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Eating Disorders
The Journal of Treatment & Prevention

ISSN: 1064-0266 (Print) 1532-530X (Online) Journal homepage: http://www.tandfonline.com/loi/uedi20

Including the excluded: Males and gender
minorities in eating disorder prevention

Leigh Cohn, Stuart B. Murray, Andrew Walen & Tom Wooldridge

To cite this article: Leigh Cohn, Stuart B. Murray, Andrew Walen & Tom Wooldridge (2016)
Including the excluded: Males and gender minorities in eating disorder prevention, Eating
Disorders, 24:1, 114-120, DOI: 10.1080/10640266.2015.1118958

To link to this article: http://dx.doi.org/10.1080/10640266.2015.1118958

Published online: 15 Dec 2015.

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THE LAST WORD

Including the excluded: Males and gender minorities
in eating disorder prevention
Leigh Cohn, Stuart B. Murray, Andrew Walen, and Tom Wooldridge

National Association for Males with Eating Disorders, Naples, Florida, USA

By operating under the outdated premise that eating disorders (ED) predo-
minantly affect females, prevention efforts have been disproportionately
aimed at girls and young women. This article will show how one-sided the
research and program development has been, and present recommendations
for how to expand curricula and policy to be more gender inclusive.
Ultimately, ED and related issues (e.g., body image dissatisfaction, obesity,
comorbid conditions, weight prejudice, etc.) cannot be expected to decrease
unless everyone is involved, regardless of gender. We wouldn’t only inoculate
girls for measles—preventing ED across the board is the only fully effective
approach.

Adolescent girls: The face of a disorder

Try telling a stranger that you specialize in “males and eating disorders,” and
the typical response is, “You mean like those poor starving girls. I didn’t
know guys got eating disorders.” It’s infuriating, but somehow worse when it
is members of the ED field thinking that way. This kind of ignorance starts
with inaccuracies. Since the 1980s, the oft-repeated, not-cited statistic has
been that 10% of individuals with ED are male. Erroneous to begin with, the
number originated from a study that counted 241 people referred for ED at
one hospital over a period of 3.5 years, prior to 1985. Twenty-four were
males, some of which didn’t meet ED criteria, but because it wasn’t clear how
many of the women fully met the criteria, the 10% is somewhat vague
(Andersen, 1985). The figure does not represent other treatment providers’
admissions or the general population, and it was not replicated. Further, few
physicians or members of the general public knew much about ED in the
early 80s, and the admissions in those years predated the field’s emergence
that soon followed. It is likely that the actual male prevalence at that time was
much higher, as became evident in later studies.

Nonetheless, 10% has been parroted in books, professional articles, on ED
organizations’ websites, and in popular media for the nearly 30 years, and it

CONTACT Leigh Cohn Leigh@gurze.net Eating Disorders: The Journal of Treatment and Prevention, P.O. Box
2238, Carlsbad, CA 92018, USA.

EATING DISORDERS
2016, VOL. 24, NO. 1, 114–120
http://dx.doi.org/10.1080/10640266.2015.1118958

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has minimized the drive for gender equality within the ED field. Usually, the
National Eating Disorders Association (NEDA) is attributed as the source,
because up until 2015—when Leigh Cohn updated their website’s statistics
on males—they published this prevalence figure, although without a refer-
ence. Had anyone dug deeper, they would have discovered that, not only was
the 10% figure dated and misrepresented (instead of referring to males in
treatment, as the study indicated, sometimes it is incorrectly used to indicate
general prevalence), it was also always wrong for reasons that persist today.
Oftentimes, men do not seek treatment because they are reluctant to ask for
help; but beyond that, they are consistently stigmatized by the idea that they
might have an adolescent girl’s problem. Men and boys are less educated
about ED, so they might not even consider that their behavior (e.g., extreme
weight loss, purging, binge eating, compulsive exercise, etc.) is on the ED
spectrum. They might actually suffer from a diagnosable ED and think that it
is normal behavior. In one study, male patients with anorexia nervosa
emphasized the lack of gender-appropriate information and resources for
men as an impediment to seeking treatment (Räisänen & Hunt, 2014).
Additionally, assessment tests underscore males because they have been
written for females (Darcy & Lin, 2012). For example, the Eating Disorders
Inventory has a question, “I think my thighs are too large,” which resonates
far less for men than women, whereas the Eating Disorders Assessment for
Males (EDAM) uses a statement “I check my body several times a day for
muscularity,” which is more oriented toward the concerns of males (Stanford
& Lemberg, 2014). However, the EDAM was not available back in the 80s
and the EDI was the standard. So, let’s forget about that 10% number once
and for all!

The best data available (Hudson, Hiripi, Pope, & Kessler, 2007) indicate that
males account for 25% of individuals with anorexia nervosa and bulimia
nervosa and 36% with binge eating disorder. Further data from pre-adolescent
samples illustrates that up to half of those with selective eating are boys
(Nicholls & Bryant-Waugh, 2009), which is significant when considering the
evidence suggesting that selective eating is often a precursor to the develop-
ment of full-blown ED psychopathology in adolescence (Nicholls, Christie,
Randall, & Lask, 2001). When it comes to subclinical eating disordered beha-
viors, according to a review of numerous studies (Mond, Mitchison, & Hay,
2014), the percentages are even higher for males in subclinical ED (42–45%
binge eat, 28–100% regularly purged, 40% endorsed laxative abuse and fasting
for weight loss). Perhaps the most illustrative recent data point to disordered
eating practices in the community, for the very first time, increasing at a rate
faster in males than females (Mitchison, Mond, Slewa-Younan, & Hay, 2013).
Okay, if this rising prevalence now means that about 25–50% of individuals
with ED are male, shouldn’t we see at least a similar distribution of prevention
studies? Doesn’t the absence of prevention studies continue to marginalize the

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male experience of disordered eating, and continue to propagate the notion
that eating disorders just don’t bother the boys?

A 2007 meta-analysis described 32 prevention studies, only four (12.5%) of
which included boys (Stice, Shaw, & Marti, 2007). Eating Disorders: The
Journal of Treatment and Prevention has published 69 articles focused on
prevention prior to this current issue, and 54% were exclusively female, and
39% of those that mentioned gender included males. None addressed gender
minorities. Only one, “Beauty Myth and the Beast: What Men Can Do and
Be to Help Prevent Eating Disorders” by Michael Levine (1994)—in the
journal’s second issue—solely addressed males, but only within the context
of how they can help females not to develop ED. Actually, when Levine’s
contributions are removed, only 34% of this journal’s articles have included
males. The authors of a university prevention study summed up the popular
thinking of researchers, “Men were not recruited because women are much
more likely than men to develop body image disturbances and eating dis-
orders (Ridolfi & Vander Wal, 2008).” In other words, the 25–50% of males
with disordered eating are insignificant—or the investigators were stuck with
the 10% figure.

Incidentally, overall research shows a similar bias. At a session on males
and ED at the International Conference on Eating Disorders in 2013, Mark
Warren reported that a PubMed search for papers on anorexia nervosa
between 1900–2010 showed that men were included in 26% of them.
Speaking on the same panel, Cohn stated that “males” were found in fewer
than 7% of abstracts between 2000–2012 that referenced “eating disorders.”

This current special issue of this journal includes 12 articles besides this
one, and no one else is addressing the importance of including males.
Although the authors, many of whom are the field’s foremost experts, offer
excellent ideas, they are all overlooking the needs and roles that males play in
the ED continuum. Only four even mention males (two of which added
information about male prevention after being queried editorially), and the
others either ignore gender, which is fine, or use offer feminine examples
(e.g., Girls Scouts, sororities, school-based programs for girls, etc.). Again, no
one mentions gender minorities.

Prevention amongst high-risk male groups

Male eating disorders and related issues are multi-cultural and exist across
age groups, but there are certain specific populations that are particularly at
high risk. The types of universal and selected prevention strategies that are
described elsewhere in this journal should be gender inclusive, but beyond
that, special attention needs to be focused on certain groups. Most school
programs have been developed in consideration of risks for girls (e.g.,
pressure to be thin), but they also need to take into account the concerns

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of boys (e.g., pressure to be lean and muscular); and, lessons, about media
literacy for example, should be gender inclusive (e.g., show before and after
computer-altered images of women and men). Additionally, there are a few
specific populations in which non-female members should be reached.

People who identify as lesbian, gay, bisexual, transgender, and questioning
(LGBTQ) are at higher risk of developing an ED (Brown & Keel, 2012).
While approximately 3% of men in the general population identify as gay or
bisexual, studies show that they comprise as high as 42% of men in treat-
ment. Although globally more heterosexual males have ED, there are a higher
percentage of gay males (15%) who are diagnosed (Feldman & Meyer, 2007).
The idealized body type of being lean and muscular is particularly desired by
gay men, many of whom suffer from body dissatisfaction, anxiety about
appearance, excessive body checking, and negative physical-self evaluation,
which all are risk factors for developing an ED. The LBGTQ community is
proactive in seeking equal rights and recognition, and concerted efforts
within the ED prevention community should be integrated into existing
avenues for information and education. For example, university advocates
who organize eating disorders awareness education and prevention efforts
should coordinate with the LBGTQ Center on campus. Also, beginning at the
pre-elementary level, putting an end to bullying (an identified precursor to
ED behaviors) and teaching acceptance about gender diversity (including
stereotypes as they relate to sexuality) should be a part of every prevention
curricula.

Certain athletes are at higher risk for an ED. For example, wrestlers,
boxers, jockeys, gymnasts, and long distance runners often lose weight by
purging, fasting, and excessively exercising. Some football linemen force feed
themselves to gain weight, and many athletes binge and exercise to work off
the calories, unaware that their behavior might be considered bulimia ner-
vosa. Through decades of prevention work with the NCAA and Olympic
Committee, Ron Thompson and Roberta Sherman have led the way toward
educating coaches at the college level. They’ve collaborated with adminis-
trators, coaches, athletes, and cheerleaders; and, in this journal’s first issue,
they contributed an article, “Reducing the Risk of Eating Disorders in
Athletics” (1993) in which they outlined risk reduction strategies including
deemphasize weight, eliminate group weigh ins, and stop dangerous “weight
cutting” behaviors. In 1998, Thompson wrote a “Last Word” editorial in this
journal after three wrestlers had died from exercising in saunas—two were
wearing plastic suits at the time. He indicated that the NCAA was moving to
adopt new restrictions on the use of destructive weight loss techniques, and
shortly afterward the NCAA implemented prohibited practices that are still
enforced, “The use of laxatives, emetics, excessive food and fluid restriction,
self-induced vomiting, hot rooms, hot boxes, and steam rooms is prohibited
for any purpose. The use of a sauna is prohibited at any time and for any

EATING DISORDERS 117

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purpose, on or off campus (NCAA, 2013).” In the 16 years after these rules
were put into effect, no collegiate wrestler died as a result of unsafe weight
cutting practices (Rosenfeld, 2014). While this is evidence that prevention
efforts can save lives, the same ideas Thompson and Sherman voiced 24 years
ago still need to be more widely implemented from elite levels down to
children’s teams. Furthermore, prevention programs must be repeated reg-
ularly due to the high turnover rate among coaches, especially in youth
leagues, where many of the parents who coach are uneducated about body
image issues, teasing, and other risk factors for ED, especially among males.

In the related demographic of body builders, increased research, educa-
tion, and prevention surrounding muscle dysmorphia is crucial. The drive for
muscularity becomes a compulsion for some men (and some women), who
spend excessive hours in the gym and abuse steroids or performance enhan-
cing supplements like creatine and protein powders, which are typically
increased over time. Trainers, lifters, and fitness club staff, should be edu-
cated about harmful consequences (e.g., kidney or liver problems, distorted
body image, body objectification, social isolation) and the difference between
healthy and unhealthy exercise and eating.

Last but not least, more research and prevention must be devoted to binge
eating disorders. The most common ED and affecting far more males than
anorexia and bulimia combined, BED, especially how it presents in males, is
understudied clinically and is virtually absent in the prevention literature.
Many men who can be classified with BED don’t even realize that bingeing
isn’t normal guy behavior. Too often it is lumped together with obesity, even
when the prevention field is perfectly aware that not everyone who is obese
binges and not everyone who binges is obese. The insecurities that men have
about their weight and body, sex and money, global fears and archaic
definitions about what it means to be a man can result in binge eating
for emotional comfort, so men need to be educated about feelings, commu-
nication, community, and other areas that may be unfamiliar to them. They
also must learn about principles of healthy living, because, frankly, a lot of
men have misconceptions about nutrition, fat versus fit, and body/self-
empowerment—to name just a few.

Transforming beauty and the beast

Levine’s aforementioned article was directed at how fathers, husbands, broth-
ers, and other men can help women. In the abstract, he writes, “Eating
disorders are in part created and maintained by the inter-related phenomena
of male-female relationships…” but he is clearly most concerned about the
women, “I am frightened—for my daughter, my wife, my female colleagues…”
instead of men, including his sons. Although the article is monumental as the
only prevention article that purely spoke to men—even though he ignored

118 L. COHN ET AL.

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those with ED—it misses an important point: when males are more sensitive to
the needs of females, the better it will be for both sexes, and visa versa.

This is certainly not a revolutionary concept—compassion for everyone—
but the ED prevention field has been too female centric. If it is good
prevention strategy to teach a class of high school girls that pictures of thin
models are digitally enhanced, can lead to poor body image, and are emo-
tionally manipulative; then, shouldn’t boys be instructed in the same lessons
too? In that instance, boys would discover that these kinds of sexually
objectifying images are not only demeaning and harmful for the girls, but
that their own preconceptions about beauty were being influenced. And,
shouldn’t they all be shown how the men on magazine covers have their
muscles highlighted with body makeup and Photoshop, and that those
models were possibly abusing anabolic steroids or supplements in the pursuit
of those six-pack abs and ripped chests? Shouldn’t women be told that men
are insecure about their bodies in profound ways, that they engage in
stigmatized behaviors that fill them with shame and other feelings that they
have difficulty expressing in words. Women are learning to become empow-
ered with tools like mindfulness, self acceptance, body love, media literacy,
and self-respect; but, their insights to self awareness are only going to be truly
effective if men learn these same methods for their own benefit, as well as for
the women in their lives. That’s how both men and women can find support,
eliminate stigmas surrounding ED, and experience an overall better life.

Society must move away from the paternalistic hegemony, and nowhere is
that more true than in the arena of ED. That women have been victimized by
men is not breaking news. Most women with ED have had negative experi-
ences with men (e.g., father hunger, cruel words, sexual abuse) in one way or
another, but so have males with ED! While feminism has campaigned so
ardently for gender equality, the continued focus on female approaches to ED
prevention and treatment—at the exclusion of non-females—may be funda-
mentally anti-feminist. Beyond that, a new paradigm must emerge that
reflects a society with increasing gender equality. While the LGBTQ com-
munity makes inroads in areas such as gay marriage, and women are making
strides in corporate boardrooms, a new heterosexual male must also manifest
itself. He has to give up the chauvinistic mentality and develop underutilized
cognitions (i.e., his feminine side) to exist more evenly in the balanced
utopian world we’d all like to see. While that world may not be realistically
possible, we should, nevertheless, strive toward that goal.

References

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referred to an eating and weight disorders clinic. Bulletin of the Menninger Clinic, 49(3),
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http://dx.doi.org/10.1080/10640269308248268

Sexual Health (WHO 2006)
Sexual health is:
A state of physical, emotional, mental and social well-being related to sexuality
Not merely the absence of disease, dysfunction or infirmity
Relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion discrimination and violence.

2
2

WHO = world health organization
Broad definition to cover broad range of topics. Has to be inclusive of multiple elements, not just one fact that can be misrepresented.

