Stigma respecified: Investigating HIV stigma as an interactional phenomenon

Abstract In this paper, I discuss stigma, understood as a category which includes acknowledged, enacted degradation, discreditation and discrimination. My discussion begins with an analysis of HIV stigma, as discussed in a social media post on Twitter. I then analyse a fictionalized clinical stigma scenario. These two analyses are undertaken to highlight aspects of the conceptual anatomy and interactional dynamics of stigma and by extension shame. Brief social media declarations and short, fictionalized clinical interactions are rich with information which helps us understand how stigma—degradation, discreditation and discrimination—is operationalized in interaction.

shame here is internal. What this means is that where shame has stigma-degradation, discreditation or discrimination-as its object, as what it is about, then that stigma is part of what shame is; it becomes part of the meaning, part of the content, of one's shame. To lay it out: the term 'stigma' denotes a category of acknowledged, enacted discreditation, degradation and discrimination, and these phenomena are internal to the meaning of the shame one experiences when stigmatized.* In testifying to the relationship between shame and stigma, Matthew Hodson's tweet goes further; his tweet is making a declaration: he is/will be, 'open, proud and brazen even' about his HIV status and this will serve to deny shame a foothold. Pride is the antonym of shame, and Matthew Hodson is asserting pride in his status as a man living with HIV. Shame is characteristically associated with withdrawal 3 and closing oneself off from the social world, and Matthew Hodson is declaring openness, and doing so in a public social media post. Finally, we have the commitment to be 'brazen', a word for which shamelessness is often listed as a synonym. So, Matthew is declaring that he will resist attempts to discredit or degrade him based on his HIV status; he will refuse to acknowledge discriminatory interactions as reflective of his status as a person.
Matthew is asserting his agency, his commitment to exercise control and affirm his worth.
One way of unpacking this is to observe that social phenomena, such as discreditation, degradation and discrimination are interactionally produced and that members of situations, of social or interactional contextures, are those who, through their interactional work, produce the phenomenon. Matthew Hodson is asserting that he will resist taking a role in the production of stigma, by being open, proud and brazen about his HIV. This leads to a third observation that we can make about the tweet. In addition to highlighting for us the internal relationship between stigma and shame and his commitment to reject stigma and shame by affirming his pride, openness and brazenness, Matthew Hodson's short tweet also testifies to how stigma, as a category term for acknowledged, enacted discreditation, degradation and discrimination, is not about discrediting or degrading attributes, where the attribute is understood to have fixed or invariant (discrediting or degrading) meaning. Rather, the attributes which are the locus of shame and stigma are indexical; that is to say, their meaning is connected to, is indexed to, how they are operationalized in particular contextures, in interactionally constituted situations, in which one participates. HIV isn't invariantly degrading or discrediting, it is so, where it is, only when it has been operationalised as such. Matthew Hodson recognizes he has input into these interactionally produced contextures and therefore to the meaning his HIV has. He is declaring that he will challenge attempts to depict his HIV as discrediting, degrading or as grounds for discrimination and will proactively proclaim his HIV as a source of pride and as status-affirming.
HIV is stigmatizing, when it is, because of how it is oriented, and how its meaning is locally produced and fixed, in specific interactional situations. These situations have the character of Gestalt contextures, where the meaning of the situation is constituted by the actions of those comprising the situation, while those actions have the sense they do as parts, or constituents, of the situation. † One goal for us, as stigma researchers, is to recover how, and in what ways, HIV is operationalized to be stigmatizing and elicit shame.
