The Impacts of Stigma on People with Disabilities: A Systematic Review

. Disability stigma has become a popular research topic in the past twenty years. Researchers find people tend to hide their disability to avoid stigmatization. This study systematically examines the impacts of stigma on people with disabilities. It offers a theoretical foundation for establishing effective interventions to reduce the disability stigma in the future. The paper searches articles related to the impacts of disability stigma through the online database, then analyzes the impacts of stigma on disabled people through social access and support, life experiences, and psychological perception. Findings indicate that stigma has negative impacts on disabled people’s social access and support, life experiences, and psychological perceptions.


Introduction
Disability stigma has become a popular research topic in recent years.Many studies indicate that individuals may attempt to hide their disabilities to avoid potential stigmatization [1][2][3].Stigma has been found influenced their disclosure decisions, engagement, and willingness to accept support [2].Individuals with physical and intellectual disabilities are in a challenging setting: they face stigma and barriers in their daily lives, and develop various symptoms, which prevent them from receiving accommodation and social support to change their living environment [4].Inequalities at the macrolevel are played out in micro-level interactions, which in turn strengthen inequalities at the macrolevel [5][6].
Former studies have shown some effects of disability stigma, yet their analyses are disorganized and lack structure.Some articles investigate the impacts of disability stigma on health care and employment; others suggest stigma impacts community inclusion and disabled people's psychological well-being; and the others focus on internalization of stigma, etc.These findings are separate and unclear.Studies for people with physical disabilities (PD) have established robust theoretical frameworks in the past decades of years, yet researchers rarely included impacts of stigma with PD.Therefore, studying for impacts of stigma on PD is still meaningful.Although disability studies in the past two decades focus on intellectual disabilities (ID), the analysis of influences of stigma on ID is still not exhaustive.
Given the detrimental effects that social stigma has on the lives of those living with PD and ID, it is necessary to understand the significance of stigma, and conduct a comprehensive analysis of the influences of stigma on disabled people.This paper develops an overview of the impacts of stigma on individual with physical and intellectual disabilities.It explores the disability stigma in a systematic manner, which offers a theoretical foundation for establishing effective interventions to reduce the disability stigma in the future.
The concept of stigma is broad and culturally variable, which depends on its attached conditions and historical or social norms.The earliest definition of stigma is from Ervine Goffman, who defined stigma as the public's perception of a person who is "seriously discredited within a particular social encounter" due to an attribute that fails to fulfill societal norms [7].Some scholars developed this theory and expanded upon conceptualization and dimensions of stigma.Herek defined stigma as negative regard, low social status and relative powerlessness given by the social collective to people with specific characteristics or belonging to specific groups [8][9].Other social psychologists have posited that stigma is made up of cognitive, psychological, and behavioral aspects, such as discrimination, prejudice, and biases.Misconceptions and generalizations about a stigmatized group inevitably lead to bias and discrimination in some form or another [10][11].This paper explains stigma as perceived negative attributes or consequences associated with disability, such as health, appearance and ability.Although there may be some overlap between stigma and stereotype, the research distinguishes these two constructs that stereotype can be explained as favorable or unfavorable (e.g.diligent or lazy).In contrast, stigma is always unfavorable [12].People are shown to experience structural stigma when societal circumstances, cultural norms, and institutional rules limit the opportunities, resources, and well-being of people in their society [13].These conceptualizations of stigma facilitate the development of disability stigma.
Disability is an outcome of social construction.People with disabilities may have limited capacities, not because of intrinsic limits, but because they live in a "disabling environment" generated by impediments to social engagement that are created by social circumstances [14].In other words, their "disability" is caused by a socially constructed environment.The disabled are viewed as abnormal by the public, and institutional barriers prevent them from obtaining opportunities or improving their social standing.According to the Social Model of Disability, the fundamental causes of the disadvantages disabled individuals face are not their physical impairments or the disparities in their bodies, but rather the barriers they face in the social and economic environments [15].According to Shakespeare, disability is defined as restrictions on social activities generalized by social organizations, which do not consider people with functional impairments and therefore exclude them from mainstream social activities [16].Intellectual disability refers to an individual whose intellectual function is significantly lower than the average level (IQ is lower than 70) and accompanied by impairment of adaptive function [17].People who have a physical or intellectual disability are highly stigmatized by society.In reality, according to the Social Model of Disability theory, stigmatization of people with disabilities is common in Western countries due to the structure of industrial capitalism and the construction of reliance and independence [18].
Researchers have long realized that the visibility of disability or the age at which disability is acquired may affect the psychological status and social standing of disabled people [19].In 1948, Lee Meyerson wrote in his book the 1948 JSI, "disabled are not in physical, but in societal and psychological level" [20].Given that disclosure of disability is required to receive support, not only with a physical disability, but people with intellectual or invisible disabilities tend to conceal their disability due to fear of discrimination and perceived negative outcomes [21].They experienced abuse or rejection from society, and finally internalized the stigma or tainted label on themselves.When people with internalized notions of what disability entails are diagnosed with disability, these notions may have negative psychosocial repercussions [14] [22].
To advance knowledge of effects of stigma on PD and ID, this study started the investigation by searching online databases such as Ebsco Host, ResearchGate.net,Elsevier, Taylor & Francis Online, Taylor & Francis Group, ERIC, Science Direct, Springer Link, Semantic Scholar, Google Scholar, Sage Journals, and ProQuest to identify research published on disability stigma.The keywords used in this search were physical disability, intellectual disability, people with physical disabilities, people with intellectual disabilities, stigma, internalization of stigma, impacts of stigma, impacts of stigma on people with disabilities, impacts of disability.There are 27 articles included in this investigation.