The Sexual Body
Social Construction of Body Image
Changes over time
Changes across culture

3
Society is preoccupied with physical perfection, which can have both healthy and unhealthy consequences.

Critics, including some health professionals, believed that corsets caused cancer, anemia, birth defects, miscarriages, and damage to internal organs. The tight restriction of the body did deplete lung capacity and caused fainting.
The popular concept of an obsession with a tiny waist is probably exaggerated. The competition of cinch in to improbable dimensions was more of a fetish or a fad and not the norm as depicted in the 1939 film, Gone With the Wind, when Scarlett O’Hara cinches her corset to a 17″ waist
5

Sexual Health Disparities
Exist on multiple dimensions:
Sexual Orientation
Race or Ethnicity
Class/Socioeconomic Status (SES)
Gender

6
Lesbian issues–breast cancer, medical treatment (stigma), lifestyle, etc.
Race or ethnicity–lack of access to education for many, decreased access to health care
Class/SES–same as race/ethnicity
Gender–less focus in research, different dr-pt. Relationship, outright abuse in some cultures–female genital mutilation (in other cultures and in our own–as a cure for masturbation). Also male circumcision in our own culture.

Extreme Influence on Individuals certainly exists today, just in different forms
Plastic Surgery
Eating Disorders

Eating Disorders

Unfortunately, our standard of beauty tends to equate beauty and health, with thinness.

Eating Disorders

While we have moments of opposing messages, largely this has held true culturally
Over the past three decades eating disorder prevalence has risen rapidly
Eating Disorders

While most of those with eating disorders are women, we often stereotype the disorder as only belonging to women
10% of those with an eating disorder are men, and that number is rising rapidly in younger generations
Eating Disorders

Two main Diagnoses
Anorexia Nervosa
Bulimia Nervosa
Additionally, binge eating disorder
Eating Disorders

Eating Disorders/Sexuality
Retreating from sexuality
Eating-disordered patients have a higher than average history of abuse
May have been raised to be fearful of sex and view the body as sinful or dirty
Generally feel ambivalent about their sexual natures and bodies

Retreat from sexuality:
May also relate to the conflict regarding sexuality–may appear dangerous/evil and desirable/beautiful, which may cause a person to become disembodied.
Often develop during adolescence.
May be related to a need to control their bodies and lives.
Retreating from sexuality
Eating-disordered patients have a higher than average history of abuse
May have been raised to be fearful of sex and view the body as sinful or dirty
Generally feel ambivalent about their sexual natures and bodies
13

Anorexia nervosa
Characterized by an all-controlling desire for thinness

14
Often a symptom of an underlying psychological disturbance.
Afffects menstruation, hormonal levels, pubertal development, skin & hair, teeth & gums, & bones.
Two types of anorexia are restricting and binge eating/purging:
Restricting–diet & excessive exercise but no binging.
Binge/Purge–may do one or the other or both.

A refusal to maintain a healthy body weight
Intense fears of becoming overweight
Comorbidity with Body Dysmorphic Disorder
In women, amenorrhea occurs as well
Anorexia Nervosa

Restricting Type
Restrict foods, starting with unhealthy foods but then branching out to all types
Little variability in diet (a lot of order/repetition)
Anorexia – Typology

Binge-eating/purging type
Lose weight by purging after meals (through vomit, laxatives, excess exercise)
May engage in bouts of binge eating, but not necessary
Anorexia – Typology

Upwards of 90% of cases occur in women
Men feel stronger pressure in our society to make their body larger, more likely to have binge eating disorders, use steroids, etc.
Disorder occurs in 1-2% of women in western countries
More than that display symptoms however
Rates increasing in Western societies as well as Japan
Anorexia

Onset is usually in adolescence, or high school
Early onset usually looks like dieting behaviors or a “health focused” new attitude
Anorexia

Those initial behaviors tend to escalate usually after a stressful event
Separation/divorce
Big life changes (moving, death of a loved one, etc.)
Personal failure
Bullying
Anorexia

While its important to remember that most people recover from anorexia
2-6% become seriously ill and die as a result of complications
This makes it one of the psychological disorders with the highest mortality rate!!
Anorexia

The underlying drive for anorexics is an all-encompassing desire for thinness
This drive contains a lot of anxiety/fear for the individual
Fear of gaining weight
Fear of allowing one’s self to feed a hunger response
Importantly, fear of losing control
Anorexia

Many people at first believe they would “know” who is anorexic by seeing if they eat food
However, all anorexics eat food (unless their condition is critical)
You need some calories to even function as a result of burning calories daily
Anorexia

Anorexics are in fact obsessed and preoccupied with food
Think about food often (fantasize about it as well)
Read cookbooks, food magazines
Plan and cook meals (often very elaborate ones)
Anorexia

These symptoms are also seen in individuals who voluntarily starved themselves to help science/their country in WW2
“Minnesota Starvation Experiment”
Anorexia

Cognition is affected in those with the disorder
Poor body image (to an extreme)
High overestimations of weight/proportions
Tend to hold perfectionist attitudes
And false perceptions of how to attain perfection
Often don’t feel disordered, believe anorexia is healthy and being thin is perfection
Anorexia

Characterized by bouts of binging and purging
Bulimia Nervosa

Purging-type
Engage in ways of trying to make food/calories leave the body before they are absorbed into the body
Vomiting, laxatives, diuretics, enemas
Nonpurging-type
Try to compensate for calories taken in by going on fasts, or exercising excessively
Bulimia Typology

Upwards of 90% of those with the disorder are female
Men are more likely to engage in the binging…without the purging (binge eating disorder) in the hopes of gaining weight, or to “eat” away negative feelings
Bulimia

Onset is a bit older than anorexia typically
However, even childhood rates for both are on the rise
Typically in high school and early college years
Bulimia

Those with bulimia are not usually excessively thin like those suffering from anorexia
Weight fluctuates, sometimes rapidly
Can also have anorexia, or develop anorexia
Bulimia

Many youth have bulimia role-modeled for them by family or friends and take up the behaviors thinking it will help lose weight
Some studies suggest up to half of high school students have at some point engaged in binge eating or purging behaviors
For some people symptoms may be periodic, and not long lasting like those with anorexia
Bulimia Prevalence

Binging and Purging behaviors are usually secretive
The rate of these behaviors can vary, some as low as once a week with others performing them multiple times daily.
Bulimia

Food intake during a binge is rapid
Foods are usually chosen that are soft and easy on the stomach
Can take in 1000-3000 calories in a single binge
Bulimia – Binging

Binges are usually brought on by moments of anxiety/tension & feelings of helplessness
Eating the food feels great. Endorphin rush, pleasure, satisfaction…but is followed by:
Self-blame
Guilt
Depression
Health/weight fears
Bulimia – Binging

Anorexics often live in a reality where they believe what they are doing is healthy, bulimics often realize what they do is harmful
Guilt after binging leads to compensatory behaviors
Now tension is directing them to get rid of what they just took in
Bulimia

Most common are vomiting and the use of laxatives
Purging doesn’t really work
Vomiting only removes up to half the calories consumed
Usually produces more hunger
Laxatives really have no effect other than dehydration and psychologically feeling less guilt
Bulimia – Purging

Typically onset is often after a period of strict dieting.
First bouts of binge eating often occur during those periods of denial in a diet
Bulimia – Onset

Shocker: new research shows that in America, around HALF of ALL grade school girls are on diets currently. CURRENTLY!!!!!

Health Disparity
When a demographic group experiences worse health outcomes compared to another demographic group that can’t be accounted for based on biology alone.

Extreme Makeover

Very popular today, as evidenced in the variety of reality television shows that specialize in makeovers that involve plastic surgery.
Extreme evidenced in plastic surgeries, brazilian waxing (and permanent hair removal).
40

Can range from small procedures, to those who obsess with changing selves through surgery. For instance, the infamous “cat lady” Jocelyn Wildenstein
41

Genital Plastic Surgery
Vaginal Rejuvenation
Labiaplasty
Hoodectomy (Clitoral unhooding)
Hymenoplasty (revirgination)
G-spot enhancement
Anal and vaginal (vulva) bleaching
Breast augmentation
Penis elongation and fat injections
Vaginal Surgeries have increased by more than 30% since 2006.

43
Very popular today, as evidenced in the variety of reality television shows that specialize in makeovers that involve plastic surgery.
Extreme evidenced in plastic surgeries, brazilian waxing (and permanent hair removal).
Clinics marketing labiaplasty as “female genital rejuvenation”

Steroids
Anabolic steroids
Used to enhance body image and
athletic performance
Can cause serious and permanent body damage
Sterility, heart attacks, stroke, liver damage, and personality change.
Can cause the body to shut down production of testosterone.
Breasts will grow and testicles atrophy

Research shows that women want their body size to be smaller, and men want their body size to be larger. Effect of masculinity/femininity dichotomy.
While we see most men wanting a larger frame, and most women wanting a smaller one…we do see those defying the numbers. And greater numbers of boys developing eating disorders
45

Variations in sexual desire (fetishes/kinks)
Know very little about how they form
But many are thought to be conditioned (often highly contextual)
Fetishes and kinks are not considered disorders, just variations in sexual interest, and are perfectly healthy unless:
They remove the possibility of consent
They cause permanent injury
Pleasure cannot be gained from doing anything else (a healthy sexuality includes a little variation)

Sex, Ethics, and the Law

Sexual Laws
Most societies attempt to regulate sexual behavior, both by custom and law.
Why????

Sexual Laws
Most societies attempt to regulate sexual behavior, both by custom and law.
Why????
Attempts to protect the individual
Attempts to protect the structure or integrity of the family
Attempts to protect society’s morals
Difficulties & Confusions
Whose morals?
What kinds of families?

Genres of Laws
Crimes of Exploitation & Force
Rape/Sexual Assault and Childhood Sexual Abuse
Criminal Consensual Acts
Sodomy
Cohabitation
Adultery
Crimes Against Norms
Exhibitionism
Voyeurism
Crimes Against Reproduction
Homosexuality
Sodomy
Birth Control & Abortion
Commercial Sex
Prostitution
Obscenity (pornography)
Laws Related to HIV

Criminal Consensual Acts
Fornication (sex before marriage)—as of 2002, fornication was illegal in 11 states and DC.
Cohabitation—as of 1994, cohabitation was outlawed in 14 states.
Adultery—is a crime in 24 states and DC.
Grounds for divorce in almost every state.
Varies as to whether both partners or just the married person can be charged.
What constitutes adultery? One incident or habitual?

Criminal Consensual Acts
Sodomy—various definitions—”crimes against nature”
In 1986, 24 states prohibited sodomy, with a court case upholding the right to prosecute under these laws.
In 1998, Lawrence vs. Texas case
Lawrence & Garner appealed and, in 2003, Supreme Court ruled that sodomy laws are an invasion of privacy, invalidating remaining state laws.

Popular Contemporary Ethical Issues regarding sex
Moralism: An attitude that emphasizes moral behavior, usually according to strict standards, as the highest goal of human life.
Pluralism: An attitude that affirms the value of many competing opinions and believes that the truth is discovered in the clash of diverse perspectives.
Contemporary Issues:
Same-Sex Marriage and other queer civil rights
Civil rights for transgender and non-binary folks
Contraception & Abortion access
Sex Work
HIV/AIDS
Technology

Obscenity?

Erotica vs. Porn
Erotica: from Greek for “love poem”
May have artistic value, involve mutuality, respect
refers to portrayals of sexually arousing material that hold or aspire to artistic or historical merit,
Erotica – positive evaluation of sexually explicit material whereas “pornography” often connotes the prurient depiction of sexual acts, with little or no artistic value.
In practice, pornography can be defined merely as erotica that is perceived as “obscene.”
The definition of what one considers obscene can differ among persons, cultures and eras.
This leaves legal actions by those who oppose pornography open to wide interpretation. (especially since the supreme court won’t define it)

History of Porn
12, 000 BCE. The walls La Marche cave in western France are literally blanketed with erotic images, 14,000-year-old drawings reminiscent of the Kamasutra.
One image of a head plunging between a woman’s thighs seems to portray oral sex.
Another shows a standing couple, their bodies entwined, while the man’s penis penetrates his partner.

La Marche
11

Greece
13

Pompeii
15

Kama Sutra pages
17

Native Americans
Nigeria
Japan
Vikings
Inca
Indonesia

Which do you think makes more money in the United States per year?
NFL
MLB
NHL
NBA
PGA

Which do you think makes more money in the United States per year?
NFL
MLB
NHL
NBA
PGA
Or pornography?

The porn industry makes more than all sports associations combined…every year.

Viewing Porn Causes What?

To be honest, no one really knows for certain.

To be tested you would need an experiment with a control group of men who have never seen porn that match up on demographic variables with men who have seen porn. (and a control group large enough to be compared to the typical population)

Research does show some consistent correlations but then show other correlations we wouldn’t expect:

Viewing Porn Causes What?

Research does show some consistent correlations but then show other correlations we wouldn’t expect:

DJ Miller (2019) more frequent porn use associated with increased masturbation, desire for sex like that in the porn they are watching

Laemmle-Ruff (2019) viewing porn may decrease body-image satisfaction. Watching with a partner may increase the drive for muscularity among women

Mellor (2019) sexual offenders less likely than general population to regularly view porn

Viewing Porn Causes What?

Most correlational studies seem to agree that:

-repeated viewing of violent/objectifying pornography can lead to a number of negative psychological effects

-The effects really depend on the type of pornography used

-porn addictions are not caused by porn, just like other compulsive behaviors aren’t cause by shopping/video games/etc. But another underlying cause

Today’s Lecture

We’ll be focusing on just a few aspects of the *very* large world of sex work

Sex work on the Internet

Psychological aspects of sex work

Legal aspects of sex work

Sex workers are a highly diverse population and resist easy generalization

Today’s lecture cannot represent all of their experiences

I’m happy to refer you to further reading if you have questions that don’t get answered today!

What is “Sex Work”?

Sex work is a broad term which includes individuals who provide some form of sexual service in exchange for money or goods

The term ‘sex work’ was created to emphasize the labor aspect of sex work-

Some feel that the term ‘prostitute’ conflates the person with the work

‘prostitute’ is a stigmatized term

Sex Work includes women, men, trans people in all areas of the sex industry- from porn to stripping to BDSM to prostitution

Today’s lecture will focus on prostitution and porn

Venue Matters
Where you work influences
$$
Control over services provided
Control over schedule
Safety
Risk of arrest
Risk of violence

Independent
Agency Escort
Madame referrals
Erotic Masseur
Brothel Based
Bar Based
Street Based

Racial and Economic Stratification of Sex Work

Much like other forms of employment, sex work is not ‘equal opportunity’

Sex workers face discrimination based on race, ethnicity, economic class, migration status

Female sex workers earn almost twice as much as men

Independent escorts earn the most, work in safer conditions

Street based workers earn the least, are most vulnerable to arrest, victimization by clients or pimps

Outdoor Sex Workers
Street based workers
Estimated 10% of U.S. prostitutes
Often homeless, may be adolescent runaways, or escaping domestic violence
More likely to have substance abuse problems than non-street-based workers
Most frequently targeted by police
Among men, street-based workers are less likely to consider themselves gay
The majority of the research on sex workers in the US has sampled women on the street
90% research samples 10% of sex workers

Outdoor Sex Workers
Have a VERY young average age of entry into the work. Often between 14-16.
Often coerced/forced into job
This is not the average for indoor sex workers, particularly in legal work environments

Survey Results
Safer Sex:
Condom use for vaginal sex was close to 100%
The majority of the women used condoms for oral sex ‘always’ or ‘usually with few exceptions’
28 /30 HIV-
2 were untested/refused to answer
Rates/Race:
Range from 180 – 1,000 per hour
Top end: Multiple hour minimums; 600-1,000
Mode for White women:
$500
Mode for women of color:
$400
BBWs, Mature women, Fetish providers
made less $

Results from a study done on safer sex practices with escorts here in NYC by Dr. Koken
32

Legal vs. illegal
What differences exist for customers, and sex workers in a legal/illegal environment?

Legal Sex Work
Licensed in Nevada to work in a brothel
Perform regular weekly STD checks
Lose license if caught practicing unsafe sex/testing positive for certain illnesses
Benefits?
Comparison to illegal street work?