What needs to be in place for that to happen? In seeking to do this, we could do much worse than learn from those such as Matthew Hodson, by studying the day-to-day work of resistance, reframing and status affirmation they undertake.
The final point contained in Matthew Hodson's tweet that I shall discuss is the claim that 'fear and ignorance lead to stigma'. While this is another important insight contained in the tweet, I want to use it to also make a case for exercising caution. Undoubtedly, some of the degrading, discrediting and discriminatory attitudes and behaviour directed at a person living with HIV are based on fear and ignorance and it is therefore important to take steps to combat this. However, it is also important to recognize that such a strategy alone will not eradicate stigma because there are instances of degrading, discrediting and discriminatory behaviour which, a. aren't intentional or deliberate. For example, there are cases where the stigmatiser does not intend to and nor are they deliberately stigmatizing; indeed, a person might act to degrade another yet be sincerely shocked and remorseful in finding that their actions were experienced as degrading, and b. even where the stigmatization is intentional or deliberate it might not be based on ignorance of facts but rather based on a value judgement made with disregard, ambivalence or contempt for the facts about HIV prognosis and transmissibility. Status-degrading interactions might be interactions driven by (negative) value judgements of one party to the interactions, and value judgements can be and often are formed with indifference to facts. Motives for discrimination might turn out to be fact-free, prejudice-based hostility toward people with different lifestyles, taking sides in a culture war, the enactment of moral mythologies, convenient 'sticks' to beat people with to obtain a social advantage, tribalism, opportunistic ways of expressing anger, attempts to gain advantage or power over an interlocutor, and such like. *This is a point about the relationship between an emotion, such as shame, and its object (what the emotion is about), such as (but not exclusively) stigma; I am not seeking to provide a definition of shame, much less define shame as always having stigma as it's object. Stigma features prominently as the object of shame, but it is not exclusively the object of shame. Where stigma is the object of shame, the relation between shame and stigma is not external (e.g., causal) but internal (meaning). What is being argued is that where shame has stigma as its object, then that stigma-the discrimination, discreditation or degradation-is part of the meaning that shame has for the person experiencing it. † This idea can be traced to Harold Garfinkel's work, 4,5 in which he conceives of social phenomena as interactional or praxiological Gestalts. The same logic can be discerned in Ludwig Wittgenstein's idea of language-games. 6 The key point is that there is a kind of synergy between the identity or meaning of the whole and the meaning of the constituent acts or utterances. So, we make the basic contextual point that my actions might be stigmatising in one situation but not in another and then show that the context, the situation, is itself a contexture, which is co-constituted by the interactions of the members of that contexture.
So, while combatting ignorance of the facts about HIV is both important and will go some way towards reducing HIV stigma, eradicating ignorance will not eradicate stigma. Discrimination is not exclusively based on ignorance of facts because facts often don't feature at all in discrimination. Discrimination is often based on a fact-free negative evaluation. Indeed, in some cases, even where putative facts (or factoids) do feature in an attempt to justify degrading or discrediting behaviour they do so in a way which is secondary to, or in service of, the (priorly embraced) values; so, the (negative) evaluation frames, filters or distorts the (putative) facts that are appealed to. Put another way, even where ignorance is a feature of stigma, that ignorance can be willful ignorance motivated by values. To address willful ignorance we need to address it at the level of the motivating values that underpin that will to ignorance.

