged by previous stigma models, we propose a cross-cultural formulation that stigma also deeply reflects a fundamentally moral process in which stigmatized conditions threaten what is most at stake for sufferers. Losing face, by representing a person’s loss of moral standing, illustrates how stigma is embedded in the moral life of individuals. The upholding and use of face to achieve opportunities for individuals to marry, have children, and perpetuate the family structure constitute core lived values around which many social groups in China revolve. Upholding face thus exemplifies a “moral mode” of experience, or moral experience, which refers to that register of everyday life and practical engagement that defines what matters most for ordinary people in a local world, such as status, money, life chances, health, or relationships (Kleinman, 1998). We conceive of stigma as a fundamentally moral issue of stigmatized conditions threatening what deeply matters for those in a local world who are engaged in a process of gripping life and preserving what matters. Put differently, while stigma affects many life domains, stigma’s lived experience is felt to coalesce around those engagements or life domains that are felt to matter most to sufferers, responders, and observers. In China, the stigmatized find what is held as most dear- moral face- to be seriously menaced. This threat is also felt by stigmatizers, who respond using discrimination as pragmatic responses to what they understand to be real danger to preserving their face. In China, what matters most is upholding face, but the core lived values that define distinct moral worlds in other settings will be locally-constituted (e.g., in local U.S. contexts, these might be the achievement of individual freedoms; Yang et al., 2007). The focus on moral experience reconceptualizes how the social world shapes stigma by allowing a more adequate understanding of the behaviors of both the stigmatized and the stigmatizers, for it allows us to see both as interpreting, living, and reacting to what is most at stake and what is most threatened.

Our analysis also highlights stigma’s impact on the individual’s ability to mobilize sources of social capital. Other than Kurzban & Leary (2001) who emphasize poor capacity for social exchange as a reason for stigmatization, the links between stigma and social capital remain largely unarticulated. The ‘social support’ conceptualization of social capital and health- whereby one’s ability to draw upon resources through connections is central to objective and subjective welfare (Kawachi, Kim, Coutts & Subramanian, 2004)-appears most relevant to stigma. The literature linking perception of low SES with prolonged states of anxiety and arousal, ultimately resulting in long-term health problems, might fruitfully be applied to stigma (Wilkinson, 1996). Because loss of social capital appears to be a significant determinant of health care access, mental health, mortality, and health status (Szreter & Woolcock, 2004), this construct also suggests an important pathway to explain stigma’s effects. For example, stigma might affect mental health by endangering access to both ‘structural’ (i.e., institutions that provide treatment services) and ‘cognitive’ (i.e., trust that increases feelings of security) aspects of social capital (Harpham et al., 2002). Future studies might also specify how stigma threatens entitlement to specific material or informational resources and the ability to gain from them, capabilities which are commonly mediated through one’s social connections. Although the loss of guanxi provides an especially vivid example, we propose that our analysis of how stigma adversely affects mobilization of social capital in China may extend to other cultures, particularly when network- and connection-based exchanges occur more frequently as opposed to where capitalist and marketplace transactions predominate.

Conclusion

Our central concern is that stigma be reconceived as a moral process. Through our analysis of face and stigma, we propose that moral status, and the effects that stigma has on limiting social capital, be viewed as crucial to empirical research aimed at better understanding the sources and consequences of stigma. Further, we propose that efforts at destigmatization be developed to improve moral status so that evaluation studies can determine if this stigma approach can benefit policy and programs both within China and in other cross-cultural settings.

Acknowledgments

The preparation of this manuscript was supported, in part, by National Institute of Mental Health grant K01 MH734034-01, which has been awarded to the first author. The authors thank research assistant Kathleen Janel Sia for her aid with the literature review and formating of the manuscript.

Footnotes

1Fei describes families as “small lineages” to illustrate how the nuclear family is but one circle among a structure of multiple concentric social circles and to underscore the inherent long-term continuity of Chinese families.

2Yang (1994) also presented guanxi networks as an informal redistributive power that opposes the universalistic distributive ethics of the socialist state.

3Social face, or mianzi, represents one’s social prestige gathered via personal effort or strategic maneuvering and is based entirely on external evaluations (Hu, 1944).

4Theorists debate whether social capital can more accurately be described as a property of the social structure or of individuals within the social environment. To depict guanxi dynamics in China, we utilize Putnam’s (1993) view that social capital can be conceptualized at a relational level- that it is a property of individuals but only due to their association with a group (Szreter & Woolcock, 2004).

5Loss of mianzi (diu mianzi) results from neglecting a social convention that does not impugn one’s character and produces milder shame. Losing moral face (lian), however, causes complete loss of social face (mianzi).

6To treat individuals abandoned due to stigma, we recommend establishing government-funded shelters for such persons to receive psychological and medication counseling, vocational training, peer support, and to share in a “family concept”. Reconciliation with families can be attempted after 3–6 months after patient stabilization (such as among AIDS patients in Malaysia; Edwards, 2007).

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Contributor Information

Dr. Lawrence Hsin Yang, Columbia University New York, NY UNITED STATES.

Arthur Kleinman, Harvard University, ude.dravrah.hjw@namnielk.

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