Legal vs. illegal
Even in a legal environment, which aspects of prostitution would still need to remain illegal and require law enforcement investigation?

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Journal of Cognition and Development

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Beyond Discrete Categories: Studying Multiracial,
Intersex, and Transgender Children Will
Strengthen Basic

Developmental Science

Yarrow Dunham &

Kristina R. Olson

To cite this article: Yarrow Dunham & Kristina R. Olson (2016) Beyond Discrete
Categories: Studying Multiracial, Intersex, and Transgender Children Will Strengthen Basic
Developmental Science, Journal of Cognition and Development, 17:4, 642-665, DOI:
10.1080/15248372.2016.1195388

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Beyond Discrete Categories: Studying Multiracial, Intersex,
and Transgender Children Will Strengthen Basic

Developmental Science

Yarrow Dunham

Yale University

Kristina R. Olson

University of Washington

Developmental research on social categorization has overwhelmingly focused on perceptions about
and experiences of individuals who are clear or prototypical members of discrete and usually
dichotomous social categories. For example, studies of social categorization, stereotyping, prejudice,
and social identity have generally explored how children reason about others who are gender-typical
boys or girls or monoracial White or Black children. Similarly, research participants have generally
been gender-typical and monoracial. However, our efforts to build theories that account for the true
range of variation require acknowledging the increasing visibility of children who do not fit into
these discrete categories and raise the question of whether existing theories can capture the dynamics
that arise for them. Focusing on race and gender/sex, the social categories that have received the
most attention in the developmental literature, we review research that has gone beyond simple
dichotomies by including multiracial, gender-nonconforming, or intersex children, either as the
targets of social perception or as participants themselves. We argue that this emerging work reveals
problematic assumptions built into our theories and methods and highlights the value of building a
more inclusive science.

One way to reduce the dizzying complexity of the social world is to place individuals into
discrete categories: Black or White, man or woman, American or foreign. We do this not only as
naïve perceivers, but also as scientists. In our research focusing on social groups, for example,
we routinely ask children to report their preferences for people who are Black or White or male
or female (e.g., Aboud, 1988; Raabe & Beelmann, 2011); our consent forms frequently include
boxes for parents to check indicating which race or gender describes their child; and we theorize
about the experiences of children in these categories, thus treating each individual as an
exemplar of a broader category within which we have determined they reside. This focus on
discrete categories has been the foundation for much work on intergroup cognition, as well as
the majority of our own work, and it has taught us many useful things. But in this article, we
would like to raise the concern that it has—often unintentionally—excluded many people’s

Correspondence should be sent to Yarrow Dunham, Yale University, 2 Hillhouse Avenue, New Haven, CT 06511.
E-mail: yarrow.dunham@yale.edu

JOURNAL OF COGNITION AND DEVELOPMENT, 17(4):642–665
Copyright © 2016 Taylor & Francis Group, LLC
ISSN: 1524-8372 print/1532-7647 online
DOI: 10.1080/15248372.2016.1195388

mailto:yarrow.dunham@yale.edu

experiences, limited the generalizability of our findings, and, perhaps most importantly, limited
the ability of our theories to adequately explain real-world social phenomena. On the basis of
these considerations, we argue for the importance of broadening existing work on social
categorization to include the perceptions and experiences of people who do not reside within
our most studied categorical spaces. In particular, we focus our discussion here on individuals
who are multiracial (people with lineage from more than one racial group), transgender (people
whose sex and gender diverge), and intersex (people whose sex is not clearly male or female).
We argue that considering these diverse identities necessitates broadening our theoretical
framework and, at least in some cases, reflecting on whether the methods we employ do justice
to the phenomena of interest.

One question we should address at the outset is why this article is housed in a special issue
focused on integrating work from typical populations (traditionally studied by cognitive
developmentalists) with work on atypical populations (traditionally studied by developmental
psychopathologists). Do we mean to imply that the populations we focus on here (transgender,
intersex, multiracial) are atypical in any sense analogous to, for example, developmental
disabilities like Down syndrome or Williams syndrome? To be clear, we do not believe
these populations are “atypical” in the sense of, for example, experiencing an impairment
that may require specialized education or intervention. Rather, here we mean “atypical” in a
strictly statistical sense—samples that are less often represented in the literature and, at least in
most of the cases we discuss, statistically less common in the population. Thus, while atypical
in a different sense, we argue that these populations have been neglected in the literature and
that their inclusion will benefit our science. Finally, we do hope that, although outside the
scope of our argument here, some of the considerations we take up (e.g., whether to think of
variation in terms of categories or continua, or the tendency to pathologize atypicality)
will resonate with similar debates that have occurred in the case of developmental disability
(Wing & Gould, 1979) and will resonate with several other themes introduced in this special
issue (Burack et al., this issue; Landry et al., this issue).

Although we discuss these three groups (intersex, transgender, multiracial people) together
and separately throughout this article, we do not mean to simplistically equate them. There are
profound differences between biracial or multiracial identities, gender-nonconformity or trans-
gender identities, and intersexuality—differences that likely outweigh similarities. Indeed, there
are divergent views about the relative “legitimacy” of each, including the reasons why each
group might be treated discretely (e.g., evolutionary vs. more social or cultural reasons), and
reasonable people can disagree about the ways in which each group is or is not relevant to
broader discussions about cognitive development. We also acknowledge that these groups can
intersect, as in the case of multiracial transgender individuals or people who are intersex and
identify as transgender (for more on intersectionality, see Cole, 2009). Thus, the connection we
draw attention to here is at a more formal level: The social, cultural, and even medical
discussions around each are affected by a psychological tendency to make complex and diverse
individuals conform to discrete categories that, as it happens, many do not fit. This tendency
affects both lay people and professionals and has had a range of problematic consequences for
those who are nonprototypical group members, as well as for our efforts to build a psychological
conception of human variation. We note that gender, sex, and race are likely the most studied
social categories, making consideration of the way in which they have been conceptualized a
particularly critical matter even if one sees few commonalities between them.

BEYOND DISCRETE CATEGORIES 643

The Focus on Discrete Categories

There are several reasons why the field of cognitive development tends to focus on discrete
categories and, specifically, the most prototypical members of familiar social categories. Some
are straightforward practical reasons such as the logic of experimental control in which we seek
to eliminate confounding or confusing aspects of the stimuli to home in on the single contrast in
which we are most interested. In other cases, it reflects the desire to maximize the size of a
possible effect and/or to start with the clearest cases before moving to the more ambiguous
middle. For example, if we are not sure whether children can distinguish racial categories in the
first place, it is reasonable to begin an investigation by seeing if children can categorize images
of people who are, by adult judgment, the cleanest examples of each category. But although an
understandable first step, work all too rarely goes on to widen the focus to encompass a fuller
range of variation.

In addition, these choices sometimes reflect structural properties of our methods. For example,
the Implicit Association Test (Greenwald, McGhee, & Schwartz, 1998), the most common
measure of implicit attitudes in both children and adults, requires a pair of category labels and
involves making dichotomous categorization decisions about individuals. To be clear, there is
nothing intrinsically unreasonable about many of these decisions; indeed, we ourselves regularly
make them in our own work (Dunham, Newheiser, Hoosain, Merrill, & Olson, 2014; Dunham,
Srinivasan, Dotsch, & Barner, 2014). But we have begun to worry that when these decisions come
to predominate, the assumptions embedded within them can become obscured by habit. As a
result, the use of these measures may begin to reinforce an assumption that is incorrect (in at least
some cases)—namely that the categories themselves, rather than just their operationalization
within our methods, are essentially discrete.

The Allure of Discreteness

Why worry about the field’s focus on discrete social categories? A central reason comes from the
provocative evidence that thinking in terms of discrete categories—and in particular, dichoto-
mies—is a less-demanding cognitive default that—due to the simplification it entails—promotes
higher degrees of stereotyping and less sensitivity to real gradations within categories. Such
effects may emerge quite early in development, thereby representing an interesting aspect of our
basic approach to variation. In one recent demonstration with preschool-aged children, Master
and colleagues (Master, Markman, & Dweck, 2012; for a conceptually similar example with
adults see Rothbart, Davis-Stitt, & Hill, 1997) induced a dichotomous versus graded encoding of
the same individuals by introducing children to characters who varied continuously along a
dimension (in this case, the dimension of niceness) but were described either via binary category
labels (e.g., “this one is nice”; “this one is mean”) or graded trait descriptors (e.g., “this one is a
little nice”; “this one is really nice”; “this one is a little mean”; “this one is really mean”). In the
former case, each nice character was described via a trait adjective irrespective of the degree to
which they embodied the trait. In the latter case, each character was described via their position
on the underlying continuum. While the properties of the actual characters were held constant,
children in the category condition as compared with the graded condition tended to overestimate
intercategory differences between the characters by considering the “a little mean” and “a little
nice” character to be more different from one another, while also underestimating intracategory

644 DUNHAM AND OLSON

differences by treating, for example, the “little mean” and “really mean” characters to be more
similar to one another. Thus, appreciation of continuous variation was powerfully curtailed when
that variation was described using dichotomous category labels. In a follow-up study in which
stimuli were presented neutrally, withholding both category labels and graded trait terms,
children’s judgments paralleled those in the categorical condition, suggesting that the default
mode of construal is categorical. Applied to, for example, the gender domain, there is evidence
that using the labels “boy” versus “girl” does in fact accentuate the differences between boys and
girls, thereby promoting stronger stereotyping (Hilliard & Liben, 2010) and thus obscuring the
fact that there are some girls whose preferences and behaviors are closer to some boys than to
other girls. Insofar as this involves children being tacitly encouraged to see themselves as
prototypical boys or girls, rather than as children toward the middle of the gender spectrum,
this tendency toward dichotomization could have consequences not only for categorization, but
even for mental health and well-being.

Related work has long suggested that category labels themselves enhance similarity judgments
in both children and adults, either by serving as an additional feature that binds category members
together (Sloutsky, 2003) or by suggesting to children that the categories represent deep, essentia-
lized distinctions that can support novel inferences about shared properties (Gelman & Heyman,
1999). Taken together, these findings suggest that categorical thinking enhances stereotypical
reasoning and obscures perception of potential similarities among those who do not belong to the
same category, a potentially self-reinforcing effect that could raise unwarranted confidence in the
reality of the discrete conception itself. Indeed, for both adults (Eidelman, Crandall, & Pattershall,
2009; Kahneman, Knetsch, & Thaler, 1991) and children (Tworek & Cimpian, in press), there is a
pervasive tendency to believe that the way things are (including the way they are described and
categorized) is the way things ought to be. Thus, once we have conceptualized categories as
dichotomous or have decided that the dichotomous options are normative, departures from that
dichotomy may come to be seen as deviant and therefore bad, just as other contingent and even
arbitrary decisions come to acquire normative weight merely by being presented as settled fact
(Eidelman et al., 2009). If so, individuals who deviate from these normative poles might be
perceived as deviant or problematic. As we will discuss in greater detail, it is in fact the case that
multiracial, transgender, and intersex people have all, at one time or even today, been considered
deviant in this way.

Some of these effects of categorical thinking can be conceived of as cognitive heuristics
making it less mentally taxing to represent complex spaces.

Abstract

ly speaking, representing
a whole group of individuals as belonging in one of two groups requires just a single bit of
binary data, while representing them as lying on a continuum requires more cognitive
resources to make graded decisions and more mnemonic resources to store those distinctions.
This “heuristics” account has been supported in the adult literature, where individual-
differences tendencies to prefer simpler, more “black and white” solutions has been linked
to greater category-based stereotyping (e.g., Crawford & Skowronski, 1998; Webster &
Kruglanski, 1997), greater dislike for category-ambiguous social stimuli (Dickter & Kittel,
2012), and greater essentialism of social categories (Roets & Van Hiel, 2011; i.e., greater
belief that category membership is based on deep, enduring internal properties). While it is
not as well explored in children, Gaither, Schultz, et al. (2014) found that children who more
strongly endorsed social category essentialism tended not to use a multiracial categorization
option, suggesting they favored a simpler dichotomous category space. These findings are

BEYOND DISCRETE CATEGORIES 645

consistent with the idea that reducing complex and continuous spaces to discrete categories
(and especially dichotomies) can be a means of reducing uncertainty and simplifying com-
plexity for social perceivers.

Why Go Beyond the Discrete?

The tendency to focus on discrete categories, and the most prototypical members of those categories,
reflects not merely a limiting tendency in the psychology of our participants, but in ourselves as well
and thus a potential trap into which our science can fall. Problematic consequences can take several
forms. First, many people do not fit binary identities, and thus, their experiences may not be captured
by the field. In fact, the number of people falling outside binary identities is growing in the United
States, making this is an increasingly large problem for our field. For example, multiracial children
grew from 1% of all American infants in 1970 to 10% of American infants in 2013 (Pew Research
Center, 2015). Transgender people are coming out at younger and younger ages and are increasingly
visible and vocal about this identity (through media, lawsuits, etc.), meaning more people are
becoming familiar with the existence of transgender individuals (Halloran, 2015). In addition,
genetic testing is making it clear that many more people might be intersex than originally believed
(Ainsworth, 2015), and these diagnoses are now being made at earlier and earlier ages, even before
birth in some cases (Casey & Gomez-Lobo, 2015). We assume it is uncontroversial to insist that our
theories of the kinds of people populating the social world should adequately capture the variation
that characterizes that world. This statement represents the first and foremost reason for a more
inclusive science. There has been some important movement in this direction (including one recent
piece consistent with the argument here, Kang & Bodenhausen, 2015). For example, we have seen
an uptick in research on social groups focusing on biracial children as targets and participants (e.g.,
Gaither, Chen, et al., 2014, Roberts & Gelman, 2015) as well as those focusing on transgender
participants (Olson, Key, & Eaton, 2015).

Second, and perhaps less intuitively, moving beyond the dichotomous conceptions we have high-
lighted will also spur theoretical gains. As we alluded to earlier, we believe that the reliance on discrete
categories in our methods has a tendency to reify or reinforce those categories within our theories. For
example, discrete and dichotomous views of gender have been taken for granted to the point that we
benchmark normative development with it, most often by asking a child, “Are you a boy or a girl?” and
“Will you be a man or a woman?” and assuming that understanding gender is synonymous with an
answer that aligns with one’s sex at birth (Zucker & VanderLaan, 2016). Further, those who deviate
from normative views on these items (e.g., transgender children) are thought to show a cognitive
deficiency or delay (e.g., Zucker et al., 1999). Thus, by focusing on the most prototypical members of
groups, the field may be overstating or oversimplifying our theories about social categorization in early
childhood. We will discuss these and other issues in more detail in the following sections, but the
upshot is that a sufficient theoretical account of social categorization must have the resources to capture
the true range of variation that constitutes those category spaces.

BEYOND DISCRETE CATEGORIES: THE CASE OF RACE

Children of multiracial descent are the largest-growing youth population in the United States
(Saulny, 2011). An estimated 1 of every 10 children born in the United States today is

646 DUNHAM AND OLSON

multiracial (Pew Research Center, 2015). Despite this dramatic increase, at least until recently,
our science has paid scant attention to multiracial individuals. We begin with a brief background
concerning why categorical models of race are limited and then move to discussing two ways in
which research should move beyond dichotomies—namely, research focusing on the perception
of multiracial individuals on the one hand and research incorporating multiracial participants on
the other.

Race as Continua Versus Category

Any discussion concerning categorical treatment of race should acknowledge the modern scien-
tific consensus, which has largely rejected the notion of discrete racial categories or real racial
essentialism (reviewed in Cosmides, Tooby, & Kurzban, 2003; Goodman, 2000; Maglo, 2011).
Rather, most contemporary views of race stress continuous variation across a large number of
genetically transmitted but independent phenotypes, so-called “clines” (e.g., Lieberman,
Stevenson, & Reynolds, 1989). Thus, even to say that race should be conceived of as a continuum
is an inadequate corrective to categorical thinking; rather, race is a space defined by a large number
of orthogonal continua within which we have contingently imposed a system of discrete cate-
gories. Of course, categories have psychological power: Once we are accustomed to them, discrete
race categories appear obvious or even natural, and thus, multiracial people can become difficult or
ambiguous perceptual objects, at least to monoracial perceivers (Chen & Hamilton, 2012).