I began with Matthew Hodson's tweet not only because in a few
short sentences it captures a number of the issues that I want to discuss but also to show that these distinctions are there to be found in the conversations, interactions and declarations one finds 'in the wild'. We do not need academic theories that define stigma, we need to look carefully at how people who are subject to stigma negotiate, combat, communicate about, challenge, avoid and make witnessable their experiences of discreditation, degradation and discrimination.
We don't need uniquely academic analyses of structural stigma, we need rather see how structural discreditation, degradation, discrimination, bias and so on are operationalized and made manifest in interaction. Furthermore, we need (much) more than surveys of stigma, which at best give us a very rough idea of the prevalence of stigma in society. These are of little use. We need to understand the conceptual anatomy and the interactional dynamics of stigma, by focussing on interaction.
In what follows, I will analyse a stigma scenario, with a view to exploring the interactional dynamics and conceptual anatomy of stigma. Before I lay out the example and conduct the analysis I will say a little about the method I am employing.

| EXAMPLES, CASE STUDIES AND SITUATION ANALYSIS
My practice in what follows will take the form of Situation Analysis, an approach which Doug Hardman and I are developing together 7 which is derived from the philosophical method of Frank Ebersole. [8][9][10] I take this to be a companion to the philosophy-as-case-studies or fieldphilosophy of Harold Garfinkel 4,5  The purpose of pursuing this method is to find the sense in certain words and actions as part of a situation when that sense might be in question. This is an art, not a science; our examples are not there to serve as evidence to settle matters, much less to prove a hypothesis, but as resources for reflection and as 'objects of comparison'. 6

| OUR EXAMPLE/CASE STUDY
The following example is a fictionalized example.
A patient, Karolina, visits the doctor for an appointment for breathing problems. The patient is not new to this Health Centre, but today's doctor, the GP, is new to this patient. The first minute of the consultation has gone without anything of note occurring. Following initial greetings, the exchange is polite and unremarkable. Both patient and doctor seem to be conversing naturally, as would be expected in such a setting, and a rapport seems to be developing. The situation is mundanely social-two people who've not met before are interacting politely so as to communicate effectively. They take turns in speaking, questions elicit answers, and smiles, nods and audible 'mmmm's are used to indicate each is listening to the other, without interrupting.
In addition to being mundanely social, the interaction has some institutionally specific features-it is taking place in a health centre during clinic hours, in the presence of paraphernalia that exhibits this: the room contains an examination table, clinical waste bins, the doctor is wearing an NHS lanyard and ID card. Moreover, the doctor is sat in front of a PC, and, as the patient enters, invites them to take a seat on a chair adjacent to the PC and so on. In addition to these situational features, the conversation in and of itself exhibits the difference in roles, or membership categories, 12,13 of the two participants. The conversation, in its unfolding, indicates that one person has experiential authority: that is, the patient is the authority on the experience of the symptoms, which is exhibited in the form the conversation has, the types of questions the patient asks and the type of questions asked of her. Equally, the conversation indicates that the other party has medical authority: that is, the doctor has medical training which confers authority in this situation on how to interpret the patient's reported experience of the symptoms and arrive at a diagnosis, and this is exhibited in the conversation by the kinds of question the doctor asks, HUTCHINSON | 863 the kinds of questions asked of her by the patient and the kinds of answers the patient provides. The roles, or membership categories, are co-constituted by and exhibited in the interaction. This segues into our final observation about the situation, and that is that there is a witnessable goal-or achievement-orientation, observable in their interaction-the patient exhibits that they want a diagnosis and treatment to relieve their symptoms; they also want to understand what it is they are experiencing. The doctor wants to provide this, in the time allotted for a consultation. We read this off the institutional context: the patient is attending an appointment at a GP surgery, but we can also recover this information by close attention to the conversational exchange. Such as the doctor's greeting including the question 'so what seems to be the problem today' and so on.
Two minutes into the consultation, things change and understanding why they do so and making sense of the actions that both immediately precede and take place after proceedings have taken this turn will serve as our topic of investigation.
After the opening greetings and a couple of minutes or so of polite interaction, the doctor, smiling, glances at the screen, and then begins to turn as if to re-engage in conversation with Karolina before appearing to hesitate and returning focus to the screen. The doctor's smile drops momentarily, and she seems to be distracted or absorbed by what she is looking at on the screen, before re-initiating the turning in her chair to face Karolina. Concurrently, Karolina seemed to notice the doctor was about to re-engage and was therefore preparing for re-engagement herself, as the doctor began to turn; only this re-engagement action was discontinued as she saw the doctor break off to return to the screen. As the doctor turns from the screen the second time and re-initiates the conversation, she

