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Background <p>Internalized stigma undermines recovery in patients with schizophrenia. The evidence for gender differences remains inconsistent, particularly in North African settings.</p> Methods <p>We conducted a cross-sectional study of clinically stable outpatients with schizophrenia at a Tunisian university clinic (<i>N </i>= 82; 42 men, 40 women). Internalized stigma was measured with the Arabic Internalized Stigma of Mental Illness Inventory (ISMI-29), and insight was measured with the Arabic Birchwood Insight Scale (BIS). The primary outcome was moderate-to-severe internalized stigma (ISMI &gt; 2.5). We estimated sex-stratified logistic regressions with prespecified covariates. Across ISMI domains, multiplicity was addressed by Benjamini–Hochberg false discovery rate control (<i>q</i> = 0.05). Model performance included the area under the receiver operating characteristic curve (AUC) by bootstrapping, the Brier score, and Hosmer–Lemeshow (HL) calibration.</p> Results <p>The mean ISMI score was 2.6 ± 0.3. All participants scored at least in the “mild” internalized&#xa0;stigma range; 56% met the moderate-to-severe threshold. Compared with men, women were more likely to meet the moderate-to-severe threshold and showed higher perceived discrimination and lower stigma resistance, whereas alienation, stereotype endorsement, and social withdrawal did not differ materially. In men, a longer duration of psychiatric treatment increased the odds of moderate-to-severe stigma (Adjusted odds ratio (AOR) = 1.11; 95% CI 1.01–1.23), whereas long-acting injectable antipsychotics (LAIs) were associated with lower odds (AOR = 0.10; 0.01–0.65). In women<b>,</b> better insight (BIS) was independently associated with higher odds. The discriminative performance was acceptable (men: AUC = 0.83, <i>R</i><sup>2</sup> = 0.59; women: AUC = 0.71, HL <i>p</i> = 0.21, Brier = 0.12, <i>R</i><sup>2</sup> = 0.39).</p> Conclusions <p>Gender appears to shape profiles of internalized stigma. Among men, longer treatment was associated with greater stigma, which was attenuated with LAI use. In women, stigma is more insight-linked and domain-specific and is characterized by greater perceived discrimination and lower resistance<b>.</b> These findings support sex-responsive anti-stigma interventions and routine stigma monitoring.</p>

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Gender-based differences in internalized stigma and its predictors among patients with schizophrenia: a cross-sectional Tunisian study

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  • 发表日期：

    2025年10月16日

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  • Ali Kerkeni,
  • Fatima Amorri,
  • Wafa Abbes,
  • Safa Kolsi,
  • Amal Bouaziz,
  • Khawla Medhaffar,
  • Khalifa Zitoun

摘要

Background

Internalized stigma undermines recovery in patients with schizophrenia. The evidence for gender differences remains inconsistent, particularly in North African settings.

Methods

We conducted a cross-sectional study of clinically stable outpatients with schizophrenia at a Tunisian university clinic (N = 82; 42 men, 40 women). Internalized stigma was measured with the Arabic Internalized Stigma of Mental Illness Inventory (ISMI-29), and insight was measured with the Arabic Birchwood Insight Scale (BIS). The primary outcome was moderate-to-severe internalized stigma (ISMI > 2.5). We estimated sex-stratified logistic regressions with prespecified covariates. Across ISMI domains, multiplicity was addressed by Benjamini–Hochberg false discovery rate control (q = 0.05). Model performance included the area under the receiver operating characteristic curve (AUC) by bootstrapping, the Brier score, and Hosmer–Lemeshow (HL) calibration.

Results

The mean ISMI score was 2.6 ± 0.3. All participants scored at least in the “mild” internalized stigma range; 56% met the moderate-to-severe threshold. Compared with men, women were more likely to meet the moderate-to-severe threshold and showed higher perceived discrimination and lower stigma resistance, whereas alienation, stereotype endorsement, and social withdrawal did not differ materially. In men, a longer duration of psychiatric treatment increased the odds of moderate-to-severe stigma (Adjusted odds ratio (AOR) = 1.11; 95% CI 1.01–1.23), whereas long-acting injectable antipsychotics (LAIs) were associated with lower odds (AOR = 0.10; 0.01–0.65). In women, better insight (BIS) was independently associated with higher odds. The discriminative performance was acceptable (men: AUC = 0.83, R2 = 0.59; women: AUC = 0.71, HL p = 0.21, Brier = 0.12, R2 = 0.39).

Conclusions

Gender appears to shape profiles of internalized stigma. Among men, longer treatment was associated with greater stigma, which was attenuated with LAI use. In women, stigma is more insight-linked and domain-specific and is characterized by greater perceived discrimination and lower resistance. These findings support sex-responsive anti-stigma interventions and routine stigma monitoring.