Even in countries with large multiracial populations, such that dichotomous conceptions of race
seem inadequate, the tendency to impose discrete categories frequently still emerges through the
addition of a third discrete category term that encompasses multiracial individuals, such as
“Coloured” in South Africa (Dunham, Newheiser, et al., 2014; Newheiser, Dunham, Merrill,
Hoosain, & Olson, 2013) and “Pardo” in Brazil (Telles, 2002). We suspect that many of the problematic
aspects of dichotomous categories will also appear in these cases. A third category goes only a very
small way toward capturing continuous variation and still imposes a need to discretely classify
“boundary” cases in ways that will not always be obvious or accurate.

Multiracial Individuals as Targets of Social Perception

Until quite recently, the vast majority of research on the social perception of race has focused on
how (predominantly White) participants view monoracial others. Thankfully, during the last
several years, new work has finally begun to more systematically address the omission of multi-
racial targets (e.g., Gaither, Chen, et al., 2014; Gaither, Schultz, et al. 2014; Roberts & Gelman,
2015). By revealing tensions in several aspects of previous models of racial perception and
demonstrating that categorization of multiracial individuals is affected by ideological concerns,
this work presents clear evidence of the importance of a conception of social categorization that
goes beyond a dichotomous treatment of race. For example, and as we detail further in the
following sections, more recent work has suggested that previous claims concerning young
children’s understanding of racial categories have been exaggerated and also that existing notions
of racial identification can be insufficient to capture the dynamic unfolding of social identification
in multiracial children.

We have suggested that the tendency to perceive even multiracial others as belonging to
discrete racial categories is widespread. Anecdotal support comes from the fact that even

BEYOND DISCRETE CATEGORIES 647

individuals known to be multiracial are frequently described or conceived of in monoracial
terms. For example, President Obama is widely considered the first Black president of the
United States, only infrequently the first multiracial president, and never a White president; Ann
Curry, a well-known American news anchor, is widely considered Asian American, despite
having a biological parent who is not Asian American; and British author Zadie Smith tops
many international lists of top Black authors despite also being multiracial. Of course, some
multiracial individuals choose to self-identify in terms of one specific racial identity, and such
self-identifications may affect how others see them. But beyond these anecdotes, there is
abundant evidence that when asked to categorize unfamiliar multiracial targets, monoracial
perceivers frequently place them into discrete racial categories even when a multiracial category
is available (Chen & Hamilton, 2012; Roberts & Gelman, 2015) despite the fact that many
multiracial individuals actually prefer to identify and be seen as multiracial (Townsend,
Markus, & Bergsieker, 2009; Udry, Li, & Hendrickson-Smith, 2003).

Broadly speaking, the tendency to prefer a single discrete category is consistent with
psychological essentialism (i.e., with the assumption that each individual “really is” a member
of one specific racial group). But the specific direction in which these classifications play out
suggests that essentialism cannot be the only factor. In particular, categorizations of multiracial
targets frequently exhibit the phenomenon of hypodescent (i.e., the tendency to classify mixed-
race individuals via the lower status or more stigmatized category)—a phenomenon that emerges
in childhood (Roberts & Gelman, 2015) and remains stable into adulthood (Ho, Sidanius,
Levin, & Banaji, 2011; Peery & Bodenhausen, 2009). This outcome cannot be derived from
essentialism alone, because both parental essences should, absent other considerations, contri-
bute to the child’s category membership equally. Hypodescent suggests, then, that racial
categorizations are influenced by ideology—for example, a tendency to police the boundary
of higher-status racial categories a la the “one-drop rule” in which even a small degree of Black
ancestry yields Black category membership. Supporting this contention in adults, political
conservatism, racial essentialism, and social dominance orientation have all been linked to the
tendency to categorize multiracial faces as Black rather than White (Ho, Roberts, & Gelman,
2015; Ho, Sidanius, Cuddy, & Banaji, 2013; Krosch, Berntsen, Amodio, Jost, & Van Bavel,
2013; see also Kang, Plaks, & Remedios, 2015). And at least one of these links—that between
essentialism and the perception of multiracial or racially ambiguous faces—emerges quite early,
with White children who more strongly essentialize showing worse face memory for both Black
and White-Black ambiguous faces (Gaither, Sommers, & Ambady, 2013).

Another aspect of the historic reliance on monoracial targets is also important to mention.
Much of that work used as stimuli photographs of individuals who would be considered very
characteristic or “prototypical” members of racial categories. In so doing, previous work has
artificially simplified the perceptual landscape by removing the real range of variation from the
stimulus space. This simplification becomes problematic when racial classification is used as an
index of whether or not children “understand” race (e.g., as reviewed in Aboud, 1988). Thus,
while work in this vein has suggested adultlike classification performance in children as young
as 4 years, because this conclusion is based almost exclusively on children’s ability to correctly
classify highly prototypical racial exemplars, it appears to have overestimated what children
actually understand about the perceptual underpinnings of racial variation. Indeed, when stimuli
encompassing a full range of variability are introduced, the picture looks very different
(Alejandro-Wright, 1985). One series of recent studies, for example, asked children to categorize

648 DUNHAM AND OLSON

faces drawn from a large set in which skin color and other aspects of facial physiognomy were
independently varied across the White-Black and White-Asian category boundaries (Dunham,
Dotsch, Clark, & Stepanova, 2016; Dunham, Stepanova, Dotsch, & Todorov, 2014). Thus,
children were presented with highly prototypical faces as well as faces that were near the
category boundary or that were prototypical in one but not another dimension. On this more
complex task, children’s performance was substantially different from adults, and the evidence
suggested their knowledge of the specific physiognomic cues that mark category boundaries was
in fact not in place until at least the upper elementary school years. Given the range of actual
variation to which children are exposed, as well as the proportion of the population who would
reject a unitary classification into a single racial category, equating racial understanding with the
ability to classify an extremely limited set of maximally prototypical stimuli is problematic on
both conceptual (because racial categories are not discrete entities) and perceptual grounds
(because even the most prototypical features vary independently, creating a very complex
perceptual learning problem for the developing child).

The Experiences of Multiracial Individuals

In addition to underemphasizing perception and cognition about multiracial individuals, we have
also, until recently, given insufficient attention to the social cognition of multiracial individuals
themselves. This is critical, because much of what we assume to be the case about emerging
social cognition and social identity does not apply to children who themselves do not neatly fit
within a single race category (for reviews, see Gaither, 2015; Poston, 2011). By revealing
tensions in previous models of race-related cognition, this work presents clear evidence of the
importance of broader conceptions of social categorization and racial identity. Further, multi-
racial individuals also appear to face some additional psychological burdens relating to how they
are perceived by themselves and others. For example, multiracial individuals are sometimes
judged more negatively than their monoracial counterparts (Sanchez & Bonam, 2009), and
multiracial individuals are sometimes called upon to define or defend their racial identity in
ways that monoracial individuals are not, a process that can come with psychological costs
(Sanchez, Shih, & Garcia, 2009; Townsend et al., 2009). It appears that identifying with more
than one racial category is associated with more positive well-being in adolescents (Binning,
Unzueta, Huo, & Molina, 2009), suggesting that an overemphasis on discrete racial categories
may have negative consequences for at least some multiracial individuals, for whom having their
identity accurately recognized can be important. That is, being perceived as multiracial is, for
some multiracial individuals, an important aspect of being understood by their social partners
(Remedios & Chasteen, 2013).

Thus, it seems clear that biracial and multiracial children are traveling along developmental
trajectories that may differ in critical ways from their monoracial peers, with distinct implications
for the development of social categorization and social identity (Rockquemore, Brunsma, &
Delgado, 2009). Some research has begun to characterize these trajectories, suggesting, for
example, that biracial children possess more sophisticated knowledge of race-related perceptual
cues as well as more flexible racial identification (Chiong, 1998; Poston, 2011). Some of these
differences may appear remarkably early; a study of 3-month-old infants revealed that multiracial
babies exhibited different patterns of visual attention to faces than did monoracial babies,
suggesting they were engaging different processes to build a broader representation of the faces

BEYOND DISCRETE CATEGORIES 649

around them (Gaither, Pauker, & Johnson, 2012). More broadly, work with non-monoracial
children provides reason to think that central constructs in intergroup social cognition, including
notions of “ingroup preference” or “outgroup derogation,” must be considered in a new light when
individuals do not fit within a single category and can thus identify in complex ways (e.g.,
considering oneself to belong to more than one or neither monoracial category and/or to belong
to a different biracial or multiracial category).

Indeed, there is now an emerging body of evidence suggesting that both multiracial adults
and children flexibly shift their social identities in response to contextual demands. For example,
one recent study primed biracial children with one racial identity (Gaither, Chen, et al., 2014)
and then had them engage in a learning task modeled after the testimony literature (Koenig,
Clement, & Harris, 2004) in which they had the opportunity to learn from a monoracial
individual who matched or did not match the primed identity. Children showed a tendency to
preferentially learn from individuals who matched the primed identity as well as, at least in some
cases, enhanced social preferences for “matched” individuals. Conceptually similar findings
have been observed with biracial adults (Gaither et al., 2013; Pauker, Ambady, & Freeman,
2013). These findings suggest that for multiracial individuals, social contexts activate different
components of racial identity in a highly flexible manner. No monolithic conception of group
identity can account for this flexible and contextually contingent form of racial identification.

Contributions to Developmental Science: Present and Future

Overall, we take this emerging body of work as a powerful demonstration that notions of
group and identity must be broad and flexible enough to actually encompass the true range of
variation that increasingly characterizes our society. Research that has embraced greater
complexity in category boundaries has benefitted the field by providing a more accurate
picture of racial perception (Dunham, Stepanova, et al., 2014; Roberts & Gelman, 2015),
racial socialization (Rockquemore et al., 2009), and the dynamics of racial identification
(Gaither, Chen, et al., 2014). Future work can build on these findings by continuing to build
more of the world’s real complexity into research designs. Indeed, we would argue that even
when a study does focus on monoracial children, either as participants or targets of percep-
tion, the researchers would do well to explicitly acknowledge it as a limit to generalizability
and include at least some discussion of the potential implications findings might have for a
more diverse sample. Of course, we recognize that multiracial participants are more prevalent
in some regions of the world than in others and that practical demands can sometimes work
against their inclusion, but we are hopeful that the field will move toward a more thorough
documentation of their experiences.

Many questions remain. Do multiracial children conceive of racial constancy in the same way
as monoracial children, or might they conceptualize racial identity in a more fluid manner,
something that can be changed or adopted with changing circumstances? In one sense, this could
reflect the early emergence of “code switching,” in which individuals adopt linguistic or
behavioral patterns that match their interaction partners (Auer, 2013). Conversely, for children
growing up in diverse environments, how is racial variation itself understood? Might early
experience with diversity lead them to reject dichotomous or overly essentialist views of racial
variation? In addition, how can measures be adapted or developed to assess the full spectrum of
racial diversity? For example, might researchers interested in implicit social cognition consider

650 DUNHAM AND OLSON

less categorical measures, such as priming measures, rather than more categorical ones, such as
the Implicit Association Test (IAT)? More broadly, we suspect that as our science becomes more
inclusive, researchers will discover new questions that are derived specifically from considering
the experiences of multiracial people, rather than merely extending theories focused on mono-
racial individuals to accommodate them.

BEYOND DISCRETE CATEGORIES: THE CASES OF GENDER AND SEX

While multiracial individuals have been vastly understudied within social cognition and
cognitive development, our next categories—individuals who are transgender (have a gender
that does not match their sex) and individuals who are intersex (have a biological sex that is
neither fully male nor female)—are not only rare in that they are understudied in mainstream
cognitive development, but they are also statistically rare. With that said, these identities are
actually more frequent than many people believe. Although comprehensive epidemiological
studies of transgender identities in childhood are needed, some initial studies suggest that at least
a broader category of gender nonconformity is quite common. Somewhere between 2% and 3%
of school-aged children both “behave like the opposite sex” and “wish to be the opposite sex”
with regular frequency (Van Beijsterveldt, Hudziak, & Boomsma, 2006; see Zucker &
Lawrence, 2009, for a review), suggesting that an unexpected “mismatch” between sex and
gender likely occurs within nearly one in every two classrooms. And a recent representative
study of New Zealander high school students showed that 1.2% of them identified as transgen-
der, with 94.7% identifying as nontransgender (the remainder was unsure or did not understand
the question; Clark et al., 2014). Depending on the specific definition one uses of intersex, these
children are also more common than many believe as they represent 0.02% to 1.7% of children
(Ainsworth, 2015; Fausto-Sterling, 1993; Sax, 2002). Thus, although rare, these intersex and
transgender children are at least as common as children who are blind (Foster & Gilbert, 1992)
or who have Williams syndrome (Stromme, Bjomstad, & Ramstad, 2002), and both of these
groups have received considerable attention in the mainstream developmental literature (e.g.,
Bedny & Saxe, 2012; Johnson & Carey, 1998; Landau, Gleitman, & Landau, 2009; Meyer-
Lindenberg, Mervis, & Berman, 2006).

Sex and Gender as Continua Versus Categories

While in most Western cultures we tend to think of gender and sex as discrete, outside of the
Western, middle-class “WEIRD” (Western, Educated, Industrialized, Rich, and Democratic)
context (Henrich, Heine, & Norenzayan, 2010), conceptions of nonbinary gender and sex
abound. For example, in India, a group of individuals called the Hijra is fully recognized as a
third gender, roughly mapping onto our category of “transgender” (Nanda, 1986). Similarly, in
Samoa, there is a group of people, identified early in development, as being fa’afafine, a
recognized alternative to male and female (Bartlett & Vasey, 2006). There are regions of the
world where intersex births are especially common, as is the case with children with 5α-
reductase deficiency in Papua New Guinea (Imperato-McGinley et al., 1991) and the
Dominican Republic (Thigpen, Davis, Gauthier, Imperato-McGinley, & Russell, 1992).
Scientific advances in genetics and human biology more broadly are also increasingly leading

BEYOND DISCRETE CATEGORIES 651

to the conclusion that a large number of people fall outside the male/female distinction
(Ainsworth, 2015). Thus, experiences of gender or sex “atypicality” are occurring all over the
world, yet nearly no cognitive developmental psychologists are examining these children nor are
they discovering the ways in which they can contribute to our theories of gender development.

Gender and Sex-Diverse Individuals as Targets of Social Perception

Gender and sex are primary lenses through which we view ourselves and others (e.g., Blau &
Kahn, 2006; Lytton & Romney, 1991; Money & Ehrehardt, 1972; Raley & Bianchi, 2006).
Common examples include asking about the sex of a baby immediately upon learning that a
friend is pregnant and giving gifts that are gendered in various ways (e.g., even liberal academics
are unlikely to give the parent of a baby boy a pink dress). These assumptions continue to
structure our lives into adulthood, from our designation of male versus female bathrooms to the
decision of which Transportation Security Administration agent will pat us down on our way
through airport security (e.g., Notaro, 2015). Further, research has clearly indicated that there are
consequences to the categorizations we make: We treat others differently as a function of their
(presumed) gender. To give just one example, parents report their boys are stronger/better
crawlers than their girls, yet objective raters, blind to the gender of the baby, do not
(Mondschein, Adolph, & Tamis-LeMonda, 2000). What these examples make clear is that in
most cases, most of us assume that gender and sex align from birth, that these categories are
binary, and that they have a clear impact on children’s behaviors and dispositions—in particular,
our tendency to see them through the lens of familiar gender stereotypes.