Stigma Effects On Disabled People
Articles in this search demonstrate many influences of disability stigma.However, no published study has rigorously examined this body of knowledge.This discovery analyzes and summarizes impacts of disability stigma into three aspects--social access and support, life experiences, and psychological perceptions.Articles used in analyzing the impacts of disability stigma are listed in Table 1.

Social Access and Support
The findings indicate that disability stigma may impact individuals' employment, resulting in employment discrimination against disabled individuals [6] [21] [23][24][25][26].Beliefs in mainstream society view them as "helpless", "dependent", "possessing limited abilities", or only be employed in specialized workshops [6] [23] [25].A study reveals that only about 15 percent of Americans with developmental disabilities hold paid, and community-based employment [6].In addition, disabled individuals are less likely to get high-quality health care and have higher risks of experiencing health issues than the general population [5] [17] [23][24][25].Many studies investigate that stigma may impact the learning of disabled children through low quality of education, perceived negative attitudes from teachers or peers, and institutional stigma such as lacking policy protection for students who are disabled [21] [23-24].Research also finds that stigma will lessen disabled people's access to civil rights, safe housing, and raise the risk of poverty [5] [18] [24][25].Although there are many consequences of disability stigma, they all have the same characteristic: individuals are rejected by the opportunities for social and economic development, and their rights are not realized.Therefore, these stigma impacts can be summarized as social access and support aspect.Stigma prevents individuals with disabilities from obtaining better social support and limiting access to social resources to change their life.

Life Experiences
Studies indicate that people with disabilities have much less community integration and engagement compared to those without disabilities [23][24][25].Disabled people are excluded from the community because they look different from dominant groups or are perceived as threatening [23] [27].The ability of participating community leisure activities is essential to integrate into their living environment.However, people with disabilities have a greater propensity to limit their engagement in leisure activities because of fear of being teased and mocked [23][24].In addition, impaired body or childlike behavior may lessen the possibility of developing an intimate relationship in disabled people [18] [24] [26].It is difficult for them to attract and find an ideal spouse.They are less likely to have the autonomy to make decisions because their supervisors or family will make decisions for them.They are always conceived incapable of self-determinization [24][25].It is clear that the impacts aforementioned are about personal experiences for people with PD and ID.This study claims that stigma will negatively affect the life experiences of disabled people.

Psychological Perceptions
The discovery indicates that stigma has detrimental influences on psychological well-being and quality of life to disabled people [3][4][5][6] [18] [25] [27].It makes individuals vulnerable to mental health issues and increases rates of depression and psychological distress [5] [21].They are experiencing high risks of mental health issues.Also, this search discovers internalization of stigma in people with disabilities.Individuals with disabilities internalize prevailing negative attitudes, tend to hold negative judgment of their disability, and finally develop an unhealthy sense of themselves [3][4][5][6] [21] [25][26][27].This internalization is correlated with sense of shame, depression, and demoralization, which induces diminished individuals' self-esteem and self-worth [21] [26].They stigmatize themselves, and hide their disabilities to avoid potential stigmatization, although the disclosure of disability is essential to obtain social support [3] [21].The environment of unfavorable attitudes isolates individuals with disabilities, which increases the likelihood of mental illness and decreases the likelihood of developing a healthy self-perception and psychological health [3].These pieces of evidence reveal that stigma may induce unfavorable outcomes for psychological issues of disabled people.The impacts of disability stigma in this demonstration are all about psychological feelings, recognition, and perception.Thereby, they can be categorized as psychological perceptions.

Conclusion
This paper categorizes the impacts of stigma into multiple aspects, concluding that stigma negatively impacts disabled people's social access and support, life experiences, and psychological well-being.Studies on the impacts of disability stigma mention many consequences: employment, health care, education, access to civil rights, safe housing, poverty, community participation, leisure activities, intimate relationships, autonomy, psychological well-being, mental health, and internalization of stigma.Although previous discoveries regard tens of consequences of disability stigma, there is no comprehensive examination in this field.Those stigma influences have similar features that can be generalized into the same aspects.This paper provides a new perceptive analyzing disability stigma.Influences of disability stigma in employment, health care, education and school experiences, access to civil rights, poverty, and safety of housing are summarized as social access and support.This is because theses impacts have a common feature: individuals with PD and ID are isolated and rejected by social and economic opportunities, which will lessen their potential to change their living environment or achieve social mobility.Community participation and integration, leisure activities, intimate relationships, self-determination and autonomy are included in the analysis of life experiences because they closely relate to personal feelings and experiences living in society.Psychological well-being, mental health, and internalization of stigma are all about individuals' psychological reactions to stigma, such as feelings, psychical recognition, and perception.Thus, this study classifies them as psychological perceptions.
This study establishes a systematic overview of influences of stigma on people with physical and intellectual disabilities.Discovery suggests that stigma has impacts on disabled people's social access and support, life experiences, and psychological perceptions.It provides a theoretical basis for the establishment of successful treatments to lessen the stigma associated with having a disability in the future.Future studies can advance this body of language and expand the field of impacts of disability stigma into social, personal, and psychological level.

Table 1 .
Impact of stigma for PD and ID Number of papers Context of the impacts