| SEEING AN ACTION UNDER AN ASPECT: THE MEANING OF PUTTING ON THE GLOVES
The mundane sociality and convivial rapport observable in the first 2 min gives way to discordance and trouble. We can observe, from the example, that Karolina's anger and the social discord were immediately preceded by the doctor's attention being seemingly grabbed by something on the screen, this causing her to break off and initiated re-engagement and then by her beginning to put on the latex gloves. What comes after is discordance, because while the doctor seems to proceed as if there is no change in circumstance, or where each note is heard as part of the melody and as pregnant with the notes which follow. This is a familiar 'tune' for Karolina, one she has heard many times before.
The patient sees the doctor putting on gloves as degrading her; the sequence of three actions that culminate in this relates to a newly established Gestalt contexture, of establishing new rules and therefore a new language-game, where the action of putting on gloves, in this language-game, is seen as 'putting-on-gloves-as-protection-from-youbecause-you-have-HIV'.
The doctor sees the putting on of the gloves as a routine part of her own medical practice: she is simply putting-on-gloves-forroutine-examination. The same behaviour has a different sense; there is discord. It can be tempting here to ask which comes first the contexture or the act, the language-game or the action as a move within it, but this is a misguided question. Seeing the action as a precautionary act directed at this patient's HIV status rather than as a routine act is also to establish a new contexture, at the same time.
The question as to who has seen the action correctly here is academic, because in the world the harm is done. This would be like saying that seeing the Jastrow duck-rabbit picture ‡ as a duck and not as a rabbit is the correct way of seeing it because you have ducks at home, had duck eggs for breakfast and have never seen line drawings of rabbits before. Sure, these serve to clarify to us why you see it as a duck, but they do not carry over to general claims about the right way to see the picture. Put another way, the question of intent is irrelevant to the question of the reality or objectivity of acknowledged, enacted degradation.
We could go into more detail about this example, we could talk about how we might discuss questions about such things as the responsibility of the doctor to anticipate and seek to block the emergence of this contexture by always explaining why they are putting on gloves before doing so, or by giving an account as to what took their attention on the screen. If we had AV data, perhaps we could do even more work (though not necessarily). However, the point I want to make is that for something to be an enacted degradation the action needs to have that sense and be acknowledged as such by the person experiencing the degradation. The sense emerges from the internal, or meaning, relationship holding and being acknowledged between the identity of the specific action, which is the doctor putting on gloves as protection against this patient's HIV, and the identity of the Gestalt contexture, as an interaction in which one's HIV status is the motive for behaviour. This relationship is established as the actions are, sequentially, reconstituting the Gestalt and the Gestalt is the pattern or form of which those actions are seen as parts. What we see in acknowledged, enacted degradation, discreditation and discrimination, where the degrading act was not deliberate or intended, can be understood by our seeing the divergence of contextures take place in the interaction. To see the emergence of the contexture which enables the degradation or discreditation, one needs to see it from the perspective, under the same aspect as, the person degraded and discredited, to the extent that this is contexture forming. In terms of our talk of this in terms of meaning, you must be alive to the meaning relations that are in play for the person who has been degraded or discredited. This certainly demands you must see the situation via the concepts available to the participants. It also might mean that you need to have some degree of unique adequacy, 5,14 such that you see the internal relation between, for example, HIV and status-degradation. If you don't, if, for example, you think HIV is just a virus like the common cold and do not know the grammatical relation between HIV and fear, generated over decades by public health messaging that employed fear tactics, then you will be unable to see this relationship in situations like we've discussed here. What we generally refer to as stigma is a complex category of phenomena and we need to understand the interactive dynamics of those phenomena if we are to address stigma. In many cases, self-degradation, anticipated discreditation and nonintentional degradation are a big part of the problem and serve as the scaffold or support for the more commonly discussed degrading, discrediting and discriminatory acts, which are, perhaps, morally motivated, and intentional. I chose as my example in this paper a degradation in which there was no intention to degrade and no ignorance about HIV on the part of the person who performed the degrading act, so as to emphasize the extent to which such instances of stigma are to be found and might even be pervasive. This should help us guard against the widely-held view that stigma-degradation, discreditation and discrimination-is (always) caused by ignorance and the solution to, say HIV stigma, will be found solely in education campaigns. Hodson who graciously said he was happy for me to use his tweet in the way I do.

CONFLICT OF INTEREST
The author declares no conflict of interest.

DATA AVAILABILITY STATEMENT
Data sharing not applicable to this article as no datasets were generated or analysed during the current study.