Much like we discussed in the last section with the case of race, these assumptions can bleed
into our research. With few exceptions, the study of perceptions of gender and sex within
developmental psychology has focused on the perceptions of prototypical boys and girls—those
with clear sex assignment at birth and whose sex aligns with their gender. One exception has been
an occasional study of children’s responses to peers with gender counter-stereotypical preferences
(e.g., Carter & McCloskey, 1984; Martin, 1989; Theimer, Killen, & Stangor, 2001), but even here
the children are presumed to match a stereotype of the “other” gender rather than being conceived
of as nonbinary. Of course, focusing on typical boys and girls is reasonable in many cases; they are,
after all, the overwhelming majority. However, as more and more transgender and gender-
nonconforming children become visible and vocal about their identities, and school districts,
sports teams, and clubs respond, it is increasingly likely that even gender or sex-“typical” children
will hear about and know such children, making it no longer appropriate to leave them out of our
research programs entirely. Against this backdrop, it must be acknowledged how little we know
about children’s perceptions of transgender children. Thus, we encourage researchers to assess
children’s perceptions of such children and encourage researchers of applied cognitive develop-
ment to consider how, for example, teachers or parents might best introduce the concept of
transgender children to other children, so as to make the inclusion of these children more positive
and less stigmatizing (e.g., McGuire, Anderson, Toomey, & Russell, 2010).

Aside from the practical issue of understanding how children conceive of transgender and
gender-diverse children because they are now visible parts of children’s everyday social world,
there is also considerable theoretical value in considering the implications of the true range of
variation as well. Assessing how children reason about transgender targets can speak to existing
theories about essentialism (e.g., when children are essentializing “gender,” are they actually

652 DUNHAM AND OLSON

essentializing sex or gender? Are they essentializing biological features or some other aspect of
fixed internal identity? What behaviors would a child assume a target has if that child reports
feeling he was a boy since infancy, despite doctors saying he was a girl?) as well as ingroup and
outgroup preferences (e.g., does sex at birth or gender identity influence the degree to which a
child sees a transgender peer as an ingroup or outgroup? If the former, what aspects of gender
identity are most relevant for child perceivers?). Similarly, we can ask whether knowing that
transgender children exist changes cisgender (nontransgender) children’s understanding of
gender stability or constancy.

Another way in which the acknowledgement of the existence of gender- and sex-diverse children
might influence the way cognitive developmentalists conduct research is by reexamining our own
assumptions in the development of our measures. For example, “passing” many of our tasks often
requires that a child comes to “believe” or “understand”: that one’s gender is determined by one’s sex,
that one’s gender in childhood will be one’s gender in adulthood, and that people can be divided into
mutually exclusive categories of male or female (e.g., Bem, 1989; Ruble et al., 2007; Slaby & Frey,
1975). Children are not said to understand gender until they understand these “facts” (e.g., Kohlberg,
1966)—yet the scientific and political understanding of the truth of these claims is changing. We now
know that there are people whose gender is in fact different than their sex, we now know that there are
some people whose gender changes during the course of their development, and we know that there are
people who are neither male nor female by standard criteria, yet our studies require that children endorse
these empirically false claims about gender and sex to be granted the “correct” understanding of gender
(e.g., Zucker et al., 1999). Imagine, for example, a child who personally knows a transgender child—
would he or she be wrong to state that a child’s sex and gender can diverge? On this point, we think the
field is especially behind. Of course, it is reasonable that children should come to learn large-scale
statistical regularities relating to gender categories, such as that most people’s sex and gender align. But
at the very least, it seems clear that children who provide answers that deviate from this norm are not
necessarily incorrect and that a child who has a different gender experience or knowledge of a different
experience (e.g., the sibling of a gender-nonconforming child) than most is not automatically disordered
or confused in some way (e.g., Fast & Olson, under review). As way of analogy, most children favor
members of their social groups, even arbitrarily assigned ones (e.g., Dunham, Baron, & Carey, 2011)—
this response is statistically the most common response—yet we would not argue that a child who
violates this norm—for example, a child who showed no group bias—is incorrect, deviant, or otherwise
problematic.

The Experiences of Individuals With Gender- and Sex-Diverse Identities

In general, the experiences of children who identify as the “opposite” gender, children who
identify as somewhere between male and female or as neither male or female, children who
show major discordance between their sex and gender expression, or children whose sex does
not appear to be neatly male or female have fallen within the purview of developmental
psychopathology rather than mainstream cognitive development (e.g., Ehrensaft, 2010;
Wallien & Cohen-Kettenis, 2008; Zucker, 2005). Not surprisingly, therefore, much of the
work with these children as participants has focused on clinically relevant questions (e.g.,
rates of psychopathology among these groups), rather than questions about basic developmental
science (though see Zucker et al., 1999). Even when the existence of these children is mentioned
in reviews of gender development (e.g., Martin, Ruble, & Szkrybalo, 2002; Ruble, Martin, &

BEYOND DISCRETE CATEGORIES 653

Berenbaum, 2006), their experiences rarely make it into broader discussions of gender devel-
opment (Liben, 2016). This separation occurs despite the fact that focusing on these less
common populations may be especially insightful to our theory development.

Our theories about the development of gender identity, gender roles, and gender presentations
are based nearly exclusively on gender-“typical” children, our stimuli nearly exclusively focus on
prototypical exemplars of boys and girls, and our theories often assume that to understand gender
is to understand “typical” gender development (Ruble et al., 2006). The inclusion of children with
diverse gender and sex identities—in particular, transgender and intersex identities—will benefit
basic research in cognitive development in several ways. First, by systematically studying a wider
swath of children with more diverse gender and sex identities, we can provide additional tests of
our theories. As an illustrative example, we take the case of gender constancy. Some cognitive
theories of gender development argue that a key (if not the key) gender milestone is coming to
understand that a person’s gender is stable across time and situations (e.g., Kohlberg, 1966; Ruble
et al., 2007). Children begin to show evidence that they understand this principle around 5 to
7 years of age, with younger children believing, for example, that if a boy grows out his hair or
wears a skirt he becomes a girl (Slaby & Frey, 1975). Researchers have pointed out that this
understanding often occurs at the same time as, and may even lead to, other aspects of gender
cognition (e.g., Ruble et al., 2007; Slaby & Frey, 1975; though see Arthur, Bigler, & Ruble, 2009;
Levy & Carter, 1989, for some counterexamples). For example, children who show an under-
standing of gender constancy show greater preference for gender-stereotypical toys as well as
greater distortions in gender-typed memory (Stangor & Ruble, 1989).

However, relevant to the present context, there is a subset of children who report that their
gender identity is nonbinary (neither fully male nor female) and even some who report that their
gender identity wavers or changes over time (e.g., Ehrensaft, 2010, 2011). Given the existence of
such children and the increasing attention to gender-nonconforming children, is it accurate
or appropriate to equate responses indicating variation over time with a deficient understanding
of how gender functions? We do not think so, at least absent evidence that gender constancy is a
necessary precursor to other aspects of gender understanding in gender-nonconforming children.
For example, if such children do not believe that gender is stable but still show high levels of
gender stereotyping—similar to their gender-“typical” peers—it would provide some (addi-
tional) evidence against the claim that gender constancy is a precursor to stereotyping. In
some ongoing work, we are testing exactly this question in a group of transgender preschoolers
(Fast & Olson, under review). Including these children in such a study could provide convergent
or divergent evidence contributing to ongoing theoretical debates on this issue (Bandura &
Bussey, 2004; Martin et al., 2002).

Not only will including gender-atypical children in our research provide important test cases
for current theories, but it will also help us to answer deep questions we simply cannot answer
with gender-typical children. As an example, in “typically” gendered children, nearly all factors
that might contribute to the development of a child’s gender identity, gender role, and gender
presentation (e.g., parental input, peer socialization, genetics, anatomy, etc.) are highly correlated
and overlapping. That is, a “typical” boy not only has male genes, but he was raised as male,
reinforced for his malelike behaviors, and has the expected male body, and likely, his parents
purchased clothes and toys that signal to even strangers that he is a male. Determining what roles
each of these factors plays in each aspect of his gender development is nearly impossible (does
he feel like a male because of his genes or the way he was raised or some combination?). By

654 DUNHAM AND OLSON

studying gender and sex in more diverse children, however, especially as we learn and document
more about their lives and upbringings, we can begin to separate the possible influence of these
factors in determining gender identity. For example, many transgender children receive clear
parental input and peer socialization about what their gender identity should be, yet they develop
gender identities starkly at odds with that environmental input. Insofar as existing theories of
gender identity development emphasize the contributions of parental and community socializa-
tion (e.g., Bussey & Bandura, 1984, 1992; Mischel, 1966), these theories may not be able to
account for transgender children’s identity (at least insofar as differential socialization practices
can be ruled out). At the very least, such theories will need to be expanded to accommodate the
experiences of these children.

Similarly, including the experiences of intersex children may help our understanding of the
ways in which biological forces such as hormones at different times in development contribute
to children’s sense of gender roles and gender identity. For example, one study of women with
congenital adrenal hyperplasia (CAH), a type of intersex condition, showed that the degree of
androgen exposure in utero (caused by various mutations leading to varying degrees of mascu-
linization of genitalia) was correlated with having more male-dominated occupations, more
interest in male-stereotyped activities (e.g., interest in motor vehicles), and sexual interest in
the same sex (Frisen et al., 2009), suggesting a possible influence of prenatal hormones on
gender role, gender identity, and sexual orientation. Similar findings have been observed with
female children who have CAH (e.g., Meyer-Bahlburg et al., 2004). Critically, however, even
with maximal androgen exposure, there was considerable variability, leaving open the important
role of socialization or other less understood biological processes as influences beyond early
hormonal exposure.

Some number of children with ambiguous genitalia (one type of intersex condition) are raised
as boys and some as girls, some are aware they were born intersex, some are not, yet within each
group, some later identify as male, some as female, and some as something in between (e.g.,
Slijper & Drop, 1998). Although not a true experiment, this configuration of environments,
perhaps in combination with the study of transgender children who, for example, are or are not
allowed to “socially transition” to live as the “other” gender, could allow researchers to better
separate the impact of gender socialization on gender outcomes. By including a broader range of
gender and sex experiences, developmental psychologists will be able to revise their theories
about the emergence of different aspects of gender identity, ultimately creating what is likely to
be a more accurate (by virtue of explaining a wider range of children’s experiences) as well as
potentially more parsimonious theory of gender identity development (if it turns out that some
factors, such as an understanding of gender constancy, may not be so central).

Contributions to Developmental Science: Present and Future

We believe it is crucial moving forward for researchers to consider transgender, gender-
nonconforming, and intersex people, both as targets of perception and as participants.
Although admittedly, including them as participants is hard given their relatively small repre-
sentation in typical participant pools, we believe that doing so is feasible especially through
partnerships. Transgender children are increasingly visible and can be identified through support
groups, camps, conferences, and gender clinics (which have begun emerging throughout the
United States and Europe at an increasing rate). In addition, in our experience, clinicians who

BEYOND DISCRETE CATEGORIES 655

work with young transgender and gender-nonconforming children are open to collaborations
and discussions with researchers of basic gender development. Likely the same is true for
pediatricians who work with young intersex children.

Even when these particularly unusual groups (e.g., transgender and intersex children) cannot
be recruited, researchers can more easily recruit gender-nonconforming children and can come to
think of gender identity as a less discrete identity. Further, even when such children cannot be
recruited in large enough volume as participants, authors can theorize or make predictions about
how their existing theories of gender may or may not hold for these groups, thereby highlighting
that such children are in fact integral to testing theoretical predictions. Regardless of access to
these participants, everyone has the ability to contribute to discussions about perceptions and
understanding of transgender, gender-nonconforming, and intersex people, which in turn will
advance the goal of moving beyond thinking of gender and sex as discrete categories.

Contributions to Developmental Psychopathology: Present and Future

So far, we have focused almost exclusively on what cognitive developmentalists can gain from
studying a broader array of gender and sex minorities, but might clinically oriented researchers
also benefit from collaboration with cognitive developmentalists on issues of gender categoriza-
tion? We cautiously suggest that the answer is “yes.” Most notably, several pediatricians and
psychologists working in gender clinics have specifically stated a desire to know more about
basic development among gender-diverse youth and a desire to collaborate more with research-
ers of basic gender development (e.g., Hidalgo et al., 2013). We focus here on two examples of
how more knowledge about basic development in gender-diverse youth could influence clinical
practice.

A critical issue in contemporary work on gender identity in developmental psychopathol-
ogy concerns the likelihood that children who are “gender-nonconforming” in childhood will
be transgender in adulthood. This question is important because of the direct implications for
treatment (e.g., Byne et al., 2012; Steensma & Cohen-Kettenis, 2011). On the one hand, if
these children will desist in their behaviors and identities anyway, some argue, why not try
to make that behavior desist earlier (e.g., Meyer-Bahlburg, 2002) and therefore reduce
anxiety and/or peer maltreatment that results from the gender nonconformity (Wilson,
Griffin, & Wren, 2005)? On the other hand, if a gender-nonconforming child is highly
likely to be a transgender adult, one might suggest providing familial (Hidalgo et al., 2013)
and medical (de Vries, Steensma, Doreleijers, & Cohen-Kettenis, 2011) support, especially
given that both have been linked to better mental health among transgender adults (e.g., de
Vries et al., 2011; Hill, Menvielle, Sica, & Johnson, 2010; Olson, Durwood, DeMeules, &
McLaughlin, 2016). Thus, increasing the ability to identify which children will (or will not)
identify as transgender adults is of utmost importance. How can developmental psychologists
help? One clear way is in documenting the pathways of different gender identities—at what
ages do we see differences that predict which children will identify as transgender and which
will not? For example, if signatures of gender behavior and cognition emerge early in
development among a group of transgender children (e.g., Olson et al., 2015) and these
same children retain their gender identity into adulthood, their responses at this earlier age
can be one contributing piece of the complex clinical and parental decision regarding how
and when to support children in social transitions.

656 DUNHAM AND OLSON

Similar considerations apply to the case of intersex children. If developmentalists are clearer
about what patterns of gender cognition are most common for children who identify as male,
female, or (increasingly) another gender early on, they might also be able to help parents and
clinicians identify signs that an intersex child is being raised as the “wrong” gender. That is, the
medical establishment has reported many cases where parents of intersex children were told to
raise their children as a particular gender or even conducted surgery to “assign” a gender, but
then later it became apparent that the child’s assigned gender did not feel authentic to the child
(e.g., Dessens, Slijper, & Drop, 2005; Reiner, 2005). Indeed, a current lawsuit in South Carolina
focuses on the very issue of wrongful or erroneous early assignment (Greenfield, 2014).
Although there are now pushes to delay or even stop surgeries for intersex children altogether
(e.g., Frader et al., 2004), research on early childhood development among intersex children
could contribute by helping us to understand, at an earlier age, the nature of the child’s gender
identification and will therefore increase the likelihood that if the intersex child has a more
binary identity, that child is raised as that identity insofar as possible (e.g., the roster at school or
the child’s passport lists the correct gender). This understanding in turn can be linked to better
support strategies and can hopefully prevent some of the mental health challenges that emerge
among misgendered intersex people (Slijper & Drop, 1998).

DISCUSSION

Rates of children who can be described as multiracial are increasing faster than any other racial
group in the United States. Transgender children are increasingly visible and supported, and more
parents are letting their intersex children live as intersex (rather than male or female) or switch their
gender presentation if the initial “guess” was inaccurate. Yet despite the intense attention given to
the development of social identity and social categorization with respect to race, gender, and sex,
the experiences of all of these diverse individuals have largely been overlooked by cognitive
developmentalists. At least until recently, we have known very little about how children perceive
members of these groups as well as how members of these groups themselves experience their
early social realities. This lack of knowledge is a problem for several reasons. First, surely our
ultimate goal as cognitive developmentalists is to accurately account for (all of) human develop-
ment, which requires focusing our attention on the true forms that variation takes. Indeed, a version
of this very argument should be familiar from the recent calls to move beyond wealthy Western
samples (e.g., Hernich, Heine, & Norenzayan, 2010). Second, as we reexamine our methods and
theories, it becomes clear that the tendency to simplify complex spaces into simple dichotomies
taints not just our participants’ social perception, but ours as well. That is, in striving to make
generalizable discoveries, we have simplified the world into categories that, in actuality, do not
always exist in the forms in which we study them and in some cases even use endorsement of those
false dichotomies as criteria for attributing understanding to children. Although a range of basic
cognitive tendencies may help explain why we do so, it is worth attending to the biases that have
occurred in our own and others’ work.

