This central question has been given a variety of answers. Goffman originally argued that it occurred because of some threat to orderly social interaction. From a sociological point of view, deviations from predictability in social encounters pose a threat to the smooth running of society and there is some evidence that this is part of the answer (Albrecht et al., 1982).
Another possibility involves attribution theory, particularly beliefs about the cause of the condition (Weiner et al., 1988). It seems that people are more likely to be stigmatised if they are seen as having control over the onset or maintenance of their condition (Weiner et al., 1988; Crandall & Moriarty, 1995; Martini & Page, 1998). This idea is particularly relevant to understanding the stigmatisation experienced by people who have nicotine or alcohol dependence, but perhaps also to acne since there is a widespread belief that a poor diet and an unhealthy lifestyle can contribute to its development. The Just World Hypothesis is related to attributions. This is the notion that negative events occur to people because of retributive justice for their actions (Lerner & Miller, 1978). That is, people get what they deserve; if someone has a skin disease they must have done something to merit their appearance.
Another approach to understanding stigmatisation is based on the 'beautiful is good' stereotype. There is considerable evidence for the suggestion that attractive people are viewed differently than unattractive people (Dion et al., 1972; Eagly et al., 1991). Attractive people tend to be seen more positively on a wide variety of dimensions, including intelligence, warmth and social competence, a view that develops in children while they are quite young. The notion that the converse also holds (i.e. that people with disfiguring conditions are perceived as 'bad') has not been tested directly, but media and literary portrayals that often equate evil with such skin conditions as scarring would suggest that a connection of this kind is often made.
It seems likely that all of these ideas have power in explaining stigmatisation across a variety of conditions. A common thread throughout is the possibility that a person with a mark poses some kind of threat to personal or social well-being. There might be a threat to orderly social interaction, perhaps, or that a person is in some way responsible for their condition and should therefore be ostracised as punishment. These beliefs could be operating out of consciousness and awareness.
For dermatological conditions, however, there could be a more direct type of threat - a threat to physical health. There is a growing consensus that stigmatisation has an evolutionary origin because, in our species' past, avoidance of potential threats had advantages for survival. The evolutionary explanation has been outlined by Kurzban and Leary (2001). They argue that this approach to stigmatisation provides a parsimonious and elegant explanation over a wide range of conditions and behaviours, but it might be particularly relevant to skin conditions. As noted above, people with psoriasis and vitiligo can often cite instances when someone avoided making physical contact or touching any object they have used. Such examples lend themselves to understanding stigmatisation and rejection of those with skin conditions in terms of potential contagion. Many people with vitiligo and psoriasis complain that others often do not understand the nature or causes of their conditions, and assume that they might be 'catching'.
Rozin and Fallon (1987) summarise their view that disgust has an evolutionary origin, designed to protect the person from contamination. Their analysis includes a description of the typical expressions of disgust - a characteristic facial express and physical distancing - mirroring the reactions reported above. Rozin and Fallon argue that disgust develops during the first 8 months of life.
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