For child clinical researchers, we hope this review will be a useful reminder that because
developmentalists have not often considered the experiences of people who do not fit into a
single category, it is unclear whether the theories and methods developed will be appropriate for
them. Instead what might be necessary is collaboration between individuals who have thought

BEYOND DISCRETE CATEGORIES 657

considerably about the theories of basic (or modal) development and those who actually know
the experiences of nonbinary individuals. Together, we are optimistic that both cognitive
development and developmental psychopathology will benefit from such intersections and
potential collaborations.

Such an approach is likely to not only advance our existing theories, but also to yield
interesting new research questions. For example, because of our tendency to place individuals
in discrete categories, there are many cases where an outside observer may view an individual as
a member of a category with which the individual himself or herself does not actually identify
(e.g., a child who sees himself as male but whom other people see as female; a person who
seems herself to be biracial but whom others see as Black). What are the psychological
implications of this mismatch between one’s own and others’ group perceptions? Might this
mismatch in and of itself impact a child’s view of his/her own group membership or even groups
in general, to say nothing of the influence on how that individual is treated by others? In what
ways might this experience be different from the experience of someone who also does not fit a
discrete group membership but who is actively seen by others as defying categorization (e.g., a
visibly gender-nonconforming individual)? Some of these questions have begun to be fruitfully
examined in the case of multiraciality (for reviews, see Gaither, 2015; Shih & Sanchez, 2005),
and we hope that the general approach will continue to be pursued there as well as in the other
areas we have identified here.

Although we have in some cases emphasized conceptual commonalities uniting the study of
race, sex, and gender, we want to reiterate that this emphasis should in no way be taken to imply
that we think the same issues arise with each. Surely each needs to be studied with an
appreciation of its distinct context and demands. For example, while transgender and intersex
people are often considered the purview of developmental psychopathology, multiracial people
are generally not. Similarly, the former two groups sometimes seek medical interventions related
to their social identities, while the latter quite clearly do not; some of these identities are more
concealable than others and affect how they are conveyed and how they impact the everyday life
of those who hold them. Further, public knowledge about the existence of these groups, the
history behind the treatment of each, and the general acceptance of their identities by society are
clearly quite varied. What is more, while sex is widely considered a biological construct, race is
not, at least not by experts, and while all societies include members who have different sexes and
genders, many do not vary in racial makeup. Thus, although we have combined these diverse
experiences into one article, we want to be clear that these experiences likely have more
differences than similarities in daily life.

With that said, it was nonetheless interesting, in doing research for this piece, to discover
some surprising similarities in the ways in which these groups have been treated, especially
historically. In particular, it has raised for us the possibility that the impact of a societal emphasis
on discrete categories may itself contribute to the pathologizing of other experiences. Indeed, the
history of all three cases on which we focus here (and for one of the cases, the currently
dominant view) includes a period during which they were widely discussed—including in the
field of psychology—as problematic or deviant, needing to be “fixed” or eliminated through
treatment or avoidance.

Presently, intersex children are still considered in formal diagnostic manuals for pediatricians
and clinicians to have a “disorders of sexual development,” and many clinics conduct surgical or
hormonal treatments to “correct” these “problems” (e.g., Slijper & Drop, 1998), with others

658 DUNHAM AND OLSON

working to prevent the birth of intersex babies in the first place (New et al., 2001). Thus,
intersex children continue to be seen through a lens of “atypicality as pathology” though there is
a growing movement to change this perception (Dreger, 1998). Turning to gender, until 2013
(3 years ago, as of this writing), transgender children were considered to have “gender identity
disorder” and thus would have been included in the pathological sense of “atypical” according
to common practice in both developmental psychology and psychiatry. Even now, although the
diagnostic label “gender dysphoria” no longer carries the charged term “disorder,” it still appears
in the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition and is still deemed
by many in psychology and beyond to necessitate therapy to remove or reverse it (e.g., McHugh,
2014; Zucker, Wood, Singh, & Bradley, 2012), though this view too may be falling out of favor
(Hidalgo et al., 2013).

What about multiraciality? Despite relatively high levels of acceptance today, multiraciality
was also often characterized as a disorder historically. Arguments against interracial marriage in
venues as prominent as state supreme courts frequently asserted that children born of mixed-race
parents were problematic or even deviant (Perez v. Sharp, 1948; Scott v. Georgia, 1869), visible
in, for example, arguments before those courts: “The amalgamation of the races is not only
unnatural, but is always productive of deplorable results. Our daily observation shows us, that
the offspring of these unnatural connections are generally sickly and effeminate …” (Eggers v.
Olson, 1924). Although such sentiments are thankfully rare today, they are not absent entirely,
and while old-fashioned racism is no doubt the dominant contributor, it is possible that a general
unease with moving beyond categorical thinking may also play some role.

Conclusion

In summary, we have suggested a large number of ways in which our science has been restricted
by both the societal and scientific dichotomization of complex social landscapes. While we have
focused on some of the most central social categories with which the field has occupied itself,
the considerations we have raised likely play out in other social distinctions as well. Rich or
poor, urban or rural, liberal or conservative: In so many cases, we reduce continuous or
multifaceted dimensions to a single either/or, and we suspect that a similar, though context-
specific, set of problems will emerge in each of these cases. Thus, we suggest that an increased
focus on multiracial, transgender, and intersex people will benefit nearly all aspects of our
research, from the details of our stimuli, tasks, and methods to the theories those tools allow us
to develop. It is past time that we expand our efforts to account for and embrace the true
complexity that characterizes our social world.

FUNDING

We would like acknowledge the support of NSF grant #1523632 to Kristina Olson.

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References

Sexual Harassment/Assault, Rape &
Rape Culture

Terms
Sexual harassment – harassment using explicit or implicit sexual overtones. These include a range of actions from verbal behavior to sexual abuse or assault
Sexual Assault – sexual contact or behavior that occurs without explicit consent of the victim (attempted rape, unwanted sexual touching, forcing a victim to perform sex acts like oral sex or penetrating the perpetrator, rape)
Rape – sexual penetration without consent.

This means that all acts of rape are sexual assault, but not all sexual assaults are rape. These definitions are often based on legal definitions, not psychological ones. Each state defines rape slightly differently.
2

Sexual Harassment

What about our expectation of gender roles makes people laugh when they see this image on the left….instead of seeing it as sexual harassment. His look is indicating shock and discomfort…and yet many of us don’t attribute that to him. Thanks to our expectations of gender roles.

Sexual Harassment
Two types of behaviors are considered harassment:
Explicit
Abuse of power for sexual favors
Not explicit
Creation of a “hostile environment”

Why does sexual harassment occur?
An attempt to make the workplace unpleasant for a coworker/subordinate who is unwanted
A way of ‘keeping people in their place’ or making them feel vulnerable
Unwanted flirting can become sexual harassment when it does not stop
While these guidelines were based on male-female sexual harassment, courts have applied a similar standard to same-gender harassment
4

Sexual Harassment
There’s a big difference between sexual harassment and unwanted flirting:
The role of power
One individual may be ‘superior’ to another
Details of the approach
Level of interest in continuing contact
Key is the nature of the relationship between the parties

Countering myths about sexual harassment:
Attractive people CAN sexually harass others
Harassment can occur across/within genders
Can occur across/within ages/SES/education
You don’t need to have power over someone to sexually harass them (implicit harassment)
The key feature is that the behavior is unwanted
Politely asking someone on a date is not harassment….unless there is a consequence for saying “no”

Sexual harassment is culturally specific
Actions considered offensive to some individuals may be flattering to others, based on upbringing or cultural norms
Gender differences
Research indicates that men are more likely to interpret women’s friendliness as flirtation
Men are more likely to engage in same-gender harassment in the form of anti-gay taunting
Women may have a difficult time saying ‘no’ or ‘stop’ due to social norms
Harassment reinforces our social norms against taboo gendered behaviors:
“Non-masculine” behavior for males
“Unacceptable” sexual behavior in females
6

Harassment starts early…
Teasing, more often peer-to-peer, compared to adult/child
83% of girls and 79% of boys in grades 8-11 reported experiencing harassment at school
Harassment is often discounted or ignored by adults
Discounted as normative: “Boys will be boys”
Impact of harassment:
Girls felt less autonomous, more intimidated and embarrassed when assessed later
33% of girls and 12% of boys no longer wished to attend school as a result

Results from a large AAUW study in the early 2000s

40% of students report witnessing or experiencing harassment by teachers / other school employees
7

Smith et al. 2020
Nationally representative sample in 2019 reported:
80% of straight women, 95% of sexual minority women
77.3% of sexual minority men and 41.3% of straight men
Reported being sexual harassed while at middle or high school

Harassment starts early…
Harassment has been found to be perpetrated more often by boys in groups than by single boys
Motivation may be achieving higher status among other boys

40% of students report witnessing or experiencing harassment by teachers / other school employees
9

Harassment starts early…
In addition. Violence and mating have been found to be linked in men’s minds.
This does not mean all men are naturally violent, but it does mean men should be conscious of that link…and particularly conscious of changes in behavior in groups at all times

40% of students report witnessing or experiencing harassment by teachers / other school employees
10

Why are rates higher for sexual minorities?
Sexual harassment (particularly in school) is often because of perceived sexual orientation
Based on appearance
Based on gender role behaviors

63.7% of LGBT students reported being verbally harassed, 27.2% reported being physically harassed and 12.5% reported being physically assaulted at school in the past year because of their gender expression.

Nearly two-thirds (61.1%) of students reported that they felt unsafe in school because of their sexual orientation, and more than a third (39.9%) felt unsafe because of their gender expression. 29.1% of LGBT students missed a class at least once and 30.0% missed at least one day of school in the past month because of safety concerns, compared to only 8.0% and 6.7%, respectively, of a national sample of secondary school students. The reported grade point average of students who were more frequently harassed because of their sexual orientation or gender expression was almost half a grade lower than for students who were less often harassed (2.7 vs. 3.1). Increased levels of victimization were related to increased levels of depression and anxiety and decreased levels of self-esteem. Being out in school had positive and negative repercussions for LGBT students – outness was related to higher levels of victimization, but also higher levels of psychological well-being.
11

Heterosexism or Heterosexual Bias
An ideological system that denies, denigrates, and stigmatizes any non-heterosexual persons, form of behavior, relationship, or community
The assumption of superiority of heterosexuality (still several states where you can be fired for being LGBTQ)

Current cultural debates over human rights center on whether LGBT persons are worthy of them
“I don’t approve of who you are or what you do, so I don’t think you should have the things that I do.”

Persons are most often harassed for their perceived sexual orientation
Based on appearance
Based on gender role behaviors
Two major forms of discrimination against gay, lesbian, bisexual persons:
Heterosexual bias/ heterosexism
Anti-gay prejudice

Anti-gay prejudice and homophobia are beliefs about GLB persons that may lead to discrimination
Anti-gay prejudice does effect heterosexuals
It is a problem for any individual who may be viewed as gender ‘deviant’
Used as a weapon of intimidation
Some heterosexuals feel they must “prove” their heterosexuality in order to avoid being discriminated against
e.g., those in gender atypical occupations
Same-gender friendships become suspect
12

Violence Against queer Individuals
Same sex love or sexual behavior has been targeted by many groups throughout history, even by our own country
Christian Inquisition
Nazis
McCarthy Era Blacklists

Table is from an in depth piece in the NYTimes in 2016 using primarily FBI and Williams Institute data. Among LGBT people minority transgender women face the greatest risk of violence
13

Why?
Several personal characteristics may contribute to anti-gay prejudice:
Insecurity about one’s own sexuality
Fundamentalist religious orientation
Lack of knowledge/understanding about homosexuality
Gender differences
Heterosexuals feel more antipathy towards homosexuals of their own gender
Heterosexual men are overall less tolerant than heterosexual women (masculine gender role expectations)

Rape

Brock Turner, case became famous because the judge gave him a lenient sentence because he was a good swimmer in school and came from a good family. Yet, he perpetrated a violent rape and was caught by two bystanders that didn’t know either party but saw an unconscious woman being raped in an alley and chased Brock down (they were European tourists and were so shook by what they saw that they were openly crying when filmed by the news about the incident). Its rare that a case is so clear-cut, no he said/she said but multiple witnesses and someone caught in the act…and STILL the judge gave him leniency. California recalled the judge and removed him from office. Sadly, there are countless stories like these that don’t end with justice being served across the nation. Turner’s family even feels so bold that they sued a psychologist for including the above image in a textbook chapter about rape, even though hes a convicted rapist and legally we can put his picture in any textbook about rape that we please as a result.
15

Rape
Is an act about control/power
The underlying motivation for rapists is never solely to obtain sex. That may be one of their perceived benefits of the act but is not the most driving psychological factor in why people rape others
Power/control/restoring feelings of lost masculinity are all more dominant factors in interviews with admitted rapists.

Rape
Serial rapists often have levels of sexual sadism, in which they gain sexual gratification from the act of violence itself, but most rapists wouldn’t fall under the sexual sadist category. And it’s the power/control that they are primarily getting off on
Its hard to pinpoint a single reason why any person would rape, but rather it’s a combination of factors. Control is one of the only variables that seems to cut across and combine with all causal factors
Ellis (1991) Brownmiller (1975) Thompson and Butell (1984) Barbaree (1991)
Other credible suggested factors: specific paraphilias, high sex drive combined with low impulse control and myth acceptance, attempts to bond the victim/survivor to the rapist through trauma. In all these studies, controlling others or restoring a lost sense of masculinity/control exist in all these scenarios

Societal beliefs about rape
Rape myths are very common and often guide thinking about the act

Societal beliefs about rape
Most common is the belief that rape is a violent brutal act perpetrated by a stranger in a secluded location
(this isn’t even close to being statistically correct, about 85% of rape cases in the U.S. are acquaintance rapes)

Societal beliefs about rape
Often people only think of those 15% of situations as “real rape” because of their belief in the myth
Often difficult to prove to others that acquaintance rape was indeed rape as a result of their assumptions

Myths About Rape
The victim wants to be raped
“No means yes”
Vast difference between erotic fantasies of rape and actual rape (issues of control and harm)
Rapists are ‘obviously’ mentally ill
A potential rapist would look the part.
The victim deserves to be raped/men cannot be expected to control their sexual urges.
“She was dressed like a slut”
Many women ‘cry rape’
False accusations of rape are quite uncommon (and infrequently prosecuted).
It isn’t rape or “it can’t be rape”
Rape of prostitutes often not considered rape
Rape of marital partners has often been not considered rape
Men always want sex so they cannot be raped (plus, basic physiological issue of erection).

Characteristics of rapists—proclivity toward violence (rape can be about violence, sexual gratification, or probably most commonly, both). Men who embrace traditional gender roles are more likely than men who do not. Anger toward women is a prominent attitude among some men who sexually assault women. Alcohol often contributes. Many rapists have a self-centered personality (insensitivity towards others feelings). Power and violence may be more common in stranger rape whereas a need for sexual gratification may prevail in acquaintance or date rape.
Sanday’s research on rape-prone societies—these societies glorify masculine violence, encourage boys to be aggressive and competitive and view physical force as natural and exemplary. In these cultures, men tend to have greater economic and political power, remaining aloof from “women’s work” such as child rearing. Rape-free societies share power and authority and contribute equally to the community welfare. Children of both sexes in these societies are raised to value nurturance and to avoid aggression and violence. The United States has the highest incidence of rapes among all Western Nations.
22

Legal issues
Often sexual assault laws are vague or misleading.
Survivors/victims may be confused about legal protections/rights.

Studies have shown many rape survivors view their experience in negative terms and feel victimized…but may not even know what happened meets the legal standards for rape
23

Statistics
U.S. Department of Justice National Crime victimization survey (largest and most reliable crime study)
734,630 sexual assaults in 2018(most recent data)
From 2016 to 2018 the number of victims of sexual assault doubled

Statistics
Most studies put prevalence ranges at:
¼ women will be raped in their lifetime
1/5 men will be raped in their lifetime
But new Williams Institute data suggests men’s rate may be closer to ¼
For both men and women the perpetrator is most likely to be male

Date Rape/Acquaintance Rape
most rapes are not perpetrated by strangers
Intimate partners
Casual acquaintances
Ex-partners
Alcohol / drug use associated with more than 70% of date rapes (on the part of the victim and the perpetrator)
Alcohol has been shown in studies by the WHO to increase the likelihood someone commits a violent crime (especially if they’ve already been thinking about it)
Many perpetrators get drunk or high either as a legal strategy, or to psychologically try and remove guilt they feel from their acts

False Reports
The FBI places false reporting for sexual assault at around 3%
This is far lower than many other crimes including theft and even murder
Sexual assault is HIGHLY underreported
Making a real accusation is difficult, making a false one that goes to court becomes nearly impossible in this reality

False Reports
So why do so many people believe false reports are common?
Think back to the myths and how many blame people for their own assaults
Think about gender role messages of femininity and who is “good” or “bad”
Think about old claims of hysteria, based on the idea that women have chaotic emotions, makes it more easy to believe a woman would lie about something emotional

Consent
Can’t always rely on No/Yes
Drunk individuals can’t consent
Mentally ill cannot consent with non-peers
Those under the age of 18 (17 in New York with exceptions)
Unconscious individuals
High individuals
Sleeping individuals

Consent
Gender norms about sex (men are teachers, women learners/passive) sometimes make it difficult to say no
What are other signals of “no?”
Body language (anxiety)
Trying to find excuses not to
Trying to change the subject

How you can help a survivor
Listen
Don’t be judgmental
Be patient
Help empower the individual, give them choices
Encourage but don’t force them to report
If they are willing to seek medical attention, accompany them if requested

Listen. Be there. Don’t be judgmental.
Be patient. Remember, it will take your loved one some time to deal with the crime.
Help to empower your loved one. Rape and sexual violence are crimes that take away an individual’s power, it is important not to compound this experience by putting pressure on your loved one to do things that he or she is not ready to do yet.
If you are dealing with an issue involving your child, create a safe place by talking directly to them.
If you are the non-abusing parent in a case of incest, it is important to support your child and help them through this situation without blaming them. This is also true if you are not a parent but still an observer of incest.
If your loved one is considering suicide, follow-up with them on a regular basis.
Encourage your loved one to report the rape or sexual violence to law enforcement (call 911 in most areas). If your loved one has questions about the criminal justice process, talking with someone on the National Sexual Assault Hotline, 1.800.656.HOPE, can help.
Let your loved one know that professional help is available through the National Sexual Assault Hotline, 1.800.656.HOPE, and the National Sexual Assault Online Hotline.
If your loved one is willing to seek medical attention or report the assault, offer to accompany him or her wherever s/he needs to go (hospital, police station, campus security, etc.)
Encourage him or her to contact one of the hotlines, but realize that only your loved one can make the decision to get help.
31

In situations of abuse…
Rape happens in relationships
Often a component of domestic violence
Still about power/control, not solely about a desire for sex

Why wouldn’t someone leave?

60% of rapes/sexual assaults are not reported to the police, according to a statistical average of the past 5 years.2 Those rapists, of course, never spend a day in prison. Factoring in unreported rapes, only about 6% of rapists ever serve a day in jail.
From RAINN rape abuse and incest national network rainn.org
33

Why wouldn’t someone leave?
Leaving a relationship is hard
Women often have to opt for living in poverty as opposed to men
Many cultural/social norms that encourage women to stay
Violence has become a familiar pattern
Often people love their partners still
When leaving/separating/divorcing the risk of violence/death is at its GREATEST!

Leaving a relationship, no matter how abusive, is never easy. Women who leave relationships often have to opt for living in poverty. That’s a very difficult choice to make. There are many social, cultural factors that contribute to encouraging women to stay and try and make the situation work. Often, violence is a familiar pattern for the woman, as well as the man. In addition, women often love the men who abuse them, or at least love them initially. Men who batter are not 100 percent hateful, but they can be loving and attentive partners at times. Some women remain emotionally and/or economically dependent on the batterer despite the fact that she faces continued abuse if she stays with him. Women are at highest risk of injury or violence when they are separating from or divorcing a partner. Women can be very intimidated by a partner and the consequences of her leaving. It takes a long time for a woman to give up hope in a relationship and to recognize that the only way she can be safe is to leave him.
34

Sexual Abuse Trauma
Memory – unless abuse occurred before the age of 3, most remember some details.
Traumatic sexualization
Inappropriately associate sexual behaviors and emotions
Innocent touching feels violating
Betrayal, adult survivors find trust difficult
Dependent relationships
Anger and hostility toward partner
Stigmatization, guilt, shame
Mental health problems
Fear & anxiety, post-traumatic stress disorder
sense of not being in control
compulsive behaviors such as substance use, sex, shopping

35
Of course these aren’t required. Many survivors don’t experience negative psychological outcomes, and find coping to be easier. So we shouldn’t force expectations on survivors, and allow them to be the guide/teacher/one in control.

Rape Culture

Rape Culture
Beliefs and attitudes that promote victim blaming, normalize male sexual aggression/violence, and sexism that contributes to the high rate of sexual harassment/assault people face.

The definition of rape culture has a few implications:
Rape is not natural or inevitable
Men are not naturally more inclined to rape, but are taught to

The law focuses on consent to stop rape
Yet the law can’t agree on what consent is (different state to state)
Some states don’t allow for a withdrawal of consent once penetration has begun
Other states like California require continuous consent throughout the act
States like Washington require overt displays of consent, meaning you can’t just read someone’s body language or make assumptions

Consent
many high schools and colleges are focused on teaching consent to stop rape (but what is consent? Even the law can’t agree. So what are they teaching students?)
Would a perfect understanding of consent, if we could agree on one, stop rape?
From the policy level, was sex ed policy only designed to help people follow the law?
If not then what was it intended to do?

Rape Culture
Which is why we have a focus on rape culture, prevention is always better than treatment.
If we can start early and create citizens that treat each other with equity and respect, and don’t believe myths, we have a better chance at lowering rates of rape

Rape Culture and gender role beliefs – Masculinity
Gender role beliefs strongly contribute to rape itself. Rapists often commit their crimes after feeling invalidated/weak in ways that attack their masculinity (the same is true for domestic violence, and even serial killers and mass murderers)
According to recent Williams Institute data men may be raped at a rate close to that of women (mostly by male rapists) but data was rarely included in the past because men are unlikely to report, and rapes within prison weren’t included as rape in most datasets

Rape Culture and Gender Role beliefs – Femininity
Rape culture isn’t just perpetuated by beliefs about masculinity; teachings about femininity also help to keep its structure in place
Teaching that femininity is submissive, sexually passive/coy makes overt consent more difficult for one gender than another
Teaching about women as “gatekeepers” helps to place blame on women (myths about clothing worn, certain behaviors being permission for sex, etc.)
What else?

Reling et. Al. 2017
“Beliefs that hookups are harmless and elevate social status increased rape myth acceptance, whereas beliefs that hookups express sexual freedom decreased rape myth acceptance. “
Hookup culture endorsement had the largest effect on rape myth acceptance

Reling et. Al. 2017
“Hookup practices similarly reinforce the normalcy of men as masculine pursuers/ aggressors and women as properly feminine gatekeepers. Men typically control the terms of a hookup (Bogle 2008; Wade 2017), are far more likely to experience sexual pleasure (Armstrong et al. 2012), and are more likely to socially benefit from pursuing a large number of sexual interactions with different women partners (Currier 2013; Wade 2017). They are not exempt from the social risks associated with hooking up with an undesirable partner, but they retain more power than women do to redefine less-than perfect hookups in ways that elevate their social status”

Reling et. Al. 2017
female students in the United States were less likely to report believing rape myths than male students were, and more religious students were more likely to accept rape myths
“rape myth acceptance is similar for men and women. For both, the belief that hookups elevate status demonstrates a positive association and functions as the largest predictor of rape myth acceptance. The gender-specific analyses identified some differences in the importance of control variables, with Greek-affiliated men reporting lower overall rape myth acceptance and more religious women reporting higher levels of rape myth acceptance. Greek life affiliation correlated with lower rape myth acceptance among men, even though the opposite has consistently been found in previous research”

Jozkowski 2015
“Research indicates that the college environment supports, and even fosters, sexual violence against women via low-level coercion, lack of social acknowledgment of sexual assault, and institutional acceptance of sexual violence (Armstrong, Hamilton, & Sweeney, 2006). Such attitudes support victim blaming, discourage women from reporting rape and, in turn, may contribute to women not acknowledging their experiences as acts of sexual assault or non-consensual sex (Peterson & Muehlenhard, 2004, 2011).”

Jozkowski 2015
“Therefore, it may be an important first step for students to (a) be able to acknowledge the occurrence of sexual assault between two people who know each other and (b) have the ability to articulate the social circumstances that led to the occurrence of sexual assault”

Jozkowski 2015
“The larger cultural context in which sexual assault and sexual violence occurs on college campuses may be lost when prevention efforts focus almost exclusively on emphasizing that students should obtain consent in the sexual dyad. Such conceptualizations of rape suggest that either the raped woman displayed behavioral signs of consent or did not communicate her non-consent clearly”

BioMed Central

Journal of the International AIDS
Society

Open Acce

Review

Combating HIV stigma in health care settings: what works?
Laura Nyblade*, Anne Stangl, Ellen Weiss and Kim Ashburn

Address: International Center for Research on Women, Washington, DC, USA

Email: Laura Nyblade* – lnyblade@icrw.org; Anne Stangl – astangl@icrw.org; Ellen Weiss – eweiss@icrw.org; Kim Ashburn – kashburn@icrw.org

* Corresponding author

Abstract

The purpose of this review paper is to provide information and guidance to those in the health care
setting about why it is important to combat HIV-related stigma and how to successfully address its
causes and consequences within health facilities. Research shows that stigma and discrimination in
the health care setting and elsewhere contributes to keeping people, including health workers,
from accessing HIV prevention, care and treatment services and adopting key preventive
behaviours.

Studies from different parts of the world reveal that there are three main immediately actionable
causes of HIV-related stigma in health facilities: lack of awareness among health workers of what
stigma looks like and why it is damaging; fear of casual contact stemming from incomplete
knowledge about HIV transmission; and the association of HIV with improper or immoral
behaviour.

To combat stigma in health facilities, interventions must focus on the individual, environmental and
policy levels. The paper argues that reducing stigma by working at all three levels is feasible and will
likely result in long-lasting benefits for both health workers and HIV-positive patients. The
existence of tested stigma-reduction tools and approaches has moved the field forward. What is
needed now is the political will and resources to support and scale up stigma-reduction activities
throughout health care settings globally.

Review
A renewed global focus on HIV prevention, combined
with a massive roll out of antiretroviral therapy, has
focused worldwide attention on the ability of health facil-
ities to deliver critical prevention, care and treatment serv-
ices to a growing client population. HIV-related stigma
and discrimination are now recognized as key barriers
both to the delivery of quality services by health providers
and to their utilization by community members and
health providers themselves.

Unfortunately, the health sector is one of the main set-
tings where HIV-positive individuals and those perceived

to be infected experience stigma and discrimination [1,2].
Studies show that HIV-related stigma in this context is per-
nicious, and that its physical and mental health conse-
quences to patients can be damaging [3-7]. Reducing HIV-
related stigma in health settings should be a leading prior-
ity for health care managers. Yet little attention has been
paid to this issue, particularly in low-resource countries
grappling with burgeoning HIV epidemics.

Three main challenges contribute to this lack of attention.
First, there is limited recognition of the important link
between HIV-related stigma and public health outcomes,
such as patient quality of care, and health workforce

Published: 6 August 2009

Journal of the International AIDS Society 2009, 12:15 doi:10.1186/1758-2652-12-15

Received: 31 March 2009
Accepted: 6 August 2009

This article is available from: http://www.jiasociety.org/content/12/1/15

© 2009 Nyblade et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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capacity. Stigma and discrimination by health workers
compromises their provision of quality care, which is crit-
ical for helping patients adhere to medications and main-
tain their overall health and wellbeing. Stigma also acts as
a barrier to accessing services both for the general popula-
tion, as well as health providers themselves. This can have
serious implications for health workers and health facili-
ties when HIV-infected health workers delay or avoid care
and become seriously ill or die, causing further strain on
an overburdened health care system. Second, there is
insufficient capacity among health care managers regard-
ing how to effectively address stigma and discrimination
through programmes and policies. Third, there is a per-
sistent misconception that stigma is too pervasive a social
problem to effectively change [8].

The purpose of this paper is to provide information and
guidance to those in the health care setting, not only
about why it is important to combat HIV-related stigma,
but also how to successfully address its causes and conse-
quences within health facilities. The paper begins by
defining stigma and discussing how stigma manifests in
the health care setting and its effects on patients, staff and
the health care facility. It also highlights how stigma
affects health workers living with HIV.

The paper then presents evidence-based fundamentals
that should be applied when designing stigma-reduction
efforts. This is followed by a discussion of specific strate-
gies that have been particularly effective at reducing
stigma in health facilities and addressing the needs of
HIV-positive health workers, as well as tools and resources
that are available for developing and implementing
stigma reduction efforts in health care settings.

Defining stigma
UNAIDS defines HIV-related stigma and discrimination
as: “… a ‘process of devaluation’ of people either living
with or associated with HIV and AIDS … Discrimination
follows stigma and is the unfair and unjust treatment of
an individual based on his or her real or perceived HIV
status.”[9]

Stigma often heightens existing prejudices and inequali-
ties. HIV-related stigma tends to be most debilitating for
people who are already socially marginalized and closely
associated with HIV and AIDS, such as sex workers, men
who have sex with men, injecting drug users, and prison-
ers [10,11].

Men and women may experience different forms and
intensities of stigma. For example, among HIV-positive
South African adults surveyed, men reported greater self-
abasing beliefs and adverse social reactions to their HIV
status than women [12]. Conversely, other studies have

shown that women are particularly vulnerable to stigma,
including violence, one of the harshest and most damag-
ing forms of stigma [13-18].

Stigma in health facilities

Manifestations and ramifications
There are many ways in which HIV-related stigma mani-
fests in health care settings. A study in Tanzania docu-
mented a wide range of discriminatory and stigmatizing
practices, and categorized them broadly into neglect, dif-
ferential treatment, denial of care, testing and disclosing
HIV status without consent, and verbal abuse/gossip [19].
Similarly, a study in Ethiopia found that common forms
of stigma in health facilities were designating patients as
HIV positive on charts or in wards, gossiping about
patients’ status, verbally harassing patients, avoiding and
isolating HIV-positive patients, and referring patients for
HIV testing without counselling [17].

In Indian hospitals, stigma and discrimination mani-
fested as health workers informing family members of a
patient’s HIV status without his or her consent, and doing
the following only with HIV-positive patients: burning
their bedding upon discharge, charging them for the cost
of infection control supplies, and using gloves during all
interactions, regardless of whether physical contact
occurred [20].

Stigma and discrimination in the health care setting and
elsewhere contribute to keeping people, including health
providers, from adopting HIV preventive behaviours and
accessing needed care and treatment. Fear of being identi-
fied as someone infected with HIV increases the likeli-
hood that people will avoid testing for HIV, disclosing
their HIV status to health care providers and family mem-
bers, or seeking treatment and care, thus compromising
their health and wellbeing.

With its potentially devastating consequences on care-
seeking behavior, stigma represents a major “cost” for
both individuals and public health. Both experienced and
perceived stigma and discrimination are associated with
reduced utilization of prevention services, including pro-
grammes to prevent mother to child transmission [21-
25], HIV testing and counselling [26-30], and accessing
care and treatment [31].

In addition, research has demonstrated that the experi-
ence or fear of stigma often results in postponing or reject-
ing care, seeking care far from home to protect
confidentiality, and nonadherence to medication. For
example, studies in Senegal and Indonesia documented
that men who have sex with men and injecting drug users,
respectively, often avoid or delay accessing HIV-related
services, including treatment for other sexually transmitt-

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Journal of the International AIDS Society 2009, 12:15 http://www.jiasociety.org/content/12/1/15

ted diseases, for fear of public exposure and discrimina-
tion by health workers [28,32].

Likewise, reseachers in Botswana and Jamaica found that
stigma leads many people to seek testing and treatment
services late in the progression of their disease, often
beyond the stage of optimal drug intervention [30,33]. To
conceal use of antriretroviral medications, HIV-positive
individuals in South Africa reported grinding drugs into
powder and not taking medication in front of others,
which can result in inconsistent dosing [34].

As mentioned, health care providers themselves may be
reluctant to access the same testing, care and treatment
they provide to their patients due to fear of stigma in the
workplace and in the communities they serve [35]. A
study in South Africa and Botswana found that health
workers struggle with self-stigma regarding a potential
HIV diagnosis, as well as fear of stigmatizing attitudes and
behaviours from their colleagues, which contribute to a
lack of uptake of HIV testing and early treatment, if
needed [36].

In Zambia, health workers report knowing peers who are
hiding their HIV status, are afraid to talk about their situ-
ation to others, and are suffering in silence [37]. One indi-
cation of health workers’ fears around HIV testing is their
interest in self testing. A national study of health providers
in Kenya found that nearly three-quarters would be inter-
ested in testing themselves for HIV, if such an option
existed. Interest was greatest among those who had never
tested, among medical doctors, and among health provid-
ers from the province with the highest prevalence of HIV
in the country. The main reasons given for their interest
are that self testing eliminates a potential breach in confi-
dentiality, and pre-empts stigma and suspicion from col-
leagues since they would not know that someone had
tested for HIV [38].

While health workers living with HIV may face the same
kinds of stigma as their patients because of perceived
improper or immoral behaviours, their self-blame and
shame may be compounded by their relatively higher
social and educational status in the community. As noted
by one hospital manager in a Zambia study, “In the end it
was us that were stigmatizing ourselves. I feel people that
are more educated, like nurses, find it most difficult to dis-
cuss and disclose their status …” [37].

Health providers interviewed in another study in Zambia
report that medical personnel who become infected with
HIV are commonly seen as failures in the community
[39]. Nurses in Thailand expressed concern that their pro-
fessional status would not give them the benefit of the
doubt from their colleagues regarding whether they
acquired their infection occupationally or through sex or

drugs. For them, women with HIV violate gender norms
and thus are guilty of being promiscuous [40]. This sug-
gests that health providers fear a loss of status and moral
integrity if their peers find out they are HIV positive.

Immediately actionable causes of HIV-related stigma
Research conducted among general populations around
the world has revealed three immediately actionable key
causes of HIV-related stigma in the community setting:
lack of awareness of what stigma looks like and why it is
damaging; fear of casual contact stemming from incom-
plete knowledge about HIV transmission; and values link-
ing people with HIV to improper or immoral behaviour
[2,41-43].

Similarly among health care workers, research suggests
that fear of casual contact and moral judgements contrib-
utes to stigma and discrimination directed at clients living
with HIV. Studies in Nigeria, Mexico, Ethiopia and Tanza-
nia [2,14,44-48] have found high levels of fear of conta-
gion among health workers, which is related to a lack of
understanding of how HIV is and is not transmitted, and
how to protect oneself in the workplace through universal
precautions.

In India, a study of hospital workers found that those who
expressed greater agreement with stigmatizing statements
about people living with HIV and hospital discriminatory
practices were more likely to have incorrect knowledge
about HIV transmission [20]. With regard to moral judge-
ments, studies have demonstrated that the assumption
that people with HIV have conducted themselves in some
improper or immoral way contributes to health workers’
negative attitudes toward HIV-positive people and perme-
ates client-provider interactions. In Nigeria, results of a
study among nurses and laboratory technicians showed
that 35% felt that HIV-positive people deserved being
infected as punishment for their “sexual misbehaviours”
[45]. Similarly in Mexico, three-quarters of health provid-
ers surveyed thought people with HIV bore responsibility
for having HIV [48].

The value of a supportive, stigma-free environment
There is increasing evidence of the value of supportive and
de-stigmatizing HIV services in different HIV prevalence
and socio-cultural settings.

In China, health care workers who provide medical and
emotional support are viewed favourably by HIV-positive
patients and as critical to their ability to stay healthy, espe-
cially in the light of family isolation due to intense HIV
stigma [49]. Cataldo (2008) describes new forms of citi-
zenship and socio-political inclusion among low-income
people living with HIV in Brazil, a country lauded for its
policy of free universal access to antiretroviral therapy
[50]. He documents close and supportive relationships

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between health practitioners and their clients, and
between the health system and community non-govern-
mental organizations that offer meetings, workshops,
legal advice and support groups. Through de-stigmatizing
care and treatment services they receive from the health
system and related services in the community, clients are
encouraged to claim further rights to be involved in deci-
sion-making processes, to achieve greater social inclusion,
and to challenge stigma in the workplace and within fam-
ilies.

Reducing stigma in health facilities

A focus on the individual, environmental and policy levels
Although stigma is a pervasive and daunting problem in
the health care setting, much can be done to address its
causes and consequences. A key lesson that has emerged
from recent research and field experiences is that to com-
bat stigma in the health care setting, interventions must
focus on the individual, environmental and policy levels
[3,51].

Individual level
At the individual level, increasing awareness among
health workers of what stigma is and the benefits of reduc-
ing it is critical. Raising awareness about stigma and
allowing for critical reflection on the negative conse-
quences of stigma for patients, such as reduced quality of
care and patients’ unwillingness to disclose their HIV sta-
tus and adhere to treatment regimens, are important first
steps in any stigma-reduction programme. A better under-
standing of what stigma is, how it manifests and what the
negative consequences are can help reduce stigma and dis-
crimination and improve patient-provider interactions.

Health workers’ fears and misconceptions about HIV
transmission must also be addressed. Fear of acquiring
HIV through everyday contact leads people to take unnec-
essary, often stigmatising actions. Thus programmes need
to provide health workers with complete information
about how HIV is and is not transmitted and how practic-
ing universal precautions can allay their fears. In addition
to basic HIV epidemiology, health workers must be able
to understand the occupational risk of HIV infection rela-
tive to other infectious diseases that are more highly trans-
missable and commonly found in heath care settings.

Understanding the association of HIV and AIDS with
assumed immoral and improper behaviours is essential to
confronting perceptions that promote stigmatizing atti-
tudes toward individuals living with HIV. Programmes
need to address the shame and blame directed at people
with HIV by providing health providers with a safe space
to reflect on the underlying values that lead to the shame
and blame. It is important for health care workers to dis-
associate persons living with HIV from the behaviours

considered improper or immoral that are often associated
with HIV infection.

Environmental level
In the physical environment, programmes need to ensure
that health workers have the information, supplies and
equipment necessary to practice universal precautions
and prevent occupational transmission of HIV. This
includes gloves for invasive procedures, sharps containers,
adequate water and soap or disinfectant for handwashing,
and post-exposure prophylaxis in case of work-related,
potential exposure to HIV. Posting relevant policies,
handwashing procedures or other critical information in
key areas in the health care setting enables health workers
to maintain better quality of patient care.

Policy level
The lack of specific policies or clear guidance related to the
care of patients with HIV reinforces discriminatory behav-
iour among health workers. Health facilities need to enact
policies that protect the safety and health of patients, as
well as health workers, to prevent discrimination against
people living with HIV. Such policies are most successful
when developed in a participatory manner, clearly com-
municated to staff, and routinely monitored after imple-
mentation.

Several studies have shown that stigma reduction activi-
ties in hospitals, based on the principles we have outlined,
have led to positive changes in health providers’ knowl-
edge, attitudes and behaviours, and better quality of care
for HIV-positive patients [3,51,52].

For example, following a stigma-reduction intervention in
four Vietnamese hospitals [51], the mean score on both a
fear-based and a value-based stigma index decreased sig-
nificantly among hospital workers (p < 0.05). Addition- ally, there was a significant reduction in reporting of discriminatory behaviours and practices by hospital work- ers. For example, the percentage of hospital workers reporting the existence of labels indicating HIV status on files declined from 56% to 31% (p < 0.001) in one hospi- tal, and from 31% to 17% in another (p < 0.002). During monitoring visits, various positive changes were observed (e.g., improvements in the use of universal precautions, increased voluntary HIV testing of patients and informing patients of their HIV status, and a reduction in the mark- ing of files and beds with the patient's HIV status).

The intervention accomplished this reduction in stigma
and discrimination within six months through the follow-
ing programmatic steps:

1) Implementation of a brief survey to document the need
for action to reduce stigma and guide the design of the
intervention

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2) Establishment of a steering committee to plan the
intervention

3) A flexibly scheduled 2 1/2 day participatory training for
all hospital staff (from cleaners to clerks to doctors),
which focused on increasing knowledge and awareness of
HIV, universal precautions, and fear-based and value-
based stigma, including what stigma looks like in the
health care setting

4) Participatory drafting and negotiation by all staff of a
hospital policy to foster staff safety and a stigma-free
atmosphere

5) Provision of materials and supplies to facilitate the
practice of universal precautions.

This and other intervention studies in hospitals [3,52]
suggest a number of promising pathways and approaches
for tackling the problem at the individual, environmental
and policy levels. Stigma reduction fundamentals for the
hospital setting, outlined below, are also applicable in
other health care settings, such as primary care clinics and
health posts.

Involve all staff members, not just health professionals, in
training and in crafting policy
Reaching everyone with whom a patient comes in contact
(e.g., doctors, nurses, guards, cleaners and administrative
staff) helps ensure ownership of the stigma-reduction
process and a unified response by the health care facility.

Use participatory methods
Participatory methods such as games, role plays, exercises
and group discussions create a non-judgemental environ-
ment that allows participants to explore personal values
and behaviours, while improving their knowledge and
awareness. It also creates a sense of ownership in the proc-
ess of developing stigma-reduction strategies in the health
care setting.

A variety of tested tools exist from which to find participa-
tory exercises on stigma reduction to build your pro-
gramme. They include: Understanding and Challenging
HIV Stigma: A Toolkit for Action [53], a general tool that
has worked well in health facilities, as well as two partici-
patory tools focused specifically on the health care setting:
Safe and Friendly Health Facility Trainers Guide [54], and
Reducing HIV Stigma and Gender-Based Violence: Toolkit
for Health Care Providers in India [55].

Provide training on both stigma and universal precautions
Equipping health workers with the knowledge and skills
necessary to protect themselves from occupational trans-
mission of HIV is a key step in addressing fear-based
stigma. But health workers also must be provided with the

supplies necessary (e.g., gloves, gowns, water and disin-
fectant solution) so that they can take appropriate steps to
ensure staff and patient safety.

Involve individuals living with HIV
Showing that HIV has a “human face” helps health work-
ers to better understand stigma and its insidious impact
on individuals and families. Involving members of
socially marginalized groups who are HIV positive, such
as men who have sex with men, sex workers, and injecting
drug users, also helps to address the additional social stig-
mas they face on top of HIV-related stigma.

When designing a training programme, it is important to
tap into existing networks of people living with HIV to
identify individuals to take part in training activities, as
well as to provide adequate preparation and training to
these individuals to equip them for the role they will play
in training (e.g., testimonials and co-facilitation). An
important group to have represented, if possible, is health
care workers living with HIV.

Periodically monitor stigma among health workers
One way to ensure that this happens is by enacting health
care setting regulations that mandate the monitoring of
health worker attitudes and behaviours to assess progress.
It is also important to establish anti-stigma policies and
benchmarks that health facilities can use for assessing
their efforts. For example, the government of Vietnam is
currently updating its national hospital regulations to
include stigma reduction, and is developing a tool that
hospitals can use to determine the extent to which they are
in compliance.

Take advantage of existing tools
We have described two participatory resources that have
been tested and shown to be effective in different contexts
for training health workers, as well as one for other
groups. With regard to programme planning and moni-
toring, a hospital-based intervention in India produced a
tool that health workers can use to assess the extent to
which a facility complies with anti-stigma and discrimina-
tion standards. This is the PLHA-friendly checklist [56],
which can be used to catalyze action in a given facility and
also as an evaluation tool. Another tool for training health
care workers is: Reducing Stigma and Discrimination
Related to HIV and AIDS: Training for Health Care Work-
ers [57].

Address the needs of HIV-infected health workers
Health facilities should respond in a multi-faceted way to
address HIV-positive health workers’ fear of stigma and
loss of confidentiality. The response should include pri-
vate and confidential counselling and testing services,
access to antiretroviral therapy, and professional and
emotional support, either on the premises or at a conven-

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Journal of the International AIDS Society 2009, 12:15 http://www.jiasociety.org/content/12/1/15

ient location. Also important are the enactment and
enforcement of anti-discrimination policies to protect
health workers living with HIV [36].

The way forward: investing in stigma reduction

This paper highlights the importance of combating stigma
in health facilities and discusses several feasible activities
that have been shown to reduce stigma by health provid-
ers. Stigma reduction in health facilities, as we have
argued, has important implications for improving
patient-provider interactions, improving quality of care,
and creating a safe and supportive space for clients that
can help them deal with, and in some cases, challenge
stigma from family and community members.

Stigma reduction is also a first step in creating services to
address the needs of HIV-positive health workers. The
availability of tested stigma-reduction tools and
approaches has moved the field forward. What is needed
now is the political will and resources to support and scale
up stigma reduction activities throughout health care set-
tings globally. Given the detrimental effect of stigma on
both individual health and wellbeing and public health
outcomes, it is clear that health care managers cannot
afford inaction any longer.

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

LN and AS conceived the manuscript. EW drafted the
manuscript based on papers, technical reports and presen-
tations by LN, AS, and KA, who reviewed the draft and
gave comments. All authors read and approved the final
manuscript.

Acknowledgements

The authors wish to thank the research teams in India, Vietnam and Tanza-
nia. This paper would not have been possible without their innovative work
and dedication to reducing HIV stigma in health facilities. We also wish to
thank Traci Eckhaus for assistance with citations.

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Name:________________________

1. How do the cognitive symptoms of anorexia impact someone’s thoughts and behavior, and
why can anorexia be difficult to treat?

slides- SEXUAL HEALTH beginning slide 8

2. What are some of the differences (psychologically/safety-wise) between street-based sex
workers and sex workers who work independently online (like the ones in Dr. Koken’s study)?
And which of the two groups does science know more about, and why? PT 2 lecture 11

slides – SEX ETHICS AND THE LAW beginning slide 28

3. From your reading “Beyond Discrete Categories” by Dunham and Olson, why do they say
studying variation (like intersex people) is beneficial for science overall? What is wrong with
just studying the majority?

reading found: lecture 9 required reading

4. What are some of the most common rape myths in the United States – and how are gender
role teachings connected to them? How might these myths contribute to people’s false belief
that false rape accusations are common?

slides – SEXUAL ASSAULT AND RAPE beginning slide 16

5. From your reading “Combating HIV stigma in health care settings: what works?” by Laura
Nyblade and team, what was shown about the existence of HIV stigma among medical
professionals? What impact could HIV stigma have on patients? What does the research team

Name:________________________

suggest would help combat HIV stigma in healthcare settings and among healthcare
professionals?

reading found: lecture 14 required readings

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